The Current Evidence for Marijuana as Medical Treatment
These authors present a thoughtful analysis of the current state of knowledge about the medical uses of marijuana.
Here are some of the salient points.
Marijuana and Pain
The data regarding the use of cannabinoids for pain related to injury or surgery are "murky".
A nonblinded, nonrandomized, dose-escalation study assessing the effect of an oral cannabis extract containing THC and CBD on postoperative pain found a dose dependent reduction in postoperative pain among patients taking a single dose of cannabis extract for postoperative pain; however, all patients requested some form of additional rescue pain medication and the trial was stopped early because of a serious vasovagal episode experienced by 1 patient in the high dose cannabis extract arm.
A small, doubleblinded crossover study found that cannabis extract had no effect compared with the placebo (diazepam) on the perception of pain in healthy female volunteers subjected to various painful stimuli.
Another study found that lower doses of inhaled marijuana decreased pain in healthy volunteers with prior self-reported marijuana use; however, paradoxically, it significantly increased pain intensity at higher doses.
A major limitation of these studies is the inability to properly blind participants to treatment allocation because of the psychomotor effects of THC. It is likely that subjects were able to deduce their treatment allocation, which introduces bias.
A 2018 review on the topic did not find any advantage of cannabinoids over nonopioid analgesics for pain related to injury or surgery.
Cannabinoids have been celebrated in the lay press as a potential weapon against opioid overuse and abuse, but data from human studies to support this enthusiasm are limited.
One study found that coadministration of cannabis and oxycodone increased participants’ pain threshold during a cold-water immersion test compared with monotherapy with either cannabis or oxycodone. Interestingly, coadministration of marijuana and opioids increased participants’ positive perception of the opioid drug and made them more likely to take the opioid again.
Another study found that the combined use of marijuana and prescription opioids had little effect on the pain experience of patients and was associated with increased levels of anxiety, depression, and substance abuse problems.
Among patients with traumatic musculoskeletal injuries, self-reported recreational marijuana use during recovery from a musculoskeletal injury was associated with an increased total amount of prescribed opioids and longer duration of opioid therapy compared with patients with musculoskeletal injuries who did not use marijuana during recovery.
The authors found no clinical studies evaluating the effect on pain or disease progression in osteoarthritis.
Adverse Effects of Cannabinoids
Recreational and medical users inhaling marijuana or taking cannabinoid formulations containing THC are prone to a number of psychomotor effects including memory impairment, cognitive delay, and impaired coordination.
Among daily, heavy users, marijuana use has additionally been associated with cardiovascular events (e.g., tachycardia and hypotension), respiratory effects (e.g., chronic cough), and psychiatric effects (e.g., anxiety, paranoia, psychosis, suicidal ideation, and an amotivational syndrome characterized by decreased persistence, initiative, and overall self-efficacy).
Long-term and heavy use also carries a risk of use disorder and dependence. Cannabis use disorder is an official diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), defined in part by frequent marijuana use causing failure to fulfill major role obligations in private or professional life.
Approximately 12% of frequent cannabis users (i.e., those who use it 3 or more times per week) may experience a withdrawal syndrome—indicating chemical dependence—with symptoms such as anxiety, hostility, disordered sleep, and/or depressed mood, among others.
Addiction may be present in the heaviest users who continue to use cannabis despite adverse effects on their performance in school, relationships, and/or the workplace.
It is difficult to make general statements regarding the safety and/or efficacy of cannabinoids for the treatment of medical conditions, as most cannabinoids available to the public have not been formally investigated.
Comment: Patients often ask "what about marijuana for my pain?" This article provides a review of some of the information we can consider in our response.
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