Saturday, November 17, 2018

Cannabis and Pain



Cannabis and Pain


Pain is the most common condition reported by patients for using cannabis medicine. In a 2017 National Academies report, Pain was the primary symptom with evidence supporting the use of cannabis medicines. https://www.nap.edu/resource/24625/Cannabis_committee_conclusions.pdf
The history of cannabis proves it’s use for pain management. The Chinese found evidence of medical use of cannabis more than four millennia ago. In the ninth century, the Persian physician Shapur ibn Sahl would pack the nose of migraine sufferers with juice from cannabis flower to treat their severe headache pain. Cannabis was widely used in patient medicines for a variety of symptoms, including pain, as early as the mid 1800s in the United States.
In 1887, Hobart Amory Hare, a professor of medicine at Jefferson Medical College Philadelphia, published a long article in the Therapeutic Gazette about the advantage of cannabis over opium for treating pain. https://www.scribd.com/document/77188793/Hobart-Amory-Hare-Clinical-and-Physiological-Notes-on-the-Action-of-Cannabis-Indica
The types of pain are: neuropathic (originating in nerves), visceral (originating in an organ), somatic (the skin or musculoskeletal tissue), and psychogenic (tension headache or panic attack). Unlike other pain medications, cannabis can treat all of these types of pain.
A University of California San Diego study revealed low doses of cannabis provide little relief, while moderate doses produce good pain relief (and large doses may actually increase pain levels). https://www.futuremedicine.com/doi/abs/10.2217/pmt.15.20?journalCode=pmt
Most studies on the use of cannabinoids for treating chronic pain have been encouraging. Aggarwal found that out of 38 published RCTs studies (before 2012), 71% of those studies demonstrated significant pain-relieving effects of medical cannabis. https://www.ncbi.nlm.nih.gov/pubmed/22367503
With increased use of medical cannabis as pharmacotherapy for pain comes a need for comprehensive risk-benefit discussions that take into account cannabis' significant possible side effects. As cannabis use increases in the context of medical and recreational cannabis policies, additional research to support or refute the current evidence base is essential to attempt to answer the questions that so many healthcare professionals and patients are asking” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5549367/
Cannabis has been investigated to treat forms of pain that does not respond well to opioids. Cannabis may be effective for pain-related syndromes, such as complex regional pain, reflex sympathetic dustrophy, neuropathies, and intractable cancer pain, which responds poorly to traditional analgesics. https://www.ncbi.nlm.nih.gov/pubmed/18403272 https://www.ncbi.nlm.nih.gov/pubmed/23237736
While there are no studies that show how cannabinoids can treat trigeminal neuralgia, which involves severe facial pain, patients are claiming that cannabis reduces the extraordinary intensity of the attacks.
A series of reports show that cancer patients who use cannabis had less anxiety, which can contribute to the intensity of experience of pain. https://www.ncbi.nlm.nih.gov/pubmed/24937161
Animal studies and anecdotal cases indicate that cannabis is effective against both neuropathic and visceral (organ) pain in cancer patients. https://www.ncbi.nlm.nih.gov/pubmed/27863159
Clinical data indicates that cannabis medicines may reduce the dose of opioid medicines required to treat severe pain. https://www.ncbi.nlm.nih.gov/pubmed/25978826 https://www.ncbi.nlm.nih.gov/pubmed/27001005
Cannabinoids may also reduce the tolerance buildup to opioid medicines and CBD may even reduce the severity of withdrawal. THC reduces gastrointestinal bleeding and even hemorrhages caused by nonsteroidal, anti-inflammatory drugs used to control pain.
Cannabinoids, especially the combination of THC and CBD, appear particularly effective for intractable pain conditions, including those associated with multiple sclerosis and cancer. The cannabinoid CBG is a stronger analgesic.

The Endocannabinoid System interacts with cannabis and helps to modulate pain signaling throughout the nervous system. Cannabinoids can relieve pain through a variety of mechanisms, including producing analgesic and anti-inflammatory effects, through the modulation of neurotransmitter release, and by stimulating the release of the body’s own natural opioids.
THC was found to displace opioids from the receptor to which they bind and also allow for reductions in the dose of opioids necessary to treat high levels of pain. Cannabinoids quell the transmission of ascending (toward the spine and brain) pain signals. They also modulate pain signaling in the descending pain pathway from the brain/spine to the affected region.
Endocannabinoids and their deficiency are involved in painful syndromes, such as fibromyalgia and migraines, which might possibly be addresses through low-dose cannabis prophylaxis. Cannabinoids reduce sensitivity to pain.
Medical cannabis augments the effect of opioids, making dose reduction (or even discontinuation) possible. Any changes to dose or use of opioid medications should always be undertaken with the supervision of a trusted physician. Find a trusted physician who understands cannabis, your personal conditions, and who wants to help you get off opioids. 

To establish the most effective dose of cannabis for pain, take the least amount of cannabis required to provide the level of effect needed. Take less, rather than more, and carefully increase the dose only until optimal effectiveness is reached. Doing this may decrease the possibility of developing a tolerance to the benefits of cannabis.
Patients report that oral cannabis products work for chronic pain, but finding the right dose is difficult and requires patience, caution, and knowledge of potency of the medical cannabis preparations ingested. Oral cannabis makes restorative sleep possible and reduces the perception of pain during the night. Patients can achieve pain relief by using very small doses of an edible in the morning and afternoon – typically, one-fourth of the bedtime dose. Swallowing cannabis containing THC increases the length of time they are effective for analgesia and for sleep. Use oral cannabis containing both THC and CBD. CBD prolongs the effects of THC while reducing some of its side effects.
Take 2.5 to 7.5 mg THC orally, every three to four hours, to manage low level to moderate pain. The addition of 2.5 to 10 mg of CBD to the THC dose can reduce the intensity of THC psychoactivity while providing a measure of neuroprotection. Oral cannabis may take 30 – 45 minutes for the effects to be felt. Be careful and use caution not to over medicate and not to exceed the optimal dose for relief.
Patients report that either inhaled, sublingual tinctures, or oral spray, medical cannabis removes anticipatory bad pain memories, as it treats PTSD.
Vaporized or inhaled THC is recommended for faster onset of pain relief. 2.5 to 7.5 mg of THC is recommended. Cannabis naïve patients should start with no more than 2.5 mg of THC and wait 45 minutes before taking more.


Topical applications of cannabis act by stimulating the CB2 receptors in the sensory nerve endings in the skin. A topical application relieves pain for two or more hours. Topical, high-THC cannabis is useful for pain-related conditions such as itching, skin inflammation, and dermatitis. CBD-rich cannabis medicines are also quite effective for skin inflammation. For topical preparations to work, the pain must be localized (a joint or peripheral nerve), and the preparation should have high concentrations of THC and CBD. Transdermal Cannabis patches are very helpful for localized pain relief as well as fibromyalgia.

THC is the most important pain-relieving cannabinoid currently available. CBD and terpenes (such as myrcene and beta-caryophyllene) can also contribute significantly to pain and anxiety relief. Patients need a more stimulating option for use during the day (like sativa, or high CBD varieties) and a more sedative variety for sleep at night (like indica) to assist with recovery and sleep.
Some good books to check out are: Cannabis for Chronic Pain by Dr. Ivker

Information was taken from the fabulous book: Cannabis Pharmacy by Michael Backes

For more research information check out these helpful links:

Meta-analysis of cannabis based treatments for neuropathic and multiple sclerosis-related pain - https://www.ncbi.nlm.nih.gov/pubmed/17257464

Neuropathic orofacial pain: cannabinoids as a therapeutic avenue - https://www.ncbi.nlm.nih.gov/pubmed/2515083

Cannabinoids suppress inflammatory and neuropathic pain by targeting α3 glycine receptors - https://www.ncbi.nlm.nih.gov/pubmed/22585736

Cannabinoids in the management of difficult to treat pain - https://www.ncbi.nlm.nih.gov/pubmed/18728714
Cannabidiol-Δ9-tetrahydrocannabinol interactions on acute pain and locomotor activity - https://www.ncbi.nlm.nih.gov/pubmed/28445853
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