CBD for chronic pain: The science doesn’t match the marketing
If you ask health care providers about the most challenging condition to treat, chronic pain is mentioned frequently. By its nature, chronic pain is a complex and multidimensional experience. Pain perception is affected by our unique biology, our mood, our social environment, and past experiences. If you or a loved one is suffering from chronic pain, you already know the heavy burden.
People are looking for novel, nonaddictive ways to treat pain
Given the ongoing challenges of chronic pain management coupled with the consequences of the opioid epidemic, pain management practitioners and their patients are searching for effective and safer alternatives to opioids to alleviate pain. With the legalization of marijuana in many states and resulting cultural acceptance of this drug for recreational and medical use, there has been an increased interest in using cannabis for a myriad of medical problems, including pain.
Cannabis (most commonly obtained from the Cannabis indica and Cannabis sativa plants) has three major components: cannabinoids, terpenoids, and flavonoids. While there are over a hundred different cannabinoids, the two major components are tetrahydrocannabional (THC) and cannabidiol (CBD). Historically more attention has been paid to the psychoactive (euphoric “getting high”) component of the cannabis plant, THC; there have been fewer scientific studies on the medical use of CBD, a non-psychoactive component of the plant.
What’s the thinking behind using cannabis for chronic pain?
CBD is emerging as a promising pharmaceutical agent to treat pain, inflammation, seizures, and anxiety without the psychoactive effects of THC. Our understanding of the role of CBD in pain management continues to evolve, and evidence from animal studies has shown that CBD exerts its pain-relieving effects through its various interactions and modulation of the endocannabinoid, inflammatory, and nociceptive (pain sensing) systems. The endocannabinoid system consists of cannabinoid receptors that interact with our own naturally occurring cannabinoids. This system is involved in regulating many functions in the body, including metabolism and appetite, mood and anxiety, and pain perception.
What’s the research that CBD works in humans?
Given its promising results in animal models, along with its relative safety, non-psychoactive properties, and low potential for abuse, CBD is an attractive candidate to relieve pain. Unfortunately, there is a lack of human studies about the effectiveness of CBD. However, there is an abundance of commercial advertisements about the magical effects of CBD, and it is frequently presented as a cure-it-all potion that will treat everything including diabetes, depression, cancer, chronic pain, and even your dog’s anxiety!
So far, pharmaceutical CBD is only approved by the FDA as adjunct therapy for the treatment of a special and rare form of epilepsy. Currently, CBD alone is not approved for treatment of pain in the United States. But a combination medication (that contains both THC and CBD in a 1:1 ratio) was approved by Health Canada for prescription for certain types of pain, specifically central neuropathic pain in multiple sclerosis, and the treatment of cancer pain unresponsive to optimized opioid therapy. There is currently no high-quality research study that supports the use of CBD alone for the treatment of pain.
Why is CBD presented to the public this way, when it is not without risks?
Given the rapid change in the legality of cannabis coupled with the increased appetite for something new, and driven by unprecedented profit margins, the advertising for cannabinoids in general and CBD in particular has gone wild. The FDA is very clear that it is illegal to market CBD by adding it to a food or labeling it as a dietary supplement. And it warns the public about its potential side effects, as it’s often advertised in a way that may lead people to mistakenly believe using CBD “can’t hurt.” CBD can cause liver injury, and can affect the male reproductive system (as demonstrated in laboratory animal studies).
Most importantly, CBD can interact with other important medications like blood thinners, heart medications, and immunosuppressants (medications given after organ transplantation), potentially changing the levels of these important medications in the blood and leading to catastrophic results, including death. Also, more information needs to be gathered about its safety in special populations such as the elderly, children, those who are immunocompromised, and pregnant and breastfeeding women.
Many of the CBD products on the market are unregulated
In fact, the FDA has issued several warning letters to companies and individuals that market unapproved new drugs that allegedly contain CBD. The FDA has tested the chemical content of cannabinoid compounds in some of the products, and many were found to not contain the levels of CBD the manufacturers had claimed they contain.
Beware of powerful testimonials
Finally, there is anecdotal wisdom, when experiences by patients and health professionals have positive results. While the experience or medication could be beneficial, that doesn’t mean it is going to work for everyone. That’s because each and every person is unique, and what works perfectly for one patient could have no effect on another patient. This is especially true for pain, where many other factors (our mood and stress level, our environment and other medical conditions, and our previous experiences) can affect the perception of pain. Please be careful, and keep in mind that some of these incredible-sounding testimonials are merely marketing materials meant to lure consumers to buy more products, as the CBD market is expected to hit $20 billion by 2024.
The bottom line: Don’t make CBD your first or only choice for pain relief
If you or someone close to you is considering trying CBD, I would recommend Dr. Robert Shmerling’s advice about the dos and don’ts in choosing an appropriate product. Until there is high-quality scientific evidence in humans, it is difficult to make a recommendation for the regular use of CBD in chronic pain management.
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8 Reasons CBD Might Not Be Working for Your Arthritis (and What to Do About It)
Cannabidiol, known as CBD, is a type of chemical called a cannabinoid that is found in the cannabis plant. It’s not intoxicating like THC, a different kind of cannabinoid that causes the “high” you get from using pot. Chances are you’ve heard of CBD. It’s one of the fastest-growing supplements in the U.S. and has become a popular topic among arthritis patients, from online support groups to clinical conversations in doctors’ offices.
Unlike many alternative arthritis treatments that get touted online, CBD does appear to have some positive effects, says Elyse Rubenstein, MD, a rheumatologist at Providence Saint John’s Health Center in Santa Monica, California. “There really aren’t yet any good studies to show that it works for arthritis but I’ve had patients who have found using CBD very helpful,” she says. “I haven’t seen any harm from it so it may be worth trying.”
However, for every CBD success story there are plenty of people who see little or no effects from using CBD. The first time Chris G., 37, of Denver, Colorado, tried a CBD oil tincture she felt nothing. “I might as well have been drinking straight coconut oil,” she says. Her friend had given her a bottle to help with rheumatoid arthritis pain and told her to just try it. Using CBD didn’t help the second time either. Or the third. Or the fourth. “I finished the whole bottle and never saw any difference,” she says. “I hear others talking about it and wonder why it didn’t work for me.”
Then there are the people who feel an effect — but not a good one. “It was like being drunk, but not in a fun way,” says Jason J., 46, of Minneapolis, Minnesota. The father of two tried it to treat his chronic pain from reactive arthritis as well as anxiety. He started with pure CBD oil and felt nothing so then he moved up to a CBD oil with a small amount of THC. The results were not great. While it did lessen his pain, he says it also made him feel nauseous and dizzy. He tried it a second time, this time spacing the doses further apart, but had similar results. He didn’t like the feeling and as a father was hesitant to do anything that might make him impaired while caring for his kids. “I wish it worked for me, but it did more harm than good,” he says.
If either of these experiences sound familiar, don’t give up yet. There may be good reasons CBD has not helped you — yet — and ways to make using CBD more effective for you.
1. Your CBD isn’t actually CBD
Just because cannabis products are becoming legal in certain parts of the U.S. doesn’t mean they are regulated. CBD is the wild west these days: There are a lot of “CBD” products with little or no actual cannabidiol in them, says McKenzie Mann, product development manager for Blue Forest Farms, a farm that grows high-CBD hemp and sells CBD products. The FDA doesn’t regulate CBD products and there aren’t universal quality standards, so unless you have a basement lab and chemistry degree, it’s near impossible to know exactly what you’re getting.
The fix: Look for brands that have their products independently tested (they should be able to provide you with test results), shop only at places you trust (preferably in person, not online), and when you find a brand that works for you, stick with it, says April Olshavsky, founder of Herbal Risings, a company that educates people on the proper use of CBD products.
2. You may benefit from a different strain
Not all cannabis plants are the same, which means the chemical makeup of your CBD product can differ widely. For one thing, CBD is one of many dozens of types of cannabinoids found in cannabis plants. Just as when you eat different berries (blueberries versus raspberries versus strawberries) you’re exposed to different antioxidants and plant chemicals, different cannabis plants have various amounts and types of cannabinoids and other compounds such as terpenes, which also have anti-inflammatory properties independent of the CBD.
The fix: Unfortunately, there’s no such thing as a specific strain being good for a specific disease or symptoms, says Bridget Seritt, co-founder of the Canna-Patient Resource Connection, a Colorado-based organization that is working to protect patient rights and end stigma against those who choose cannabis as medicine. A good CBD supplier should be able to show you third-party tests that include both the terpene and the cannabinoid profile. “There are hundreds of products with different formulations of each component, so knowing what goes into your products is essential. Keep a journal so you know which products worked and which did not. You can use the profile information to find similar products,” Seritt advises.
3. You need a different type of extract
There are different types of CBD extracts, and it’s important — from both a health and legal perspective — to understand their differences:
Full spectrum: This oil is how it comes raw from the plant and contains a full spectrum of compounds, including CBD, THC, terpenes, chlorophyll, minerals, and other parts of the hemp plant. “This is usually the best for most people and what we recommend — it’s the ‘entourage effect.’ All the compounds in the plant work best when they are together,” Mann explains. “Like most plants, it’s healthier to use it whole.”
Broad spectrum: This oil is similar to a full-spectrum product but with THC removed. In states where CBD is legal, laws can vary as to how much THC is permissible in CBD products in order for them to be legally sold. Many states in which certain CBD products are legal require them to contain less than 0.3 percent THC. A higher amount of THC in the product may make it more effective for certain conditions, Mann says, but this is a good option for people who live in states with THC restrictions.
CBD isolate: This oil is 99 percent straight CBD. While this might look like what you want — especially as it’s often labeled “pure CBD” — it’s the least effective form, Mann says.
The fix: Opt for a full-spectrum product if it’s legal to use where you live.
4. You didn’t wait long enough to see results
Many people do not see a difference after one or two doses of CBD. “CBD works on the endocannabinoid system in the brain and everyone’s is a little bit different,” Mann says. “One person may feel a difference within 20 minutes but others it may take several days to build up enough to where you feel it.” It can take up to eight weeks of regular use to feel an impact, says Seritt.
The fix: Give your CBD time to take effect. Try a product for at least two weeks before deciding that it’s not working for you.
5. You’re not consistent
“The biggest mistake people make with CBD is failing to follow a regular routine. You need to have patience to see the full effects,” Olshavsky says. This is especially true for people dealing with chronic pain from arthritis and other illnesses, she adds.
The fix: Do at least one dose once a day for at least two weeks to give the product time to build up in your system, Mann says.
6. You need a different method of delivery
Oral tinctures — drops that you place under your tongue — are the most popular way to use CBD but there are plenty of other options. You can also inhale it with vape pens, rub it on topically with a lotion, take it orally with capsules, or eat CBD-infused foods. Different delivery methods may be better for certain health conditions or personal preference.
For those using CBD primarily for targeted joint pain, a CBD lotion may be the best option. If you need CBD to take effect quickly for intense pain, vaping will work the fastest. Worried about prying questions? Capsules are simple and discreet to use. And for people who don’t like pills, edibles such as candy, gum, or other CBD foods are a fun way to ingest it. (However, Mann cautions that some of the potency is lost when CBD goes through your digestive tract, so capsules and edibles aren’t his top choice for efficacy.)
The fix: Talk to a reputable company about which form of CBD will work best for your specific needs.
7. You need a higher dose of CBD
People are often hesitant to take CBD because they equate it with recreational marijuana, which can lead them to under-dose, Olshavsky says. Or your dose may be sufficient but you’re not taking it often enough. What works for your friend may not be the right amount for you.
The fix: Between dosages, routine, and application method, it can take some trial and error to find the right product and regimen for you, Olshavsky says. “The best thing you can do is to keep a journal and record your symptoms and results.”
8. You may benefit from some THC
For many people, CBD works better with some THC in it. The compounds work together, with THC providing pain relief and the CBD helping to manage any negative side effects of THC, Mann explains. Many people who complain about their CBD not working are often using one of the types that has no THC in it, he adds. Even a CBD oil with just 0.3 percent THC may be more effective for you than one without any.
The fix: Consider trying something other than the “pure” isolate version of CBD (though you need to research whether or not these products are legal where you live). If you live in a place where marijuana is legal, consider a CBD oil with a ratio of 3:1 or even 5:1 of CBD to THC, Mann says.
Should You Take CBD for Pain?
People looking for a safer pain reliever are turning to cannabis-derived CBD. Michigan Medicine experts weigh in on what’s currently known about the trendy supplement.
Want to learn more on this topic? Listen to this podcast from the Rogel Cancer Center on Medical Marijuana for Cancer Patients.
CBD, short for cannabidiol, is undergoing a surge in popularity as the hot new supplement, with a promise to treat a variety of conditions including pain, anxiety, and insomnia, just to name a few. It’s also available in all manner of forms, from lotions and oils to CBD-infused food and drink. But does it work?
CBD is one of the compounds in the cannabis plant, better known as marijuana. Unlike the famous cannabinoid tetrahydrocannabinol (THC), CBD doesn’t cause the psychological effects typical of being “high”. Both CBD and THC act on the body’s natural endocannabinoid system, which plays a role in many processes including appetite, pain and memory.
The scientific evidence around CBD use is thin, a fact that is mainly due to politics. “Cannabis has been a Schedule 1 drug for a long time, which has limited the type of research needed to figure out how best to use it therapeutically,” says Kevin Boehnke, Ph.D., research investigator in the department of anesthesiology and the Michigan Medicine Chronic Pain and Fatigue Research Center. Under the U.S. Federal Controlled Substances Act, Schedule 1 drugs are defined as having no currently accepted medical use and a high potential for abuse.
Yet marijuana has been used as a medicinal plant for thousands of years, he notes. In fact, one of the first recorded uses of cannabis was for rheumatism, also known as arthritis. Cannabis products were widely used as medicines in the 19th and early 20th centuries, and were listed in the U.S. Pharmacopoeia before the onset of Federal restriction in 1937 under the Marijuana Tax Act.
Much of the research literature around CBD in particular supports its use as a treatment for childhood epilepsy. Indeed, in 2018 the FDA approved the CBD-based drug Epidiolex as a drug for childhood epileptic conditions. In a substantial policy shift, Epidiolex was designated as Schedule V, which is the least restrictive drug schedule and indicates little potential for abuse.
While there aren’t any published clinical trials on CBD in pain, Boehnke notes that ongoing preclinical studies in animals have demonstrated that CBD reduces pain and inflammation, and studies of CBD in humans show that it is well-tolerated and has few negative side effects. “There are also observational studies that ask why people use CBD and if it’s effective, and results tend to be quite positive. People report using CBD for anxiety, pain, sleep — all things that go hand-in-hand with chronic pain,” he says. The passage of the 2018 Farm Bill removed hemp-derived CBD (
So many people are turning to CBD as an alternative pain reliever, especially in light of the opioid crisis, that in a commentary published in Annals of Internal Medicine, Boehnke and Daniel Clauw, M.D., director of the Chronic Pain and Fatigue Research Center, provided advice for clinicians on how to counsel their patients about CBD and cannabis use.
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They also provided guidance for the Arthritis Foundation, who recently surveyed 2,600 people with arthritis and found that 29% currently use CBD to treat arthritis symptoms.
Boehnke and Clauw recommend that people with chronic pain talk to their doctor about adding CBD to their treatment plan, and continue to use their prescribed medication. They offer the following advice for people wanting to try CBD:
Don’t smoke or vape. Bottom line is smoking anything harms the lungs. Vaping has been associated with a recent epidemic of lung disease, according to the Centers for Disease Control & Prevention.
Purchase from reputable sources. Like vitamins and other supplements, CBD products aren’t regulated or FDA approved to treat disease, so buyer beware. Look for products that have been tested by an independent third party lab “so you don’t end up with a product that has THC in it or a product contaminated with heavy metals or pesticides,” says Boehnke.
Route of administration matters. CBD is best taken in pill or capsule form for slow extended release or as an oral tincture (infused oil that contains CBD) for faster effect onset.
Start low, go slow. Take a small amount and slowly increase your dosage until you start to get symptom relief over a matter of weeks. Track your symptoms to get a sense of whether or not CBD is a helpful part of your treatment plan.
Check your state laws. While medical marijuana is legal in many states, it’s still illegal at the Federal level, putting CBD in a legal gray zone in many areas.