Many patients already use cannabis to relieve neck pain, despite concerns over being classed as criminals and about the safety of the unregulated drug. This could all be about to change as The California Medical Association called last month for the legalization and regulation of cannabis. Their hope is that by being the first to break ranks amongst other medical authorities a national movement will arise to reschedule cannabis and allow increased research into the efficacy and safety of the drug for conditions such as neck pain, neuropathy, multiple sclerosis, and even nausea as a side-effect of other treatments.
The CMA’s president, James T. Hay, MD., said that the “CMA may be the first organization of its kind to take this position, but we won’t be the last.” Cannabis is already decriminalized in California but many physicians find themselves in the difficult position of being able to recommend the drug whilst knowing that their patients could be prosecuted for using it.
The vast differences between batches of the drug as sold on the street means most physicians are also loathe to recommend cannabis for pain relief due to safety concerns. Some street cannabis is bulked out with glass in order to try to increase the appearance of tetrahydrocannabinol (THC) crystals, and the relative potency of the drug is also hard to ascertain meaning that patients have little hope of carefully managing their pain over different batches. Patients left to self-medicate using cannabis are also at risk of suffering mental health issues as well as being drawn into habit-forming behaviors in some cases, often without feeling able to seek medical attention due to the possibility of prosecution. Those with conditions causing neck pain as one of many symptoms, such as fibromyalgia, multiple sclerosis, or thoracic outlet syndrome, may find that using cannabis helps to relieve the pain but makes their other symptoms worse.
Decriminalization of Cannabis
The CMA published a white paper on their website in mid-October calls for a federal rescheduling of cannabis for medical purposes in order to encourage research. They also recommend regulation of cannabis in a similar fashion to tobacco and alcohol for recreational use, which would include taxation on cannabis and an improved ability to educate people about the risks and benefits of the drug.
The current status in sixteen states, and the District of Columbia, is that cannabis is decriminalized, meaning that there are usually reduced penalties for offences related to the use of the drug. Legalization would allow people to cultivate cannabis, sell it, and use it without being classed as criminals. However, the federal government still lists cannabis as a schedule one drug, which places it alongside heroin, peyote, and lysergic acid diethylamide (LSD), meaning that the drug is not considered to have any accepted medical use but does have the potential for abuse. The CMA’s Legalization and Taxation of Marijuana Technical Advisory Committee was formed in 2010 to compile a white paper on the issue of removing cannabis from schedule one, pointing out that the decriminalization of the drug had unfortunately put physicians in the position of gatekeeper for a drug which they could not thoroughly investigate without great expense and difficulty.
A National Coalition for Cannabis
In California earlier this year the Health and Safety Code 11357 was implemented which means that those possessing up to an ounce of nonmedical marijuana are charged with a civil infraction rather than a criminal misdemeanor. Despite this decriminalization the regulation of the drug, and safeguards over its purity and concentration are still lacking, with some comparing this to the problems that occurred during prohibition. Evidence for the medical use of cannabis is still limited and there are concerns that the drug can adversely affect patients, particularly younger patients, in terms of mental health and development. Despite claims of efficacy for the drug in treating nausea, pain, and anorexia, the dearth of evidence means that it is difficult for physicians to recommend dosages and to advise patients about potential adverse effects of the drug.
The CMA has asked for a national coalition to be formed including state medical associations and medical specialty societies in order to work together towards a federal rescheduling of cannabis. The organization is clear that they are not expecting or encouraging doctors to promote excessive drug use in the community, rather to give their patients the best possible treatment available, whether this is cannabis or some other neck pain treatment. By legalizing the drug there are some who are concerned that patients will view it as harmless, especially due to the view of it being a natural product. However, the increasingly selective cultivation of marijuana over recent decades has significantly altered the chemical profile of the plant, with current varieties considered much stronger in terms of psychoactive effects than in previous decades.
Smoking Cannabis for Neck Pain Relief
There are also clear concerns over patients smoking cannabis to relieve pain as the adverse effects of smoking on health are well documented. Finding a safer way to administer the drug involves clinical research, which is, perhaps unnecessarily, made more arduous due to federal restrictions. Research by Ware, et al (2003), found that neck pain and myofascial pain were the most common reasons in their survey of patients suffering chronic non-cancer pain for using cannabis, comprising 68% and 65% respectively. They questioned 209 patients over six-weeks and found that 35% of patients had at some point used cannabis, with 15% stating that this had been for pain relief and 10% using the drug at the time of the study. Those using cannabis to treat pain were usually younger and were often smokers.
Post-Surgical Neck Pain and Cannabis Use
Patients using cannabis to relieve pain were more likely to have experienced pain caused by trauma, such as whiplash, or surgery (51%) and the researchers also asked about the frequency of use. A quarter of the patients using cannabis for pain smoked an entire joint as each dose, with 53% considering four puffs of a joint, or less, as sufficient for pain relief each time. More than one joint was considered necessary for pain relief by a minority of patients (12%) and the most common side-effects of the drug were reported as dry mouth and feeling high. Patients using cannabis for pain relief also noted that, along with pain, their mood and sleep patterns also improved. A number of other studies find similar degrees of drug usage amongst patients with chronic pain and there have been repeated calls for investigation into the drug and better regulation of concentrations to help patients.
Neck Pain a Common Reason for Cannabis Use
Another study by Ware, et al (2010) found that many patients also used cannabis to relieve chronic neuropathic pain, which is often poorly addressed by standard drug treatments. The researchers actually carried out a clinical trial, rather than just a questionnairre this time, involving adults with post-traumatic or post-surgical neuropathic pain. Those undergoing neck pain surgery may fall into such a category. Four different doses of THC were given to patients randomly assigned to 0%, 2.5%, 6%, and 9.4% over four two-week periods in a crossover trial. The pain experienced by patients was measured daily on an eleven-point scale and their mood, sleep, and quality of life were also monitored, along with any adverse effects of the trial.
Side-Effects of Cannabis for Pain Relief
Unfortunately this trial only involved twenty-three patients so the application of its findings to a wider population is limited. However, twenty-one completed the trial and the average pain intensity was lower in the group using the higher dose of THC (5.4 vs 6.1). The other groups, provided with intermediate dosages did not have a significantly different reduction in neuropathic pain although some relief did occur. Sleep improved when the patients took the 9.4% dose, in terms of quality of sleep and ability to fall asleep and sleep soundly. Side-effects were noted with the higher dose however, namely, headache, dry eyes, dizziness, numbness, and cough, along with a burning sensation in areas of neuropathic pain. The researchers concluded that a single inhalation of 25mg of 9.4% tetrahydrocannabinol herbal cannabis three times a day for five days improved chronic neuropathic pain and sleep and was generally well tolerated by patients.
The inhalation of THC is not without problems however, even in the absence of tobacco smoke. Sarafian, et al (2005) studied the effects of the drug on the human small airway epithelial cells and found that when inhaled as part of marijuana smoke the drug triggered changes in the expression of genes in these cells lining the respiratory pathways which could prompt pathological disease development.
A Need for Research
There have been around a dozen trials looking at the use of inhaled cannabis for medical purposes in the US in the last decade, with twenty or so conducted worldwide. It is clear however that more research needs to be done on the possible benefits and risks of cannabis use for pain relief as well as for other conditions. Patients may find that their physician is increasingly receptive to the idea of using cannabis for pain relief following this major step taken by the California Medical Association. Other medical authorities may follow suit in the following weeks and months and opening up the debate about medical marijuana could mean that in a few years cannabis is a standard treatment for neck pain relief, alongside NSAIDs, steroids, and other substances often with their root in herbal medicine.
Sarafian T, Habib N, Mao JT, Tsu IH, Yamamoto ML, Hsu E, Tashkin DP, Roth MD., Gene expression changes in human small airway epithelial cells exposed to Delta9-tetrahydrocannabinol. Toxicol Lett. 2005 Aug 14;158(2):95-107. Epub 2005 Apr 26.
Ware MA, Doyle CR, Woods R, Lynch ME, Clark AJ., Cannabis use for chronic non-cancer pain: results of a prospective survey. Pain. 2003 Mar;102(1-2):211-6.
Ware MA, Wang T, Shapiro S, Robinson A, Ducruet T, Huynh T, Gamsa A, Bennett GJ, Collet JP., Smoked cannabis for chronic neuropathic pain: a randomized controlled trial. CMAJ. 2010 Oct 5;182(14):E694-701. Epub 2010 Aug 30.
Cannabis and the Regulatory Void: Background Paper and Recommendations, California Medical Association, 2011. CMA website. http://www.cmanet.org/files/pdf/news/cma-cannabis-tac-white-paper-101411.pdf