Chronic Pain, Muscle Pain and Other Types of Pain

Medical Cannabis and Chronic Pain

Medical cannabis (aka medical marijuana) could be of immense use in managing and relieving chronic pain. If you or someone you care deeply about suffers from a serious pain condition, you already feel its heavy burden. We hope that sharing the information in this article will help you restore your quality of life and reclaim your future.

What is Chronic Pain?

Pain is the most common complaint that inspires us to seek medical attention and effective medications. Pain may also be termed acute (sudden or recent) or chronic (frequently repeated over a longer period).

Pain is a presenting symptom of so many health problems that it is essential to consider if some underlying condition may cause the pain. Indeed, chronic pain management is the principal reason for medical cannabis use.

There are many different types of pain, including physical (somatic or musculoskeletal pain), mental, emotional, and even spiritual pain. Most importantly, pain perception is personal, and it is affected by our unique personality traits and life experiences, home, social environment, and more.

Although these types of pain are often separated and treated in different ways, they can all feed into one another. Dame Cicely Saunders, renowned for her work in palliative care and the birth of the hospice movement, termed this concept “total pain.”

To give a practical example, suffering from arthritis may lead to one feeling anxious and depressed, leading to insomnia, which leads to a weakened immune system (meaning more illnesses) and increased joint pain. Therefore, treating the mood disorder may help treat physical pain indirectly, which is why antidepressants may be prescribed for chronic pain.

Unfortunately, alongside the antidepressants, patients with chronic pain may also be prescribed many other medications, including addictive ones like opioids. Managing various types of pain and reducing opioid use (and other medications, including sedatives and antidepressants) are areas of particular interest in cannabis research.

Brief Summary of Current Treatments for Chronic Pain

Current ways to treat and manage chronic pain include:

• Over-the-counter (OTC) medications like acetaminophen (Tylenol, paracetamol) and non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil, Motrin, Nurofen), acetylsalicylic acid (ASA, or aspirin) and naproxen (Aleve, Apronax)
• Prescription NSAIDs like celecoxib (Celebrex)
• Topical pain relievers for sore muscles, joint pain, and pain associated with arthritis, e.g., arnica
• Steroids and steroid injections
• Injection therapy
• Antidepressants and anxiolytics (anti-anxiety) like diazepam (Valium) and celecoxib (Celebrex)
• Anticonvulsants like gabapentin (especially for nerve pain)
• Opioid-based prescription painkillers such as codeine, fentanyl (Duragesic, Actiq), a mixture of oxycodone and acetaminophen (Percocet, Roxicet, Tylox), or a mix of hydrocodone and acetaminophen (Lorcet, Lortab, and Vicodin)
• Transcutaneous electrical nerve stimulation therapy, more commonly referred to as TENS
• Bioelectric therapy, which relieves pain by blocking pain messages to the brain and prompting the body to release endorphins
• Mind-body techniques such as meditation and biofeedback
• Exercising, especially low impact exercises like walking and some forms of yoga
• Improving diet and sleep habits
• Physical therapy (physiotherapy) and occupational therapy (OT)
• Acupuncture
• Massage
• Herbal remedies, such as lavender, rosemary, black pepper, cloves, capsaicin, and ginger
• Some utilize plants such as kratom to reduce or replace opioid use and relieve pain, but these can also be addictive.
• In rare instances, surgery

How Might Medical Cannabis Help?

The most well-known and researched constituents for pain treatment are the cannabinoids (mainly tetrahydrocannabinol or THC, cannabidiol or CBD, and beta-caryophyllene); the cannflavins A, B, and C; and the terpenes (including terpenoids).

When these compounds are taken together, they simultaneously stimulate many systems in the body, including the endocannabinoid system’s receptors (ECS). In this way, taking medical cannabis can be like taking acetaminophen (Tylenol), ibuprofen, a muscle relaxer, an antidepressant, and a potent analgesic in perfect harmony.

Here are several ways in which medical cannabis may help manage chronic pain.

• Inflammatory pain: Cannabis contains many anti-inflammatory compounds, including tetrahydrocannabinol (THC), cannabidiol (CBD), cannabigerol (CBG), and terpenes like limonene, myrcene, and linalool.
• Neuropathic (nerve) pain: Multiple randomized controlled trials (RCTs) have demonstrated the efficacy of medical cannabis in treating neuropathic pain based on quality of life (QOL) scores.
• Nociceptive pain (pain by damage to body tissue): Beta-caryophyllene, a terpene and atypical cannabinoid found in cannabis, has been shown to attenuate and decrease nociceptive pain in animal studies.
• Functional pain (pain with no obvious point of origin): It is suggested that dysregulation in one’s endocannabinoid system (ECS) is a potential cause of functional pain associated with conditions like IBS and fibromyalgia.
• Reduction in opioid use: Opioids have many adverse side effects, including tolerance, physical dependence, and respiratory depression. States with legal cannabis stores are linked to fewer opioid deaths. Other studies have shown supportive results, with patients using cannabis as medicine (CaM) as a substitute for pain medications (especially opioids), antidepressants, and arthritis medications.
• The endocannabinoid system as a “multi-facet therapeutic target“: As cannabis compounds (cannabinoids, terpenes, flavonoids) can affect multiple receptor systems, such as opioid, serotonin and dopamine receptors, it is theoretically possible that medical cannabis could be used to reduce or replace the need for multiple pills (e.g., cannabis for both depression and physical pain, as opposed to antidepressants for depression and opioids for physical pain).
• Acute pain (sudden, sharp pain that lasts less than six months): Most studies focus on cannabis for chronic pain. One pilot study assessing the effects of dronabinol (synthetic THC) on opioid medication use in patients following physical trauma showed a significant reduction in opioid medication requirements among patients given Dronabinol alongside their regular pain medication regimen. However, reductions in pain were similar between dronabinol-and-opioid and opioid-only cohorts. Although promising, this study does not reach any hard conclusions about THC’s efficacy in treating acute pain.
• Improved function: A recent guideline published by the British Medical Journal (BMJ) shows that cannabis may reduce pain and improve physical function.

Overall, the evidence suggests that medical cannabis may be beneficial in chronic pain management and an alternative to opioids, sedatives, and/or antidepressants that may be prescribed to control various types and causes of chronic pain.

Cannabinoids

THC and CBD are a highly beneficial pain relief combination, with further contribution from the entourage effects of cannabigerol (CBG), cannabichromene (CBC), and beta-caryophyllene (a terpene and atypical cannabinoid). THC has notable pain-distracting analgesic effects as well. THC and CBD act on key opioid receptors (mu and delta), meaning they can reduce inflammatory pain and modulate how pain signals are communicated to the brain.

In this way, bioactive cannabinoids can help “turn down the volume” of pain impulses. Beta-caryophyllene (an atypical cannabinoid and terpene) enhances these analgesic effects by triggering the peripheral release of the body’s endogenous painkiller, β-endorphin. THC, CBD, and beta-caryophyllene are a powerful combination against peripheral pain and related inflammation.

The lesser-known cannabinoids CBG (cannabigerol) and CBC (cannabichromene) also have significant anti-inflammatory properties, as do the acidic cannabinoids CBDa (cannabidiolic acid) and THCa (tetrahydrocannabinolic acid). Cannabis is a powerful medicine in the endocannabinoid system and throughout the body.

Cannabinoid Ratios (THC:CBD)

It is worth bearing in mind that several product lines label their products CBD:THC. Usually, if a product is THC-rich, it is given as THC:CBD. If a product is CBD-rich, it is often given as CBD:THC. The lack of regularity can be confusing when it comes to products sold at dispensaries or other licensed medical cannabis outlets, which can cause problems for patients. We will keep it consistently THC:CBD to avoid confusion.

THC-dominant– THC:CBD 5:2, 1:1, 18:1, 20:1

THC-dominant cannabis products may be more helpful for certain types of physical pain (for example, neuropathic pain) and pain that is stress-related or has a strong emotional component. One drawback is that high doses of THC can worsen anxiety. THC and its euphoric effects may also help distract from pain as well as reduce cravings for sedatives or opioids.

THC-rich cannabis cultivars (often called “strains”) include Northern Lights, Blue Dream, Bruce Banner, Strawberry Cough, White Widow, Blueberry, OG Kush and Girl Scout Cookies (GSC).

The Golden Ratio THC:CBD 1:1

A cannabis product with a 1:1 ratio has equally balanced amounts of THC and CBD.  The 1:1 THC:CBD ratio can benefit people seeking to relieve pain, including neuropathic (nerve) pain. Other potential health benefits of the 1:1 THC:CBD ratio for pain patients include stress relief, improved sleep quality, and reduced pain related to muscle spasms in persons with multiple sclerosis (MS). For more information, check out our Leafwell article on the famous Golden Ratio of cannabis. Balanced THC:CBD ratios may also be helpful for managing various kinds of autoimmune diseases, where chronic pain, inflammation and a dysregulated immune system are present.

Balanced THC:CBD 1:1 (or approximately 1:1) cultivars include CBD Shark Shock, Royal Highness, Cannatonic, Sweet & Sour Widow, Hurkle, and Argyle.

CBD-dominant– THC:CBD 1:18, 1:20

CBD-dominant cannabis products may be more helpful for pain conditions where inflammation plays a significant role. CBD-rich cannabis products may be ideal for neuroinflammatory and neurodegenerative conditions like epilepsy, Alzheimer’s, and Parkinson’s.

CBD-rich cultivars include Charlotte’s Web, ACDC, Ringo’s Gift, Harle-Tsu, Sour Tsunami, and Critical Mass.

Terpenes and Terpenoids

Several terpenes present in cannabis can be useful for easing pain symptoms, and cannabis strains vary widely in their terpene content. The primary terpenes reported most commonly as helpful for pain relief include linalool, myrcene, pinene, and beta-caryophyllene (beta-caryophyllene is both a cannabinoid and a terpene).

So, checking the COA (certificate of analysis) of your cannabis product(s) for the linalool, myrcene, pinene, beta-caryophyllene, and other terpene content could be a way of finding out which one is most effective.

Flavonoids

The cannabis plant contains many anti-inflammatory compounds. Among them are flavonoid compounds known as “cannflavins.” These amazing molecules work along with the cannabinoids in cannabis to contribute to the entourage effect and elicit pain relief. One recent study showed that they are 30-times more effective than aspirin or an equivalent dose of ibuprofen.

Effective Ways of Taking Medical Cannabis for Chronic Pain

Routes of Administration

• Oral administration
• Sublingual administration (under the tongue)
• Inhalation
• Topical or salve
• Transdermal
• Suppository

Special Formulations

Both THC and CBD are of use.

CBC also has significant anti-inflammatory properties. Cannabidiolic acid (CBDa/CBDA) also has anti-inflammatory properties, and THCA may also help. Linalool, myrcene, pinene, and beta-caryophyllene could be useful.

THC has analgesic, pain-distracting & anti-inflammatory effects as well.

THC:CBD: 1:20; 18:1; 5:2; 1:1; 2:1; 3:1

High THC may also help for pain, particularly physical pain (although high doses may worsen anxiety).

Those seeking medical cannabis for pain relief may wish to try products or cannabis strains (cultivars) with moderate amounts of THC and CBD and high amounts of beta-caryophyllene. Terpenes like linalool, myrcene, humulene, limonene, and pinene may also be useful.

Dosing Methods

The following methods of cannabis consumption may be useful in managing chronic pain:

• Inhalation: inhaler, vaporizer, and, although generally not recommended, combustion and smoking
• Tinctures
• Edibles
• Drinkables
• Topicals
• Transdermal patches
• Suppositories

Potential Adverse Effects

• High doses of THC may give rise to anxiety, panic, and/or paranoia, especially if user tolerance is low.
• Similarly, despite cannabis’ general antiemetic effects, high doses of THC and CBG may prompt queasiness, nausea, or vomiting.
• Dizziness, vertigo, or loss of balance, again usually associated with high doses of THC.
• High doses of CBD may cause gastrointestinal (GI) upset.
• Can enhance the effects of some medications, especially opioids and sedatives, so careful tapering of these prescriptions should be undertaken with the supervision of a physician to prevent overdose

What are the Pros and Cons of Taking Medical Cannabis for Chronic Pain?

Just as with any medication, there are some potential pros and cons to using medical cannabis to manage chronic pain.

Potential Pros

• The cannabis plant contains many anti-inflammatory compounds, including THC, CBD, linalool, myrcene, and beta-caryophyllene.
• THC and beta-caryophyllene have analgesic effects.
• CBD can also act as an allosteric modulator of the mu- and delta-opioid receptors, which can help change the way pain signals are processed. CBD can help “turn down the volume” of pain signals.
• Medical cannabis can be used for pain, including neuropathic, physical, emotional, and even spiritual pain. This is due to cannabis’ “entourage effect” and the fact that several different receptor systems are being affected by the endocannabinoid system (ECS), whether directly or indirectly.
• A substantial amount of evidence suggests that increased levels of anandamide in the body via suppressed fatty acid amide hydrolase (FAAH) inhibition can stop the pain.

Potential Cons

• Cannabinoids may not be helpful for some of the more extreme levels of pain.
• Does cannabis kill or just distract from the pain? Most evidence suggests a little of both, but there could be a placebo effect.
• There is some suggestion that THC may increase sensitivity to pain for some people (and studies suggesting the opposite).
• One four-year study shows that cannabis is not necessarily effective for chronic pain.

Useful Anecdotal Information

• ‘Medical cannabis ‘saved my life’’
• ‘How Medical Marijuana Changed My Life’
• ‘Is medical cannabis really a magic bullet?’
• ‘London man resorts to growing his own cannabis to manage his chronic pain’
• ‘Guest Viewpoint: After 7 years, it’s time to choose medical cannabis in South Carolina’

Scientific Data Overview and Studies

We have included studies on chronic pain, cancer pain, central pain syndrome, generalized pain, menstrual pain, and associated conditions for this data overview.

• Total Studies = 229
• Positive Studies = 200
• Inconclusive Studies = 26
• Negative Studies = 3
• 151 Meta-Analyses (124 positive, 24 inconclusive, 3 negative); 33 Animal Studies (all positive); 22 Double-Blind Human Trials (20 positive, 2 inconclusive); 14 Human Trials (all positive); 9 Lab Studies (all positive)
• 3 studies include CBD (all positive); 1 study includes THC (positive); 1 study includes CBC (positive).
• No. of Leafwell Patients (2021) = 22,000 for chronic pain specifically.
• Possible Overall Efficacy: High

Quotes from Studies

Although some of these studies may suffer from bias, the high number of positive results in all types of studies suggests that medical cannabis may play a role in chronic pain management in the future and potentially has a place as an alternative to or substitute for opioid-based painkillers.

In a study on the use of cannabis as a substitute for prescription drugs (2,841 respondents), the authors noted:

“Pain medication (67.2%), antidepressants (24.5%), and arthritis medication (20.7%) were the most common types of drugs replaced with CaM. Among substitution users, 38.1% reported termination of prescription drug use, and 45.9% a substantial decrease in prescription drug use. The most frequent type of cannabis used as a substitute was CBD-oil (65.2%), followed by ‘hash, pot or skunk’ (36.6%). More than half (65.8%) found CaM much more effective compared to prescription drugs, and 85.5% that the side effects associated with prescription drug use were much worse compared to use of CaM.”

In another study on medical cannabis for patients with chronic noncancer pain (CNCP):

“All the included publications provided a recommendation supporting medical cannabis for CNCP in general and for the specific conditions of neuropathic pain, chronic pain in people living with Human Immunodeficiency Virus (HIV), and chronic abdominal pain, with detailed information sharing and comprehensive consideration of a patient’s own values and preferences.”

As for patients with cancer pain:

“A large observational study of cancer patients using cannabis over 6 months demonstrated a decreased number of patients with severe pain and decreased opioid use, whereas the number of patients reporting good quality of life increased.”

Conclusion

There is a good body of scientific literature to suggest that medical cannabis and cannabinoids could be useful in the management of chronic pain and in reducing opioid use. There is also good evidence that the ECS regulates pain sensation “with modulatory actions at all stages of pain processing pathways.” More research is needed on the mechanism of how the ECS operates and modulates at different stages of pain processing.

Other theoretical models of the ECS and its relationship to stress, inflammation, and pain regulation — actors implicated in the etiology of almost if not every health problem — also suggest that medical cannabis could help manage common symptoms that occur across various illnesses and injuries. This can include insomnia, anxiety, depression, appetite loss, headaches/migraines, nausea/vomiting, appetite loss, cramps, spasticity, GI upset, and pain.

Despite the potential bias of the studies available, the huge numbers of people using cannabis as medicine (CaM) for chronic pain management reporting reduced pain and better QOL scores cannot be discounted. Further research is also needed into what types of pain medical cannabis may help manage and the effects and potential uses that various combinations and dosages of cannabinoids, terpenes, and flavonoids may have.

Related Articles

• Anxiety, Insomnia and Chronic Pain: How Medical Cannabis & Telehealth Helped People During the Pandemic
• Webinar: Why Cannabis is Effective for Chronic Pain and Insomnia
• How to Use Cannabis to Manage Chronic Pain
• NSAID Alternatives for Pain and Inflammation
• THC Tampons: Gimmick, or Legitimate Way to Treat Menstrual Pain?
• Medical Cannabis for Nerve Pain (Neuropathy)

Note: the information in this article does not constitute medical advice.

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