Medical Cannabis for Neuropathic Pain – Part 1 of 3

Treating Neuropathic Pain with Medical Marijuana

The legalization of marijuana (cannabis) for medical use in 29 states and the District of Columbia (as of the writing of this article) has fueled a growing acceptance of marijuana as a treatment option for a number of conditions. Despite criticism of the programs (whether for prescribed medical conditions or recreational), there is real science behind the use of cannabinoids for therapeutic effects by binding to specific receptors on the surface of cells. The commercial availability of medical cannabis has moved patient usage quickly, and many unanswered questions remain as to how to best utilize these medical marijuana product offerings.

Medical cannabis may be identical in form to recreational marijuana because both are derived from the Cannabis plant (agricultural base).  Products from the plant (and not just from chemicals or “synthetic”) cannabis consist of two main components, THC (tetrahydrocannabinol) and CBD (cannabidiol) and secondary components present in smaller amounts (terpenes) that may also provide unique benefits.  THC has the psychoactive properties that make people feel high, but many patients find that uncomfortable.  CBD, on the other hand, offers some of the benefits without the buzz. Hemp, which is legal, generally has negligible THC levels.

THC and CBD, the main components of medical cannabis bind specifically to receptors on the surface of nerve cells (neurons) in much the same way as many active medicines

Cannabinoid receptor

Figure 2: Cannabinoid Receptor

This is the introduction (Part 1) for a 3-Part series on “Medical Cannabis for Neuropathic Pain”. In Part 1 (below) I will describe the use of medical cannabis today by neuropathic pain patients. The upcoming Part 2 will discuss the science on how and why cannabis works at the cellular receptor level and the clinical research that has been done to date in patients with neuropathic pain.

Also in Part 2 of this series, we will discuss the mechanism of action for medical cannabis, which has been well described over the last 3 decades. As is shown in the graphic to the left, THC and CBD, the main components of medical cannabis bind specifically to receptors on the surface of nerve cells (neurons) in much the same way as many active medicines. Animal studies show that the effects (both positive and negative) from medical cannabis are predictable and undeniable.

The concluding Part 3 will discuss the wide range of cannabis products containing different amounts of THC and CBD (diagram below) including formulations, strains and “ratios”. The medical community is just starting to learn how to customize the products for particular patients symptoms and needs. The diagram below outlines the different conditions and the predominant component of medical cannabis that may be recommended for them by their physician.

THC : CBD ratios generally thought to be most effective for listed conditions

Figure 3: THC : CBD ratios generally thought to be most effective for listed conditions. THC has the psychoactive properties that make people feel high, but many patients find that uncomfortable.  CBD, on the other hand, offers some of the benefits without the buzz.

The medical cannabis preparations allowed for sale in many states adhere to general pharmaceutical principles and packaging. Examples of cannabis products (tinctures and oils) and representative packaging in NY State are in Figure 4, below.

Figure 4. Medical Cannabis products sold by Columbia Care in New York

Figure 4: Medical Cannabis products sold by Columbia Care in New York

So, let’s get started…

Medical Cannabis Use for Neuropathic Pain – Part 1

The Situation Today

Registered physicians in at least half the states in the USA approve medical cannabis for sale to qualified registered patients. In a May 2013 survey on the Medical use of Marijuana, published in the New England Journal of Medicine, 76% of physicians surveyed were in favor of the use of marijuana for medicinal purposes. Despite this, marijuana is still considered on a national level (by the DEA) to be under schedule 1 rules and regulations, meaning it is a strictly controlled substance subject to the same federal felony rules for misuse as heroin.

In this interesting nation vs. state situation, individual states willing to permit the cultivation and sale of medical cannabis are able to choose their approved conditions, allowable formulations, and timing of refills. Because medical cannabis is not an FDA approved product, it is not technically “prescribed”, therefore physicians are given little direction by the states on which products and ratios might be appropriate for their patients.

Virtually all jurisdictions that permit cannabis patient usage “allow” treatment for neuropathic pain or neuropathy as a qualifying condition, all but 3 states providing for use under the catchphrases “including but not limited to” and “chronic pain …not relieved by…

Only three states specifically list neuropathy as a qualifying condition. In those states, neuropathic pain is one of the most common uses for medical cannabis. Illinois provides a very comprehensive list of many types of neuropathy in what they consider allowable conditions for medical cannabis. New Mexico permits use of medical cannabis for “painful peripheral neuropathy”, and New York permits use of medical cannabis for “neuropathy pain”.

In the state of New York, where regulations allow for more complete data collection regarding patients using medical cannabis, Columbia Care Corp. has the following breakdown of their patients using medical cannabis. The following graphic illustrates the percentage of their customers who have the different state approved conditions, and the demographic breakdown of the patients with those conditions.

Columbia Care patients by NY State approved conditions for cannabis use

Figure 5: Columbia Care patients by NY State approved conditions

In August 2016 Columbia Care sent out an email asking medical cannabis registered NY patients to participate in an on-line survey. The top 5 reported types of pain in respondents were neuropathic (63%), joint/muscular (56%) headache (23%), abdominal (19%) and other (15%).

The survey had drop downs for the state approved qualifying conditions, so responders with Neuropathy Pain could be analyzed as a group. There were 235 responders with Neuropathy Pain as their qualifying condition.

The top 5 reported symptom types in patients with Neuropathy Pain were Pain; neuropathic chronic or generalized (80%), muscle spasticity (40%) depression/anxiety (40%), sleeplessness (30%) and joint inflammation (30%).

As will be discussed in part 3 of this series, patients with neuropathic pain are often recommended a 1:1 or CBD predominant medical cannabis formulation. Survey respondents indicated (Figure 4) that the majority of patients are on a High THC: Low CBD mixture, whereas 34% are on a 1:1 hybrid mixture, and the fewest are on a Low THC: High CBD ratio.

THC: CBD ratios used by cannabis-registered patients with neuropathic pain responding to survey

Figure 6: THC: CBD ratios used by cannabis-registered patients with neuropathic pain responding to survey

THC makes people feel high, CBD offers some of the benefits without the high.

The product that many patients were currently using was not what was originally recommended by their doctor in over 40% of the cases. (Figure 7). Although on-line surveys are not scientific, it isn’t hard to think many patients may have changed their original physician recommended THC : CBD ratio over time to balance relief with adverse effects.

Percentage of survey respondents who were using a different THC: CBD ratios for their neuropathic pain from what was originally recommended by their physicians

Figure 7: Percentage of survey respondents who were using a different THC: CBD ratios for their neuropathic pain from what was originally recommended by their physicians

The most commonly reported unwanted effects from medical cannabis in the surveyed patients are shown in Figure 5: increased appetite (32%) and sedation (25%). The complete results from this question in the survey are in Figure 8. The survey asked respondents about most of the common complaints that people have on cannabis. The “other” category did not have any one common complaint that was truly unique from the other choices.

Figure 8. Adverse effects with their current cannabis usage reported by cannabis-registered patients with neuropathic pain responding to survey

Figure 8: Adverse effects with their current cannabis usage reported by cannabis-registered patients with neuropathic pain responding to survey

Most importantly, Figure 9 shows that the majority (77%) of patients felt they were receiving at least some relief of their Neuropathy pain symptoms with medical cannabis.

Figure 9: Survey respondents indicate their symptom improvement with medical cannabis for neuropathic pain

Figure 9: Survey respondents indicate their symptom improvement with medical cannabis for neuropathic pain

Given the newness of the medical cannabis programs in most states, and the ever-evolving product assortments available, physicians and patients are still trying to understand the right product for them. Clinicians need to become familiar with both potential risks and benefits of medical cannabis.

Clearly there are a lot of additional studies to be done to help provide data to recommending physician and the pharmacists about the best choice for individual patients.

I hope you find these articles informative and encourage you to contact the Neuropathy Journal, and/or myself, with any questions you may have by clicking here or by commenting below.

In Part 2 of this series on “Medical Cannabis for Neuropathic Pain”, we discuss the active ingredients of medical cannabis. Animal studies show that the effects (both positive and negative) from medical cannabis are predictable and undeniable. You can read the second article of this series “Medical Cannabis for Neuropathic Pain – Part 2 of 3” by clicking here.

In Part 3 of this series on “Medical Cannabis for Neuropathic Pain”, we will discuss which formulation of THC or CBD is best for patients with certain conditions and symptoms, including treating neuropathic pain. You can read the final article of this series “Medical Cannabis for Neuropathic Pain – Part 3 of 3” by clicking here.

About the Author

Rosemary Mazanet, MD PhD - Chair, Scientific Advisory Board Columbia Care

Rosemary Mazanet, M.D. PhD, is Chair of the Scientific Advisory Board for Columbia Care, a board certified oncologist; an alumna of the Dana-Farber Cancer Institute and Brigham and Women’s Hospital; and is a trustee at the University of Pennsylvania Health System. Under her expert supervision Columbia Care is launching clinical trials with one of the largest and most prestigious teaching hospitals in the United States.

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8 Comments

  1. I was pleased to see your article about pain relief. I have Fibromyalgia and the pain has been very bad for the last three days. I take Tramadol 50mg, but it really does not do much. I would like to see medical marijuana available in Florida. I weaned myself off Percocet 7.5 in three weeks because I had a terrible time trying to get my RX filled. On a pain level of 1 to 10 with 10 being the worst mine is a nine. I hardly leave the house any more. By the way I am 81yrs old. I am told I look about 65 but I feel like a 100.

    1. Hi Janet, I am sorry to hear about the chronic pain you have been living with. The drugs you have been prescribed, Tramadol and Percocet are both synthetic opiates, which are commonly known as opioids. This class of drugs is among the least effective at treating neuropathic pain. The type of pain you are experiencing because of your Fibromyalgia. In addition to medical cannabis, the most effective drugs for treating neuropathic pain are anti-depressants and anti-seizure medications. If you continue to feel no relief with your current prescriptions, I would recommend you read and then print the article “Treating Neuropathic Pain” and discuss it with your doctor. Here is the link https://www.neuropathyjournal.org/how-is-neuropathic-pain-treated/ Anti-depressants are preferable over anti-seizure medications. Even though they are among the best medications for treating neuropathic pain, they normally only give about 85% relief, which is a great deal more than what you are getting now. There are also alternative treatments, but they normally do not work as fast. It is best, after consulting with your doctor, to use them in addition to your treatments. However, I stress, discuss any treatments with your doctor first. You may want to also read “Alternative and Complementary Medicines for Neuropathy” Here is the link: https://www.neuropathyjournal.org/alternative-and-complementary-medicines-for-neuropathy/ I hope this helps.

  2. Hi, I am 60 yrs young, seizure disorder since 5 yrs old. Neuropathy for about 4 yrs along w/ Fibromyalgia and Anxiety. I have found taking B12, B6, and Folic Acid, walking, and loosing weight have helped my Neuropathy about 75%, for me. In my feet and calves. I have been on an anti-convulsant since I was 5 yrs. old :(. I found a CBD tincture extremely helpful that I took for about a year and would like to share this information:) I have my medical Marijuana license and look forward to get back to doing CBD! I take Cymbalta for my Fibro., I don’t like taking it :(. I’m not sure if it helps or not, I’ve been taking it for about 5 yrs. I dont remember if I was in more pain than I am now? I am very interested in hearing about studies on CBD, my Neurologist is not as excited about it as I am….
    thank-you

  3. I Have neuropthy. Have your patients gotten more relief from a ticture or vape. Have no relief from tincture after week. I had better relief from recreational Weed. Any suggestion? Tks

  4. This is completely unscientific, why bother publishing this?

    There is no talk about how cannabis binds to receptors in the synapse and the effect it has on pain through nocioception. AKA how it works. Which strains or methods of intake are most effective? What kind of neuropathies did the patients have, MMF, SFN, CDIP?

    IF we don’t get real with the science people will loose faith in the product and it will be determined as snake oil by the medical profession. Stop wasting sense.

    1. The purpose of these articles was to discuss some of the issues for the general readership of the Journal. The last part of the series is still to be published, awaiting the inclusion of conclusions from the first comprehensive review since 1999 released by a panel of scientific and medical cannabis experts from the National Academies of Sciences, Engineering, and Medicine.

      This treatise, titled ³The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research² will be summarized in Part 3 of this series, but the panel concluded that ³While a myriad of studies have examined cannabis use in all its various forms, often these research conclusions are not appropriately synthesized, translated for, or communicated². They further state that ³shifting public sentiment, conflicting and impeded scientific research, and legislative battles have fueled the debate about what, if any, harms or benefits can be attributed to the use of cannabis or its derivatives, and this lack of aggregated knowledge has broad public health implications².

      It is hard to argue with these conclusions, and we can only hope that going forward, individual states (if not the federal government) will allow the appropriate translational and clinical studies to be conducted by cannabis using different strains and ratios, rather than the current regulations which limit preclinical or clinical research to cannabis from the NIH (through a single supplier, the University of Mississippi) or one particular formulation that is in an FDA approval pathway.

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