A recent shift away from opioid therapy has increased interest in medical cannabis as a therapeutic alternative for chronic pain.
However, currently, there is a lack of evidence to support the use of cannabis for chronic musculoskeletal pain, including low back pain.
The results of this research present an opportunity for evidence-based chiropractors. Medical doctors and their patients will be searching for effective and safe alternatives.
A man in his late-20s presents to your clinic with a five-month history of chronic low back pain. He has tried OTC medications and Lyrica prescribed by his medical doctor, but these have failed to bring relief. He wants to try cannabis because he thinks it is safe, and a friend uses it daily to make his pain tolerable.
The patient’s wife suggested that he check out chiropractic care. The patient mentions that he and his wife are trying to get pregnant. How should you advise your patient? What does the current research say?
The Prevalence of Chronic Pain
According to the Centers for Disease Control and Prevention, 50 million adults in the United States have chronic daily pain, 19.6 million of whom experience high-impact pain that interferes with everyday life or work activities. The cost of pain to our nation is estimated at over $600 billion annually. A recent shift away from opioid therapy has increased interest in medical cannabis as a therapeutic alternative for chronic pain.
Research on Cannabis
Currently, there are no randomized, placebo-controlled trials assessing the effectiveness of cannabis for chronic low back pain. The BMJ recently published an umbrella review of meta-analyses that reported on the efficacy and safety of cannabis, cannabinoids, or cannabis-based medicines.1
This research team found that cannabinoids can benefit patients with chronic cancer-related pain and neuropathic pains such as complex regional pain syndrome, spinal cord injury, and peripheral neuropathy. No benefit was found for patients with non-cancerous neck or back pain, or other non-cancerous musculoskeletal disorders.
Additionally, a randomized, placebo-controlled trial found no improvement in pain in patients with chronic knee pain.2
Currently, there is a lack of evidence to support the use of cannabis for chronic musculoskeletal pain, including low back pain.
Safety Profile for Cannabis
Numerous adverse reactions are associated with cannabis. These include dry mouth, memory problems, dizziness, impaired motor coordination, diarrhea, anxiety, depression, hallucinations, drowsiness, and fatigue. Cannabis can also interact with medications, such as blood thinners.
Serious Harms
A systematic review and meta-analysis demonstrated that cannabis smokers had more than double the risk of suicide attempts compared with non-cannabis users (odds ratio 2.33).3 In a case-control study, researchers reported that daily cannabis users had triple the incidence of psychotic disorders compared with never-users (odds ratio 3.20).4 Another study revealed that cannabis use almost doubled the rates of anxiety disorder (adjusted odds ratio, 1.92).5
Furthermore, male exposure to cannabis ≥1 time per week doubles the risk of spontaneous abortion in a female partner by negatively affecting sperm quality and DNA. This risk persists even when the female partner does not use marijuana.6
Clinical Advice
Considering that there is no evidence for cannabis’ effectiveness in patients with chronic low back pain and that serious harms are frequent, you should recommend that your current male patient avoid cannabis. The potential harms outweigh the benefits, especially if he and his wife want to conceive children.
Opportunity for Chiropractors
Recently, an international multidisciplinary research team conducted a systematic review and meta-analysis to compare the benefits and harms of common treatments for adults with nonspecific chronic low back pain without radiculopathy.7 This meta-analysis provided 22 summary data points.
Overall, the research team found that manipulation and acupuncture were effective in reducing pain intensity. The benefits of the pharmacological or invasive interventions were uncertain due to the absence of trials meeting the eligibility criteria.
The harm warnings (serious adverse events) were lowest for acupuncture, spinal manipulation, NSAIDs, combination-ingredient opioids, and steroid injections, while they were higher for single-ingredient opioid analgesics (moderate risk) and surgery (very high risk).
The results of this research present an opportunity for evidence-based chiropractors. Medical doctors and their patients will be searching for effective and safe alternatives.
References
Solmi M, De Toffol M, Kim JY, et al. Balancing risks and benefits of cannabis use: umbrella review of meta-analyses of randomised controlled trials and observational studies BMJ, 2023;382:e072348.
Campbell CM, Mun CJ, Hamilton KR, et al. Within-subject, double-blind, randomized, placebo-controlled evaluation of combining the cannabinoid dronabinol and the opioid hydromorphone in adults with chronic pain. Neuropsychopharmacol, 2023 May 18.
Fresán A, Dionisio-García DM, González-Castro TB, et al. Cannabis smoking increases the risk of suicide ideation and suicide attempt in young individuals of 11-21 years: a systematic review and meta-analysis. J Psychiatr Res, 2022;153:90-98.
Di Forti M, Quattrone D, Freeman TP, et al.; EU-GEI WP2 Group. The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study. Lancet Psychiatry, 2019 Mar 19.
Hines LA, Freeman TP, Gage SH, et al. Association of high-potency cannabis use with mental health and substance use in adolescence. JAMA Psychiatry, 2020;77:1044-1051.
Harlow AF, Wesselink AK, Hatch EE, et al. Male preconception marijuana use and spontaneous abortion: a prospective cohort study. Epidemiol, 2021;32:239-247.
Feise RJ, Mathieson S, Kessler RS, et al. Benefits and harms of treatments for chronic non-specific low back pain without radiculopathy: systematic review and meta-analysis. Spine J, 2022;S1529-9430(22)01006-3.
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