Posted on

Is cbd oil with thc better for pain

Evidence for THC versus CBD in cannabinoids

Knowledge Translation Expert, with the PEER Group in the Department of Family Medicine at the University of Alberta in Edmonton and the Alberta College of Family Physicians.

Knowledge Translation Expert, with the PEER Group in the Department of Family Medicine at the University of Alberta in Edmonton and the Alberta College of Family Physicians.

Professor, with the PEER Group in the Department of Family Medicine at the University of Alberta in Edmonton and the Alberta College of Family Physicians.

Clinical question

Do tetrahydrocannabinol (THC), cannabidiol (CBD), or THC-CBD combined have differing benefits or harms?

Bottom line

Of 4 RCTs, 1 found THC-CBD superior to THC but this was inconsistent within the study and with other studies. Adverse events are prevalent with THC, CBD, and THC-CBD. While some early poor-quality research in healthy users suggests CBD attenuates some psychiatric effects of THC, better research in real patients is needed to verify any benefits of specific components.

Evidence

Four RCTs compared THC, CBD, or both combined.

One RCT (N = 243 terminal cancer and weight loss patients) compared THC-CBD, THC, and placebo for 6 weeks. 1 There was no statistical difference in appetite or adverse events for THC-CBD versus THC.

-A pain reduction of 30% or more was seen in 38% of the THC-CBD group versus 21% in the THC group (number needed to treat = 6). There was no difference for pain reductions of 10% or more or 50% or more.

-Baseline pain score was 7.5 of 10. The THC-CBD and THC groups’ pain reduced by about 1.3 points, statistically significantly more than 0.6 points with placebo.

-Versus starting THC-CBD, patients’ pain management was the same or better in 38% with repeat THC-CBD, 33% with THC, and 17% with CBD (no statistical difference).

Context

-Adverse events included somnolence (number needed to harm [NNH] = 4), diarrhea (NNH = 5), and appetite loss (NNH = 5). A recent RCT of adults with Lennox-Gastaut (seizure) syndrome found similar results. 6

One guideline recommends low THC or a high CBD-to-THC ratio to reduce THC adverse events based on small studies of healthy volunteers (some with history of other drug use) examined with magnetic resonance imaging or short-term scale changes. 7

Implementation

A Canadian guideline recommends cannabinoids (pharmaceutically derived first) only in refractory neuropathic pain, palliative cancer pain, nausea and vomiting from chemotherapy, and spasticity. 8 Current guidance for smoked dried cannabis for pain recommends titrating up to 400 mg/d of 9% THC. 9 Health Canada permits patients with a prescription for medical cannabis to legally possess up to 150 g, a 1-month’s maximum supply, equating to 5 g/d. 10 A content analysis of Canadian licensed producers found that 58% of THC-predominant products had concentrations of 15% THC. 11 Thus, patients might be using much higher doses than studied or recommended.

Notes

Tools for Practice articles in Canadian Family Physician are adapted from articles published on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in Canadian Family Physician are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician and are peer reviewed. Feedback is welcome and can be sent to [email protected]. Archived articles are available on the ACFP website: www.acfp.ca.

Footnotes

Competing interests

The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.

References

1. Strasser F, Luftner D, Possinger L, Ernst G, Ruhstaller T, Meissner W, et al. Comparison of orally administered cannabis extract and delta-9-tetrahydrocannabinol in treating patients with cancer-related anorexia-cachexia syndrome: a multicenter, phase III, randomized, double-blind, placebo-controlled clinical trial from the Cannabis-in-Cachexia-Study-Group. J Clin Oncol. 2006; 24 (21):3394–400. [PubMed] [Google Scholar]

2. Johnson JR, Burnell-Nugent M, Lossignol D, Ganae-Motan E, Potts R, Fallon M. Multicenter, double-blind, randomized, placebo-controlled, parallel-group study of the efficacy, safety, and tolerability of THC:CBD extract and THC extract in patients with intractable cancer-related pain. J Pain Symptom Manage. 2010; 39 (2):167–79. [PubMed] [Google Scholar]

3. Berman JS, Symonds C, Birch R. Efficacy of two cannabis based medicinal extracts for relief of central neuropathic pain from brachial plexus avulsion: results of a randomised controlled trial. Pain. 2004; 112 (3):299–306. [PubMed] [Google Scholar]

4. Notcutt W, Price M, Miller R, Newport S, Phillips C, Simmons S, et al. Initial experiences with medicinal extracts of cannabis for chronic pain: results from 34 ‘N of 1’ studies. Anaesthesia. 2004; 59 (5):440–52. [PubMed] [Google Scholar]

5. Devinsky O, Cross JH, Laux L, Marsh E, Miller I, Nabbout R, et al. Trial of cannabidiol for drug-resistant seizures in the Dravet syndrome. N Engl J Med. 2017; 376 (21):2011–20. [PubMed] [Google Scholar]

6. Thiele EA, Marsh ED, French JA, Mazurkiewicz-Beldzinska M, Benbadis SR, Joshi C, et al. Cannabidiol in patients with seizures associated with Lennox-Gastaut syndrome (GWPCARE4): a randomised, double-blind, placebo-controlled phase 3 trial. Lancet. 2018; 391 (10125):1085–96. [PubMed] [Google Scholar]

7. Fischer B, Russell C, Sabioni P, van den Brink W, Le Foll B, Hall W, et al. Lower-risk cannabis use guidelines: a comprehensive update of evidence and recommendations. Am J Public Health. 2017; 107 (8):e1–12. [PMC free article] [PubMed] [Google Scholar]

8. Allan GM, Ramji J, Perry D, Ton J, Beahm NP, Crisp N, et al. Simplified guideline for prescribing medical cannabinoids in primary care. Can Fam Physician. 2018; 64 :111–20. (Eng), e64–75 (Fr). [PMC free article] [PubMed] [Google Scholar]

9. Kahan M, Srivastava A, Spithoff S, Bromley L. Prescribing smoked cannabis for chronic noncancer pain. Preliminary recommendations. Can Fam Physician. 2014; 60 :1083–90. (Eng), e562–70 (Fr). [PMC free article] [PubMed] [Google Scholar]

10. Health Canada. Controlled Drugs and Substances Act. Access to cannabis for medical purposes regulations. Ottawa, ON: Government of Canada; 2016. [Google Scholar]

11. Mammen G, de Freitas L, Rehm J, Rueda S. Cannabinoid concentrations in Canada’s regulated medical cannabis industry. Addiction. 2017; 112 (4):730–2. [PubMed] [Google Scholar]

Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada

THC vs. CBD for Pain Relief: What’s Better?

People with arthritis and other chronic musculoskeletal pain are increasingly turning to cannabis products for relief from different symptoms, such as pain, fatigue, insomnia, and anxiety. In fact, a recent CreakyJoints survey of people with arthritis found that more than half had tried marijuana or CBD for a medical reason.

While cannabis plants are complex and different varieties have different chemical compositions, almost all of them contain some combination of two medically important compounds: tetrahydrocannabinol (THC) and cannabidiol (CBD).

THC is responsible for that “high” that people get from marijuana, which may also play a role in pain relief. CBD doesn’t usually cause an intoxicating feeling, but research suggests it, too, may help ease arthritis symptoms.

These two chemicals both show potential in easing pain, but in different ways. Choosing a product rich in THC, CBD, or both could make a difference in the kind of pain relief you experience — if any. (Here are reasons your CBD product might not be working for you.)

Here’s what experts say about the differences between THC and CBD for pain relief.

How THC and CBD May Offer Pain Relief

CBD and THC activate different cannabinoid receptors in your body that can stimulate or inhibit brain chemicals and cause certain effects.

“We know a lot more about how THC works in terms of the molecular mechanism [than CBD],” says Steve Alexander, associate professor of molecular pharmacology at the University of Nottingham Medical School, who researches cannabinoids.

“THC activates certain cannabinoid receptors, one of which is in the nerve cells and the other is in the immune cells. When it activates the one in the nerve cells, it reduces the sensation of pain,” he adds.

The high that THC provides can also play a role in how people experience pain. “A little bit of euphoria can help us not care that we’re experiencing quite as much pain, much in the same way that other pain medications work,” says Angela D. Bryan, PhD, professor of psychology and neuroscience at the University of Colorado Boulder, who has studied cannabis and health.

CBD is much less understood than THC by researchers, although there is anecdotal evidence that it may provide pain relief in some people.

“We’ve got a hypothesis that CBD might have some interference with [the brain chemical] serotonin and some influence on glycine receptors, which may be involved with pain. We think it may do what it does by hitting multiple targets with a fairly light touch,” says Dr. Alexander. “It’s difficult to pick apart — lots of people are trying [to study it], but no one has yet succeeded.”

Researchers have not found much evidence that CBD can offer mental relief from pain. However, the placebo effect may help some individuals experience less pain after taking CBD.

“The human mind is a very powerful thing, and a lot of the ways we experience medication is related to our expectancies about that medication,” says Dr. Bryan.

How CBD Can Help with Anxiety

Scientists suspect that CBD may help relieve anxiety, though. That, in turn, could affect someone’s perception of pain and potentially make them more comfortable. The research is still developing, though, and it’s too early to draw anything conclusive.

“We know that chronic pain patients also have a number of other morbidities, like stress, anxiety, and depression. I’m interested in the possibility that cannabidiol might also have mechanisms by which we can relieve some of those additional problems,” says Dr. Alexander.

That said, CBD may offer pain relief in more physical ways. It seems to show promise in reducing inflammation, which could provide pain relief from autoimmune diseases like rheumatoid arthritis, says Dr. Bryan.

The bottom line: THC seems to have a greater effect on the way the mind perceives pain, whereas CBD may work to ease pain at the local source.

Which Is Better for Pain Relief: THC or CBD?

There’s no definitive answer to the debate between THC and CBD for pain relief. Cannabis is still considered a Schedule 1 drug by the federal government — a legal status that limits the kinds of research that can be conducted.

Using the current research available, Dr. Bryan says she believes that a combination of THC and CBD together shows the most promise for pain relief.

“To the extent that we have good data, it’s unlikely that either THC or CBD on its own is going to be particularly effective for pain. It probably needs to be a combination of the two,” she explained. “We’re totally speculating at this point, but the way they work together might be that CBD has anti-inflammatory properties while THC has properties that can help us better cope with pain.”

CBD and THC: Side Effects and Legal Concerns

THC might not be an option for everyone, though. Some people may live in states where THC is illegal; while others simply don’t want the psychoactive effects of the substance. In those cases, it might be worth trying CBD on its own to see if it offers pain relief for you.

CBD isn’t legal everywhere either. And in states where CBD is legal, laws can vary as to how much THC is permissible in CBD products in order for them to be legally sold. Many states in which certain CBD products are legal require them to contain less than 0.3 percent THC.

Before trying either substance, it’s worth considering potential side effects they may cause. Side effects of CBD include nausea, fatigue, and irritability, according to Harvard Health. CBD can also interact with certain medications (such as blood thinners) and either increase or decrease the concentration of certain drugs in the bloodstream.

THC has its own set of side effects, including sleepiness and lethargy, increased appetite, increased heart rate, coordination problems, dry mouth, red eyes, slower reaction times, memory loss, anxiety, and mood changes.

“It’s quite likely that individuals will respond to different versions of these cannabinoids, and some may not respond at all,” says Dr. Alexander. “There’s a tendency for anecdotal evidence to highlight the positives of people who do respond [to CBD], which is useful, but it’s difficult to measure the numbers of people who don’t get a lasting benefit.”

If you’re interested in trying CBD or THC to manage your pain, talk to your doctor and experiment to see whether CBD or THC (or both) relieves some pain.

You can also learn more in a new, free course on the health effects of THC and CBD, created by Kent Hutchison, PhD, professor of psychology and neuroscience at the University of Colorado in Boulder.

“Start with low doses and go slowly to find out what works for you,” says Dr. Alexander. “I find it difficult to believe that there is one version of cannabis or CBD that will be best for everyone.” Learn more here about how to find your optimal CBD dose.