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Substituting Cannabidiol for Pain Medications: An Experiment Well Underway in Fibromyalgia Patients

Substituting Cannabidiol for Pain Medications: An Experiment Well Underway in Fibromyalgia Patients

A new survey study shows that people living with fibromyalgia are already substituting CBD for opioids and other pain drugs, despite what the clinical trial evidence says.

Fibromyalgia is a common condition characterized by widespread pain and accompanying symptoms like fatigue, sleep problems, and cognitive issues. The few medications available to treat fibromyalgia, including the antidepressants duloxetine and milnacipran, and the anti-seizure drug pregabalin, only provide modest pain relief, with many patients experiencing significant side effects. As such, many people with fibromyalgia are looking for alternatives to help them manage their pain, including cannabidiol (CBD), one of the active ingredients (known as cannabinoids) in cannabis.

Now, a new online survey study reports that nearly three-quarters of almost 900 study participants with fibromyalgia who used CBD did so as a substitute for other pain medications, including opioids. The researchers, led by Kevin Boehnke, University of Michigan Medical School, Ann Arbor, US, and colleagues further show that most of these study participants reported that they decreased or even stopped the use of their pain drugs. In addition, the participants who used CBD in lieu of pain medications reported greater pain relief than those who did not substitute CBD. Interestingly, these real-world findings contrast with recent work showing a dearth of evidence to support the use of cannabis and cannabinoids to ease chronic pain.

The findings are “quite striking,” said Ian Gilron, Queen’s University, Kingston, Canada. “They speak to a huge need for better treatments and better clinician supervision. The results clearly show, because of the lack of effective treatments, that people are willing to try new things, even if the evidence for their effectiveness isn’t quite there yet. It’s something that both researchers and clinicians should be paying attention to,” according to Gilron, who was not involved with the new research.

The study appeared May 21, 2021, in the Journal of Pain.

The natural landscape of CBD use

The new study is a secondary analysis of a large online survey the researchers had conducted previously to understand how common CBD use is in people with fibromyalgia (Boehnke et al., 2021). That earlier work found that approximately 60% of 2,701 study participants with fibromyalgia had tried CBD in the past or currently used it. About one-third of participants currently used CBD, primarily for pain, anxiety, and sleep. Many reported improvements in their symptoms.

In the new study, Boehnke and colleagues wanted to learn whether the survey participants with fibromyalgia were using CBD in place of pain medications, especially in light of the 2018 US Farm Bill. This bill legalized cannabis plant products provided they contain no more than 0.3% tetrahydrocannabinol (THC), the psychoactive ingredient that causes marijuana’s hallmark “high” sensation. The result was that the market was soon flooded with a variety of different CBD products.

“We know that people are very interested in using CBD and, now that the 2018 Farm Bill passed, it’s becoming much more widely available,” Boehnke explained. “Given that so many FDA [US Food and Drug Administration]-approved drugs aren’t well tolerated by people with fibromyalgia, my colleagues at the University of Michigan and the National Association of Fibromyalgia and I were interested in understanding the natural landscape of CBD’s use.”

In the new study, Boehnke and colleagues included 878 adults from the original survey who reported they were experiencing chronic pain. The researchers collected demographic information and also asked questions about CBD use, including whether study participants substituted it for other medications, and whether it helped their pain and associated symptoms.

The researchers discovered that 72% of participants reported substituting CBD products for nonsteroidal anti-inflammatory drugs (NSAIDs; substituted by 59% of participants), opioids (53%), gabapentinoids (35%), and benzodiazepines (23%). What’s more, of that group, most participants reported either reducing or stopping use of other pain medications. Boehnke said the extent to which people were substituting and then weaning off other medications surprised him.

The survey results also indicated that most participants substituted CBD for their pain medications because they wanted fewer side effects and better management of their symptoms. And, those who substituted indeed reported that they had larger improvements in health and pain, compared to those who did not substitute.

“We saw that 50% of those substituting CBD products for other drugs completely stopped using the other medications,” Boehnke said. “While there are a lot of limitations in this kind of survey, especially with regard to the different products people were using or had access to, that is a big number. Most people said they were making the switch because of the side effects of other medications. And while CBD is not without risk, if you look at the side effect profile, people don’t die of CBD overdoses. They don’t get intoxicated on it. And they feel like CBD is helping them.”

The “real” world versus clinical trials

In 2018, the International Association for the Study of Pain convened a task force to look at the evidence supporting the use of cannabis and cannabinoids (including CBD) for the treatment of pain. Gilron, who was a member of the task force, said the group of 20 clinicians and researchers did a series of systematic reviews to investigate both the efficacy and safety of cannabis and cannabinoids as a treatment for chronic pain conditions.

In a position statement published in March 2021 in PAIN, the group concluded: Reviews of preclinical research and clinical safety and efficacy of cannabis and cannabinoids for pain relief have identified important research gaps. Due to the lack of high-quality clinical evidence, the International Association for the Study of Pain (IASP) does not currently endorse general use of cannabis and cannabinoids for pain relief. IASP recognizes the pressing need for preclinical and clinical studies to fill the research gap, and for education on this topic.”

Gilron said that making any recommendations about the use of substances like CBD is a challenge. These are substances that have been used for thousands of years – there are even ancient Chinese medical texts that reference it – but there is a lack of randomized, controlled clinical studies to test whether the substances actually work compared to placebo.

“When doing these sorts of reviews, we want to look at the highest-quality evidence, which, for the most part, are randomized controlled trials,” he said. “There were actually no trials of cannabinoids for fibromyalgia that met our review’s eligibility criteria. That means there’s no good quality evidence to say whether these substances work or not, which, of course, informed our position statement. But because we cannot currently endorse the use of CBDs doesn’t mean we dismissed the lived experiences of people with pain who found benefit with their use.”

When Boehnke was asked about how he squares his new results with the IASP Task Force conclusion, he said that he doesn’t see a conflict.

“They look at the most rigorous studies – clinical trials. The absence of evidence means that you can’t draw firm conclusions about whether CBD works. But the fact of the matter is that people are turning to CBD and saying they find it helpful. While we don’t have the clinical trials, I think it’s just as important to understand what people are actually doing in the real world versus what the science says they should do.”

Moving forward

Gilron said the current study results are important and can help researchers with the design of future studies to test the efficacy of CBDs for pain management.

“The survey identified different subgroups of people who seem to get benefit,” he said. “That could give us some direction in creating studies in the future. Because, if we are going to recommend CBD to help with pain, we need more high-quality research. And we need to do studies where people haven’t already tried it so we can see what the effect really is.”

Boehnke added that he thinks the survey results highlight the need for clinicians to have more upfront conversations with their patients about what those patients may be doing to help manage their pain.

“Doctors need to talk to their patients about whether they are currently using CBD or are contemplating using it, and it’s important they do so in a way that enhances the therapeutic alliance between them,” he said. “They need to know what kind of products they are using. The results show us that many people are already using CBD, so when we can have a better sense of what people are doing and why they are doing it, we are in a better position to help people come up with more effective strategies to live with these conditions.”

CBD – Anyone have experience with it for RA pain?

anyone have experience with cbd either oral, cream or oil with severe RA? Already taking simponi, plaquenil, steroids 10 mg daily for 13 yrs. On fentynal 12 patch. What if I tried cbd? Can I hope to replace the fentynal?thanks, Mary. Ps. I’ve never tried pot

Beginning of the discussion – 5/29/19

CBD – Anyone have experience with it for RA pain?

Hi @Mbuletza ‍ – great question and I am sure some members will be responding to you; however, I want to bring your attention to some of the top discussions were CBD was discussed as a method for treating pain. Feel free to check out these discussions and comment, as these are already on going discussions. Not each is in the RA group, but still may be of assistance as most of the conversations are about pain.

I also would recommend you join the chronic pain group by clicking here and clicking the Join Group button. I would also recommend posting your question in that group as well – That group is dedicated for anyone, no matter what the cause (RA, OA, lupus, etc.), who is dealing with chronic pain.

Here are some of the top discussions about CBD (feel free to also use the Search at the top left of the screen)

CBD – Anyone have experience with it for RA pain?

@Mbuletza‍ how has the fetanyl patch worked for you? Did it help with pain? What about side-effects?

CBD – Anyone have experience with it for RA pain?

Yes it helps. It’s better than pills that have a roller coaster effect. It’s now been over 2 yrs on fentynal and the pain is mostly controlled but not eliminated. I don’t have any side effects that I’m aware of. I just worry because it is an opioid and the nature of RA is good and bad days. I’m just so tired of dealing with pain every day.

CBD – Anyone have experience with it for RA pain?

Hi @Mbuletza‍ I started looking for some cbd products a while back as a solution to manage my mom’s arthritic pain which has gotten worse over the years and so glad I came across CBD Infusion’s products. Their cbd cream for pain is excellent stuff and works fast. This stuff has dramatically improved my mom’s life as she can now take longer walks at the park and play with her grand kids. I got it at [link removed by moderator for violating community standards] – worth a try!

CBD – Anyone have experience with it for RA pain?

How are you doing? I thought I’d revive this older discussion as there’s been more and more talk about CBD and its benefits in the medical community in recent years.

For those who may not know, CBD , short for cannabidiol , is a chemical compound extracted from the hemp plant, a cousin of the marijuana plant. CBD is a naturally occurring substance used in products like oils or edibles which gives a feeling of relaxation or calm when consumed. Unlike its relative, delta-9-tetrahydrocannabinol (THC) , which is the major active ingredient in marijuana, CBD is not psychoactive . Research is still underway into the efficacy of topical CBD, but initial findings have shown that it may be helpful in managing chronic pain and inflammation .

Have any of you tried CBD for your RA? Has it worked for you? And for those that haven’t, is it something you’d be interested in trying?
@Adams8866 ‍ @JVandemark ‍ @Kimelrod ‍ @Sharleen ‍ @jriedel ‍ @campbell071704 ‍ @BillieJ ‍ @daria.rutkowski ‍ @rodriguezb310 ‍ @Zestfulonewithostomy2011 ‍ @Vectra ‍ @MottoMom ‍ @cathyhart ‍ @madison10 ‍ @Angus1 ‍

Feel free to share your thoughts and experiences here!

CBD – Anyone have experience with it for RA pain?

Yes, My mom has anxiety patient, and she have some pain on her feet also, so she use CBD oil, Actually I suggested to my mom which I got through [link removed by Community Manager for violation of community standards], she feels really good result of it.

CBD – Anyone have experience with it for RA pain?

I had never tried any kind of drug before, but I was told that CBD oil might be good for my anxiety. The first time I felt the effects of it, it hit me like a wave all thanks to [link removed for violation of community standards] for the wonderful product. It was strange at first but eventually I found myself feeling an overwhelming sense of relaxation and peace.

CBD – Anyone have experience with it for RA pain?

There is an error in the description of CBD. Yes, you can extract CBD from hemp, but it is nowhere near as effective as CBD from marijuana which is what I use. Topical is very good. Edibles do help. My fave is a 40:1 CBD to THC. If you can buy it online, it’s from hemp. I live in WA and buy it at my local pot shop. It doesn’t wipe all the pain away, but reduces it and lowers general anxiety.

CBD – Anyone have experience with it for RA pain?

I like everything related to medicine, so I would like to join your thread. You will probably find such information on the Internet. Anyway, believe it or not, but I have almost the same problem and in the past I could not even imagine that a product could help me forget about health problems. So, just try to consume CBD from this source which will also help you improve the state of health. Believe me, then try it if you are interested in it.

Medicinal cannabis for chronic pain – it’s worth a trial

I get it. I was hesitant too. We work our whole lives for our reputations. Heck, I didn’t want to be known as ‘Dr Pot’. But the overwhelming initial anecdotal evidence is what motivated me to do what I am doing today. And believe me, my patients are better for it.

Dr Matthew Moore, GP, Dunsborough

Here is my journey and why you may want to consider medicinal cannabis, at least for your chronic pain patients.

Having watched industry developments in North America for many years before moving to Australia, when cannabis became legal to prescribe here in 2016, I was paying attention.

My first patient had post-surgical abdominal pain from both adhesions and a neuropathic aetiology. He was in a bad way, on substantial doses of both opiates and benzodiazepines, and tanking both physically and mentally. His current status was the driving force behind overcoming my discomfort with prescribing.

Honestly, I am open-minded and had every intention of doing so ‘one day’, but he was desperate. He was a father and husband, just like me, and was losing hope. I bit the bullet and applied for approval and wrote my first medicinal cannabis prescription.

Medicinal cannabis worked well in this case. And with frequent consultations, while titrating up his cannabis oil and slowly decreasing his opiates and benzos, he was able to cease both, control his pain and improve his quality of life.

We, as practitioners, commonly deal with the frustration of reaching the ceiling of medication management with the down-regulation of receptors and subsequent drug tolerance. But the frustration is mostly for our patients as they see their dosages rise while their quality of life plummets.

In seeing this ‘end of the road’ in their treatment, life can get hard. Hope is lost and it’s a slippery slope as depression sets in. We shouldn’t blame our patients. We’d probably be the same if we had to live with significant pain despite maximal doses of conventional therapies.

Of the 6000-plus monthly SAS-B approvals now in Australia, 70-80% are for chronic pain. From December 2019 to December 2020, there had been an increase in SAS-B approvals of nearly 60,000 bringing the total since 2016 to more than 85,000 medicinal cannabis approvals. There are now more than 180 authorised prescribers. This increase is mainly due to public and medical education that shows that it is a viable option, and not dangerous.

More clinicians are having success with this alternative treatment.

The same as you, I follow guidelines based on research. When people state that there isn’t enough data, that’s simply not true. There is. No, not to the extent that we need in order to use cannabis as a first-line therapy. But enough to show that it’s safe and that more research is needed.

Recent decisions worldwide, including the UN removing cannabis from the list of dangerous drugs, will see the cannabis research space expand.

Whether you agree with its use or not, it is relatively safe, has minimal side effects and increases the chance that you may actually get your dependent patients off their opiates and benzodiazepines. This has real value.

We must continue to educate ourselves as clinicians. The body of knowledge in and around cannabis as a medicine is increasing. We need to know how to navigate this space for our patient population. Reading is what we do, right? And it may give you the confidence needed to accept the risk and talk to your patients about the potential option of medicinal cannabis.

Key messages
  • There is research to underpin use of medicinal cannabis
  • It is safe to use, but not first line
  • Quality of life can be significantly improved.

Author competing interests – nil

Graphic source: Australian Government Department of Health, Submission to the Senate Community Affairs References Committee, Senate inquiry into the current barriers to patient access to medicinal cannabis in Australia, January 2020. Condition % applied to 2020 SAS B Figures.