Prevalence of Cannabinoid Use in Patients With Hip and Knee Osteoarthritis
State legalization and widespread marketing efforts have increased the accessibility and consumption of off-label, non–FDA-approved, cannabinoid (CBD) products. Although clinical evidence is largely absent for the treatment of musculoskeletal pain, patients are experimenting with these products in efforts to relieve joint pain. Assessment of the prevalence, perceived efficacy compared with other nonsurgical modalities, and usage patterns is warranted. The purpose of this study was to report the prevalence and perceived self-efficacy of CBD products in patients with symptomatic hip and/or knee osteoarthritis (OA).
Two-hundred consecutive patients presenting with painful hip or knee OA were surveyed at their initial evaluation at a large academic center. Using Single Assessment Numeric Evaluation (SANE) scores, survey questions assessed perceived pain and effectiveness of CBD products, in addition to other nonsurgical treatment modalities. Chart review provided demographic factors. Descriptive statistics were used to characterize the data.
Of the 200 patients (80 hip OA, 108 knee OA, and 12 both), 66% were female, and average age was 67 years (range 36 to 89 years). Twenty-four percent (48/200) of patients endorsed use of CBD products before their presentation. The average presenting SANE score (range 0 to 100) for non-CBD users was 50.8 compared with 41.3 among CBD users (P = 0.012). Sixty percent of patients learned about CBD through friends, and 67% purchased CBD directly from a dispensary. Oral tinctures (43%) and topical applications (36%) were the most commonly used forms. In addition, 8% of participants in this study had tried marijuana for their pain.
A 24% incidence of CBD usage was found among patients presenting with hip or knee OA. No significant perceived benefit of CBD use seems to exist compared with its nonuse, as patients who used CBD reported significantly worse SANE and visual analogue scale scores than nonusers at baseline. Follow-up studies are warranted to assess these findings.
State legalization and widespread marketing efforts have increased the accessibility and consumption of off-label, non–FDA-approved, cannabinoid (CBD) products. Subsequently, these products have been promoted for the treatment of numerous ailments, including joint pain. Although clinical evidence is largely absent for the treatment of musculoskeletal pain, patients are experimenting with these products in efforts to relieve joint pain. 1,2,3,4,5,6 If proven effective, these medications could provide multimodal pain control in the treatment of arthritis-related pain.
Surgeons should be aware of the effects of over-the-counter medications, especially non–FDA-approved medications that their patients are consuming. Given the increased availability of CBD products, investigations into the prevalence and perceived efficacy of CBD for treatment of osteoarthritis (OA) are warranted. To our knowledge, data evaluating the prevalence and perceived efficacy of CBD products for the treatment of OA are limited. Therefore, the purpose of this study was to report the prevalence and subjective efficacy of CBD products in patients with symptomatic hip and/or knee OA presenting for an initial orthopaedic surgery consultation.
After institutional review board approval, 200 consecutive patients presenting with painful hip or knee OA were surveyed at their initial arthroplasty clinic evaluation at a single high-volume academic center. As part of the initial intake screening, patients were asked to complete a 21-question survey. Questions concerning function and perceived efficacy of treatments were assessed using Single Assessment Numeric Evaluation (SANE) on a 1 to 100 point scale, with a score of 100 indicating the highest perceived benefit (SANE). 7,8 In addition, medical chart review was undertaken for background demographic factors.
After completion of questionnaires (see appendix for questionnaire example, Appendix 1, http://links.lww.com/JG9/A108), answers were categorized and tabulated. Average SANE scores for interventions were calculated as well. Questions results were binary (yes/no), numeric (SANE/visual analogue scale [VAS]), or free text (ex “Question 14: ‘How did you hear about CBD?’”). Free text answers were manually reviewed for each respondent and categorized into nominal reviewable outcomes (Table (Table5). 5 ). Radiographs for every patient were reviewed by two independent reviewers. Descriptive statistics were performed to characterize the population; T-tests were used to compare the variation of continuous variables. Comparison of proportions for sample populations was performed with z-tests. All statistical analysis was performed with JMP statistical software (SAS Institute).
Characterization of CBD Use and Procurement Among the Sample Population
|Frequency of use|
|Three times daily||2|
CBD = cannabinoid, HCP = healthcare provider
Of the 200 consecutive patients, 100% completed the survey. Sixty-six percent were female, and the average age was 67 years. Knee OA was the most common complaint (n = 108) followed by hip OA (n = 80), and a minority of patients had symptoms in both joints at presentation (n = 12). Thirty-seven percent of these patients were symptomatic on the right side, 31% on the left side, and 32% presented with bilateral complaints. Knee OA had an average Kellgren-Lawrence OA grade of 2.7 (range 0 to 4). Average Tönnis scale grading of the affected hip OA was 1.8 (range 0 to 3) (Table (Table1 1 ).
Demographic and Radiographic Variables of Arthroplasty Clinic Sample Population
|No. of patients, n||200|
|Age (y) (±SD)||67.21|
|Female, n (%)||112 (56)|
|Joints, n (%)|
|Laterality, n (%)|
|Knee osteoarthritis grade a (n = 159), n (%)|
|Hip osteoarthritis grade b (n = 107), n (%)|
Twenty-four percent (48/200) of patients endorsed use of CBD products before their presentation. The average presenting SANE score (range 0 to 100) for non-CBD users was 50.8 compared with 41.3 among CBD users (P = 0.012). The average VAS score (range 0 to 10) for non-CBD users was 5.7 compared with 6.6 among CBD users (P = 0.036). No difference in the asymptomatic contralateral joint SANE score (range 0 to 100) was found when comparing non-CBD users with CBD users (81.9 versus 75.9, respectively, P = 0.129) (Table (Table2 2 ).
SANE and VAS Scores Among Non-CBD and CBD Users, Respectively
|Factor||Non-CBD Users (n = 152), n (%)||CBD Users (n = 48), n (%)||P Value|
|Symptomatic joint SANE (average)||50.8||41.3||0.012|
|Contralateral unaffected joint SANE (average)||81.9||75.9||0.129|
|VAS pain rating (average)||5.7||6.6||0.036|
CBD = cannabinoid, SANE = Single Assessment Numeric Evaluation, VAS = Visual Analogue Scale
Among non-CBD users, 73% had tried NSAIDs for symptomatic relief compared with 90% among the CBD using group. A statistically higher percentage of patients in the CBD group had used NSAIDs for symptomatic relief compared with non-CBD users (P = 0.017). No significant difference was found in the number of patients who had tried bracing treatment, steroid injections, or viscosupplementation injections between the two groups. A significantly higher percentage of marijuana use was found among the CBD group compared with non-CBD users (31% versus 1%, respectively, P < 0.001) despite similar rates of “Other” recreational drug use (15% CBD users versus 11% non-CBD users) (Table (Table3 3 ).
Frequency of Alternative Treatments for Symptomatic Osteoarthritis Used by Study Sample Population Non-Cannabinoid (CBD) and CBD Users, Respectively
|Factor||Non-CBD Users (n = 152), n (%)||CBD Users (n = 48), n (%)||P Value a|
|NSAID||111 (73)||43 (90)||0.017|
|Bracing treatment||43 (28)||26 (54)||0.289|
|Steroid injection||79 (52)||28 (58)||0.119|
|Viscosupplementation injection||30 (20)||11 (23)||0.575|
|Marijuana||2 (1)||15 (31)||<0.001|
|Recreational “other” drug use||16 (11)||7 (15)||0.928|
A significant difference was seen after NSAID use; non-CBD users reported an improvement with an increase in the average SANE to 52.7, whereas CBD users decreased to a SANE of 39.0 (P = 0.012). Otherwise, the differences in SANE scores between the two groups after bracing treatment, steroid injection, viscosupplementation injection, or marijuana use were not statistically significant (Table (Table4 4 ).
SANE Score Averages Among Two Groups After Nonsurgical Treatments
|Average SANE Scores||Non-CBD Users (n = 152), n||CBD Users (n = 48), n||P Value|
CBD = cannabinoid, SANE = Single Assessment Numeric Evaluation
Among CBD users, 60% of patients learned about CBD through friends, and 67% purchased CBD directly from a dispensary. Oral tinctures (43%) and topical applications (36%) were the most commonly used forms of CBD. Twenty-two percent of all the patients in this sample reported ongoing CBD utilization (Table (Table5 5 ).
In this prospective cohort of 200 consecutive patients, 24% (48 patients) reported trying CBD-containing products for relief of their arthritis-related pain before their initial orthopaedic surgical consultation. Although CBD use has not been previously characterized in this population, its prevalence is similar to the reported 15% to 22% of the general US population that reported marijuana use. 9,10 However, this reported CBD use is much higher compared with marijuana use in an older population. Han and Palamar 11 found that 9% of adults aged 50 to 64 years and 2.9% of adults aged 65 years and older reported marijuana use, which was similar to the 9% of patients who reported marijuana use in our study. This large difference in CBD and marijuana usage in a similarly aged population demonstrates the growing trend and popularity of CBD utilization. Given that more and more patients will arrive in clinic having tried or wanting to try these products, it is crucial that the orthopaedic surgeon is aware of CBD products and current trends in utilization. In addition, in the setting of the opioid crisis, it is imperative that we continue to identify new and potentially less-addictive modalities for pain relief. The goal of this study was to characterize and analyze CBD usage and perceived effectiveness in patients presenting for primary consultation with hip and/or knee OA.
To understand why CBD has become such a rapidly growing trend, a brief history is helpful. The passage of the US Hemp Farming Act of 2018 removed hemp (defined as cannabis with less than 0.3% tetrahydrocannabinol [THC]) from Schedule I Controlled Substances. 12 CBD can be derived from cannabis, which comes from the plant Cannabis sativa. Virtually overnight, a new US industry was created. This industry brought with it a legal, unregulated product with broad claims of treating anxiety, insomnia, PTSD, and reducing pain and inflammation. Although not containing high percentages of THC, hemp can still contain CBD, which augments the body’s endogenous CBD system primarily through CB1 and CB2 receptors in both the central and peripheral nervous system. These receptors have been shown to play roles in modulating nociception and inflammatory pathways. 13 However, the full effects of CBD are still not fully understood. Although animal models have shown CBD to decrease OA-related pain, 14,15,16,17,18,19 its efficacy in humans has not been fully supported. 18,20,21
As the stigma surrounding THC and CBD use decreases and these products become more readily available, the prevalence of their use will likely increase. Previously, research has been hampered by lack of funding and the Schedule I classification of cannabis. Given the wide availability of CBD in the United States at present and movements to remove cannabis from the Schedule I classification, it is believed that more knowledge about how THC/CBD functions will come to light. A study using National Inpatient Sample database showed that marijuana/THC use was associated with decreased mortality in patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA), total shoulder arthroplasty (TSA), and traumatic femur fixation. 22 In addition, two previous, recently published studies in the orthopaedic literature have explored the use of CBD and THC in arthroplasty. 4,5 Hickernell et al 4 examined the use of dronabinol, a synthetic form of THC, in a multimodal pain regimen after THA and TKA surgery. In their study, the group taking a prescribed dose of drocannabinol had significantly shorter stays and significantly fewer total morphine equivalents. However, this was a small (81 patients) retrospective study and warrants further studies to fully support this trend. Runner et al 5 found that 16.4% of patients following TKA or THA reported use of CBD or THC in the perioperative period. Compared with nonusers, no significant difference was observed in the length of narcotic use, total morphine equivalents used, postoperative pain scores, or the length of stay. Patients in this study were self-medicating without uniformity, which is in contrast to the prescribed dose of drocannabinol used in the Hickernell study.
Our study, however, showed no significant perceived benefit of CBD use compared with nonuse, and patients who used CBD actually reported significantly worse SANE and VAS scores at baseline than nonusers. The symptomatic joint(s)’ SANE score significantly differed between CBD users and nonusers at initial presentation (41.3 versus 50.8, P = 0.012). Previous literature has suggested that the minimally clinically important difference for knee injury interventions is approximately 7 to 19, suggesting that perhaps baseline presentation SANE scores may have been statistically different but not clinically measurable. 23 In addition, VAS pain rating for CBD users was significantly higher at baseline than nonusers (6.6 versus 5.7, P = 0.036). Interestingly, patients who used CBD products were also significantly more likely to use NSAIDs. This finding suggests that the patients taking CBD products may have had more symptomatic OA or more prone to self-medicating. Patients who reported CBD use were also significantly more likely to report marijuana use.
Several limitations of this study must be acknowledged. Although this was a prospective study, recall bias may be present as patients were asked to recall use of treatment and its effectiveness leading up to their first visit. In addition, only patients presenting for primary hip and knee arthroplasty consultation were included in this study. This restriction limits the generalizability of our findings to other orthopeadic specialties. Future studies are warranted in other subspecialties, such as sports medicine, where injuries are more acute. The perceived efficacy of CBD products may be different for acute pain than for chronic pain. The source of CBD product and route of administration was also not standardized, which may play a role in its effectiveness. In addition, this study had a limited sample size of 200 patients and as such may be subject to type 2 error when concluding no difference. Therefore larger, multicenter studies are needed to fully evaluate CBD use in this population and to enhance generalizability as well as a randomized controlled trial with placebo and a controlled dose of CBD. Finally, a substratification of severity of OA in either group would be useful in future studies attempting to determine the efficacy of CBD in symptomatic relief.
To our knowledge, this is the first prospective study to evaluate the usage of over-the-counter CBD products in a hip and knee OA population. A 24% incidence of CBD usage was found among these patients. We found no significant perceived benefit of CBD use compared with nonuse, and patients who used CBD actually reported significantly worse SANE and VAS scores than nonusers.
None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Deckey, Dr. Lara, Dr. Gulbrandsen, Dr. Hassebrock, Dr. Spangehl, and Dr. Bingham.
Doctors Say That Cannabis Should be Prescribed for Elderly People with Chronic Pain. Can Cannabis help to reduce pain? How does Cannabis treat pain?
Medical experts say that cannabis-based medication including medications containing THC should be prescribed instead of opioids.
Elderly people who suffer with chronic pain conditions such as back and joint injuries, should be prescribed cannabis instead of conventional painkillers, doctors have said. Recent polls suggest that over 75% of people over the age of 55 would consider taking it.
Doctors have advised that cannabis-based medicines that contain THC which is the cannabinoid that is renowned for creating the infamous high, should be used in place of opioid medications.
Draft guidance that was published last month by the National Institute for Health and Care Excellence (“NICE”) recommended that prescription guidelines for patients with chronic pain will soon move away from drugs like paracetamol, aspirin, ibuprofen and opioid medications such as codeine, tramadol and morphine.
The NICE guidance suggests that over one million chronic pain patients in the UK should be prescribed a specific exercise programme or acupuncture instead of opioids medications or OTC painkillers.
Doctors have suggested that patients with back pain could see a benefit from using cannabis oil which was legalised for certain conditions in November 2018. While medical cannabis and cannabis oil is not widely available on the NHS, some private clinics are licensed to prescribe medical cannabis once other medication has failed to work.
A recent poll by Open Cannabis had results that suggested that over 75% of people over the age of 55 would seriously consider using cannabis medication if it was offered to them. This compared to 66% of the population as a whole. Open Cannabis is a campaign to widen access to cannabis medicines in the UK. Open Cannabis is working to share accurate information and data about cannabis medications with both the public and healthcare professionals, to initiate debate about the positive impact cannabis medicines could have on people’s lives. Open Cannabis also want to focus on educating UK patients about cannabis-based medicines and the options that are available to them.
Prescriptions could keep patients from resorting to the black market
Making medical cannabis more widely available could prevent patients from accessing cannabis on the black market through illegal transactions with potentially dangerous drug dealers. Dr. Steve Hajioff, a former chair of the British Medical Association said that cannabis should be made available legally using prescriptions to prevent patients resorting to the black market for drugs to provide pain relief.
Dr. Steve Hajioff stated that cannabis-based medicines can fill the void in helping patients suffering from chronic pain and gradually replace opioids prescribed for pain-management and non-steroidal anti-inflammatory drugs.
Patients who may benefit the most from medical cannabis need to be aware of the legal routes through which they can access cannabis-based medications in the UK. There is no definitive data on how many people are using cannabis illegally for pain relief. However, the Centre for Medicinal Cannabis carried out research in collaboration with YouGov which conducted a survey of 10,602 adults. This survey found that over 1.4 million people which is 2.8% of the British population, are currently using cannabis illicitly to treat chronic health conditions such as chronic pain, anxiety, insomnia and depression.
This statistic illustrates that people are feeling the benefits of cannabis even when it is not prescribed in a form that is not of a medical standard. The quality of medical cannabis that chronic pain sufferers could receive once they have a prescription would likely be far greater than that of cannabis sold on the street. Illegal cannabis is often sprayed with various chemicals and the user has no idea where the product has come from. Sales of this scale on the black market also leads to widespread gang violence, as there is a fight for market share of the black market.
Cannabis was legalised for medicinal purposes in November 2018 following a ground-breaking campaign to allow access to cannabis prescriptions for children with treatment-resistant epilepsy, who used cannabis oil to manage their seizures.
It is now legal to be prescribed medicine containing THC, the chemical compound in the cannabis plant that induces the high that recreational users seek. This is banned for recreational use in the UK at the moment and is only legal when prescribed by a doctor. CBD has also been proven to have many positive benefits for chronic pain issues, anxiety, insomnia and depression and is legal to be sold in the UK. CBD has no psychoactive effects and works in a similar manner to THC to reduce inflammation and interact with the endocannabinoid system.
Since the change in the law in November 2018, very few medical cannabis prescriptions have been issued on the NHS. This results from NICE guidelines that suggested that doctors should be wary about providing cannabis oil to patients before full medical trials have taken place. There have yet to be any randomised controlled trials in the UK investigating the benefits and side effects of medical cannabis. However, there are developments in this fast moving and nascent industry, and there is hope that a randomised controlled trial can be initiated in 2021.
The NHS have stated that a much larger trial over an extended period of time is required to prove to the government that medical cannabis is safe and effective. Once this is proven it should then be made available through the NHS for a wider group of people.
The Reduced Stigma of Cannabis
For years cannabis has been associated with violence and illegal activity and has not been viewed as a medication. However, these perceptions are gradually changing with older adults taking a different view on cannabis and opening their minds to the prospective benefits. A study undertaken recently in the United States discovered that cannabis use among adults defined as ‘older’ meaning over 65, has been steadily increasing. This study found that cannabis use within this demographic has risen from 2.4% to 4.8% from 2015 to 2018.
There are several factors that contribute to this change in perception of cannabis and the increased use within the elderly population. One key factor is that the stigma surrounding cannabis is slowly evaporating and it is being recognised as a socially acceptable pass time and a genuine medication for certain ailments. Cannabis within pop culture is now integrated casually into TV shows and music, whereas in the past it was often presented as a nefarious activity and those partaking were acting in a rebellious manner.
More research needs to be carried out in the UK before the NHS will even consider prescribing cannabis on a large scale. It is up to pioneers within the medical, cannabis and pharmaceutical industries to make this happen and it will require contributions from a wide range of people to provide definitive evidence of the efficacy and safety of medical cannabis. The public’s perception of cannabis is vital to achieve this too. Public support will be required to pressure the government into acting and assisting doctors to enable them to prescribe cannabis medicines to patients whose daily lives could be dramatically improved.
What is Medical Cannabis?
Medical cannabis uses the cannabis plant or specific cannabinoids found within the cannabis plant to treat diseases or conditions. The cannabis plant contains more than 100 different chemicals known as cannabinoids; each one has a varying effect. Delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are the two cannabinoids that have been researched the most. THC & CBD are typically the two cannabinoids that administered within medications.
Research is being conducted to see if cannabis-based medicines could be used to treat an array of diseases such as:
- Appetite issues
- Crohn’s disease
- Immune diseases such as HIV/AIDS and Multiple Sclerosis (MS)
- Mental health conditions like posttraumatic stress disorder (PTSD)
- Rheumatoid arthritis
The greatest amount of evidence for the therapeutic effects of cannabis-based medicines are its ability to reduce chronic pain, nausea and vomiting due to chemotherapy and spasticity caused by Multiple Sclerosis.
How Does Cannabis Produce Its Effect on the Human Body?
THC exerts all of its known effects on the central nervous system through interactions with the CB1 cannabinoid receptor. Research into cannabinoid mechanisms has been allowed by the availability of specific antagonists acting at CB1 receptors.
THC’s chemical structure is comparable to the chemical found in the brain named anandamide. The similarity in the chemical structure between the two allows the body to recognise THC, this then causes an alteration in normal brain communication.
Endogenous cannabinoids such as anandamide function as neurotransmitters as they send chemical messages between neurons throughout the central nervous system. Anandamide affects the areas of the brain that influence thought, memory, pleasure, coordination, movement and the perception of time.
Due to the similarity in the chemical structure, THC can attach to molecules named cannabinoid receptors on neurons within these areas of the brain and then activate them. This disrupts various mental and physical functions causing the aforementioned functions such as thought and movement to be affected. The neural communication network that these cannabinoid neurotransmitters exist within is called the endocannabinoid system. The endocannabinoid system is integral to the functioning of the central nervous system and interfering with the endocannabinoid system can have profound effects.
THC can manipulate the functioning of the hippocampus and orbitofrontal cortex.
The effects that cannabis can have on the central nervous system include the disruption of psychomotor behaviour, stimulation of appetite, antinociceptive actions – most importantly against pain of neuropathic origin. While there are signs of mental impairment within long-term cannabis users there is little evidence to suggest that the effects are irreversible.
How does Cannabis relieve different types of pain?
There are three different types of pain.
- Nociceptive pain
- Neuropathic pain
- Central pain – there is still much debate into this kind of pain, Fibromyalgia is a common example of Central pain
Pain is caused by the coordinated activation of brain cells. Specific brain regions lead to the sensation of pain and the strength of pain signals can be modulated. There are examples of people having a physical injury, i.e. nociceptive pain, but feel pain free. There are also examples of there being an absence of physical injury, but the individual is in a great deal of pain, this is central pain.
Nociceptive pain, also referred to as inflammatory pain, is the result of tissue damage. Subjectively, it can be described as aching, throbbing or a sharp pain that is the result of physical damage. If you’re injured, the damaged tissues recruit immune cells to repair the damage to your body. The recruited cells then release proteins and chemicals that activate receptors on nerves which then travel to the spinal cord and then onto the brain, thus causing the sensation of pain.
Nociceptive pain can be reduced by decreasing the pain signals at the area of injury by blocking the inflammatory process and the signals that are sent. An alternative manner in which to dampen the pain is to limit their effects as the pain signals travel up the spinal cord to the brain. Cannabis can be used to optimise both of these processes to decrease pain.
Both THC & CBD can reduce pain at the site of an injury, THC & CBD also both have anti-inflammatory effects. THC’s anti-inflammatory effects are driven by the activation of CB2 receptors on immune cells that dampen the body’s pain inducing reaction to an injury. CBD reduces inflammation through blocking inflammatory mediators and changing the activation of macrophage repair cells to the anti-inflammatory type from the pro-inflammatory type.
THC & CBD’s benefits of helping to relieve nociceptive pain are documented in rodent studies and in human clinical trials.
THC can directly activate CB1 receptors which modulates pain at the level of the spinal cord, this indirectly increases the opioid receptor activation. CBD increases the level of anandamide, which operates in the same way as THC to activate CB1 receptors. CBD also enhances the activity of the receptors for GABA which is a primary inhibitory neurotransmitter. This inhibitory effect can dampen the pain signals as they travel to the brain.
CBD can also improve your mood by activating serotonin receptors which has both stress reducing and anxiety reducing effects. Those who suffer from chronic pain conditions are more likely to suffer from depression or anxiety, meaning that CBD can be a valuable edition when fighting a chronic condition.
When you are in a positive frame of mind your focus on pain is likely to decline and it can be a powerful tool to fight pain. However, as time passes is can become near impossible to achieve these positive feelings.
Neuropathic pain arises from damage to the central nervous system. Neuropathic pain affects between 7-10% of the population and can result from an injury. Multiple Sclerosis is when the insulation of nerve cells is broken down that causes neuropathic pain. Other instances of diseases that inflict neuropathic pain are HIV, AIDS, diabetes, shingles and Parkinson’s diseases. Chemotherapy can also cause neuropathic pain due to its destructive effects on cells in the body.
In a similar manner to treating nociceptive pain, over activation of the CB1 receptors caused by taking THC can lead to the pain having a weaker effect and therefore effecting the sufferer to a lesser extent. Balanced cannabis prescriptions would be more efficacious over a longer period as the effect of the pain would continually decrease over time.
Neuropathic pain is extremely difficult to treat as it doesn’t result from inflammation that can be treated by non-steroidal anti-inflammatory drugs. Whether the pain is caused by chemotherapy, amputation or a disease, cannabis could be an effective treatment for neuropathic pain. Medical cannabis is a promising treatment option as its benefits have been observed in cancer and non-cancer instances of neuropathic pain in both rodent and human clinical studies.
Central pain refers to a type of pain that arises from dysfunction to the nervous system. Often pain arises in the absence of any demonstrable cause, this means that it can be particularly difficult to treat. Fibromyalgia is an instance of central pain that arises from dysfunction in the way pain signals make their way to the brain. The origin of fibromyalgia is largely unknown, and the specific cause of fibromyalgia is yet to be determined. The symptoms of fibromyalgia are often inconsistent from patient to patient.
There have yet to be extensive studies investigating the benefits of cannabis in treating central pain. However, the benefits of treating fibromyalgia with cannabis has been established. In a study of 26 fibromyalgia sufferers, every participant reported an improvement in their condition from cannabis use and half of the participants stopped taking all other medication they were using prior to the trial. This study suggests that medical cannabis may provide essential pain relief for those with fibromyalgia and other central pain conditions where the origin of the pain cannot be established.
High THC products may be an effective pain reliever, but they may not be an optimal pain relief strategy. A balanced THC:CBD ration or CBD rich products may provide a better long term treatment option for chronic pain conditions. This is primarily down to the side-effects of THC.
How does Medical Cannabis help?
Cannabinoids which are the active chemicals within medical cannabis are similar to the chemicals in the body that modulate appetite, memory, pain and movement.
Medical cannabis has received a lot of press over the last few years due to its positive effects on helping children with epilepsy control their seizures. Epidyolex was fast tracked to ensure it was available on the NHS as of the 6 th of January 2020 for the thousands of people who could be prescribed the drug to treat their epilepsy. Clinical trials researching the effects of Epidyolex showed that the treatment could reduce the number of seizures by up to 40% in children with epilepsy when used in combination with Clobazam.
Another instance of a cannabis-based medicine being approved is Sativex which can be used to treat Multiple Sclerosis. However, Sativex has only been approved for a limited number of patients because of the high cost of the medication.
Chronic pain is the issue that medical cannabis could be prescribed to the largest number of patients for. While medical cannabis is not strong enough to manage severe pain such as post-surgical pain or a broken bone. While more definitive evidence is needed in the form of a randomised clinical trial, initial evidence suggests that medical cannabis is effective for treating chronic pain conditions that plague millions of people in the UK. Chronic pain is likely to affect everyone’s lives as they age, whether it is a family member or a direct experience. Nerve pain is another instance of where medical cannabis could be effective. There are very few options at the moment, and the existing options such as Neurotin and Lyrica are highly sedating, meaning that they are not easily incorporated into daily life. One of the key benefits of cannabis which has been disclosed by patients and via anecdotal stories, is that using cannabis to manage pain allows the sufferer to resume activities that they had to stop due to pain without feeling disengaged.
Cannabis is also a muscle relaxant and people swear by its ability to lessen the tremors in Parkinson’s disease.
Discussing Cannabis with your Doctor
Many people find themselves in a position where they wish to learn more about the prospective benefits of using cannabis to treat the condition from which they are suffering from. There is a distinct lack of education concerning cannabis and its therapeutic effects within both the medical community and the general population. Educating General Practitioners and Medical staff within the NHS and Private Medical sector is imperative if cannabis is ever going to be widely available as a medication. The medical community has been dismissive of cannabis in general for many years, however as the evidence proving its efficacy and safety improves and increases it becomes more difficult to dispute the therapeutic benefits of cannabis. Many patients that use illicitly sourced cannabis to treat issues such as pain and anxiety feel that they cannot discuss the positive impact cannabis has out of fear of being reprimanded or scolded by their doctor.
Rigorous studies are needed before doctors will embrace medical cannabis. The risks and side effects of using cannabis regularly over an extended period of time also need to be assessed and proven.
As with any medication it is always crucial to discuss the side effects of any medication you are prescribed with your doctor. If the cannabis-based medicine that’s prescribed contains THC it may cause psychoactive effects. Diarrhoea and decreased appetite may also be experienced.
The Future of Medical Cannabis in the UK
Despite the legalisation of medical cannabis in 2018, it is still extremely difficult for a patient to obtain a medical cannabis prescription in the UK. All treatment options have to have been expended and the patient’s GP has to be receptive to allowing them to be prescribed cannabis. Medical cannabis is currently only available on the NHS for children and adults with rare, severe forms of epilepsy. It is also available for cancer patients experiencing severe vomiting and nausea due to chemotherapy and to people diagnosed with Multiple Sclerosis.
To receive a medical cannabis prescription in the UK, a patient has to actively seek it and then visit a private clinic at their own expense. Medical cannabis is not covered by medical insurance so both the cost of the consultation and the medication itself must be paid for by the patient.
The patient must first have an eligibility consultation with a medical cannabis clinic to assess whether they are eligible for a prescription. The limited evidence to date and the fact that cannabis-based medicines are unlicensed, prescribing cannabis-based medicines is restricted to clinicians listed on the Specialist Register of the General Medical Council. A GP can make a referral to a specialist doctor once their patient has reached the appropriate point in the treatment pathway. This means that the patient has to visit a specialist at their own expense.
The cost of the eligibility consultation, then the appointment with a specialist and finally the medication itself is likely to cost the patient in the region of £500. The cost of a month’s supply of a medical cannabis prescription is approximately £250.
This is simply unaffordable to the vast amount of the population, especially for those who suffer with chronic pain as their condition can often mean they are unemployed.
Allowing bulk imports of cannabis into the UK was a positive step in reducing the cost of medical cannabis for the patient.
Ultimately, randomised clinical trials need to be conducted to prove the efficacy and the safety of cannabis-based medicines. Providing this evidence is the only way in which the NHS will subsidise medical cannabis to either make it available on the NHS or more affordable via a private clinic.
It is likely that the participants in a randomised controlled trial will have to pay for the cost of the medication if a trial is to materialise. Otherwise it will be too big an expense for any pharmaceutical or cannabis company to risk initiating a trial. This would mean that there would be no consultation costs which could make the medication more affordable and allow participants to pay around £200 per month for their cannabis-based medicine. The trial would require thousands of participants and would need to last for several years. If a randomised controlled trial like this is successfully undertaken, it could lead to medical cannabis being available on the NHS.
Pain management is the largest treatment area that cannabis could address. A trial into the efficacy of medical cannabis to treat chronic pain could revolutionise the treatment options available to chronic pain sufferers. It could present an option with limited long-term side effects that enables normal life to continue and ensure that their condition is not debilitating.
Cannabis has the potential to be used to create medications that improve millions of people’s lives, enhance chronic pain sufferers’ daily lives and allow people to stay in employment for longer. More research must be carried out, but cannabis seems to have the potential to truly help people individually and society as a whole.
Causes of Hip Pain
The primary cause of hip pain is arthritis, specifically osteoarthritis. Arthritis is the most common chronic condition and is characterized by inflammation of the joints. Common causes of arthritis include wear and tear on the bones and joint cartilage, most often when the body has too much weight to support. This can be caused by carrying heavy loads consistently for years but is more commonly a byproduct of being overweight.
Common Arthritis Myths
- Only older people have arthritis.
- Arthritis is caused by cold, wet weather.
- Each day is the same for an arthritis patient.
- Arthritis is a minor physical inconvenience.
Osteoarthritis is the most common form of arthritis, affecting over 21 million Americans. Three times as many women suffer from the disease than men.
Osteoarthritis occurs when the covering on the ends of bones gradually wears away, becoming frayed and rough. It typically develops due to many years of use and affects people middle-aged and older. Osteoarthritis targets hands and weight-bearing joints, such as knees, hips, and feet.
- Age- 45 yrs or older
- Gender- majority of sufferers are women
- Certain hereditary conditions including defective cartilage and malformed joints
- Joint injuries caused by physical labor or sports
- Diseases that alter normal structure and function of cartilage
Symptoms (usually come on slowly)
- Pain and inflammation
- Pain may develop gradually and feel like a deep ache.
- Swelling and stiffness
- May be worse in the morning and feel better with activity
- Loss of range of motion
- “Sticking” and weakness
- Loose fragments of cartilage and other tissue can cause locking or “sticking."
- Joint may lose strength and buckle or lock.
Our hips form and develop in mass and strength in proportion to the amount of weight our body was designed to hold. So if you are a small woman, your hips are meant to hold a smaller amount of weight than if you are a six-foot tall man. Although the body is very adaptable and can learn to hold different weights, a point can be reached where the body is simply not comfortable supporting excess weight.
In some cases, along with surgery, a lifestyle change needs to take place to keep chronic pain at bay. For instance, diet should be addressed immediately, and an exercise regime should ensue following recovery from surgery.
Avascular necrosis occurs when the tissue in the joints literally die when the blood supply is cut off to the bones. This can be a temporary blood supply loss or a permanent loss. Causes of avascular necrosis can include alcoholism, steroids, or blood disorders.
In the early stages of avascular necrosis, pain only occurs when pressure is put on the joint. However, as the necrosis worsens the pain is present even while resting the joint. In many cases, the blood supply is lost permanently and the damage tissue must be removed and replaced with a hip replacement.
Mechanical abnormalities are rare, but can stem from childhood disfigurement or fractures that never healed properly. Initially, the body will try to compensate for the abnormality. However, as time passes, this will create wear and tear on other parts of the body. Ultimately, the remedy for this can be hip replacement.
Those with fragile bones that may easily break have osteoporosis. The disease is the result of lower than average amounts of phosphate and calcium in the bones, which cases them to become porous and brittle. Bones that most commonly break are the bones in the wrist and hip.
There are both controllable and uncontrollable risk factors that increase or decrease odds of developing the disease. For instance, people of all ages, races and genders get osteoporosis, but it is a condition most commonly found in Caucasian and Asian females over the age of 60. Other uncontrollable risk factors include family history, certain diseases and hormone levels. Controllable factors encompass those things that an individual can do during their lifetimes to lower their risk for developing osteoporosis. For instance, smoking, excessive drinking (more than 7 ounces of alcohol per week), poor nutrition with low calcium intake and lack of exercise can all contribute to the development of the disease.
The best treatment for the disease is prevention by consuming the recommended amounts of calcium and phosphate throughout a lifetime. When the disease is recognized, calcium is prescribed into the diet immediately, hormone treatments may help and an exercise regimen is recommended to abate further deterioration of the bone. To find out if you have osteoporosis, an energy X-ray absorptiometry (DEXA) scanning can analyze bone density.
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