CBD and Pain: Issues Psychiatrists Should Consider

What happens when your patient uses cannabinoid compounds for pain, especially if there are currently taking opioids? Just in time for Pain Awareness Month, the results from these new studies provide insights and guidance.

RESEARCH UPDATE

As legalization and interest in cannabinoids for pain have increased, physicians and researchers alike are curious and concerned about their use and their safety. Three new studies shine some light on the acceptance of cannabinoid compounds for treating pain, potential unintended consequences, and best practices to protect your patient.

Examining public opinions, attitudes

To help address the question of patients’ knowledge about and attitudes toward CBD, the American Society of Anesthesiologists (ASA) commissioned a nationwide study. They found that 75% of respondents who expressed interest in using marijuana or cannabinoids for pain management were under the impression these compounds were safer or had fewer adverse effects than opioids and other medications.¹

The survey also found that 58% of respondents believed marijuana and cannabinoid agents have fewer adverse effects than other prescription medications. Specifically, 62% of respondents thought marijuana and cannabinoids were safer than opioids, and 57% of respondents believed those agents had fewer adverse effects than other prescription medications. Perhaps most disturbing was that almost half (40%) of the respondents believed that CBD sold at grocery stores, truck stops, health food stores, or medical marijuana dispensaries were approved by the US Food and Drug Administration.

While millennials were most likely to have a favorable view of marijuana and cannabinoids, there was interest across all age groups and demographics. Approximately three-quarters of millennials surveyed said they would consider using marijuana or cannabinoid compounds (CBD or THC) to address pain.

In comparison, about two-thirds of baby boomers and Gen-Xers expressed interest in using the compounds to manage pain. Millennials also reported use at a higher rate, with 37% reporting use of these agents for pain. Meanwhile, 25% and 18% of Gen-X and baby boomer respondents, respectively, reported use. Paradoxically, only 13% of those surveyed said they were interested in or used marijuana/cannabinoids because they found other pain management therapies were ineffective.

Mixing CBD and opioids

To better understand the impact of CBD on opioid use, Rogers and colleagues² looked at a sample of 450 adults between the ages of 18 to 64 with moderate to severe pain within the previous four weeks.² The participants had chronic pain that persisted for at least three months and were taking opioid medications for the pain. Over a third of participants (39%) reported cannabis use within the previous three months. The majority of the participants were Caucasian (77.8%), and nearly half (40.4%) had achieved an Associate’s degree or higher.

The researchers found that concurrent opioid and cannabis use was related to significantly greater mental health issues as well as risk for substance abuse. Specifically, for those using cannabis, the prevalence of anxiety and depression were increased significantly (estimated marginal mean of 2.33 versus 1.56 and 2.50 versus 1.80, respectively. Similarly, those who were using were more likely to misuse opioids as well as use tobacco, alcohol, cocaine, and sedatives. The authors did not find any significant difference in terms of pain intensity or disability between the cannabis-using and non-using participants.

“The results from this study suggest that cannabis use in the context of opioid use for chronic pain is associated with significantly worse mental health and substance use outcomes, and there may be particular clinical utility in focusing on cannabis use in this population,” the researchers noted. “For people reporting opioid and cannabis co-use, it may also be important to intervene on the cannabis use . . . and associated mental health/substance use problems prior to the initiation of opioids.”

What’s the bottom line?

Although many scientists and plenty of patients look to cannabis as a potential new wonder drug, there is still little research available in terms of its safety and efficacy, especially considering the wide variety of compounds that make up CBD products. To help clinicians better understand the issues, researchers at the Mayo Clinic are exploring the potential efficacy and purported safety profile of these products. In a piece published in Mayo Clinic Proceedings,VanDolah and colleagues³ reviewed potential therapeutic actions as well as safety concerns and adverse effects.

In addition to reviewing the science behind CBD, the researchers provide some guidance for clinicians to help their patients find quality products. For instance, they suggest that patients check that compounds are extracted by carbon dioxide with no solvents, like with other herbal supplements. They added: “Because of the unclear regulations in the United States as well as some of the noted problems with online product labeling, it is recommended that patients utilize products imported from Europe, which actually has even more stringent requirements for low THC levels at less than 0.2% dry weight compared with the US requirement of less than 0.3% dry weight as well as a more established regulatory system for hemp.”

“We encourage physicians to not disregard patients’ interest in these therapies and instead to retain clinical curiosity as well as healthy skepticism when it comes to attempts to explore new options, especially in the context of curbing addiction and opioid overuse,” they wrote. “Our hope is that this article will inspire physicians to continue to educate both patients and themselves about alternative therapies utilized by growing numbers of the public, with the example of CBD and hemp oils in particular as it continues to come to the forefront of public interest.”

References:

1. American Society of Anesthesiologists. Survey reveals skyrocketing interest in marijuana and cannabinoids for pain. Press release. 

https://www.newswise.com/articles/survey-reveals-skyrocketing-interest-in-marijuana-and-cannabinoids-for-pain

. Accessed September 3, 2019.

2. Rogers AH, Bakhshaie J, Buckner JD, et al. Opioid and Cannabis Co-Use among Adults With Chronic Pain: Relations to Substance Misuse, Mental Health, and Pain Experience. J Addict Med. 2019;13:287-294.

3. VanDolah HJ, Bauer BA, Mauck KF. Clinicians' guide to cannabidiol and hemp oil. Mayo Clin Proc. 2019 June Epub ahead of print] https://www.mayoclinicproceedings.org/article/S0025-6196(19)30007-2/fulltext. Accessed September 3, 2019.