Navigating Cannabis Options for Pain and Related Symptoms
Edibles. CBD oil. Buds. When using medical marijuana for pain relief, the strain, dose, and route of administration can make a difference. Plus, a word about hemp.
With David Bearman, MD
A growing body of clinical research and a history of anecdotal evidence support the use of cannabis for the relief of some types of chronic pain, including neuropathic pain, and spasticity (ie, stiffness or tightness) associated with multiple sclerosis. 1 In a recent comprehensive review of existing data on the health effects of cannabis and cannabinoids, the National Academies of Science concluded that adult patients with chronic pain who were treated with cannabis/cannabinoids were more likely to experience a clinically significant reduction in pain symptoms. 2 They rated these effects as “modest.”
Studies also suggest some efficacy for cancer-related pain, migraines, and fibromyalgia, and other pain conditions. 3 However, how different species, routes of administration, and doses differ in their effect is less clear, and more research is needed.
- How Medical Marijuana Changed My Life
- How to Ask Your Doctor about Trying Medical Marijuana for Pain
- How to Talk to Your Physician About Medical Cannabis: 10 Points to Guide You
Cannabis is Complex: CBD Versus THC
The chemical complexity of cannabis itself has made it difficult for researchers to untangle its effects on pain and, at the same time, difficult for clinicians and patients to find the most effective species and route of administration. Cannabis is the genus name for a disputed number of plant species. The two most widely accepted species are Cannabis sativa and Cannabis indica, though hybrid species are also common.
Cannabis oil and edibles
Chemically speaking, cannabis is complicated. To date, 568 unique molecules have been identified in the cannabis; of these, more than 60 are cannabinoids — these are compounds that act on receptors in the body’s endocannabinoid sy stem. This system plays a key role in endogenous pain control. 4
Two of the cannabinoids found in cannabis, Δ 9 -tetrahydrocannabinol (THC) and cannabidiol (CBD), along with other cannabinoids, terpenes, and flavonoid compounds, are thought to exhibit synergistic effects that promote pain relief. 5 THC is the most psychoactive cannabinoid found in cannabis and is primarily responsible for the “high” associated with marijuana. It can also reduce nausea and increase appetite. CBD does not provide the euphoria associated with THC and is associated with reduced pain and inflammation. 6
The FDA’s View on Cannabis for Pain
Approval by the US Food and Drug Administration has, so far, been limited to synthetic or pharmaceutical-grade components of cannabis. In June 2018, the agency approved Epidiolex (GW Pharmaceuticals) — a high CBD, low THC whole-plant alcohol extract — for the treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients age 2 and older. FDA has also approved Marinol (AbbVie) and Syndros (Insys Therapeutics), which both contain dronabinol, or synthetic THC. Both are indicated for weight loss associated with anorexia and HIV. Marinol is also indicated for severe nausea associated with cancer chemotherapy, as is FDA-approved Cesamet (Meda Pharmaceuticals). Cesamet contains the active ingredient nabilone, which has a chemical structure similar to THC.
Herbs, Oils, and Edibles, Oh My!
The form/route of administration may also play a role in the pain effects of cannabis. Medical cannabis comes in herbal (marijuana), tincture, oil, and edible forms. It can be smoked, vaporized, ingested in edible or other oral forms, taken sublingually (under the tongue), or applied topically (oil). Research on the efficacy of different routes of administration for pain is sparse. However, a 2013 randomized, placebo-controlled, double-dummy, double-blind study compared analgesic effects of smoked marijuana and dronabinol. 7 The results indicated that under controlled conditions, marijuana and dronabinol both decreased pain. However, compared with marijuana, dronabinol produced longer-lasting decreases in pain sensitivity and lower ratings of abuse-related subjective effects, which can be predictive of use and abuse patterns. Other studies suggest that smoking cannabis produces rapid effects, while oral forms take longer to work but may last longer. 8
Strains of cannabis may come with names like Purple Diesel and Blue Sky. While the term “strain” is commonly used by dispensaries, medical cannabis users and even physicians, it’s not a term used for plant nomenclature. 9 A strain name may come from a grower, producer, processor, or dispensary. A 2018 study out of Washington state found that commercial Cannabis strains fell into three broad chemotypes (chemically distinct plants that otherwise appear indistinguishable) that were defined by the THC:CBD ratio. 10
“There is little consistency in plant constituents between products’ strain names,” said David Bearman, MD, a physician in private practice who specializes in pain management and has more than 40 years of experience in managing substance abuse. “These names are mainly marketing tools and tell little about the constituents of the product. The best advice is to read the label and understand it.”
Dr. Bearman is also the co-founder of the American Academy of Cannabinoid Medicine, and a board member of Americans for Safe Access – a national member-based organization of patients, medical professionals, scientists and concerned citizens promoting safe and legal access to cannabis for therapeutic use and research,and of Patients Out of Time – a Virginia-based nonprofit that works to educate all disciplines of healthcare professionals, the legal profession, and the public about medical cannabis. It’s also important to know that dispensary cannabis is not regulated by the FDA so what you get in one state, or at one time, may be different from another.
A Word About Hemp
Hemp products — including oils, extracts, and even “gummies” — aimed at relieving pain and anxiety abound on the internet. But what is hemp and how does it differ from marijuana? The conventional answer is that hemp and marijuana are two different species of the Cannabis genus of plants.
Hemp, which is primarily used for industrial purposes (particularly fiber products), is considered to be the Cannabis sativa species; marijuana (used for medicinal and recreational purposes) is considered to be the Cannabis indica species. The two species differ not only in appearance but also in levels of THC and CBD.
C. sativa is associated with higher levels of THC while C. indica is associated with higher levels of CBD. The science is more complicated. A 2015 study 11 of genetic structures of marijuana and hemp suggests that “C. sativa and C. indica may represent distinguishable pools of genetic diversity but that breeding has resulted in considerable admixture between the two.” Researchers also found that hemp has more in common genetically with C. indica than with C. sativa. Differences in THC production held true.
See also, a 2019 blog on PainDr (managed by Jeff Fudin, PharmD, PPM editor-at-large) on hemp use and drug screenings).
State Legalization of Medical Marijuana
Medical cannabis is currently legal in 34 states (as of spring 2019), many of which require patient registry or identification cards for the purchase and use of the substance for specific diagnosed medical conditions. These conditions differ by state and continue to change. At the federal level, marijuana is classified as a Schedule I substance under the “Controlled Substances Act,” and there are no recognized medical uses. In many of the states with legalized cannabis, some type of product testing is required, however, testing varies by state and may be limited contamination tests or may include quantification of CBD and THC levels.
California, for example, requires dispensaries to sell only marijuana that has been tested for pesticides, contaminants, and microbial impurities. Beginning in July 2018, California also began to require testing to determine plant potency (ie, levels of THC and CBD). This information is included on the product label. 12 In addition to t he above, 12 states have enacted legislation allowing for limited use of medical marijuana (ie, low CBD: THC ratios).
These states, as of spring 2019, include: Alabama, Georgia, Indiana, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee, Texas, Virginia, Wisconsin, and Wyoming. It is important to know that consistency and quality of the product received may vary from dispensary to dispensary and from state to state. Stay up to date with the National Conference of Sttae Legislatures which lists current medical marijuana laws at http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx.
The Amount of CBD or THC You Use Matters
Where does this leave chronic pain patients interested in trying medical cannabis? Regardless of the strain or form of cannabis, the key is the amount of THC and CBD in the final product, according to Dr. Bearman.
For those with concerns about the psychogenic effects, he recommends starting with a one-to-one ratio of THC to CBD for chronic pain. “I usually suggest that people start with 7.5 mg [which, using a standard unit converter amounts to 0.003 oz.] of THC and 7.5 mg of CBD, three or four times a day,” he told Practical Pain Management. “I tell them that the most likely effect is that (a) it’s not going to make their pain go away, and (b) they’re not going to get high.”
For pain relief, he recommends a dose of 15mg THC (0.0005 oz) to 15 mg CBD. In his experience, doses of THC less than 15 mg generally don’t provide pain relief. Doses may be increased if necessary, best guided under a doctor’s orders, to achieve pain relief without unacceptable side effects.
The key to using medical cannabis for pain is two-fold. For starters, a personalized approach is needed. Each person is different, and many adjustments may be needed to zero in on the dose that controls pain with minimal side effects. It’s also important to start on a low dose of THC and CBD.
Dr. Bearman said he also prescribes dronabinol, the man-made or synthetic THC, for some patients. “It doesn’t work as well as cannabis, it’s more expensive than cannabis, and it has more side effects than cannabis. Nevertheless, there are some good reasons for prescribing it,” he noted. Specifically, because dronabinol is regulated by the FDA and must meet purity and manufacturing standards, he knows exactly how much THC a patient is getting.
Be sure to talk with your doctor about the right dose and route of administration before taking any prescribed of dispensed medical cannabis product for pain relief or related symptoms. Note that Medicare does not cover the product; check with your insurer for other program coverage.
Read more about CBD Oil and its risks on our sister publication.
In PPM online poll, about half of respondents said they had tried medical marijuana to help alleviate their pain and related symptoms.
- National Academies of Sciences, Engineering, and Medicine. 2017. The health effects of cannabis and cannabinoids: Current state of evidence and recommendations for research. Washington, DC: The National Academies Press.
- Hill KP. Medical Marijuana for Treatment of Chronic Pain and Other Medical and Psychiatric Problems: A Clinical Review. JAMA. 2015;313:2474-83.
- Fine PG and Rosenfeld MJ. The Endocannabinoid System, Cannabinoids, and Pain. Rambam Maimonides Med J. 2013;4:e0022.
- Lewis MM, Yang Y, Wasilewski E, et al. Chemical Profiling of Medical Cannabis Extracts. ACS Omega. 2017; 2: 6091–103
- Russo EB. Taming THC: potential cannabis synergy and phytocannabinoid-terpenoid entourage effects. Br J Pharmacol. 2011; 163: 1344–64.
- “Marijuana as Medicine.” National Institute on Drug Abuse, June 2018, https://www.drugabuse.gov/publications/drugfacts/marijuana-medicine Accessed September 11, 2018.
- Cooper ZD, Comer SD, and Haney M. Comparison of the Analgesic Effects of Dronabinol and Smoked Marijuana in Daily Marijuana Smokers. Neuropsychopharmacology. 2013;3;1984–92.
- MacCallum CA and Russo EB. Practical considerations in medical cannabis administration and dosing. Eur J Intern Med. 2018;49:12-9.
- United States Department of Agriculture, Natural Resources Conservation Service, National Plant Materials Manual, Fourth Edition (Washington, DC, 2010). Available at: www.nrcs.usda.gov/Internet/FSE_DOCUMENTS/stelprdb1042145.pdf. Accessed September 1, 2018.
- Jikomes N and Zoorob M. The Cannabinoid Content of Legal Cannabis in Washington State Varies Systematically Across Testing Facilities and Popular Consumer Products. Sci Rep. 2018;8:4519.
Sawler J, Stout JM, Gardner KM, et al. The Genetic Structure of Marijuana and Hemp. PLoS One. 2015;10(8):e0133292.
Before trying medical cannabis, or marijuana, for chronic pain, find out which strain, dose, and route of administration may be best to treat your symptoms. A review of CBD oil, edibles, flower buds, vaping, and more.
Understanding the confusing world of CBD and THC ratios
The world of CBD-rich marijuana products is getting bigger.
This post is part of our High-tech High series, which explores weed innovations, and our cultural relationship with cannabis, as legalization in several U.S. states, Canada, and Uruguay moves the market further out of the shadows.
There’s a flurry of new numbers on marijuana product labels, and the ratios can feel like a confusing math problem.
But there’s a method to the madness — one based more on anecdotes than broadly recognized scientific research.
A variety of vape oils, tinctures, salves, and edibles with numbers like 18:1, 4:1, and 1:1 — noting the amount of CBD to THC — have been showing up at dispensaries in recent years in both medical and recreational states. THC will make you high, while its sister compound CBD generally won’t — and has therapeutic potential. Most marijuana strains have around 18 percent THC with less than 1 percent CBD (with THC sometimes being pushed beyond 20 percent).
The cannabis companies behind the trend aren’t chucking THC; they’re just flipping the ratios. For decades, growers have focused on breeding weed with increased amounts of THC. That’s still the case to a large degree, but a sliver of the market sees big things for CBD-rich marijuana products.
“They kept getting bred to go higher and higher in THC, so most strains have very low CBD,” said Dennis Hunter, cofounder of Cannacraft, a Santa Rosa cannabis producer with a line of CBD-rich products under the brand name Care by Design. “Now they’re starting to breed those to be higher and higher in CBD.”
Care by Design, and other companies like Pure Ratios in San Diego, use previous customers’ experiences to guide new users toward their preferred ratio.
But with scant evidence-backed scientific research regarding the impact of each ratio, consumers resort to trial and error to see what works for them.
A 1:1 CBD to THC vape pen.
Image: Care by Design
An 18:1 CBD to THC vape pen.
Image: Care by Design
CBD-rich products are marketed toward those seeking relief from anxiety, arthritis, seizures, stress, inflammation, and overall wellness, not necessarily a high. They’re also being used to ease those once spooked off by a bad marijuana experience back in. Baby boomers are Care by Design’s biggest growing customer base.
There are plenty of anecdotes from customers reporting life-changing relief with unregulated CBD-rich products, but it’s still a gamble and you’re the guinea pig. And these products aren’t cheap. Care by Design’s cartridges are $50 and its droppers are $40. Pure Ratios’ droppers are around $30. CBD oil made from hemp, which has less than 0.3 percent THC, from Bloom Farms, for example, ranges from $60 to $90.
Cinnamon Bidwell, a neurobiologist at the University of Colorado Boulder’s Institute of Cognitive Science, cautions not to get swept up in the testimonials promoted by cannabis manufacturers.
“The marketing and the consumer lure is far ahead of what the research can really support,” said Bidwell. That seems to be the case for marijuana in general since its classification as a so-called Schedule 1 drug — which means the federal government believes it has “no currently accepted medical use and a high potential for abuse” — makes it difficult to study. Bidwell’s lab, which is in a state that has legalized recreational marijuana, is conducting a 5-year study comparing the cannabinoids subjects ingest to what shows up in their bloodstreams in relation to clinical outcomes.
What’s more, all the ratios can be hard to understand. Care by Design offers five (18:1, 8:1, 4:1, 2:1, and 1:1), while Pure Ratios cut down to three (18:1, 4:1, and 1:1) because customers were confused by the variety, said CEO Chad Conner.
Image: Bob Al-Greene / Mashable
Here’s a rule of thumb: The higher the CBD, the less of a high you’ll get from the THC, both because there’s less of it and CBD generally combats THC’s psychoactive effects, depending on the amount of THC you’ve consumed, according to cannabis researchers and producers.
When you’re deciding which ratio is right for you, it’ll take some experimenting. Both Hunter and Conner suggest starting with a high-level of CBD and working your way down to a more balanced product. You’ll have to play around with the amount, too, but take it slow.
Care by Design sells a sampler pack to help in the guessing game. The ends of the spectrum, 18:1 or 1:1, are its best sellers; either consumers don’t want to feel psychoactive effects or they do, it seems.
The trial and error, Bidwell said, is what happens when cannabis products rush into the market before there’s sufficient research.
There is, however, a prescription 1:1 CBD to THC mouth spray called Sativex made in the UK and available in several countries including Spain, Germany, Canada, and Brazil that’s meant to treat spasms in MS patients. It’s undergoing clinical trials in the U.S. Epidiolex, the first FDA-approved cannabis-derived drug in the states, is high in CBD with trace amounts of THC (not enough to have any pharmacological effect). It’s used to treat seizures.
“We’re starting to understand what CBD does, but even that is very minimal. And in terms of these different ratios, there’s an idea or a hypothesis that there’s something there in terms of THC facilitating CBD’s action in a different way, if not more in different amounts. But in terms of the science being able to contribute to that in any kind of clear way, we’re not there yet,” Bidwell said.
Elliot Altman, biology director of the Tennessee Center for Botanical Medicine Research, disagrees with that assessment when it comes to CBD’s therapeutic benefits. His lab at Middle Tennessee State University studies CBD and hemp. Marijuana isn’t legal in Tennessee, but hemp is. Most CBD products are made from hemp extract, while the ratio products tend to include a variety of cannabis strains to get the right proportion.
It’s clear to Altman, who does not study THC, that CBD provides relief for those with inflammatory or autoimmune conditions, but if you’re looking for pain relief, that’s going to come from THC. Altman’s lab works with private groups looking to sell CBD from hemp as a nutritional supplement.
“THC is for pain, and CBD is for when your immune system is compromised,” Altman said. His take on these emerging products is pretty simple: “If what you’re really after is CBD, but you’re in a marijuana state, take a little THC to take the edge off, don’t take excessive THC.”
What do CBD to THC ratios mean and what can they really do?