Is Cannabis Harmful During Pregnancy and Adolescence?

By Hilary Marusak, Wayne State University

Cannabis is a widely used psychoactive drug worldwide, and its popularity is growing: The U.S. market for recreational cannabis sales could surpass $72 billion by 2023.

As of early 2023, 21 U.S. states and the District of Columbia have legalized cannabis for recreational use for people age 21 and up, while 39 states plus the District of Columbia have legalized it for medical use.

The growing wave of legalization and the dramatic increase in cannabis potency over the past two decades have raised concerns among scientists and public health experts about the potential health effects of cannabis use during pregnancy and other vulnerable periods of development, such as the teen years.

I am a developmental neuroscientist specializing in studying what’s known as the endocannabinoid system. This is an evolutionarily ancient system found in humans and other vertebrates that produces natural cannabinoids such as THC and CBD.

Cannabis and its constituents interact with the body’s endocannabinoid system to product their effects. THC and CBD are the most commonly known cannabis extracts and can be synthesized in a lab. My lab also studies the risks versus potential therapeutic value of cannabis and cannabinoids.

Potential Health Risks

People often assume there’s no risk when using cannabis or cannabinoids during vulnerable periods of life, but they’re basing that on little to no data. Our research and that of others suggests that cannabis use during pregnancy and adolescence can present myriad health risks the public should be aware of.

Data shows that many people who use cannabis continue to do so during pregnancy. But there are health risks. More and more pregnant people are using cannabis today compared with a decade ago, with some studies showing that nearly 1 in 4 pregnant adolescents report that they use cannabis.

Many cannabis-using people may have not known they were pregnant and stopped using when they found out. Others report using cannabis for its touted ability to ease pregnancy-related symptoms, like nausea and anxiety. However, studies do not yet confirm those health claims. What’s more, the potential harms are often downplayed by pro-cannabis marketing and messaging by dispensaries, advocacy groups and even midwives or doulas.

In addition, physicians and other health care providers often are not knowledgeable enough or don’t feel well equipped to discuss the potential risks and benefits of cannabis with their patients, including during pregnancy.

While research shows that most people who are pregnant perceive little to no risk in using cannabis during pregnancy, the data show there is clear cause for concern. Indeed, a growing number of studies link prenatal cannabis exposure to greater risk of preterm birth, lower birth weight and psychiatric and behavioral problems in children. These include, for example, difficulties with attention, thought, social problems, anxiety and depression.

Cannabis and Brain Development

When cannabis is inhaled, consumed orally or taken in through other routes, it can easily cross through the placenta and deposit in the fetal brain, disrupting brain development.

A recent study from my lab, led by medical student Mohammed Faraj, found that cannabis use during pregnancy can shape the developing brain in ways that are detectable even a decade later.

We used data from the National Institutes of Health Adolescent Brain Cognitive Development Study, which is the largest long-term study of brain development and child and adolescent health in the U.S. It has followed more than 10,000 children and their families from age 9-10 over a 10-year period.

Through that analysis, we linked prenatal cannabis exposure to alterations in functional brain networks in 9- and 10-year-old children. In particular, prenatal cannabis exposure appeared to disrupt the communication between brain networks involved in attentional control, which may explain why children who were exposed to cannabis in utero may develop difficulties with attention or other behavioral issues or mental disorders as they develop.

While alcohol abuse has steadily declined among adolescents since 2000 in the U.S., cannabis use shows the opposite pattern: It increased by 245% during that same period.

Data reported in 2022 from the Monitoring the Future survey of over 50,000 students in the U.S. found that nearly one-third of 12th grade students reported using cannabis in the past year, including cannabis vaping. Yet only about 1 in 4 12th grade students perceive great harm in using cannabis regularly. This suggests that many teens use cannabis, but very few consider it to have potential negative effects.

Research shows that the adolescent brain is primed to engage in high-risk behaviors such as experimenting with cannabis and other substances. Unfortunately, owing to ongoing brain development, the adolescent brain is also particularly susceptible to the effects of cannabis and other substances. Indeed, many neuroscientists now agree that the brain continues to develop well into the second and even third decade of life.

In line with this vulnerability, research shows that, relative to those who did not use cannabis during adolescence, those who started using it during adolescence are at increased risk of developing depression, suicidal ideation, psychosis and reductions in IQ during adolescence and adulthood. Neuroimaging studies also show residual effects of adolescent cannabis use on brain functioning, even later during adulthood.

‘No Amount Is Safe’

Despite common misconceptions that cannabis is “all natural” and safe to use during pregnancy or adolescence, the data suggests there are real risks. In fact, in 2019, the U.S. surgeon general issued an advisory against the use of cannabis during pregnancy and adolescence, stating that “no amount … is known to be safe.”

Cannabis may be harmful to the developing brain because it disrupts the developing endocannabinoid system, which plays a critical role in shaping brain development from conception and into adulthood. This includes neural circuits involved in learning, memory, decision-making and emotion regulation.

While much of this research has focused on cannabis use, there is also other research that comes to similar conclusions for THC and CBD in other forms. In fact, although CBD is widely available as an unregulated supplement, we researchers know almost nothing about its effects on the developing brain. Of note, these harms apply not only to smoking, but also to ingesting, vaping or other ways of consuming cannabis or its extracts.

In my view, it’s important that consumers know these risks and recognize that not everything claimed in a label is backed by science. So before you pick up that edible or vape pen for stress, anxiety, or sleep or pain control, it’s important to talk to a health care provider about potential risks – especially if you are or could be pregnant or are a teen or young adult.

Hilary Marusak, PhD, is an Assistant Professor of Psychiatry and Behavioral Neurosciences at Wayne State University. She directs the WSU THINK Lab, which focuses on pediatric anxiety and understanding the impact of childhood trauma on neural development. Dr. Marusak receives funding from the National Institutes of Health and the State of Michigan.   

This article originally appeared in The Conversation and is republished with permission.

Our Bodies Produce Chemicals Similar to THC in Cannabis

By Drs. Prakash and Mitzi Nagarkatti, University of South Carolina

Over the past two decades, a great deal of attention has been given to marijuana – also known as pot or weed. As of early 2023, marijuana has been legalized for recreational use in 21 states and Washington, D.C., and the use of marijuana for medical purposes has grown significantly during the last 20 or so years.

But few people know that the human body naturally produces chemicals that are very similar to delta-9-tetrahydrocannabinol, or THC, the psychoactive compound in marijuana, which comes from the Cannabis sativa plant. These substances are called endocannabinoids, and they’re found across all vertebrate species.

Evolutionarily, the appearance of endocannabinoids in vertebrate animals predates that of Cannabis sativa by about 575 million years.

It is as if the human body has its own version of a marijuana seedling inside, constantly producing small amounts of endocannabinoids.

The similarity of endocannabinoids to THC, and their importance in maintaining human health, have raised significant interest among scientists to further study their role in health and disease, and potentially use them as therapeutic targets to treat human diseases.

THC was first identified in 1964, and is just one of more than 100 compounds found in marijuana that are called cannabinoids.

What Are Endocannabinoids?

Endocannabinoids were not discovered until 1992. Since then, research has revealed that they are critical for many important physiological functions that regulate human health. An imbalance in the production of endocannabinoids, or in the body’s responsiveness to them, can lead to major clinical disorders, including obesity as well as neurodegenerative, cardiovascular and inflammatory diseases.

We are immunologists who have been studying the effects of marijuana cannabinoids and vertebrate endocannabinoids on inflammation and cancer for more than two decades. Research in our laboratory has shown that endocannabinoids regulate inflammation and other immune functions.

A variety of tissues in the body, including brain, muscle, fatty tissue and immune cells, produce small quantities of endocannabinoids. There are two main types of endocannabinoids: anandamide, or AEA, and 2-arachidonoyl glycerol, known as 2-AG. Both of them can activate the body’s cannabinoid receptors, which receive and process chemical signals in cells.

One of these receptors, called CB1, is found predominantly in the brain. The other, called CB2, is found mainly in immune cells. It is primarily through the activation of these two receptors that endocannabinoids control many bodily functions.

The receptors can be compared to a “lock” and the endocannabinoids a “key” that can open the lock and gain entry into the cells. All these endocannabinoid receptors and molecules together are referred to as the endocannabinoid system.

The cannabis plant contains another compound called cannabidiol, or CBD, which has become popular for its medicinal properties. Unlike THC, CBD doesn’t have psychoactive properties because it does not activate CB1 receptors in the brain. Nor does it activate the CB2 receptors, meaning that its action on immune cells is independent of CB2 receptors.

Endocannabinoids Help Us Feel Better

The euphoric “high” feeling that people experience when using marijuana comes from THC activating the CB1 receptors in the brain.

But when endocannabinoids activate CB1 receptors, by comparison, they do not cause a marijuana high. One reason is that the body produces them in smaller quantities than the typical amount of THC in marijuana. The other is that certain enzymes break them down rapidly after they carry out their cellular functions.

However, there is growing evidence that certain activities may release mood-elevating endocannabinoids. Some research suggests that the relaxed, euphoric feeling you get after exercise, called a “runner’s high,” results from the release of endocannabinoids rather than from endorphins, as previously thought.

The endocannabinoids regulate several bodily functions such as sleep, mood, appetite, learning, memory, body temperature, pain, immune functions and fertility. They control some of these functions by regulating nerve cell signaling in the brain. Normally, nerve cells communicate with one another at junctions called synapses. The endocannabinoid system in the brain regulates this communication at synapses, which explains its ability to affect a wide array of bodily functions.

Research in our laboratory has shown that certain cells of the immune system produce endocannabinoids that can regulate inflammation and other immune functions through the activation of CB2 receptors.

In addition, we have shown that endocannabinoids are highly effective in lessening the debilitating effects of autoimmune diseases. These are diseases in which the immune system goes haywire and starts destroying the body’s organs and tissues. Examples include multiple sclerosis, lupus, hepatitis and arthritis.

Chronic Pain Linked to Low Levels of Endocannabinoids

Recent research suggests that migraine, fibromyalgia, irritable bowel syndrome, post-traumatic stress disorder and bipolar disease are all linked to low levels of endocannabinoids.

In a 2022 study, researchers found that a defect in a gene that helps produce endocannabinoids causes early onset of Parkinson’s disease. Another 2022 study linked the same gene defect to other neurological disorders, including developmental delay, poor muscle control and vision problems.

Other research has shown that people with a defective form of CB1 receptors experience increased pain sensitivity such as migraine headaches and suffer from sleep and memory disorders and anxiety.

We believe that the medicinal properties of THC may be linked to the molecule’s ability to compensate for a deficiency or defect in the production or functions of the endocannabinoids.

For example, scientists have found that people who experience certain types of chronic pain may have decreased production of endocannabinoids. People who consume marijuana for medicinal purposes report significant relief from pain. Because the THC in marijuana is the cannabinoid that reduces pain, it may be helping to compensate for the decreased production or functions of endocannabinoids in such patients.

Deciphering the role of endocannabinoids is still an emerging area of health research. Certainly much more research is needed to decipher their role in regulating different functions in the body.

In our view, it will also be important to continue to unravel the relationship between defects in the endocannabinoid system and the development of various diseases and clinical disorders. We think that the answers could hold great promise for the development of new therapies using the body’s own cannabinoids.

Prakash Nagarkatti, PhD, and Mitzi Nagarkatti, PhD, are Professors of Pathology, Microbiology and Immunology at the University of South Carolina. They receive funding from the National Science Foundation and the National Institutes of Health.

This article originally appeared in The Conversation and is republished with permission.

DEA Considers Synthetic THC Illegal

By Pat Anson, PNN Editor

The Drug Enforcement Administration considers a synthetic form of THC — the psychoactive compound in cannabis and hemp — a controlled substance that is illegal under federal law.

Hemp was legalized federally under the 2018 Farm Bill, in part because hemp contains only trace amounts of THC. However, some companies developed a synthetic form of hemp-derived THC — called THC acetate ester (THCO) — to give consumers an intoxicating effect. Because THCO was modeled after the THC found in hemp, they claimed it could be legally sold and consumed.

However, in a recent letter to Rod Kight, an attorney who specializes in cannabis law, the head of the DEA’s Drug & Chemical Evaluation Section said the agency considers delta-8 and delta-9 products containing THCO to be Schedule I controlled substances, which are illegal to sell or possess.

“Delta-9-THCO and delta-8-THCO do not occur naturally in the cannabis plant and can only be obtained synthetically, and therefore do not fall under the definition of hemp. Delta-9-THCO and delta-8-THCO are tetrahydrocannabinols having similar chemical structures and pharmacological activities to those contained in the cannabis plant,” the letter states.

Kight said he’s been telling clients and personal friends that THCO is potentially dangerous.

“Although I do not always agree with the DEA’s view on cannabis matters, I agree with this opinion and, frankly, am not surprised,” he wrote.  “It has always been my view that THCO is a controlled substance under federal law. Although it can be made from cannabinoids from hemp, THCO is not naturally expressed by the hemp plant. It is a laboratory creation that does not occur in nature, at least not from the hemp plant.”

As Kight points out in his blog, the DEA letter does not address delta-8 or delta-9 THC, which are natural and derived from hemp. Although those substances are considered legal at the federal level, over a dozen states have banned products containing them.

In states where they remain legal, delta-8 and 9 are widely available in candy, gummies, cookies, tinctures and beverages. Some companies claim the products have “uniquely potent effects on pain” and other health conditions, even while admitting there is little evidence to support those claims.

The FDA became so alarmed by the profusion of delta-8 and delta-9 THC products — and their marketing to children — that it sent letters to five companies in 2022 warning them to stop making unsubstantiated medical claims.

"These products often include claims that they treat or alleviate the side effects related to a wide variety of diseases or medical disorders, such as cancer, multiple sclerosis, chronic pain, nausea and anxiety," FDA Principal Deputy Commissioner Janet Woodcock, MD, said in a statement. "It is extremely troubling that some of the food products are packaged and labeled in ways that may appeal to children.”

The FDA says it had received over 100 reports of adverse events involving delta-8 THC, with poison control centers reporting over 2,300 cases, including one that involved the death of a child.

Florida Study Blames Cannabis for Hundreds of Deaths

By Pat Anson, PNN Editor

Advocates of medical marijuana – or cannabis use in general – have long said you can’t overdose on cannabis and that the natural plant is even “safer than many foods.”   

But researchers at Florida Atlantic University say cannabis products – particularly synthetic cannabis – are riskier than many people believe. In a study recently published in the Journal of Nursing Scholarship, they called cannabis “a legitimate public health concern” that has killed hundreds of Floridians in recent years.  

Analyzing 2014 to 2020 data from the Florida Department of Law Enforcement, researchers found that 386 people died as a result of drug intoxication caused by cannabis use. It’s important to note that the vast majority of those deaths (98.7%) involved accidents such as motor vehicle crashes, with a handful of deaths caused by murder or suicide. No overdoses were reported.

Most of the Florida deaths also involved other substances such as alcohol, opioids, heroin and cocaine. In nearly two-thirds of the deaths, synthetic cannabinoids such as K2 or Spice were involved. Synthetic cannabinoids are chemicals sprayed onto dried, shredded leaves that mimic the effect of cannabis, but are often quite stronger.  

“Synthetic cannabinoids are part of the new psychoactive substances that are two to 100 times more potent than THC, the main psychoactive compound in marijuana,” said lead author Armiel Suriaga, PhD, an assistant professor in FAU’s College of Nursing.

Suriaga and his colleagues found that over 13 percent of those who died had cardiac-related conditions such as high blood pressure, atherosclerosis, cardiac arrhythmias or an enlarged heart. There was one death from an ischemic stroke and one death from a hemorrhagic stroke, both related to synthetic cannabis use.

“The persistent deaths from cannabis and synthetic cannabis use are a legitimate public health concern,” said Suriaga. “The public should remain vigilant of the adverse health outcomes associated with these substances and their unpredictable effects, especially for men who are disproportionately affected, and particularly for people with underlying cardiovascular and respiratory conditions.”

‘Misleading and Sensational’ Study

Marijuana advocates say it was unfair of the researchers to include synthetic cannabis in their study, which was funded by the National Institutes on Drug Abuse and the American Association of Colleges of Nursing. 

“To lump in adverse effects from synthetically produced compounds in this analysis is misleading and sensational, as these products are not cannabis and their safety profile is not at all comparable to that of natural cannabis,” said Paul Armentano, Deputy Director of NORML.

“Cannabis is psychoactive and that is why advocacy groups opine in favor of its regulation, including the imposition of age controls and product testing for purity and potency. Adverse effects from cannabis, like dysphoria (anxiety), are possible but are best mitigated by regulation and education — not by criminal prohibition.”

Previous studies have looked at the relationship between cannabis and motor vehicle accidents, with mixed results. A survey of people in Michigan who used medical marijuana for chronic pain found that over half had driven while under the influence of cannabis, and one in five say they've driven while “very high.”

Other studies found a decrease in traffic fatalities in states that legalized medical marijuana. That may be because patients were substituting cannabis for alcohol and other drugs used to relieve their symptoms.

Medical Cannabis Reduced Opioid Use in High Dose Patients

By Pat Anson, PNN Editor

In recent years, there have been several studies and surveys – most of them anecdotal -- suggesting that cannabis reduces the need for opioid pain medication. A large new study takes that research a step further, finding direct evidence that chronic pain patients, including those on high doses, significantly reduced their opioid use once they started using medical cannabis.

Researchers with the New York State Department of Health and University of Albany School of Public Health followed over 8,100 patients on long-term opioid therapy (LOT) after they began using medical cannabis. All of the patients had been on opioids for at least 120 days, including some on relatively high daily doses of 90 or more morphine milligram equivalents (MME).

Researchers found that average daily doses declined significantly over time, especially for patients on high opioid doses. After eight months of using medical cannabis (MC), patients taking over 90 MME saw their daily doses fall by nearly 70 percent, compared to a 29% reduction in those getting 50 to 90 MME and a 15% reduction in those on 50 MME or less.

“This cohort study found that receiving MC for longer was associated with opioid dosage reductions. The reductions were larger among individuals who were prescribed higher dosages of opioids at baseline. These findings contribute robust evidence for clinicians regarding the potential benefits of MC in reducing the opioid burden for patients receiving LOT and possibly reduce their risk for overdose,” researchers reported in JAMA Network Open.

The study has some weaknesses. Researchers did not track the pain levels of patients or the types of pain conditions they suffered from. Also unknown is the dose or types of cannabis products they consumed.   

Although the study was conducted at a time when patients nationwide were losing access to opioids or having their doses reduced, researchers say it is “highly unlikely” that impacted their findings because the dosage decline for their patients didn’t begin until they started consuming cannabis.  

Marijuana advocates cheered the study findings.  

“The relationship between cannabis and opioid use is among of the best-documented aspects of marijuana policy,” Paul Armentano, Deputy Director of NORML, said in a statement. “In short, the science demonstrates that marijuana is a relatively safe and effective pain reliever — and that patients with legal access to it consistently reduce their use of prescription opioid medications.” 

A similar study of over 500 chronic pain patients being treated at medical cannabis clinics found a significant decline in their pain levels. And 85% of patients reported they either reduced or stopped using opioids.

A Third of Chronic Pain Sufferers Used Cannabis for Pain Relief

By Pat Anson, PNN Editor

Nearly a third of U.S. adults (31%) with chronic pain have used cannabis as an analgesic, according to a new survey that found over half of those who used cannabis said it enabled them to decrease their use of opioid medication and other pain therapies.

The survey findings, published JAMA Network Open, involved 1,724 people with chronic non-cancer pain who live in the 36 states (and Washington DC) that have legalized medical marijuana.

Unlike other studies that only focused on cannabis reducing opioid use, this survey found that over half of pain sufferers using cannabis also reduced or stop using non-opioid prescription pain relievers and over-the-counter analgesics. Many respondents also reported decreasing their use of physical therapy (39%), cognitive behavioral therapy (26%) and meditation (19%).  

“Most persons who used cannabis as a treatment for chronic pain reported substituting cannabis in place of other pain medications including prescription opioids,” wrote lead author Mark Bicket, MD, an Assistant Professor in the Department of Anesthesiology, University of Michigan School of Medicine.

“The high degree of substitution of cannabis with both opioid and nonopioid treatment emphasizes the importance of research to clarify the effectiveness and potential adverse consequences of cannabis for chronic pain. Our results suggest that state cannabis laws have enabled access to cannabis as an analgesic treatment despite knowledge gaps in use as a medical treatment for pain.”

The survey did not ask whether respondents smoked, vaped or ingested cannabis products, so there’s no way to tell which method was more effective at reducing pain. Nevertheless, it adds to a growing body of evidence that cannabis reduces pain and helps pain sufferers decrease their use of medications and other therapies.  

“Cannabis has established efficacy in the treatment of multiple conditions, including chronic pain, and it possesses a safety profile that is either comparable or superior to other controlled substances,” said Paul Armentano, Deputy Director of NORML, a marijuana advocacy group.

“So it is no wonder that those with legal access to it are substituting cannabis in lieu of other, potentially less effective and more harmful substances. As legal access continues to expand, one would expect the cannabis substitution effect to grow even more pronounced in the future.”

Several previous studies have also found that cannabis users often reduce their use of prescription opioids. A large survey conducted last year found that most medical marijuana users either stopped (42%) or reduced (37%) their use of opioids. A small number were also able to stop using psychiatric medications for anxiety, depression and PTSD.  

Another recent study at Cornell University found that legalization of recreational marijuana in 11 states led to significantly reduced prescribing for Medicaid patients for a broad range of medications used to treat pain, depression, anxiety, seizures and other health conditions.

A 2021 Harris Poll found that twice as many Americans are using cannabis or CBD to manage their pain than opioids.

Guideline Recommends Surgery Patients Be Screened for Cannabis Use

By Pat Anson, PNN Editor

New medical guidelines recommend that all patients undergoing anesthesia should be screened for cannabis use before surgery, and that procedures should be delayed if patients are thought to be under the influence or impaired.

The guideline by the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) is intended for anesthesiologists. It was developed by a panel of experts that included anesthesiologists, pain specialists and a patient advocate to deal with the growing number of people using either recreational or medical marijuana. An estimated 10% of Americans use cannabis monthly.

“Before surgery, anesthesiologists should ask patients if they use cannabis – whether medicinally or recreationally – and be prepared to possibly change the anesthesia plan or delay the procedure in certain situations,” Samer Narouze, MD, ASRA Pain Medicine president, said in a statement.

“They also need to counsel patients about the possible risks and effects of cannabis. For example, even though some people use cannabis therapeutically to help relieve pain, studies have shown regular users may have more pain and nausea after surgery, not less, and may need more medications, including opioids, to manage the discomfort. We hope the guidelines will serve as roadmap to help better care for patients who use cannabis and need surgery.”

The guideline recommends that patients be asked about their cannabis use before surgery, including whether it was smoked or ingested, the amount used, how recently it was used, and the frequency of use. It does not endorse drug testing of patients, meaning patients would have to be taken at their word.

If a patient admits recently smoking cannabis, the guideline recommends that non-emergency, elective procedures be postponed for a minimum of two hours because of the increased risk of a heart attack before, during and after surgery.

“In my opinion, these guidelines appear to be overly cautious at best and discriminatory at worst,” said Paul Armentano, Deputy Director of NORML, a marijuana advocacy group. “The relationship between cannabis and opioids is well-established, with nearly 100 papers in the literature showing that pain patients typically reduce or eliminate their intake of opioids over time following cannabis use.” 

Armentano cited a recent pilot study that found people who use cannabis respond no differently to local anesthesia than those who do not. Local anesthesia is different from general anesthesia because patients remain conscious during a procedure such as dental work. 

The evidence on cannabis and general anesthesia is rather thin, and because of that the ASRA guideline gives low grades to several of its recommendations, including the one about delaying surgery.  No recommendations are made about tapering cannabis use before or after surgery, or whether to prescribe opioids to patients who use cannabinoids due to “current lack of evidence.” Anesthesiologists are instead urged to use their own clinical judgement.   

In 2020, the Perioperative Pain and Addiction Interdisciplinary Network (PAIN) released more restrictive guidelines about cannabis use, recommending that heavy cannabis use be tapered or stopped before surgery.

Cannabis Works No Better Than Placebo in Pain Studies

By Pat Anson, PNN Editor

The placebo effect is responsible for much of the pain relief experienced by participants in clinical trials of cannabis, according to new analysis that also found a “strong positive bias” in media coverage of the studies.

Researchers at the Karolinska Institute in Sweden analyzed the results of 20 placebo-controlled studies of cannabis products involving almost 1,500 people with chronic pain conditions. The cannabis products were administered as pills, sprays, oils, smoke or vapor; and most of the studies were conducted in the United States, UK or Canada.

Researchers found that many participants reported significant pain relief, but there were no differences in pain reduction between those who used cannabis products and those who used a placebo, a sham treatment that should have no effect.

“There is a distinct and clinically relevant placebo response in studies of cannabis for pain,” says Filip Gedin, PhD, a researcher in the Department of Clinical Neuroscience at Karolinska and lead author of the study published in JAMA Network Open.

Gedin and his colleagues also examined coverage the 20 studies received in the news media using Altmetric, a method of evaluating mentions in the media as either positive, negative or neutral. They did not identify the publishers of the 136 news articles that were analyzed or provide any examples of their coverage.

Researchers found that the cannabis studies received much greater media attention than other clinical studies and tended to be more positive, regardless of what the studies’ outcomes actually were. The media coverage of cannabis was so positive, in fact, that researchers wonder if it might influence findings in future studies.  

“The positive media attention and wide dissemination may uphold high expectations and shape placebo responses in future trials, which has the potential to affect the outcome of clinical trials, regulatory decisions, clinical practice, and ultimately patient access to cannabinoids for pain relief,” Gedin wrote. “We therefore consider this question to be of high importance, as the positive reporting toward cannabinoids regardless of study quality and effect size may subsequently lead to increased expectations that may ultimately influence the outcomes in clinical trials.”

The placebo effect is a well-documented but poorly understood condition in which a patient responds to a sham drug or treatment that should have no therapeutic value. A 2018 study at Northwestern University, for example, found that about half of patients who took a sugar pill they thought was an analgesic had a 30% reduction in pain – a level considered good enough for an actual painkiller.    

In another study, researchers identified some participants as “placebo responders” who are more likely to respond to a sugar pill because their brains react differently – which may explain why some patients find a medication effective and others don’t.    

Whatever the cause, researchers at the Karolinska Institute say more effort is needed to understand the placebo effect and how media coverage could make it even more potent.

“We cannot say with 100% certainty that media coverage is responsible for the high placebo response observed in our review,” Gedin wrote in an op/ed published in The Conversation.

“But given placebos were shown to be just as good as cannabis for managing pain, our results show just how important it is to think about the placebo effect and how it can be influenced by external factors – such as media coverage. For treatments, such as cannabinoids, that receive a lot of media attention, we need to be extra rigorous in our clinical trials.”

Why Cannabis Holds Promise for Pain Management

By Benjamin Land, University of Washington Center for Cannabis Research

Drug overdose deaths from opioids continue to rise in the U.S. as a result of both the misuse of prescription opioids and the illicit drug market.

But an interesting trend has developed: Opioid emergency room visits drop by nearly 8% and opioid prescriptions are modestly lower in states where marijuana is legalized.

Marijuana is produced by the cannabis plant, which is native to Asia but is now grown throughout the world. Individuals use marijuana for both its psychoactive, euphoria-inducing properties and its ability to relieve pain.

Chemicals produced by the cannabis plant are commonly known as cannabinoids. The two primary cannabinoids that occur naturally in the cannabis plant are THC – the psychoactive compound in marijuana – and CBD, which does not cause the sensation of being high.

Many marijuana users say they take it to treat pain, suggesting that readily available cannabinoids could potentially be used to offset the use of opioids such as morphine and oxycodone that are commonly used in pain treatment. A safer, natural alternative to opioid painkillers would be an important step toward addressing the ongoing opioid epidemic.

Intriguingly however, research suggests that cannabis use could also lessen the need for opioids directly by interacting with the body’s own natural opioid system to produce similar pain-relief effects.

I am a neuropharmacology scientist who studies both opioids and cannabinoids as they relate to pain treatment and substance abuse. My research focuses on the development of drug compounds that can provide chronic pain relief without the potential for overuse and without the tapering off of effectiveness that often accompanies traditional pain medications.

How Opioids Work

Our bodies have their own built-in opioid system that can aid in managing pain. These opioids, such as endorphins, are chemicals that are released when the body experiences stress such as strenuous exercise, as well as in response to pleasurable activities like eating a good meal. But it turns out that humans are not the only organisms that can make opioids.

In the 1800s, scientists discovered that the opioid morphine – isolated from opium poppy – was highly effective at relieving pain. In the last 150 years, scientists have developed additional synthetic opioids like hydrocodone and dihydrocodeine that also provide pain relief.

Other opioids like heroin and oxycodone are very similar to morphine, but with small differences that influence how quickly they act on the brain. Fentanyl has an even more unique chemical makeup. It is the most powerful opioid and is the culprit behind the current surge in drug overdoses and deaths, including among young people.

Opioids, whether naturally produced or synthetic, produce pain relief by binding to specific receptors in the body, which are proteins that act like a lock that can only be opened by an opioid key.

One such receptor, known as the mu-opioid receptor, is found on pain-transmitting nerve cells along the spinal cord. When activated, mu-receptors tamp down the cell’s ability to relay pain information. Thus, when these opioids are circulating in the body and they reach their receptor, stimuli that would normally cause pain are not transmitted to the brain.

These same receptors are also found in the brain. When opioids find their receptor, the brain releases dopamine – the so-called “feel-good” chemical – which has its own receptors. This is in part why opioids can be highly addicting. Research suggests that these receptors drive the brain’s reward system and promote further drug-seeking. For people who are prescribed opiates, this creates the potential for abuse.

Opioid drugs, which include heroin, oxycodone and fentanyl, are highly addictive.

Opioid receptors are dynamically regulated, meaning that as they get exposed to more and more opioids, the body adapts quickly by deactivating the receptor. In other words, the body needs more and more of that opioid to get pain relief and to produce the feel-good response. This process is known as tolerance. The drive to seek more and more reward paired with an ever-increasing tolerance is what leads to the potential for overdose, which is why opioids are generally not long-term solutions for pain.

How THC and CBD Relieve Pain

Both THC and CBD have been shown in numerous studies to lessen pain, though – importantly – they differ in which receptors they bind to in order to produce these effects.

THC binds to cannabinoid receptors that are located throughout the central nervous system, producing a variety of responses. One of those responses is the high associated with cannabis use, and another is pain relief. Additionally, THC is believed to reduce inflammation in a manner similar to anti-inflammatory drugs like ibuprofen.

In contrast, CBD appears to bind to several distinct receptors, and many of these receptors can play a role in pain reduction. Importantly, this occurs without the high that occurs with THC.

Because they target different receptors, THC and CBD may be more effective working in concert rather than alone, but more studies in animal models and humans are needed.

Cannabinoids may also be helpful for other conditions as well. Many studies have demonstrated that cannabinoid drugs approved for medical use are effective for pain and other symptoms like spasticity, nausea and appetite loss.

Along with the pairing of THC and CBD, researchers are beginning to explore the use of those two cannabinoids together with existing opioids for pain management. This research is being done in both animal models and humans.

These studies are designed to understand both the benefits – pain relief – and risks – primarily addiction potential – of co-treatment with cannabinoids and opioids. The hope would be that THC or CBD may lower the amount of opioid necessary for powerful pain relief without increasing addiction risk.

For example, one study tested the combination of smoked cannabis and oxycontin for pain relief and reward. It found that co-treatment enhanced pain relief but also increased the pleasure of the drugs. This, as well as a limited number of other studies, suggests there may not be a net benefit.

However, many more studies of this type will be necessary to understand if cannabinoids and opioids can be safely used together for pain. Still, using cannabinoids as a substitution for opioids remains a promising pain treatment strategy.

The next decade of research will likely bring important new insights to the therapeutic potential of cannabinoids for chronic pain management. And as marijuana legalization continues to spread across the U.S., its use in medicine will undoubtedly grow exponentially.

Benjamin Land, PhD is a Research Associate Professor of Pharmacology at the University of Washington School of Medicine and the UW Center for Cannabis Research. Land receives funding from the National Institutes of Health for cannabinoid research, and has received cannabinoid related funding from the University of Washington Addiction and Drug Abuse Institute and SCAN Design Foundation.

This article originally appeared in The Conversation and is republished with permission.

Smoking Marijuana More Effective Than CBD Extracts for Back Pain

By Pat Anson, PNN Editor

One of the reasons many medical marijuana users prefer edibles over smoking is that they are perceived as healthier.  Marijuana smoke contains many of the same chemicals and carcinogens as cigarette smoke, and could have harmful effects on people with respiratory or cardiovascular problems.

But a small new study conducted in Israel found that smoking marijuana is better than ingesting it, at least when it comes to treating chronic lower back pain. Researchers enrolled 24 adults with MRI or CT scans that showed evidence of disc herniation or spinal stenosis, and had them try two different types of cannabis treatment.

The first was a cannabis extract rich in cannabidiol (CBD), which was taken sublingually under the tongue daily for 10 months. After a month of no treatment, the same group smoked cannabis flowers rich in tetrahydrocannabinol (THC) up to four times a day for 12 months. Participants were allowed to take pain medication as needed, including oxycodone and acetaminophen.

The study findings, published in the Rambam Maimonides Medical Journal, showed there was little to no improvement in back pain when participants took the extract, but significant improvement when they smoked cannabis. The use of analgesic drugs also dropped significantly while smoking.

Notably, three patients dropped out of the extract phase of the study because it wasn’t helping them, but then returned to participate in the smoking phase.

“The current study is the first, to our knowledge, to indicate that THC-rich smoked therapy is more advantageous in ameliorating LBP (lower back pain), than low THC CBD-rich sublingual extracts. Despite the small number of patients, our data indicate that THC-rich smoked therapy is helpful in mitigating LBP,” researchers reported.

The most commonly reported adverse events during the study were nausea, dizziness, drowsiness and fatigue during the extract phase; sore throat and drowsiness were reported during the smoking phase. All of the adverse symptoms disappeared after a dose tolerance was reached. Most of the adverse effects were in female patients.

A 2019 study of medical marijuana users also found that smoking cannabis provided more pain relief than ingesting it. Over 3,300 people logged their symptoms on a mobile app while using a variety of cannabis products, including dried flower, edibles, tinctures and ointments. Smoking the dried flower provided more pain relief than any other cannabis product, regardless of the amount of THC.

Another problem with CBD edibles is that they are frequently mislabeled. A recent study of 80 CBD oils found that only 43 had concentrations of cannabidiols that were within 10% of their label claims – an accuracy rate of just 54 percent.

Lab Mice Agree: Delta-8 Just Like Taking Delta-9

By Pat Anson, PNN Editor

Laboratory mice at a research facility have figured out something that Congress failed to do when it legalized hemp in 2018: the tetrahydrocannabinol (THC) found in hemp can get you just as high as the THC found in marijuana.

That finding, in a new study led by researchers at the University of Connecticut, undermines one of the tenets of the 2018 Farm Bill, which made it possible for U.S. farmers to grow hemp again as a cash crop. The thinking at the time was that since hemp contained less than 0.3% tetrahydrocannabinol, the main psychoactive ingredient in marijuana, it couldn’t be used to get high.

The mice found otherwise. When given Delta-8 THC derived from hemp twice a day for five days, the mice showed signs of lethargy, dependence and “liking” behavior. Although not as potent as the Delta-9 THC derived from marijuana, researchers reported in the journal Drug and Alcohol Dependence that Delta-8 had similar psychoactive effects on the mice, “including evidence of dependence and abuse potential.”

“So they’re telling us the same thing people buying the stuff in gas stations tell us: (Delta-8) feels like THC,” says Steve Kinsey, PhD, a UConn School of Nursing professor and director of the Center for Advancement in Managing Pain.

Kinsey and his colleagues say Delta-8 and Delta-9 molecules are similar and act in the same way on the body. But while Delta-9 is illegal under federal law, Delta-8 is legally being sold in a wide array of edibles, beverages, tinctures and other products. Because they are made with CBD and THC derived from hemp, they can be purchased without an ID or marijuana prescription – even in states where medical or recreational marijuana is illegal.  A recent study found that some hemp-based edibles have 360% more THC than those sold in cannabis dispensaries.

“It’s creating a fight between marijuana and hemp” growers, says John Harloe, an attorney on a Colorado taskforce that is trying to address the different chemical variations of THC and their hazy legal status.

“(Marijuana) must be sold through dispensaries and pay high taxes, while hemp producers can sell essentially the same product but without the same regulations, due to the ambiguity in the Farm Bill,” Harloe said in a statement.

The Food and Drug Administration has been slow to regulate CBD products, but earlier this year the agency sent the first warning letters to companies for selling products containing Delta-8. The letters don’t take issue with Delta-8’s legal status, but focus instead on its unauthorized marketing as a treatment for chronic pain, nausea, anxiety and even cancer.

Biden Pardons Thousands Convicted of Marijuana Possession

By Pat Anson, PNN Editor

President Joe Biden is pardoning everyone who has been convicted of simple marijuana possession under federal law and is urging governors to take similar action for those convicted of possession under state laws.

Biden’s blanket pardon will affect over 6,500 people who have been convicted or charged with federal offenses for marijuana possession. If governors join in, it could potentially impact millions of others who have been convicted of possession under state laws and now have criminal records. The pardon does not alter federal or state laws that prohibit marijuana trafficking, marketing and under-age sales.

“Sending people to prison for possessing marijuana has upended too many lives and incarcerated people for conduct that many states no longer prohibit. Criminal records for marijuana possession have also imposed needless barriers to employment, housing, and educational opportunities,” Biden said in a statement. “Just as no one should be in a Federal prison solely due to the possession of marijuana, no one should be in a local jail or state prison for that reason, either.” 

The mass pardon partially fulfills a campaign promise made by Biden during the 2020 election campaign and begins the process of changing marijuana’s status under federal law. Biden said he would ask Attorney General Merrick Garland to “expeditiously” review how marijuana is classified.

Marijuana was classified by the DEA as a Schedule I controlled drug in 1970, on the same level as heroin and LSD, which means it has “no currently accepted medical use.” That classification now makes little sense, with 37 states and the District of Columbia having legalized medical marijuana as a treatment for chronic pain and other health issues.

“We are pleased that today President Biden is following through on this pledge and that he is also encouraging governors to take similar steps to ensure that the tens of millions of Americans with state-level convictions for past marijuana crimes can finally move forward with their lives,” said Erik Altieri, Executive Director of the National Organization for the Reform of Marijuana Laws (NORML).  

Altieri said the DEA should “deschedule” marijuana under the Controlled Substances Act, and not just change its status to a less restrictive Schedule II or III level. Descheduling would amount to full legalization.

“Nearly half of voters now agree that legalizing marijuana ought to be a priority of Congress, and such action can only be taken by descheduling cannabis and repealing it from the US Controlled Substances Act — thereby regulating it in a manner similar to alcohol,” he said.

In 2020, the House passed legislation to decriminalize marijuana at the federal level, but the bill never came to a vote in the Senate, then controlled by Republicans. Legalization would appear unlikely if the 2022 midterm elections result in the GOP taking control of either the House or Senate.

Last week, a House GOP caucus released a “Family Policy Agenda” saying Congress should not legalize marijuana. The report claimed legalization at the state level “led to an explosion of marijuana use among children, which is having a hugely negative impact on their health.”

More Americans are now using marijuana and cannabis-based products to manage their pain than pharmaceutical drugs. A 2021 Harris Poll found that 16% of adults are using cannabis or CBD for pain relief, compared to 8% who use opioid medications and 11% who use non-opioid pain relievers.

Medical Cannabis Helps Pain Patients Stop or Reduce Use of Opioids

By Pat Anson, PNN Editor

A large new survey of medical marijuana users found that many who have chronic pain were able to reduce or even stop their use of opioid pain medication. The survey also found that pain patients reported less pain and better physical and social functioning once they started using medical cannabis.

Researchers at Emerald Coast Research and Florida State University College of Medicine surveyed 2,183 people recruited from marijuana dispensaries in Florida. Participants had a range of health problems, including chronic pain, anxiety, depression, insomnia and post-traumatic stress disorder (PTSD).  Most were using medical cannabis daily.

Answers to the 66-question online survey revealed that nine out of ten participants found medical cannabis to be very or extremely helpful in treating their medical conditions.

Most (61%) reported using opioid pain medication prior to medical cannabis. Of those, 79 percent reported either stopping (42%) or reducing (37%) their use of prescription opioids. A small number were also able to stop using psychiatric medications for anxiety, depression and PTSD.

“The majority of Florida medical cannabis users surveyed described medical cannabis as helpful and important to their overall quality of life. Notably, a large percentage of patients reported improvements in the areas of physical functioning, social functioning, and bodily pain after beginning medical cannabis,” wrote lead author Carolyn Pritchett, PhD, founder of Emerald Coast Research.

“We also found a substantial number of patients reduced the amount of OBPM (opioid-based pain medications) used after gaining access to legalized medical cannabis, with some patients specifically describing improved functioning in daily life as a result.”

The survey findings, published in the journal Substance Use and Misuse, lend credence to previous studies suggesting that legalization of cannabis leads to fewer prescriptions for opioids and other medications.

A recent study by researchers at Cornell University found that legalization of recreational marijuana in 11 states significantly reduced prescribing for Medicaid patients for a broad range of medications used to treat pain depression, anxiety, seizures and other health conditions.

A 2021 study of chronic pain patients being treated at medical cannabis clinics also found that most were able to stop or reduce their use of opioids. Almost half (48%) reported a significant decrease in pain, and most said they had better quality of life (87%) and better physical function (80%) while using medical cannabis.

A 2021 Harris Poll found that twice as many Americans are using cannabis or CBD to manage their pain than opioid medication.

Hemp-Derived Delta-8 Raises Health Concerns

By Eric Berger, Kaiser Health News

Suzan Kennedy has smoked marijuana, and says her Wisconsin roots mean she can handle booze, so she was not concerned earlier this year when a bartender in St. Paul, Minnesota, described a cocktail with the cannabinoid delta-8 THC as “a little bit potent.”

Hours after enjoying the tasty drink and the silliness that reminded Kennedy of a high from weed, she said, she started to feel “really shaky and faint” before collapsing in her friend’s arms. Kennedy regained consciousness and recovered, but her distaste for delta-8 remains, even though the substance is legal at the federal level, unlike marijuana.

“I’m not one to really tell people what to do,” said Kennedy, 35, who lives in Milwaukee and works in software sales. But if a friend tried to order a delta-8 drink, “I would tell them, ‘Absolutely not. You’re not putting that in your body.’”

The FDA and some marijuana industry experts share Kennedy’s concerns. At least a dozen states have banned the hemp-derived drug, including Colorado, Montana, New York, and Oregon, which have legalized marijuana. But delta-8 manufacturers call the concerns unfounded and say they’re driven by marijuana businesses trying to protect their market share.

So what is the difference? The flower of the marijuana plant, oil derived from it, and edibles made from those contain delta-9 tetrahydrocannabinol, the substance that produces the drug’s high, and can be legally sold only at dispensaries in states that have legalized marijuana.

Similar products that contain delta-8 THC are sold online and at bars and retailers across much of the U.S., including some places where pot remains illegal. That’s because a 2018 federal law legalized hemp, a variety of the cannabis plant. Hemp isn’t allowed to contain more than 0.3% of the psychotropic delta-9 THC found in marijuana.

Delta-8 Contaminants

The concerns about delta-8 are largely focused on how it’s made. Delta-8 is typically produced by dissolving CBD — a compound found in cannabis plants — in solvents, such as toluene that is often found in paint thinner. Some people in the marijuana industry say that process leaves potentially harmful residue. A study published in the journal Chemical Research in Toxicology last year found lead, mercury, and silicon in delta-8 electronic cigarettes.

The FDA has issued warnings about the “serious health risks” of delta-8, citing concerns about the conversion process, and has received more than 100 reports of people hallucinating, vomiting, and losing consciousness, among other issues, after consuming it. From January 2021 through this February, national poison control centers received more than 2,300 delta-8 cases, 70% of which required the users to be evaluated at health care facilities, according to the FDA.

Delta-8 is “just the obvious solution to people who want to have access to cannabis but live in a state where it’s illegal,” said Dr. Peter Grinspoon, a primary care physician at Massachusetts General Hospital and a longtime medical cannabis provider. “You can either get in a lot of trouble buying cannabis, or you can get delta-8.”

Grinspoon described delta-8 as about half as potent as marijuana. But because of the lack of research into delta-8’s possible benefits and the absence of regulation, he would not recommend his patients use it. If it were regulated like Massachusetts’ medical and recreational marijuana programs, he said, harmful contaminants could be flagged or removed.

‘Incredible Potential as Therapeutic’

Christopher Hudalla, chief scientific officer at ProVerde Laboratories, a Massachusetts marijuana and hemp testing company, said he has examined thousands of delta-8 products and all contained contaminants that could be harmful to consumers’ health.

Delta-8 has “incredible potential as a therapeutic” because it has many of the same benefits as marijuana, minus some of the intoxication, said Hudalla. “But delta-8, like unicorns, doesn’t exist. What does exist in the market is synthetic mixtures of unknown garbage.”

Justin Journay, owner of the delta-8 brand 3Chi, is skeptical of the concerns about the products. He started the company in 2018 after hemp oil provided relief for his shoulder pain. He soon started wondering what other cannabinoids in hemp could do. “‘There’s got to be some gold in those hills,’” Journay recalled thinking. He said his Indiana-based company now has more than 300 employees and sponsors a NASCAR team.

When asked about the FDA’s reports of bad reactions, Journay said: “There are risks with THC. There absolutely are. There are risks with cheeseburgers.”

He attributes the side effects to taking too much. “We say, ‘Start low.’ You can always take more,” Journay said.

Journay said that he understands concerns about contaminants in delta-8 products and that his company was conducting tests to identify the tiny portion of substances that remain unknown, which he asserts are cannabinoids from the plant.

An analysis of 3Chi delta-8 oil conducted by Hudalla’s firm last year and posted on 3Chi’s website found multiple unidentified compounds that “do not occur naturally” and thus “would not be recommended for human consumption.” Delta-8 oil is still sold on 3Chi’s site.

Journay said the analysis found that only 0.4% of the oil contained unknown compounds. “How can they then definitively say that compound isn’t natural when they don’t even know what it is?” he said in an email.

“The vast majority of negative information out there and the push to make delta-8 illegal is coming from the marijuana industries,” Journay said. “It’s cutting into their profit margins, which is funny that the marijuana guys would all of a sudden be for prohibition.”

Delta-8 products do appear to be significantly cheaper than weed. For example, Curaleaf, one of the world’s largest cannabis companies, offers packages of gummies that contain 100 milligrams of delta-9 THC for $25, plus sales tax, at a Massachusetts dispensary. At 3Chi, gummies with 400 milligrams of delta-8 cost $29.99 online, with no tax.

Journay’s criticism of the marijuana industry holds some truth, said Chris Lindsey, government relations director for the Marijuana Policy Project, which advocates for legalization of marijuana for adults.

“We see this happen in every single adult-use legalization state,” said Lindsey. “Their established medical cannabis industry will sometimes be your loudest opponents, and that’s a business thing. That’s not a marijuana thing.”

Still, the bans might not be working fully. In New York, which banned delta-8 in 2021, Lindsey said, it’s available at any bodega.

“In an environment where whole-plant cannabis is legally available, there would be little to no demand for these alternative products.”

— Paul Armentano, NORML

In July, Minnesota implemented a law that limits the amount of THC, including delta-8, allowed in hemp products outside of its medical marijuana program. News reports said the law would wipe out delta-8. But the state cannot “control what’s being sold over the internet outside of Minnesota and shipped in,” said Maren Schroeder, policy director for Sensible Change Minnesota, which aims to legalize recreational cannabis for adults.

Max Barber, a writer and editor in Minneapolis, remains interested in delta-8 despite his state’s restrictions. Even though he could likely obtain a medical marijuana prescription because he has an anxiety disorder and chronic sleep problems, he hasn’t pursued it because pot made his anxiety worse. He used CBD oil but found the effects inconsistent. In March 2021, he tried a 10-milligram delta-8 gummy.

“It got me pretty high, which I don’t enjoy,” he said.

Then he found what he considers the right dosage for him: one-third of a gummy, which he takes in the evening. He said he now gets between six and eight hours of sleep each night, has less anxiety, and is better able to focus. “I have become kind of an evangelist for delta-8 for everyone I know who has sleep problems,” said Barber, who bought enough gummies to last for months after the new law went into effect.

To address concerns about delta-8, the federal government should regulate it and make accessing cannabis easier for consumers, said Paul Armentano, deputy director of the National Organization for the Reform of Marijuana Laws.

He pointed to a recent study in the International Journal of Drug Policy showing that the number of Google searches for delta-8 in the U.S. soared in 2021 and that interest was especially high in states that restricted cannabis use. “In an environment where whole-plant cannabis is legally available, there would be little to no demand for these alternative products,” said Armentano.

Lindsey, of the Marijuana Policy Project, isn’t so sure that would matter. When he first learned of delta-8’s growing popularity in 2021, he thought it would go the way of drugs like K2 or Spice that he said fall between the regulatory rules long enough to get on shelves before eventually getting shut down.

“That didn’t materialize,” said Lindsey. “The more that we understand about that plant, the more of these different cannabinoids are going to come out.” And that, he said, will in turn spur interest from consumers and businesses.

Kaiser Health News is a national newsroom that produces in-depth journalism about health issues.

Older Adults Look Beyond Western Medicine for Help With Joint Pain

By Pat Anson, PNN Editor

Most older Americans use over-the-counter pain medication and exercise to manage their joint pain, according to a large new survey of adults over age 50. Marijuana, opioids and non-steroidal anti-inflammatory drugs (NSAIDs) were rated the most effective pain relievers among those who used them.

The survey of 2,277 adults aged 50 to 80 was conducted online and over the phone early this year as part of the University of Michigan’s National Poll on Healthy Aging. It found that many older adults looked beyond conventional Western medicine for help with their joint pain, but few talked to their doctors about it.

Eight out of ten people (80%) with joint pain said they were confident they could manage it on their own. The survey found that two-thirds (66%) used over-the-counter pain relievers such as NSAID’s or acetaminophen.

The vast majority (89%) also used non-pharmacologic treatments to manage their symptoms, including exercise (64%), massage (26%), physical therapy (24%), splints or braces (13%), and acupuncture or acupressure (5%).

One in four (26%) said they take supplements, such as glucosamine, chondroitin and turmeric, while 11% use cannabidiol (CBD) products and 9% use marijuana.

Only a minority use prescription-based treatments, such as non-opioid pain relievers (18%), steroid joint injections (19%), oral steroids (14%), opioids (14%) and disease-modifying anti-rheumatic drugs (4%).

NATIONAL POLL ON HEALTHY AGING

“There are sizable risks associated with many of these treatment options, especially when taken long-term or in combination with other drugs. Yet 60 percent of those taking two or more substances for their joint pain said their health care provider hadn’t talked with them about risks, or they couldn’t recall if they had,” said Beth Wallace, MD, Assistant Professor of Internal Medicine at Michigan Medicine and a staff rheumatologist at the VA Ann Arbor Healthcare System.

“This suggests a pressing need for providers to talk with their patients about how to manage their joint pain, and what interactions and long-term risks might arise if they use medications to do so.”

Both NSAIDs and oral steroids have health risks, especially for older adults. Chronic NSAID use can worsen medical conditions such as hypertension, kidney disease, gastrointestinal bleeding and cardiovascular disease. Short-term use of oral steroids is associated with similar problems, as well as increased risk of developing diabetes, cataracts, insomnia, depression, and anxiety.

The risks are even greater if NSAIDs and oral steroids are taken together. Despite this, about one in four older adults taking oral steroids for joint pain said they had not discussed the potential risks with their provider.

Joint pain is common among older adults, including those who have not been formally diagnosed with arthritis. Nearly half of those surveyed reported joint pain that limited their daily activities, but few rated their symptoms as severe and most regarded joint pain as a normal part of aging.

Those with severe joint pain were somewhat fatalistic about it, with nearly half (49%) agreeing with the statement that “there is nothing a person with arthritis or joint pain can do to make their symptoms better.” Only 10% of those with mild joint pain agreed there was nothing they could do about it.

“Older adults with fair or poor physical or mental health were much more likely to agree with the statement that there’s nothing that someone with joint pain can do to ease their symptoms, which we now know to be untrue. Health providers need to raise the topic of joint pain with their older patients, and help them make a plan for care that might work for them,” said poll director Preeti Malani, MD, a Michigan Medicine physician who specializes in geriatrics and infectious diseases.