Sharp. Aching. Burning. Throbbing. Shooting. There are as many causes of pain as there are ways to describe it. But when you experience the sensation, you care about only one thing: making it stop.
Enter cannabis. The cannabis plant is an annual flowering herb that produces mental and physical effects. It’s been cultivated for thousands of years, with ancient cultures ascribing curative properties to it and contemporary patients sometimes self-treating. This makes sense, according to a 2017 report released by the National Academies of Sciences, Engineering and Medicine (NASEM) that assessed the current state of research on the topic, concluding that cannabis and its extracts, cannabinoids, have been proven to significantly alleviate pain.
Many have championed cannabis as a potentially safer alternative, but the federal government classifies cannabis as a Schedule 1 drug with “no currently accepted medical use and a high potential for abuse,” and its medical use has long been mired in conflict as individual states legalize its use, while the U.S. government remains stalwart in its opposition. As a result, cannabis treatment remains a hot-button issue, wrapped up in politics, research funding and logistical nightmares, leaving many to wonder about its future.
What is pain?
Pain is like an alarm. It’s one of your body’s defense mechanisms and, triggered by damage to a nerve cell, it notifies you when something is amiss. But a complex series of interactions occurs between that trigger and the sensation, involving your brain, spinal cord, and a variety of psychological and social influences. As a result, the cause and experience of pain manifest differently in each person, often making it difficult to treat.
A robust field of traditional and alternative specialties devoted to pain management has developed over the years. Physicians often work in tandem with other health-care professionals to treat the pain associated with various conditions and diseases using anything from physical therapy to massage, acupuncture to psychiatry, over-the-counter analgesics and anti-inflammatories to prescription opioids — and these treatments just scratch the surface. Mark Bicket, MD, a board-certified anesthesiologist and pain medicine specialist, and an assistant professor at Johns Hopkins University Medical in Maryland, says he’s seen an uptick in patients who are looking for another answer. They increasingly inquire about cannabis, and he’s not surprised.
“Treating acute or chronic pain is one area that, as I went through medical training, I had interactions with patients who were clearly suffering; their needs were being unmet, not just in treatments we have to offer, but also with the levels of evidence that we have to back up the treatments that we offer them,” he said. For cannabis, the evidence is still in question.
What can cannabis treat?
Medical cannabis is the unprocessed plant, or its extracts, that are used to treat various health conditions. While the U.S. Food and Drug Administration (FDA) has not recognized marijuana, one cannabis product, as medicine, the study of its component chemicals has led to FDA-approved drugs that include oral cannabinoids. Medical marijuana has been used to treat an expanding set of conditions — curbing nausea and vomiting in cancer patients, stimulating appetite in those who have cancer and HIV, easing tremors or muscle stiffness in people living with Parkinson’s disease or multiple sclerosis, and abating anxiety. But it can also be used to treat chronic pain, which is the reason most patients seek it out.
The NASEM report indicated that its review of 10,000 scientific abstracts going back to 1999 showed evidence that cannabis substantially improves patients’ pain caused by various forms of neuropathy — stemming from diabetes and surgery, among others — as well as generalized chronic pain, which could be a result of a condition like fibromyalgia or rheumatoid arthritis.
By the numbers
Number of Americans (age 12 and older) who reported using cannabis in the past 30 days*
Percentage points risen from 2002 to 2015 of Americans who had used cannabis in the past 30 days*
Cannabis users whose purpose is exclusively medical*
Cannabis users whose purpose is both medical and recreational*
Number of times higher the incidence of poison control calls was related to children exposed to cannabis between 2000 and 2013 in states that had legalized cannabis use than in states where it remained illegal in 2013*
Number of scientific abstracts that researchers evaluated*
*Figures based on National Academies of Sciences, Engineering and Medicine report
In 1996, California became the first state to pass legislation allowing medical marijuana. Currently, 29 states and the District of Columbia allow use of medical marijuana or cannabis treatment, but it remains illegal on the federal level. To boot, earlier this year, U.S. Attorney General Jeff Sessions rescinded the Obama-era directives that removed marijuana possession from the list of federal drug enforcement priorities. The move gives each state’s attorney general greater leeway to prosecute those in possession of marijuana, for medical or recreational use, but his decision could be reversed.
Bicket believes it’s this conflict between the state and federal governments that’s largely responsible for the sparse research into cannabis compared with that of other drugs. “Different messages from the federal versus state governments need to be sorted out,” he says. “That influences our ability to conduct research. Certainly, many research products at our institutions are federally funded. There’s a sentiment that we don’t want to jeopardize existing relationships.”
Why doctors are hesitant
While many see cannabis as an alternative that could reduce addiction and overdoses, many doctors are still hesitant to recommend cannabis. There are a number of reasons for their reticence, including a pervasive belief that more research is needed before physicians can put it in their treatment arsenal.
“There’s no such thing as a free lunch,” Bicket says. “We do have a dearth of high-quality evidence from trials about effectiveness, and there’s uncertainty if there are adverse outcomes.”
Even existing research on effectiveness is based on cannabis extract products with formulations and strengths that differ from the products sold directly to customers at dispensaries. In addition, some long-term medical and social outcomes are unknown, like an increase in motor vehicle accidents or nonmedical prescription opioid addiction. There’s some evidence for the latter, Bicket says, while the opposite also seems true, according to a 2017 study published in the American Journal of Public Health indicating that opioid deaths decreased in Colorado after marijuana was legalized.
“Are we merely transitioning to something that may have harms?” he wonders.
Carolyn Katzin, MS, an integrative oncology specialist at the Simms/Mann UCLA Center for Integrative Oncology in California, agrees, saying the makeup of medical marijuana, for example, is unregulated and therefore concerning.
“When I’m dealing with cancer patients who are already being exposed to chemotherapy, they don’t want additional toxins in their body,” she says, noting sellers are not asked to disclose information about pesticides or growth stimulants used, nor do consumers know the breakdown of tetrahydrocannabinol (THC) to cannabidiol, two of the primary components of marijuana. “The variable is usually how much THC you need to get the pain relief without getting unwanted side effects,” she says, which not only includes a high, but also increased heart rate, anxiety, or paranoia.
“The benefits may be overstated, but because there’s really very little out there that we can use to compare it to, I don’t know that we really know for sure,” Katzin says. And she worries about the money-making potential of cannabis for unscrupulous businesses — including the tobacco industry. “Go back to the ’40s when doctors in white coats were telling people how helpful cigarettes are.”
Want to learn more about marijuana for pain? Read “Is Marijuana Medicine?”