If Cannabis Should Meet Fibromyalgia

Down through the ages Indian hemp (cannabis) spread from land to land. In China it was during the Wei dynasty that the famous physician Hoa Tho was able to prepare from it the sedative “Mario” which could very quickly throw the patient into so profound a sleep it was “as if he had drunk himself to death.” [from: “Triumph Over Pain” by René Fülöp-Miller, 1938: 23]

Various cannabis preparations are still widely used throughout the world, mainly for recreational purposes. But, as James Austin (2006) points out: Marijuana is often the first “herb” to lure innocents through the gate and down the garden path toward major “theobotanicals.”

Almost half of all 18-year-olds in the United States and in most European countries admit to having tried marijuana one of more times. Some have suggested that perhaps up to 10% of that teenage group can become regular users (Iverson, 2003).

In recent years concerted political efforts have been made in many countries to legalize the growing and prescribing of cannabinoids for specific medical conditions. Fibromyalgia has been included as one of a number of chronically painful conditions in which cannabis might be indicated: http://www.webmd.com/fibromyalgia/guide/fibromyalgia-and-medical-marijuana

The particular constellation of symptoms to which the name fibromyalgia has been attached exists in varying degrees of severity within all communities. These symptoms are non-specific and include widespread pain and tenderness, fatiguability, sleep disturbance, cognitive impairment, mood changes etc. When present together in various combinations they are currently understood as reflecting “polysymptomatic distress” (Wolfe et al. 2015). Self-diagnosis is not at all uncommon, through the agency of electronic media and support groups.

Indeed, this symptom cluster has been found in 2% (or more) of the general population (Vincent et al. 2013). According to the American College of Rheumatology, the “diagnosis” is most frequently made between the ages of 20 to 50. By the age of 80, approximately 8% of adults will meet the ACR criteria for fibromyalgia.

However, given that there is no objective marker or test for fibromyalgia, and it has been said that the condition can co-exist with any other painful condition, theoretically the label may be applied to many of the one in five members of the general population who report persistent pain and associated distress.

In the United States chronic pain is the most common reason given by patients reporting “medical use” of cannabis (Dyer, 2013). It follows that if fibromyalgia is listed as a “specific indication” for cannabinoids, considerable diagnostic “leakage” is bound to occur. Those who wish to continue to use “medicinal” cannabis for recreational purposes would not find it difficult to fulfill the “diagnostic criteria” for fibromyalgia.

What an enormous commercial market for cannabinoid preparations would be created!

In the words of Ware & Desroches (2014): The medical use of cannabis is not an end in itself; the patient demanding cannabis and refusing to consider other options may have motivations other than amelioration of pain and improvement in quality of life.

But is there any evidence that would justify the prescribing of cannabinoid preparations for those presenting with chronic pain and specifically for those diagnosed with fibromyalgia?

Three reviews of variable quality have been published (Martin-Sanchez et al. 2009; Lynch et al. 2011; Grotenhermen & Müller-Vahl 2012). Farrell et al. (2014) provided an overview of the first two reviews and also conducted their own literature review.

According to Farrell et al (2014): “… the effectiveness of cannabinoids in treating other chronic pain (e.g. fibromyalgia) is unclear and any benefit is likely to be modest. Mild to moderate adverse effects are often reported and long-term safety has not been established.”

So if unproven cannabinoids were to be legitimised as “treatment” for “too-easy-to-diagnose “fibromyalgia”, it is not too difficult to foresee an iatrogenic disaster that could sideline the hard-earned reputation of scientific medicine.

John Quintner

 

References:

Austin JH. Zen-Brain Reflections. Cambridge, Massachusetts: MIT Press, 2006:301-302.

Dyer O. The growth of medical marijuana. Brit Med J 2013; 347:f4755.

Farrell M, et al. Should doctors prescribe cannabinoids? BMJ 2014; 348: 348:g2737. doi: 10.1136/bmj.g2737.

Grotenhermen F, Müller-Vahl K. The therapeutic potential of cannabis and cannabinoids. Dtsch Artztebl Int 2012; 109: 495-501.

Iversen L. Cannabis and the brain. Brain 2003; 126: 1252-1270.

Lynch ME, Campbell F. Cannabinoids fro treatment of chronic non-cancer pain. A systematic review of randomized trials. Brit J Clin Pharmacol 2011; 72: 735-744.

Martin-Sanchez E, et al. Systematic review and meta-analysis of cannabis treatment for chronic pain. Pain Med 2009; 10: 1353-1368.

Vincent A, et al. Prevalence of fibromyalgia: a population-based study in Olmsted County, Minnesota, utilizing the Rochester-Minnesota project. Arthritis Care Res (Hoboken) 2013; 65(5): 786-792.

Ware MA, Desroches J Medical cannabis and pain. PAIN Clinical Updates, 2014, XXII (3).

Wolfe F, et al. The use of polysymptomatic distress categories in the evaluation of fibromyalgia (FM) and fibromyalgia severity. J Rheumatol 2015; 42(8): 1494-1501.

 

12 Comments

  1. As someone with long-term (diagnosed) fibromyalgia, chronic fatigue, and neuropathies (peripheral, small-fiber, and autonomic) I can attest that no treatment has proved more beneficial than cannabis, used sparingly and medicinally. Worries of an “iatrogenic disaster,” I believe, are borderline hysterical.

    Because the drug is potent, there exists the possibility of abuse (in the sense that its usage by some will not improve their quality of life). But, within the huge spectrum of substances and activities that can possibly be abused, marijuana is on the tame side. For example, it’s very common to hear someone casually say they decided to stop using it because it was not helpful (whereas, by comparison, struggles to stop using alcohol tend to be epic).

    At the same time, millions of recreational users find the drug to be a useful aid to relaxation, winding down, socializing, absorbing art, etc — especially given the particular stresses of the modern world. So the current fluidity of diagnosing medical users is just a reflection of the current political/legal framework — not a sign of malevolent motivations.

    (Your quote from Ware & Desroches is quite odd. The reason anyone decides to use cannabis is to improve their quality of life. What are Ware and Desroches trying to insinuate about user motivations? And what are the “other options” they are championing? Perhaps that someone wanting to wind down at the end of the day would be better served by a pharmaceutically produced anti-anxiety pill?

    I don’t yet know for sure the etiology of my illness, but I know it is debilitating. There are many competing theories, none proven (or particularly helpful). I bear this in mind whenever I read researchers saying that marijuana’s benefits are unproven. Such statements are far less compelling to me than my own experience. I can say conclusively that my quality of life drops significantly when I don’t have access to cannabis.

  2. Peter, thank you for your thoughtful response. I happen to agree with your cogent argument.

    In my country (Australia), the only way for a person to legally obtain supplies of “medicinal” cannabis is for their medical practitioner to apply for permission to prescribe it through the same bureaucratic channels as those currently being used to regulate the prescribing of drugs of addiction.

    There are a limited number of conditions for which applications to prescribe cannabis will be approved. Each of our State Health Departments is responsible for deciding which conditions will meet approval.

    One of our politicians recently remarked: “Legislation on medicinal marihuana was passed more than a year ago … it pursued the most complicated regulatory approach imaginable. As a result it is easier for a camel to pass through the eye of a needle than for a needy patient to get medical marihuana legally.” [David Leyonhjelm, Financial Review, 3rd March 2017]

  3. CANNABIS & CHRONIC PAIN
    Extracted from: “The Health Effects of Cannabis and the Current State of Evidence and Recommendations for Research (2017)” published by the National Academy of Sciences, Engineering and Medicine. The entire document can be freely accessed at: https://www.nap.edu/download/24625

    Relief from chronic pain is by far the most common condition cited by patients for the medical use of cannabis. For example, Light et al. (2014) reported that 94 percent of Colorado medical marijuana ID cardholders indicated “severe pain” as a medical condition. Likewise, Ilgen et al. (2013) reported that 87 percent of participants in their study were seeking medical marijuana for pain relief. In addition, there is evidence that some individuals are replacing the use of conventional pain medications (e.g., opiates) with cannabis. For example, one recent study reported survey data from patrons of a Michigan medical marijuana dispensary suggesting that medical cannabis use in pain patients was associated with a 64 percent reduction in opioid use (Boehnke et al., 2016).
    Similarly, recent analyses of prescription data from Medicare Part D enrollees in states with medical access to cannabis suggest a significant reduction in the prescription of conventional pain medications (Bradford and Bradford, 2016).

    Combined with the survey data suggesting that pain is one of the primary reasons for the use of medical cannabis, these recent reports suggest that a number of pain patients are replacing the use of opioids with cannabis, despite the fact that cannabis has not been approved by the U.S. Food and Drug Administration (FDA) for chronic pain.

    Are Cannabis or Cannabinoids an Effective Treatment for the Reduction of Chronic Pain?

    Systematic Reviews
    Five good- to fair-quality systematic reviews were identified. Of those five reviews, Whiting et al. (2015) was the most comprehensive, both in terms of the target medical conditions and in terms of the cannabinoids tested.
    Snedecor et al. (2013) was narrowly focused on pain related to spinal cord injury, did not include any studies that used cannabis, and only identified one study investigating cannabinoids (dronabinol). Two reviews on pain related to rheumatoid arthritis did not contribute unique studies or findings (Fitzcharles et al., 2016; Richards et al., 2012). Finally, one review (Andreae et al., 2015) conducted a Bayesian analysis of five primary studies of peripheral neuropathy that had tested the efficacy of cannabis in flower form administered via inhalation. Two of the primary studies in that review were also included in the Whiting review, while the other three were not. It is worth noting that the conclusions across all of the reviews were largely consistent in suggesting that cannabinoids demonstrate a modest effect on pain.
    For the purposes of this discussion, the primary source of information for the effect on cannabinoids on chronic pain was the review by Whiting et al. (2015). Whiting et al. (2015) included RCTs that compared cannabinoids to usual care, a placebo, or no treatment for 10 conditions.
    Where RCTs were unavailable for a condition or outcome, nonrandomized studies, including uncontrolled studies, were considered. This information was supplemented by a search of the primary literature from April 2015 to August 2016 as well as by additional context from Andreae et al. (2015) that was specific to the effects of inhaled cannabinoids.
    The rigorous screening approach used by Whiting et al. (2015) led to the identification of 28 randomized trials in patients with chronic pain (2,454 participants). Twenty-two of these trials evaluated plant-derived cannabinoids (nabiximols, 13 trials; plant flower that was smoked or vaporized, 5 trials; THC oramucosal spray, 3 trials; and oral THC, 1 trial), while 5 trials evaluated synthetic THC (i.e., nabilone).
    All but 1 of the selected primary trials used a placebo control, while the remaining trial used an active comparator (amitriptyline).
    The medical condition underlying the chronic pain was most often related to a neuropathy (17 trials); other conditions included cancer pain, multiple sclerosis, rheumatoid arthritis, musculoskeletal issues, and chemotherapy-induced pain.
    Analyses across 7 trials that evaluated nabiximols and 1 that evaluated the effects of inhaled cannabis suggested that plant-derived cannabinoids increase the odds for improvement of pain by approximately 40 percent versus the control condition (odds ratio [OR], 1.41, 95% confidence interval [CI] = 0.99–2.00; 8 trials).
    The effects did not differ significantly across pain conditions, although it was not clear that there was adequate statistical power to test for such differences.
    Only 1 trial (n = 50) that examined inhaled cannabis was included in the effect size estimates from Whiting et al. (2015). This study (Abrams et al., 2007) also indicated that cannabis reduced pain versus a placebo (OR, 3.43, 95% CI = 1.03–11.48). It is worth noting that the effect size for inhaled cannabis is consistent with a separate recent review of 5 trials of the effect of inhaled cannabis on neuropathic pain (Andreae et al., 2015).
    The pooled ORs from these trials contributed to the Bayesian pooled effect estimate of 3.22 for pain relief versus placebo (95% CI = 1.59–7.24) tested across 9 THC concentrations. There was also some evidence of a dose-dependent effect in these studies.

    Primary Literature
    In the addition to the reviews by Whiting et al. (2015) and Andreae et al. (2015), the committee identified two additional studies on the effect of cannabis flower on acute pain (Wallace et al., 2015; Wilsey et al., 2016). One of those studies found a dose-dependent effect of vaporized cannabis flower on spontaneous pain, with the high dose (7 percent
    THC) showing the strongest effect size (Wallace et al., 2015).
    The other study found that vaporized cannabis flower reduced pain but did not find a significant dose-dependent effect (Wilsey et al., 2016).
    These two studies are consistent with the previous reviews by Whiting et al. (2015) and Andreae et al. (2015), suggesting a reduction in pain after cannabis administration.

    Discussion of Findings
    The majority of studies on pain cited in Whiting et al. (2015) evaluated nabiximols outside the United States. In their review, the committee found that only a handful of studies have evaluated the use of cannabis in the United States, and all of them evaluated cannabis in flower form provided by the National Institute on Drug Abuse that was either vaporized or smoked.
    In contrast, many of the cannabis products that are sold in state-regulated markets bear little resemblance to the products that are available for research at the federal level in the United States. For example, in 2015 between 498,170 and 721,599 units of medical and recreational cannabis edibles were sold per month in Colorado (Colorado DOR, 2016, p. 12).
    Pain patients also use topical forms (e.g., transdermal patches and creams). Thus, while the use of cannabis for the treatment of pain is supported by well-controlled clinical trials as reviewed above, very little is known about the efficacy, dose, routes of administration, or side effects of commonly used and commercially available cannabis products in the United States.
    Given the ubiquitous availability of cannabis products in much of the nation, more research is needed on the various forms, routes of administration, and combination of cannabinoids.

    CONCLUSION 4-1. There is substantial evidence that cannabis is an effective treatment for chronic pain in adults.

  4. The more important issues are a comparison with properly dosed pain medication and an examination of the dosage effect over time and in particular the impact of long term use on pain as well as other cognitive factors.

    • Yes, more studies are needed, but as JQ pointed out, we know a significant bit already. And as Australia inches forward, the US risks going backward based on the twisted logic that cannabis might exacerbate opioid abuse (the old gateway-drug theory).

      In fact, this country’s current opioid epidemic is largely the result of doctors prescribing hard-core drugs for chronic pain to people who probably don’t realize how much more helpful and safer cannabis would be.

      Meanwhile, here’s an interesting new study on “micro-dosing” marijuana: http://gizmodo.com/weed-microdosing-mice-study-brings-great-news-but-ther-1795037913

  5. Peter, based on existing data, we do know that cannabinoids can have a modest analgesic effect and are relatively safe.

    But the fact that a significant percentage (up to 15%) of the population attending pain clinics in the USA are already using cannabis suggests to me that, at best, cannabinoids may be a useful adjunct to treatment.

    However, I do not see a clear therapeutic role for cannabinoids in the context of pain management. As stated in the above-mentioned extract, “… while the use of cannabis for the treatment of pain is supported by well-controlled clinical trials … very little is known about the efficacy, dose, routes of administration, or side effects of commonly used and commercially available cannabis products in the United States.”

    Regarding the opioid-sparing effect of cannabinoids, here is an extract from the Conclusion of a recent study: “In summary, pre-clinical studies provide robust evidence of the opioid-sparing effect of cannabinoids, whereas one of the nine clinical studies identified provided very-low-quality evidence of such an effect. Prospective high-quality-controlled clinical trials are required to determine the opioid-sparing effect of cannabinoids.” Reference: Nielsen et al. Opioid-sparing effect of cannabinoids: a systematic review and a meta-analysis. Neuropsychopharmacology, 2017, April 5.

    In my opinion, the opioid epidemic reflects our societal demand for a straight-forward biomedical solution to what is now being understood as a vastly more complex bio-psycho-socio-cultural problem.

    To reiterate the conclusion of the original post: So if unproven cannabinoids were to be legitimised as “treatment” for “too-easy-to-diagnose “fibromyalgia”, it is not too difficult to foresee an iatrogenic disaster that could sideline the hard-earned reputation of scientific medicine.

  6. Seems to me the crucial element in this discussion is, broadly speaking, relief.

    My doctors have occasionally prescribed opioids (and, for that matter, benzodiazepines) for my condition (fibromyalgia and widespread neurological pain). I can attest to the temporary relief these meds are capable of providing. I can also say that I would have found myself in a pretty panicky state when these prescriptions ran out — had I not known that cannabis would be available to take the edge off my constant pain. When pain is so omnipresent the knowledge that relief is about to end must be akin to taking one’s last sip of water while stuck in the desert. I can easily sympathize with those who seek out such relief by all means necessary, especially those who aren’t even aware of cannabis as a possible viable option. I’ve heard many people (e.g. in chat forums) living with chronic pain say “what do I have to lose?” when explaining their willingness to succumb to dependence on hardcore pharmaceuticals.

    Here in the US there’s currently a serious effort to crack down on prescription abuse. As a result, ordinary patients — even old farts like me — are treated with suspicion and left feeling like criminals submitting to urine tests and monthly doctor visits just to receive our prescriptions. Fine, but many patients seem to have been concluding it’s easier and cheaper, and perhaps even more dignified (!), for them to just get heroin off the street. What a mistake it would be to reverse the liberalization of cannabis access at the same time this opioid crackdown is going on.

    Cannabis legalization and medical access has brought a rapidly growing “open-source” awareness of appropriate strains, dosages, and caveats for diverse people and conditions. Until very recently, for example, there was no delineation of strains used in edibles, but now certain manufacturers are experimenting with cooking from selective trimmings. As a result, the “open-source” marketplace will know a lot sooner than the scientific community whether or not strain nuances get baked away as previously thought.

    Regardless of how assorted studies have yielded incomplete information, many many people with pain and stress, whether chronic or acute, experience significant relief from cannabis. Telling them that a study is inconclusive would only make them laugh. Still, it seems your main concern may be about _prematurely_ legitimizing cannabis as a treatment . (I would like to think you are not indicting the reality of “idiopathic” illness states simply because the bio-psycho boundary is not always perfectly clear.) Sure, there’s still a lot for the medical community to learn about cannabis, but, thankfully, culture has been shifting enough that that quest for knowledge is no longer thwarted across the board by irrational policies and fears. Culture, scientific knowledge, and the legal system have to mature hand in hand.

    Meanwhile, I would hope that, at least where it’s legal, doctors are becoming increasingly comfortable telling adventurous patients like me that they might want to give cannabis a try. Doctors can and should be able to say things like that without taking full responsibility for every possible ramification (remember “a nip of brandy” for a cold?). It’s certainly better than the all-too-common alternative when it comes to “idiopathic” disease: a shrug and a “hang in there.”

    But maybe your vision of a possible “iatrogenic disaster” is not just about scientific procedure? I’m wondering: do you have particular experiences of cannabis-related damage that makes you especially wary of its more widespread use (setting aside, of course, any concern about adolescent abuse)? I’m struggling to square your legitimate concerns with what seems to me sometimes hyperbolic language regarding a comparatively tame substance that so many like me swear by.

  7. “Seems to me the crucial element in this discussion is, broadly speaking, relief.”

    I agree with you on this point but there are other issues to consider.

    By introducing the adjective “medicinal” and then deciding that doctors are to be the gatekeepers for prescribing these substances, our lawmakers have decreed a strict line of demarcation exists between recreational and therapeutic use of these substances.

    In the former case, purchasers must take their chances in a highly competitive and at times unscrupulous market place.

    On the other hand, doctors who prescribe or recommend them to their trusting patients have a duty of care to them that has to be taken very seriously.

    The reality is that most doctors who do not work in the field of Addiction Medicine know little or nothing about these substances.

    If you are arguing in favour of decriminalising cannabis/cannabinoids and thus aligning them with other substances that can be used legally (i.e. alcohol and nicotine), then that is a matter that concerns public health officials, politicians and lawmakers.

    I am reminded that in the 19th century, Nicotiana Tabacum (the tobacco-plant) was employed as a medicine (as either fumes or decoction) for the relief of obstinate constipation. However it was also known to be an active narcotic that could produce adverse effects and, in some instances, death.

    But the history of a substance known as Bangue or Bange is more relevant to this discussion – “a species of opiate in great use throughout the East, for its intoxicating qualities. It is the leaf of a kind of wild hemp, growing in the countries of the Levant, and made into powder, pills, or conserves.” It was mainly used as a narcotic and aphrodisiac. Analgesic properties did not rate a mention.

    Reference: Hooper R. Medical Dictionary (4th edition) . London: Longman, Hurst, Rees, Orme, and Co., 1820.

  8. For me, the term “medicinal” is not at all problematic, since cannabis meets the criteria (e.g. I take specific doses at specific times to gain relief from specific symptoms). However, as you are aware, cannabis is currently in a unique liminal place where politics, medicine, and culture overlap — so it’s asking a lot of those who, like me, have found cannabis to be the most effective (and often only) drug to treat our conditions.

    As I said earlier, we can’t expect lawmakers to catch up until culture changes and the scientific community increasingly documents the value (and risks) associated with cannabis by openly studying the community of users. That means there will be some blurred lines and messiness for awhile. The alternative is to acquiesce to the inertia of distorted past policies (based on the “demon weed,” etc) — and that’s just not fair.

    Your conservatism on the matter seems a bit luxurious given the unique crossroads in which we find ourselves. The fact is, cannabis can be used both medicinally and recreationally, as well as something in between. It’s up to all of us to usher in sensible reactions and policies that accommodate this fact, even if doing so requires flexibility. Lack of flexibility favors the status quo. An example of flexibility was the Obama administration’s decision to allow state medicinal programs to continue experimenting, even though federal law still classifies cannabis as a narcotic. Bear in mind, in took years after some states allowed medicinal usage for other states to begin introducing recreational legality. So, while it may be tempting to neatly state that legal status is simply a policy decision, in reality progress comes from multiple directions.

  9. Society is running a massive social experiment with cannabis. We will not know how it turns out for many years. The last one with opioids has not turned out very well in spite of “control” by the FDA and medical system. I expect that this new experimenting may not turn out so well either. On the other hand, various behavioral therapy interventions have been effective in a number of FM studies with seemingly less risk and more understanding.

  10. Peter, here is a recent relevant press release that sounds a note of caution:

    ‘False hope is driving claims medicinal cannabis is the “magic pill” for chronic pain and doctors should not prescribe it just because they can, an Australian pain specialist warns.

    Professor Milton Cohen, director of professional affairs for for the Australian New Zealand College of Anaesthetist’s (ANZCA) faculty of pain medicine, says current evidence in support of medicinal cannabis is “not good enough”.

    “The question of evidence, I think, hangs in the air much like some smoke,” he told a meeting of Australian pain specialists in Brisbane on Saturday.

    The Federal Government in 2016 legalised a pathway for patient access to Australian-grown and manufactured medicinal cannabis, subject to state and territory regulations.
    Victoria became Australia’s first state to legalise cannabis for medical use and was quickly followed by NSW.

    Under amendments to the Poisons and Therapeutic Goods regulations, cannabis- based medications are available to a range of people for whom more mainstream treatments are not effective.
    This has left physicians treating patients with chronic pain in an “untenable“ situation, Prof Cohen told the meeting.

    “We are told that cannabinoids might work, surely we need to know that it does work.”

    “I don’t think we are in the position to say with confidence to the community that this is the case.”
    Chronic pain affects about one in five people in Australia and New Zealand. It is a complex issue and the very “modest” benefits medical cannabis may provide have been “oversold” to the public, Prof Cohen said.

    “We know that chronic pain is a much more complex phenomenon which requires a holistic approach to management that is tailored to the individual’s circumstances. To rely only on medicines is just not going to work,” Prof Cohen said.

    The faculty does not support the use of cannabinoids in chronic non-cancer pain “until such time as a clear therapeutic role for them is identified in the scientific literature”.

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