By Lawrence A. May, M.D., F.A.C.P.
Chief Medical Officer, Marpella, and practicing internist.
In contrast to the fictitious Dr. McCoy (“Bones”) of Star Trek fame, we don’t have a hypospray to magically erase pain, nor do patients insist on retaining pain as part of their identity. The unvarnished reality is that many people are desperately seeking better, natural alternatives for pain control. Their basic quality of life is profoundly damaged by their pain. As a physician, I understand the pain my patients suffer, the causes, and the consequences of bad treatments. I have become convinced that cannabis can be an effective option and complement to other modalities to alleviate the pain and suffering of many people.
Pain is a universal and complex symptom and medical challenge to diagnose and treat. It can be a symptom of a serious medical problem demanding the clinician’s diagnostic expertise and requiring the clinician to acquire the patient history, perform the physical exam and order the appropriate laboratory and imaging tests. What makes pain complex and insidious is that it is subjective. The perception, intensity and demands for diagnosis and/or relief are influenced by psychology and an individual’s tolerance for discomfort. Athletes and soldiers often function with intense pain suppressed by an outpouring of neurotransmitters precipitated by the stress. Others are incapacitated and seek relief from what appear to be mild injuries that are perceived as serious or disabling. Pain provokes anxiety because chest pain is feared to be a heart attack or headache is thought to be a brain tumor.
There are two basic types of pain: nociceptive pain and neuropathic pain. Nociceptive pain is produced by obvious triggers–falling, getting hit with a baseball or touching a hot stove. These painful events of daily living provoke a normal and protective pain response. Neuropathic pain is an abnormal or harmful response caused by hypersensitivity and/or nerve damage. It may be an exaggerated response to a painful stimulus or an unpleasant reaction to a normal sensation such as temperature or touch. This dysfunctional pain is often chronic, debilitating and more challenging to treat.
The task of the clinician is to identify and eliminate the cause of pain and/or help the patient cope with the unpleasant sensations without exacerbating the problem with unnecessary or inappropriate treatment. Most of us successfully deal with acute pain. We rest and ice the affected area and take a mild analgesic (Tylenol®) or a non-steroidal anti-inflammatory (Advil® or Aleve®). Severe acute pain may require codeine for as short a period of time as possible.
The challenge is managing chronic pain, whether musculoskeletal, spine or joint pain, abdominal distress from an irritable bowel, or headache from migraine or muscle contraction. The objective is to alleviate pain while avoiding the consequences of mistreatment. The plethora of interventions available for chronic somatic pain include drugs, acupuncture, epidurals, surgery, and even implanted devices.
There is a perception that pain can be eliminated, and people seem willing to incur expense, risk, and often create problems far worse than the initial complaint. There is no perfect drug. Tylenol® is at best modestly helpful, with recent studies demonstrating little or no benefit for treatment of back or knee pain. Less well known is that when taken in high doses for longer periods while consuming alcohol, Tylenol® is one of the common causes of liver transplantation. Aspirin is one of the oldest analgesics, now more often used to prevent heart attacks and reduce the risk of colon cancer. The non-steroidal anti inflammatories of many – Aleve® (Naprosyn), Advil® (Motrin) – are more effective, convenient and safer than aspirin but can cause gastrointestinal distress, bleeding, kidney damage and are a risk factor for cardiovascular disease.
Until the 1990s, the powerful opiates that eliminate pain – morphine, Dilaudid, codeine in its myriad of forms (often combined with Tylenol ®) – were avoided for fear of addiction and used only post-operatively or in terminal cancer patients. Physicians were accused of failing to relieve the suffering of their patients and reassured that the addictive risk of opiates was low. The pendulum then swung to more liberal prescription, resulting in an epidemic of opiate dependence and deaths due to accidental overdoses. Illicit drug use increased as people who became addicted to prescription opiates found relief with less costly alternatives such as heroin. It is a classic example of the cure being far worse than the disease.
Often, the most important treatment is mechanical (RICE—Rest, Ice, Compression, Elevation) for the acute injury.
Strengthening core muscles to alleviate back pain or the quadriceps muscles to protect an injured knee is safe and effective. For chronic somatic pain, I favor local treatment with Lidoderm patches (a topical anesthetic), Flector patches or Voltaren gel to deliver Diclofenac, a powerful anti-inflammatory, directly to the site of pain. These treatments are helpful and safe but unfortunately expensive and often not covered by insurance.
Accordingly, there is an important pain management role for cannabinoids, particularly cannabidiol (“CBD”), a known analgesic and anti-inflammatory. Topical cannabis preparations relieve the muscle spasms that are often the source of pain. Topical cannabis is remarkably effective for relief from musculoskeletal problems such as waking up with neck pain. Anti-inflammatories or opiates can be helpful in combination with topical agents when used in moderate doses for short duration.
The most common use for medical marijuana has been for the alleviation of pain. Studies of marijuana as a single agent for pain relief are limited but anecdotal enthusiasm abounds. Among the cannabinoids, CBD has the most direct analgesic and anti-anxiety effects. Most studies on pain focus on CBD. CBD in the whole leaf also balances the psychoactive components of THC, another cannabinoid. A recent, small (45 subject) trial used three concentrations of THC with a 9.4% concentration having the best efficacy in modifying neuropathic pain, though the benefits were modest and results might have been improved by using or adding CBD.
The medicinal properties of cannabis are not limited to pain relief and extend to other conditions associated with and/or related to pain. The suffering that pain induces is complex and is exacerbated by sleep deprivation, anxiety and anticipatory fear. Cannabis, particularly long acting forms such as edibles or capsules, improves sleep, with Indica strains being the most relaxing. Dr. Sanjay Gupta’s “Weeds 3” documentary on CNN highlighted several examples of the potential medical benefit of cannabis across several indications, notably PTSD, the focus of the proposed study by Sue Sisley M.D., formerly at the University of Arizona. Fibromyalgia, chronic fatigue and PTSD are probably variants of the spectrum of disorders that involve pain, sleep disturbance and brain fog. Cannabis can be an important part of a multifactorial approach to holistic healing. A small study performed utilizing amino acid based medical foods showed improvement in pain, sleep and cognition in veterans with PTSD. The psychoactive properties of cannabis would likely enhance the benefits of medical foods, prescription drugs and dietary supplements for treating PTSD and fibromyalgia.
Is “the plant” the panacea? Probably not, but it is a powerful natural “drug” with a myriad of benefits affecting sleep, anxiety and pain perception. Cannabis, particularly as a topical, is a safe, efficacious and cost effective treatment for localized musculoskeletal pain. The psychoactive benefits of cannabis combined with topical preparations for local pain, aggressive medical interventions with injections, alternative procedures such as acupuncture and cognitive behavioural therapy can be integrated into treatment plans for alleviating pain and suffering. Moreover, cannabis can reduce the opiate abuse epidemic of drug dependent chronic pain patients, which is a major societal challenge.
According to Dr. Marcia Angell in a 1982 editorial in the New England Journal of Medicine, “Few things a doctor does are more important than relieving pain… pain is soul destroying. No patient should have to endure intense pain unnecessarily.” Cannabis may be part of the overall solution and has the potential and promise of improving the health and well-being for many. It may not be the panacea, but is an emerging natural remedy for pain and a versatile cornerstone for complementary medicine.