Chronic pain affects millions of Americans. By some estimates, as many as 100 million Americans suffer from chronic pain. Broadly described as persistent pain that takes considerably longer than one would reasonably expect to heal (generally at least three months). As more states allow cannabis as a treatment option for chronic pain, more and more patients dissatisfied by commonly prescribed medications, are turning to cannabis to treat what can be a debilitating condition.

But, what exactly is chronic pain? Chronic pain, like many conditions, is complex. The potential underlying issues causing chronic pain are diverse, and vary from person to person.

Chronic pain may be caused another disease or condition, such as:

HIV/AIDS

Cancer

Fibromyalgia

Rheumatoid arthritis

Spinal diseases

Persistent headaches (such as migraines)

Neurological disorders

Left untreated — or undertreated — chronic pain can cause other symptoms that can negatively impact one’s quality of life. To name just a few other issues, it’s not uncommon for chronic pain sufferers to complain of insomnia, decreased appetite, social isolation, anxiety and depression, performance issues at work, and more.

Further, it’s important to note that chronic pain generally falls under one of two types:

Nociceptive – Resulting from tissue damage or inflammation; aching, sharp, throbbing pain associated with other conditions. .

Neuropathic – Resulting from alterations in the nervous system or damage. The pain often causes numbness or burning.

When considering cannabis as a treatment it’s important to differentiate between nociceptive and neuropathic pain, because evidence suggests cannabis is an effective treatment for chronic neuropathic pain, but not necessarily nociceptive pain. While the evidence for chronic neuropathic pain is significant, there is little evidence to prove cannabis is effective for pain that is acute (short-lasting) or nociceptive (pain arising from the stimulation of nerve cells, distinct from damage to the nerves themselves).

How is Chronic Pain Typically Treated?

Physicians often prescribe a cocktail of drugs to treat chronic pain, oftentimes to offset side effects of other drugs, or treat related symptoms, such as depression and anxiety.

Commonly prescribed drugs include:

Acetaminophen (e.g. Tylenol)

Aspirin

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as Advil (ibuprofen) and Aleve (naproxen)

Tricyclic antidepressants

Serotonin and norepinephrine reuptake inhibitors

(SNRIs) Serotonin and norepinephrine reuptake inhibitors like Cymbalta (duloxetine)

Corticosteroids (prednisone)

Anticonvulsants including Neurontin (gabapentin) and Lyrica (pregabalin)

Opioids including OxyContin (oxycodone) or Vicodin (hydrocodone)

Many of these treatments cause intolerable side effects such as constipation (which is especially common with opioids — remember the Super Bowl advert?), gastrointestinal issues, and even cardiovascular damage (which is commonly reported as a side effect from NSAIDs).

Of particular concern is the use of opioids for long-term treatment. Not only is there no evidence to suggest opioids are an effective long-term chronic pain treatment, users report having to continually up their dosage to achieve the same effect. Moreover, they’re highly addictive and as many as two-thirds of fatal drug overdoses each year involved opioids.

Cannabis to Treat Chronic Pain

Your body has an endocannabinoid system (ECS), which is not only considered the “body’s own cannabinoid system,” it’s one of the body’s most important physiological systems. Exo-cannabinoids (derived synthetically or from the cannabis plant) acting on the endocannabinoid system’s two main receptors, CB1 and CB2 (and periphery,) can exert numerous therapeutic effects including: antispastic, analgesic, antiemetic, neuroprotective, and anti-inflammatory actions.

Pain sensation is mediated through both the CB1 and CB2 receptors, while the CB2 receptor plays a greater role in inflammation and immune response.

What’s particularly notable about cannabis is that it helps treat pain through both anti-inflammatory and analgesic (pain relief) actions. This stands in contrast to many other drugs which often treat one or the other. For example, opioids work solely as an analgesic, so rather than treating any underlying causes (like inflammation), they basically “numb” the pain.

Dr. Donald Abrams, a professor and Chief of Hematology & Oncology at San Francisco General Hospital, explains “I believe that the reason we and all animal species have the complex system of cannabinoid receptors and endocannabinoids is to help us modulate the experience of pain.”

How Effective Is Cannabis?

Chronic pain and cannabinoids as a treatment is one of the best studied areas, with more than 200 studies conducted to date.

Dr. Kevin Hill, a Harvard professor and addiction psychiatrist conducted a systematic review of 28 of these studies, and concluded, “[The] use of marijuana for chronic pain, neuropathic pain, and spasticity due to multiple sclerosis is supported by high-quality evidence.” In fact six out of the six general chronic pain studies he investigated showed significant improvement in pain symptoms, while five out five neuropathic pain studies drew the same conclusion.

A 2011 Canadian review study of 18 trials concluded cannabis and cannabinoids demonstrated significant efficacy to treat chronic pain. And, noted that one study suggested cannabis was effective adjunct to opioids potentially allowing patients to reduce dependence on opioid medications. Additionally, they found cannabis treatments to improve sleep and mood, with few adverse side effects which they characterized as “mild to moderate” and “well tolerated.”

Cannabis Can Help Chronic Pain Patients Decrease (or Eliminate) Opioid Use

Dr. Michael Hart, head physician at Marijuana for Trauma in Canada, often treats chronic pain patients. He reports that, “The vast majority of patients I treat are able to eliminate opioids from their treatment protocol or significantly reduce their intake.

Studies validate Hart’s experience. A University of Michigan March 2016 Study, noting “there is little evidence that they are effective for long term [chronic pain] treatment,” and their research suggests cannabis may be an effective adjunct to chronic pain therapy.

Their research showed that cannabis use was associated with:

64% lower opioid use in patients with chronic pain;

better quality of life in patients with chronic pain; and

fewer medication side effects and medications used.

One patient, Kevin Ameling, who now works for a cannabis advocacy non-profit, IMPACT Network in Colorado, reports his own success. Initially prescribed a host of drugs including Clonazepam, Tramadol, Lexapro, and OxyContin, after consulting his physician, he turned to medical marijuana. He cut his OxyContin dosage by 50% (and often skips doses, which he previously couldn’t do); reduced Clonazepam from 3 mg to .5mg of; Lexapro from 30 mg to 5mg; and Tramadol from 300 mg to 75 mg of Tramadol.

Final Tips & Advice

Marijuana for Trauma head physician — Dr. Michael Hart — offers some tips and final words of advice to patients considering cannabis to treat their chronic pain:

Less is more. THC has a biphasic effect, meaning low to moderate doses elicit the desired effect, while too high of a dose can worsen symptoms.

Find the Effective Dosage. Appropriate dosage is subjective as every person has different tolerability levels. So it’s important to self-titrate, which means start low and increase gradually until you find the optimal dosage.

Method of Administration. Consider the method of administration. Some people prefer inhalation as it allows them to easily titrate, although other patients prefer edibles, which take longer to elicit effects, but last longer. Different patients will respond more favorably to different methods of administration, so it may take some trial and error to find what works for you.

Strains: For pain, most patients seem to prefer higher THC strains, but this is far from universal. Others prefer higher CBD. Again, it may take a bit of “trial and error.”