Medical marijuana for urologic chronic pelvic pain
It is generally acknowledged that many patients are not satisfied with the contemporary medical approach to the management of urologic chronic pelvic pain syndrome (UCPPS). Many have turned to marijuana or cannabis because of its strong anecdotal reputation of providing benefit to patients with chronic pain. In a condition in which patients are struggling to cope, the marijuana story appears to offer hope.
What is marijuana?
Marijuana or cannabis contains hundreds of known compounds (421 chemicals and counting), including cannabinoids (more than 60). Delta 9-tetrahydrocannibinol (THC) and cannabidiol (CBD) are the most widely studied to date. THC (the psychoactive cannabinoid) stimulates appetite, reduces post-traumatic stress disease (PTSD) symptoms, and can be used as a sleep aid. CBD (the non-psychoactive cannabinoid) reduces inflammation, relieves anxiety, and reduces seizures. The combination of CBD and THC may act as a muscle relaxant, relieve spasms, reduce nausea, and relieve pain. At least that is the theory.
Painful lessons learned from the UCPPS clinic
We have been prescribing medical marijuana for a number of years and are slowly figuring out how to do this properly. We had no textbook, no manual, and no instructions. The literature did not help us. It was really trial and error, with our patients teaching us the optimal strategies for the use of marijuana in UCPPS. Herein, I share the seven most important lessons we have learned.
Lesson 1: Basic research supports the theoretical use of marijuana
If you prescribe marijuana for your patients with UCPPS, you can be reassured that there are many potential theoretical mechanistic pathways by which marijuana has shown possibilities for benefit in basic science research. These include theoretical analgesic, antiemetic, antispasmodic, anti-inflammatory, antibacterial, relaxant, and anxiolytic properties.
Lesson 2: Clinical research does not provide strong support for the use of marijuana in UCPPS
Unfortunately, there are sparse clinical research studies to support the use of cannabis in UCPPS. In fact, there is almost none and we have to rely on what little clinical evidence is available for the use of marijuana in other chronic pain syndromes. There is at least some literature attesting to the possible benefits of medical marijuana in spastic disorders, PTSD, irritable bowel syndrome, rheumatic diseases, anxiety, depression, sleep disorders, inflammation, and chronic pain. Unfortunately, there is just no solid, long-term data for UCPPS management. The available literature suggests that marijuana can reduce pain by 37%, or a total of 0.5 points on a pain scale of 0–10. Inhaled cannabis results in short-term reductions in chronic neuropathic pain for one in every 5–6 patients treated. But the use of medical marijuana is also associated with known adverse side effects, which include dizziness, dry mouth, nausea, fatigue, somnolence, euphoria, vomiting, disorientation, drowsiness, confusion, loss of balance, and hallucination.
Lesson 3: Marijuana is better than opioids
For patients who are having trouble coping because of pain that has not responded to the standard therapies outlined in this supplement, turning to opioids as the last resort is not usually the best approach. Opioids, at best, offer around a 30% improvement in pain and at worse, offer a paradoxical slow exacerbation in pain intensity. With even minor pain relief comes the possibility of physical or at least psychological dependence to opioids, with desire for further increasing doses with diminished returns. Marijuana has fewer downsides, with the possibility of similar pain relief, better psychological coping, and less chance for addiction and dose escalation.
Lesson 4: Recognize patients at risk
All patients with UCPPS are not candidates for medical marijuana management. Patients with a history of substance abuse, diversion risk, and mood disorders should never be prescribed cannabis as a treatment option. If they decide to use the substance on their own, then it will not be a medical error in judgement, but rather a patient-only decision.
Lesson 5: Patient education is the key to successful use of medical marijuana
Patient education should provide a clear understanding of the benefits (30–40% reduction in pain) and risks of medical marijuana ( Table 1 ). The different modes of administration (oral, smoking, vaporization), must be a part of the teaching process. The advantages and disadvantages of the various routes of administration are described in Table 2 .
Can CBD Prevent Pelvic Pain?
The compound is certainly trendy, but the research is scant.
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I suffer from pelvic pain, specifically vaginismus. I’ve been reading about the benefits of CBD with pain. I was wondering if CBD salves or lubricants were safe to use internally? And if CBD will actually reduce the pain one experiences with vaginismus.
Vaginismus is a medical condition where the muscles of the pelvic floor (the muscles that support the bladder, vagina and rectum) have excessive tension. This can lead to both pelvic pain and pain with sex. There is no data to support using CBD vaginally (or by any other route) for this pain condition. There is some evidence linking cannabis use in the previous four months with increased vaginal yeast colonization, but CBD has not been studied independently.
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CBD, or cannabidiol, is a nonpsychoactive compound found in cannabis. CBD is “in” right now for many medical conditions, not just ones that are painful. The data supporting CBD use for most conditions is generally low quality or completely absent, so it is important to separate the fad from the facts so you can make an informed choice about your body.
CBD may play a role in reducing pain and muscle spasm for some conditions, but there are still a lot of unknowns. An oral spray with THC (tetrahydrocannabinol, which is the main psychoactive component of cannabis) and CBD is approved for use in other countries for muscle spasm caused by multiple sclerosis as well as for some kinds of chronic pain. However, it is not possible to directly translate this data to vaginal use or to apply it to a different medical condition.
We do not know how CBD would act vaginally since cannabinoid receptors in the vagina have not yet been studied. We also don’t know how much CBD would be absorbed into the bloodstream or if absorption is needed to produce an effect. (In this case, if the drug has to enter the bloodstream to work, there is probably no benefit to vaginal use).
We also don’t know what effect CBD could have on the pelvic floor muscles. There is one study that tells us natural endocannabinoids actually reduce during sexual excitement, so it is biologically plausible that CBD could increase pelvic floor muscle tone (meaning it would be very unhelpful for spasm). There is also some data that suggests cannabis use is associated with a higher rate of vaginal yeast colonization. We don’t know if this is from the THC, CBD or other cannabinoids.
Essentially, we don’t know what we don’t know about CBD and the vagina. I recommend that any woman (or man) with pelvic floor muscle spasm skip CBD and instead see an Ob/Gyn or urologist with expertise in that area, as well as a specialized pelvic floor physical therapist.
Dr. Jen Gunter, Twitter’s resident gynecologist, is teaming up with our editors to answer your questions about all things women’s health. From what’s normal for your anatomy, to healthy sex, to clearing up the truth behind strange wellness claims, Dr. Gunter, who also writes a column called, The Cycle, promises to handle your questions with respect, forthrightness and honesty.