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
When I graduated from chiropractic college in 1981 and started practice, I heard it all, and very little was positive. “You are a quack; you do not know what a subluxation is; you couldn’t get into a real health care program, so you chose the one that is slightly above a mail-order degree; you have no proof that chiropractic works; Are you really licensed?”, and so much more.
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A central challenge in creating our identity is that chiropractic is a method of care, not a technique or procedure. This is an important concept for us to promote. Our patients are treated with lifestyle modification, exercise, nutritional supplements, diet and a whole-body approach to accelerate the natural healing process. We are not simply CMT providers.
The results of a global survey released late last year (2023) unveiled some startling findings among medical and nursing students. The “Clinician of the Future: 2023 Education Edition” surveyed 2,212 students, of which 446 were in the United States, from 91 countries.
