Medically Reviewed By
PharmD Scientific Advisor, Medical Reviewer, and Clinical Pharmacist
Adjunct Faculty, UMKC School of Pharmacy
You may have a friend who tried CBD or a coworker who recommends it. Maybe you saw it at a health and wellness boutique or even your local pet store. CBD seems to be everywhere these days, and the outdated, misplaced stigmas associated with its use are rapidly disappearing.
CBD is becoming particularly popular for pain relief, and not just as an occasional supplement.
In a survey of 2,400 CBD users, 45 percent said they use CBD oil for ailments like pain and joint relief, and 42 percent said that CBD worked better than traditional pain medication like Tylenol or Vicodin.
CBD is gaining traction elsewhere too. The medical community is starting to embrace CBD as a potential treatment for pain. Professional athletes are ditching traditional pain relief medicine in favor of CBD. And CBD sales, which are nearly doubling every two years, are expected to reach $1.8 billion by 2022.
What’s driving this trend? Why are so many people turning to CBD products to treat pain?
The short answer is that CBD is proving to be a non-addictive, effective, natural alternative to traditional pain medications. The long answer is that CBD has unique neuropathic and biochemical properties that replicate our body’s natural pain modulation process.
This deep dive into the science behind CBD and pain is aimed at addressing some of the more technical aspects of CBD and explaining why it seems to be effective at modulating pain, including, potentially, your pain.
Before touching on how CBD controls pain, it’s important to first understand how our body naturally perceives and suppresses pain.
We perceive pain through a process called nociception. Essentially, our body has a multitude of receptors, each responsible for sensing things like force, touch, chemicals, and pressure. These senses can be innocuous, like a high five or a pleasing scent, or harmful, like a punch to the stomach or heat from a hot stove. The central nervous system perceives these signals as pain when they exceed a certain threshold.
When this happens, our central nervous system alerts the area of our brain that receives sensory information. Then, another part of our brain, the cerebral cortex, “decides” how to respond to the pain signal and alerts us of danger. This “alert” is how we know to quickly remove our hand from a hot stove, for example.
Nociception is a critical biological adaptation that serves an evolutionary function. It also varies by individual, resulting in a different pain threshold for each of us.
While our body works to alert us of pain (i.e. nociception), our endocannabinoid system works to suppress pain.
Endocannabinoids are neurotransmitters that bind to receptors in our cells and interrupt nociception. In other words, endocannabinoids can, among other things, suppress pain.
This is where CBD comes in.
CBD can modulate pain much like our natural endocannabinoids by binding to receptors and triggering biochemical and neuromechanical responses that disrupt nociception. Scientific American explains that part of the analgesic promise of CBD is that it can bind to many different receptors and suppress pain through several biochemical pathways.
The result: CBD has considerable therapeutic potential for a wide range of conditions, particularly pain management.
While there are many ways to categorize pain, the American Pain Society (APS) classifies it based on duration, specifically acute, chronic, cancer, and chronic noncancer.
APS defines acute pain as a “complex, unpleasant experience with emotional and cognitive, as well as sensory features that occur in response to tissue trauma.” Common sources of acute pain include minor or major trauma, surgery, labor, medical procedures, and acute diseases.
Acute pain serves a biological purpose; it’s our body’s way of perceiving pain and alerting us of danger. It’s also time-bound with a distinct period of healing.
Chronic pain is persistent and extends beyond the period of healing associated with acute pain. It disrupts normal activities such as sleeping and daily tasks and does not serve a biological function. Over time, chronic pain results in diminished health and functional capabilities.
Cancer pain is caused by the aspects of the disease itself, such as tumor growth, nerve compression, organ obstruction, and inflammation, as well as side effects of treatments, including postoperative pain, chemotherapy, radiation treatment.
APS explains that unlike acute and chronic pain, cancer pain cannot be defined by duration or pathology alone.
CNCP occurs when acute injuries such as whiplash develop into chronic pain. Some types of CNCP are excruciating and systemic, others are mild and localized, and some are a hybrid.
Different CBD products seem to provide different forms of pain relief. For the sake of simplicity, we list CBD products that appear to be effective for local pain, such muscle aches and joint pain, and those that may be more suitable for chronic pain, including cancer, neuropathic, and other systemic pain.
Evaluation of CBD’s analgesic properties is difficult to accomplish without also evaluating other cannabinoids such as THC, since many researchers assess CBD adjunctively with other cannabis extracts.
Balms, lotions, and salves are an easy and effective way to target specific areas of pain, such as joints or tight muscles. CBD topicals penetrate only the first layer of the skin, so the cannabinoids interact with pain sensors at the site of contact instead of entering the bloodstream.
Topicals can be used to repair and protect perpetually dry, cracked skin or treat local, acute pain such as a strained muscle or other aches.
Studies in animals have also shown that topical CBD products may be effective in treating more serious conditions like inflammatory arthritis pain. Researchers studied nociception (i.e., pain perception) in arthritic rats and found that a topical CBD gel significantly reduced joint pain without apparent adverse side effects.
In this study, researchers administered rats four different topical doses, including 0.62 mg, 3.1 mg, 6.2 mg, and 62.3 mg of CBD per day for four days. The three lower doses were absorbed, distributed, and metabolized in rats safely, also known as the drug’s pharmacokinetic profile, while the highest dose, for reasons unknown, did not.
These results concur with other clinical findings that reveal CBD’s high analgesic effects seem to occur at low and intermediate doses but not at high doses.
A similar study found that 5 mg of oral CBD modulated pain signals associated with rheumatoid arthritis in mice and inhibited disease progression. A 2016 study by the University of Kentucky similarly found that CBD reduced inflammation and pain in arthritic rats.
CBD oil may be effective in treating chronic pain because it offers systemic, or whole body relief. CBD oil comes in the form of tinctures, sprays, capsules, and edibles and can be consumed orally or sublingually. Depending on the consumption method, CBD will be absorbed through the digestive tract or directly into the bloodstream. Both forms of consumption appear to mitigate pain along multiple biochemical pathways.
Other products such as CBD isolates seem to offer systemic relief, but since they are inhaled, isolates are usually thought to be less potent than pure CBD oil.
A lot of chronic pain research focuses on the incapacitating pain associated with diseases such as cancer, multiple sclerosis, fibromyalgia, and others. However, CBD may have analgesic application for less severe chronic pain, such as migraines.
A drug named Sativex has garnered a lot of attention for its analgesic properties in patients struggling with debilitating pain from cancer, multiple sclerosis, and other diseases. Sativex is a spray that delivers a ratio of 2.7 mg of THC and 2.5 mg of CBD. It is available by prescription in the UK and the Catalonia region of Spain for patients with intractable cancer pain.
Sativex has been reviewed intently over the years, with more than 2,000 preclinical and clinical trials revealing a favorable profile. For example, a 2007 study of 189 patients found nearly twice the reduction in painful muscle contractions in patients taking Sativex compared with placebo over a 6-week period.
The National Cancer Institute also highlights the pharmacologic role of THC and CBD, listing cannabinoids as potentially effective in treating pain, blocking cell growth, preventing the growth of blood vessels that supply tumors, and relieving muscle spasms.
A review of 19 clinical trials involving patients with chronic pain or multiple sclerosis, found “moderate evidence” that cannabinoids, primarily nabixiomols (a cannabis plant-extract used in Sativex), improved sleep quality among patients suffering from fibromyalgia, chronic pain, and multiple sclerosis.
Another review examined 18 articles and three randomized control trials and accepted six articles and one randomized control trial for further examination. Four included an oral spray containing a combination of cannabidiol oil and THC, five examined cannabidiol and three observed dronabinol effects. All products were determined to decrease multiple sclerosis-related pain with minimal adverse side effects when compared to placebo.
Research focusing solely on CBD’s effects found that the consumption of 2.5 and 10 mg of CBD in mice protected against chemotherapy-induced neuropathic pain (CIPN) and did not yield addictive behaviors. Researchers concluded, “adjunct treatment with CBD during chemotherapy may be safe and effective in the prevention or attenuation of CIPN.”
Another study evaluating cannabinoids’ effects on chronic pain concluded “given their multi-modality effects upon various nociceptive pathways, their adjunctive side benefits, the efficacy and safety profiles to date…the future for cannabinoid therapeutics appears very bright, indeed.”
Cannabidiol oil appears to offer pain relief for ailments ranging from tight muscles and joint pain to intractable cancer pain. While CBD seems to have a safe profile with wide potential so far, the more complex the pain and medical condition, the more important it is to consult a doctor in order to determine the appropriate CBD application options to consider.
It’s important to remember that the pure CBD oil administered in a tightly controlled clinical setting is much different than many of the supplement options available on the market today. Impure, highly processed cannabinoid products will not yield the same analgesic effects as pure, high-quality CBD oil like what is being used in the clinical trials.
Currently there is no proven dose or dosage form of CBD for managing pain. Safe use of CBD requires a clear understanding of your pain (i.e., is it acute and temporary or systemic and chronic?), any other medications you’re taking, and an honest conversation with your doctor before trying a CBD supplement.
Look for brands that note the amount of CBD in milligrams and contract with independent third parties to test for purity. Brands like Rosebud CBD include serving cards with each order to help with dosing, and most brands, like Nuleaf Naturals, will provide lab tested results upon request.
Also look for brands that test for unhealthy or unsafe additives such as pesticides, herbicides, mold, fungi, heavy metals, and mycotoxins.
In short, no. Cannabis and cannabis extracts like CBD remain classified as a Schedule I drug under the Controlled Substances Act.
It can get confusing, though, since the Drug Enforcement Administration (DEA) did reclassify certain forms of CBD from a Schedule I drug to a Schedule V drug in September 2018. However, this came with significant caveats.
This reclassification applies only to “certain drug products that have been approved by the Food and Drug Administration” that “that contain CBD derived from cannabis and no more than 0.1 percent tetrahydrocannabinols.”
Essentially, only drugs with a proven (i.e., FDA-approved) medical function fall under the DEA’s category.
The FDA released a statement soon after approving Epidoliex clarifying this point. The agency pointed out that federal approval was for one specific CBD medication for one specific use, noting that the FDA’s review process ensures that CBD is delivered to patients in a “reliable dosage form and through a reproducible route of delivery to ensure that patients derive the anticipated benefits.”
Fortunately, the development of cannabis-derived drugs does not require CBD reclassification. The FDA has already approved two other synthetic cannabis drugs aimed at managing nausea (Dronabinol and Nabilone) without reclassifying cannabis.
Additionally, GW Pharmaceuticals, the makers of Epidoliex, is reportedly looking into other CBD-derived drugs to treat brain cancer, schizophrenia, and other forms of epilepsy.
PharmD Scientific Advisor, Medical Reviewer, and Clinical Pharmacist
Adjunct Faculty, UMKC School of Pharmacy
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