Over the past decade, medical cannabis has garnered increasing acceptance by the medical community as a legitimate treatment for pain. The result: In Israel, most medical cannabis licenses are issued for pain treatment purposes.
An Israeli study, which was published in the Journal of Pain Research, was set to assess how medical cannabis treatment is perceived by physicians in Israel. Two-thirds out of 79 pain management doctors completed the survey, which was published in 2018. 95% of physicians surveyed replied that they prescribe medical cannabis regularly in the course of their work. Only 5% said they avoid prescribing it completely.
What types of pain are treated with medical cananbis? 65% of physicians replied that they prescribe medical cannabis as treatment for neuropathic pain, while 50% prescribe it for cancer related pain. 29% said they would prescribe cannabis for any unexplained pain. 56% of the doctors witnessed patients with either mild side effects or none at all. 76% said they would not prescribe cannabis to a patient with a history of psychosis, while 65% would not prescribe it during pregnancy. 59% replied they would not prescribe cannabis to children under the age of 18.
In the U.S., medical cannabis is likewise used most commonly for pain. One of the reasons doctors find cannabis treatment appealing is the opioid addiction in the US, which for the past two decades has become a prolonged epidemic: one out of four Americans who have been receiving long term opioid treatment is struggling with addiction. On October 2017, the opioid crisis was declared as a national health crisis in the US by a presidential decree. The void that has been consequently created is now being filled up by medical cannabis. At the same time, cannabis de-criminalization and legalization processes, which are carried out worldwide, are turning it into a more normative option for doctors and patients alike.
What Type of Pain Do I Actually Feel?
When discussing pain treatment, the types of pain should first be classified. The chronologic classification includes 3 categories: acute pain, persistent pain (chronic) and acute pain in patients with persistent pain (acute over chronic).
- Nociceptive pain: a “regular” pain, originating from tissue damage (such as a cut, a burn or a fracture) due to the activation of pain receptors. In this case, pain intensity is likely to match the severity of the injury.
- Neuropathic pain: caused by damage or injury to nerves that transfer information to the brain and spinal cord from tissues or organs. Neuropathic pain might persist for many years, sometimes for life. It may result from trauma, surgery, disease, post organ amputation or viral infection (for example, shingles caused by herpes zoster virus).
- Centralized pain – this is a general term referring to various types of pain resulting from damage to sensory pathways of the central nervous system (an example is fibromyalgia which is characterized by augmented central nervous system pain processing). Neuropathic pain for instance, can be either centralized or peripheral.
Cannabis and Nociceptive Pain
As mentioned, nociceptive pain results from tissue damage. Upon injury, various chemicals and proteins are being released which activate receptors, and send signals through the spine to the brain – all of which eventually result in pain. Pain usually subsides once tissue healing occurs. However, it can be minimized through the inhibition of pain signals and the inflammatory process.
The accepted treatment is comprised of OTC medicines such as ibuprofen (which lowers fever and acts on inflammatory pathways), or opioids, which through the suppression of the central nervous system, modulate the body response to pain. Medical cannabis can also be useful in treating nociceptive pain, although research suggests that its main advantage is associated with the following type of pain, which is even harder to treat:
Cannabis and Neuropathic Pain
Neuropathic pain refers to pain which originates from a pathology of the nervous system, and is considered very common. According to the Israeli Ministry of Health, as of September 2020, more than 39,400 active licenses have been issued in Israel with the indication of neuropathic pain (non-cancer related).
Common causes of neuropathic pain include diseases such as multiple sclerosis, Parkinson’s disease, HIV, diabetes, shingles, and more. Chemotherapy is an additional common cause of neuropathic pain, due to the devastating effects it has on many body cells.
Neuropathic pain is notoriously difficult to treat, unlike an inflammatory pain which responds to treatment with anti-inflammatory drugs. Whether it is related to an underlying disease, amputation or chemotherapy, many people turn to medical cannabis for the alleviation of chronic neuropathic pain. In the aforementioned cases, chronic pain is merely a symptom of disease, though treatment will nevertheless focus on the pain itself and be adjusted to its degree, rather than the severity of the disease.
Cannabis may relieve various types of neuropathic pain, by reducing spinal pain signals and their processing by the brain. The main active constituents (cannabinoids) bind to CBD1 receptors, which are located mainly in the central nervous system, and to CBD2 receptors found, inter alia, in the peripheral nervous system, immune and digestive systems and more.
In a scientific article on cannabis and pain, a review was included, in which the results of cannabis-based treatments (of non- cancer associated pain) were analyzed. The review examined 18 high quality clinical studies, with a total of 766 participants. In 15 out of 18 studies, the cannabinoid tested demonstrated a significant analgesic effect after 8.5 days on average. 4 studies looked at the effect of cannabis (inhaled by smoking) on neuropathic pain. In all the studies the response to treatment was good, with either minimal side effects or none at all.
An Israeli clinical trial (2017) showed that people suffering from chronic pain who were treated with medical cannabis, suffered less from depression and anxiety, in comparison to people treated with opioids. The researchers found that 57% of those treated solely with opioids suffered from the highest degree of depression, compared to 22% of those treated with medical cannabis. Similarly, 48% of the patients treated with opioids experienced anxiety, compared to 21.5% of the patients treated with medical cannabis.
Medical Cannabis and Cancer
According to the Israeli Ministry of Health, as of December 2020, 13,689 medical cannabis licenses were issued in favor of oncology patients (including for alleviating pain). Apart from its attributed ability to ameliorate neuropathic pain, several small-scale studies showed that cannabis may decrease nausea and vomiting associated with chemotherapy, improve appetite, and may therefore prove helpful to many patients coping with aggressive medical procedures, such as chemotherapy.
Its important to note: cannabis is not a medicine and may not be relied upon as medical treatment of a disease, including cancer. The aforementioned does not constitute medical advice and the reader must consult a qualified doctor.
Medical Cannabis and Centralized Pain
Centralized pain may arise from an injury, though most commonly its cause is unknown – which explains why treatment might be challenging.
Fibromyalgia is a classic example of centralized pain, characterized by augmented central nervous system pain processing. Like other types of centralized pain, the cause of fibromyalgia is unknown.
According to a large-scale clinical trial (2019), which was carried out in Soroka hospital in Israel, medical cannabis reduced significantly fibromyalgia-derived chronic pain. According to the researchers, other medication-based treatments so far have shown only partial efficacy in ameliorating disease symptoms. The research demonstrated that after 6 months of medical cannabis treatment, 81.8% reported significant improvement in symptoms, with the average pain level decreasing from a 9.0 to 5.0 (based on a scale of 11 points). There was likewise an improvement in other symptoms of fibromyalgia, such as sleep disturbances, depression and weakness. A relatively low incidence of side effects was reported: 7.9% reported dizziness, 6.7% reported dry mouth and 5.4% reported nausea or vomiting. This is the first published research on the largest group of fibromyalgia patients treated by cannabis.
In another clinical trial held in Barcelona, all 28 fibromyalgia patients reported significant improvement in disease symptoms following medical cannabis treatment, although variations in treatment response patterns were noted. The researchers stated that knowledge gained from this research, coupled with evidence from clinical studies, data accumulated on the endocannabinoid system, together with new understandings regarding the role of the stress response in fibromyalgia – all point towards a novel therapeutic approach, and confirm the beneficial effects of cannabinoids on fibromyalgia symptoms.
So How Can I Choose the Best Strain for Me?
Many patients report the efficacy of medical cannabis in neuropathic pain reduction. But just as in the case of other medications, the effect of cannabis is individual, and may vary among patients. Therefore, its important to try different strains and change dosages gradually in order to find the most suitable strain and dosage for each patient
But how can we know which strain to try? If pain can result from various causes, each may require a different treatment strategy.
While high THC strains may act as effective analgesics at first, they may not necessarily represent an optimal strategy for chronic pain relief, as the body might develop tolerance. Therefore, in order to maintain cannabis efficacy in ameliorating pain symptoms, balanced CBD/THC strains should be considered in the long run.
Pain severity is likewise affected by other factors, such as the patient’s mood and focus on the injury. In this respect, cannabis provides an overall beneficial effect, beyond mere pain relief. CBD may improve mood by activating serotonin receptors. With regard to chronic pain associated with depression and anxiety, cannabis uplifting effects are an important aspect of treatment.
Pain Treatment With IMC’s Medical Cannabis Strains
A recent clinical survey (2021), conducted by MediCaNL, an independent clinical research organization, analyzed users’ data pertaining to 652 patients using IMC’s medical cannabis strains. The results of the clinical survey, with regard to various types of pain, are as follows:
- Neuropathic pain:
- The most commonly used strain is Roma
- Out of 167 patients experiencing neuropathic pain, at least 60% reported improvement in one or more of its symptoms (as measured by ND4 questionnaire which evaluates neuropathic pain):
- 160 patients reported improvement in sense of painful cold
- 92 reported improvement in the sense of burning
- 139 reported improvement in the sense of electric shocks
- 139 reported improvement in the sense of tingling
- 106 reported improvement in the sense of numb organs
- Rheumatoid Arthritis related pain:
- The most commonly used strain is Roma
- 5% of IMC patients (29 out of 36) reported improvement in symptoms (measured by PGIC scale)
- Oncology (disease & treatment related symptoms, including pain):
- The most commonly used strain is Roma
- 60% of IMC oncology patients (60 out of 100) reported improvement in their general health status (measured by PGIC scale)
- Back pain from various causes (including back pain with sciatica):
- The most commonly used strain is Roma
- At least 58% out of 104 patients reported improvement in Brief Pain Inventory (BPI) parameters (including pain & sleep Improvement, the ability to walk and work and more)
* This should not be construed as advertising and / or an encouragement to use medical cannabis, which is permitted to holders of a suitable prescription / license
* The contents appearing in this article are intended to expand the readers’ personal knowledge and are presented “as is” and this is not be considered as a medical recommendation or advice and / or professional medical opinion.