From arthritis.org/liveyes/podcast
More people are trying or considering using medical cannabis to relieve their arthritis pain. But what evidence is there to show us how effective and safe it is? A rheumatologist and expert on cannabis explains what is and isn’t known and offers some advice for people who want to try it
Trina Wilcox: Welcome back to the Live Yes With Arthritis podcast. I am your host for this episode. My name is Trina Wilcox. I was diagnosed with juvenile rheumatoid arthritis, as they called it, when I was 6 years old. And as we grow up with a chronic condition, we deal with so many different things, and pain is among many. So, the topic for today — I am excited to talk to you so you can be as educated as possible about it — we are talking about medical cannabis for arthritis.
People have been turning to cannabis as it's more legal widely available throughout the U.S. But it's still difficult to get research on it. We don't know much about the safety-ness, the effectiveness, for arthritis. So, today I'm glad to introduce Dr. Mary Ann Fitzcharles, a rheumatologist and pain researcher at McGill University in Montreal, Canada. Thank you so much for being here. I'm glad that we have you to talk about what is and what isn't known about CBD and other forms of medical cannabis for arthritis.
Dr. Mary Ann Fitzcharles: Good afternoon, Trina, and everyone. It's a real pleasure to be with you today. And hopefully I'll be able to share a little bit of insight that we have about medical cannabis in the management of our patients with rheumatic conditions.
Trina Wilcox: Absolutely. Dr. Fitzcharles, you're well known for your research in medical cannabis and working with arthritis. Tell me a little bit about how you got into the area and your expertise in arthritis and such.
Dr. Mary Ann Fitzcharles: Well, I think we all know that in the last number of years, probably in the last two decades, there've been amazing advances in the management of inflammatory arthritis. So, we have all of these beautiful disease-modifying agents, we've got all the biologic agents, and they're absolutely wonderful. However, even when patients are beautifully managed and their disease is, by our standards, well controlled, pain persists.
Trina Wilcox: Yeah.
Dr. Mary Ann Fitzcharles: And pain has a huge impact upon well-being, quality of life. If you have pain, you have difficulty sleeping. If you have pain, you might be anxious. Pain actually causes you not to think clearly. You're just not quite as sparky as you should be. So, pain is really a very, very important, persistent symptom in all patients with arthritis, be it inflammatory or, the old-fashioned word was degenerative, osteoarthritis.
And the second component is that our medications for pain are really and truly not great. They either cause side effects, many side effects, either impact upon the kidneys, tummy upsets, cognitive changes, and they really are just not wonderful. With all the modern world developments, we have very few new medications to treat pain. I think this is one of the reasons why our patients are turning to medical cannabis. And asking: Is this not perhaps a reasonable treatment option?
Trina Wilcox: Absolutely. So, let's start with the basics. I know that there are a lot of words that are used interchangeably but may not necessarily be synonyms. Can you kind of describe the difference between CBD and medical cannabis?
Dr. Mary Ann Fitzcharles: OK. So, let's take two steps back, and we'll go back to a botany class.
Trina Wilcox: OK. (laughs)
Dr. Mary Ann Fitzcharles: Cannabinoids are a whole group. They're a whole soup of different molecules. And when you take the cannabis plant, which is cannabis sativa, and there's cannabis indica, so there are number of genuses of this plant. There are many, many molecules within the plant, and they're probably… Cannabis has been called the plant of a thousand molecules. So, within this plant, there are two molecules that have been of great interest and that have really been studied, and that is cannabidiol, which we call CBD. And THC: tetrahydrocannabinol.
So, these are the two agents that we have studied a lot in the basic science world. And we do know that THC is the agent that has psychoactive properties. Psychoactive properties are the ones that sort of make you feel a little high, maybe a little sleepy. Whereas CBD, cannabidiol, also a cannabinoid, has almost no psychoactive properties. So, that's the difference in the two. And that's probably one of the reasons why initially people were very, very interested in the effect of CBD, because CBD supposedly is an agent that maybe has some good effect on pain, sleep, mood, but without causing the psychoactive effects.
Trina Wilcox: OK. So now that we know a little more about the CBD, what evidence is there for its use, especially those of us affected by arthritis?
Dr. Mary Ann Fitzcharles: So, we'll take another few steps back and say that really the use of cannabinoids, the use of CBD, has really run away with us. The researchers have been left in the slipstream. The reason is that we've not really been able to study these products as we normally do for other drugs. And the reason for this is that it's been very difficult to get products that have been adequately tested and regulated and allowed to be used in clinical studies.
So, a lot of our information about cannabinoids comes not from standard randomized controlled trials, but come from cohort studies and come from what patients are telling us. We have a lot of cohort studies of cannabinoids, CBD, indicating to us that patients are using the agent, are reporting the effects of the agent, but we do not have much gold standard evidence. And the gold standard evidence is randomized controlled trials.
Trina Wilcox: What can we do as advocates to get that done?
Dr. Mary Ann Fitzcharles: It's slowly moving ahead, there is no question. But the difficulty is when you are dealing with a plant product, and as I said, this is a plant with a thousand molecules. Do you take out just one molecule and test the one molecule? Or is it a combination of the molecules that seems to be effective? What is that magic mix?
Trina Wilcox: I see.
Dr. Mary Ann Fitzcharles: So, that's the first thing. Because of recreational cannabis availability in many jurisdictions, unfortunately the pharmaceutical industry has not been terribly supportive of the medical stream. The recreational stream has gone ahead on its own, and it is taking a lot of effort and a lot of convincing to get the pharmaceutical industries or the cannabis producers on board.
Trina Wilcox: OK. Well, is it effective for other conditions? Those of us that might have other problems, you know: secondary issues with sleep or something; or all those comorbidities that come along with a chronic condition.
Dr. Mary Ann Fitzcharles: And this is what we hear from patients, and this is what we hear from cohort studies and observational studies: People say that cannabinoids, and again, it's very difficult to know what are people using… Are they using sort of something that they've bought off the street, which they do certainly in Montreal in Canada. And they really have no idea what's in the product? But generally, people are saying that the cannabinoids have the best effect on pain. But many people say they use it for sleep promotion, as well as just to calm themselves, usually in the evenings.
Trina Wilcox: The bigger topic in all of this, the medical cannabis, a lot of people call it medical marijuana. And I'm not sure, and maybe you can correct me on this, there just hasn't been a ton of research in the United States. How does that compare to other countries?
Dr. Mary Ann Fitzcharles: We are really all in the same boat. Because even if a product is acceptable recreationally, to actually study a product in a patient, we've got to obtain good manufacturing practices.
The product has got to be really regulated and perfectly certified. And this has been extremely difficult to obtain really worldwide. There are a few companies that have GMP, so good manufacturing practices; and we are able to access some of those products. And this has been done quite nicely in Europe.
In Canada, we are just about to initiate a really nice study looking at CBD and THC in patients with osteoarthritis. But it's taken almost three years to get the regulatory authority to give us that GMP certificate. So, you can see that it's, you know, we're there. The researchers are there, the patients are there, we're ready to go, but we really have been roadblocked by regulatory systems.
Trina Wilcox: Can you tell me a little more about some of the research, especially what you've been involved with?
Dr. Mary Ann Fitzcharles: There is research looking at products that are pharmaceutical products. There is the product Nabilone, which is a manufactured THC product. There is also Sativex, which is a product that is a pharmaceutical product that is a combination of THC and CBD, and it's an agent that is used as a spray. Nabilone, which is pure THC, is… we just don't see such a very good effect.
And also there's been one single study in rheumatoid arthritis using Sativex. It was done quite a long time ago. It was done in the United Kingdom, and it had some promise, but unfortunately it's not accessible to our patients. It's not FDA approved for the treatment of pain. It is used in the treatment of multiple sclerosis and particularly patients with spasticity. There've been two randomized control trials that have come out of Europe, one from Vienna and one from Denmark, looking at CBD in osteoarthritis. The study from Denmark was osteoarthritis and psoriatic arthritis. They used different doses of CBD. So, this was CBD alone, not CBD plus THC. And unfortunately, both of those studies… They really were no different from placebo, which was a little disappointing.
However, we have to listen to what patients tell us. And patients very often say it's a tiny bit of THC that is added to the CBD that seems to make a difference. And this has got to be tested.
You might have heard about this entourage effect. And an entourage effect is a proposal that it's a mixture of molecules that seem to have a good effect. So again, when we listen to what patients are telling us, patients will say, "I get this particular product, product ABC, and then when I went to get my ABC product, they didn't have the ABC, they had ABD. And ABD was not as good as ABC." So, it brings to our awareness that the complexity of the product of this plan, maybe it's the complexity, and it's the mixture of molecules that's important.
Trina Wilcox: There's a lot of trial and error left up to the patient at this point.
Dr. Mary Ann Fitzcharles: You're right. But the patient should not be on their own. And I emphasize repeatedly: Involve your health care provider. Speak to your health care provider. Don't listen to the 22-year-old chap in the dispensary who is selling the product. He is not your health care provider. He is there to sell. Physicians are becoming much more educated and aware about cannabinoids. And I cannot emphasize enough: Speak to your doctor.
Trina Wilcox: We kind of covered the effectiveness. It kind of depends. And it depends on what mixture is going to work best for the patient. But what about overall safety?
Dr. Mary Ann Fitzcharles: Right. So generally, we believe that CBD, cannabidiol, is safe if it is taken orally. And we very, very strongly recommend that the agent should not be taken by inhalation.
Trina Wilcox: Ah.
Dr. Mary Ann Fitzcharles: So, no smoking, no vaping. Although, when we look at cohort studies, many patients say that they do like to vape a little bit at night. Because what happens with vaping is you have… The blood level of the product is elevated very quickly. So, it's in the system quickly. OK? So, safety: The first thing as a rheumatologist, I will always recommend against inhalation. Number two, we really don't know, we do not have the evidence for, long-term effects in our patients. We have a lot of evidence for long-term effects of recreational cannabis, but this does not necessarily apply to our patients. Long-term effects, so there's a big question.
Number three, we really strongly recommend that young people do not use cannabinoids whilst the brain is developing. Our brain develops throughout pregnancy and childhood until about mid-20s, about 24 or 25 years of age. So, whilst this brain is developing, we have concerns that if you're using an agent such as cannabis, it actually impacts the way in which the neurons connect to each other. We have concerns about young people.
We also have concerns about people using higher THC levels. In the olden days, which was probably in the 1970s when the hippies were smoking cannabis, the THC content was relatively low. THC content was 3 to 8%. Today, if you go and buy cannabis, even from a regulated supplier in Canada, recreational cannabis, you can get a THC content of up to 30%, which is very, very high. And we know that that type of amount is addictive.
Trina Wilcox: So, if someone is experiencing arthritis later on in life, and maybe they did use recreationally in their younger years, they should be fully aware that things have changed.
Dr. Mary Ann Fitzcharles: You are absolutely right. That is really, really important. And this brings us to another point that I think people should be aware of. You should look at cannabis as you would look at any other medication. So, you do not take a few gummies. You do not mix it into brownies or cannabis butter or whatever. If you're using it as a medication, treat it as a medication. Know what quantity you're using, know the milligrams that you're using. And I think this is really important.
Trina Wilcox: So, when we're talking about dosing and being safe with that, how do you know where to even start?
Dr. Mary Ann Fitzcharles: Like with many of these medications, start low, go slow. We honestly don't know where to start. And we can look to some of the studies that have been done. And generally, CBD, I would say: Start in the order of about 5 milligrams a day. If you're adding the THC to the CBD, start with a very low dose, something like 2.5 milligrams.
Trina Wilcox: Does the patient need to be as aware if they're using a topical?
Dr. Mary Ann Fitzcharles: We don't know. Topicals are really, really interesting. What do we see patients doing? Absolutely using topical, but a topical has got to be able to penetrate into the body. And cannabinoids are an oily substance. And an oily substance cannot penetrate down into the cells. So, it's got to have a vehicle that really allows it to move down. Just buying a topical from a local artisanal product place, we don't know whether it's just going to stay mostly on the top of the skin and how will it get down?
Trina Wilcox: Excellent. That's real good to know, so we don't spend money on something that might not work.
Dr. Mary Ann Fitzcharles: Right.
Trina Wilcox: So, people that may want to try it, what should they know that maybe you haven't covered? What should they look for? What should they avoid?
Dr. Mary Ann Fitzcharles: I think the first thing is, as we said: Speak to your health care provider. Number two, if you are going to try some medical cannabis, get it from at least a regulated, licensed provider. Don't go to an artisanal provider somewhere on the internet where, in all honesty, you have no idea what is inside the product. Use an oral product that you can know the amount, the exact quantity, that you're trying.
If you're going to try some cannabis, I would suggest that the first time you use it, you're at home. Everything is quiet, everything is relaxed. And you will try it maybe towards an evening. Not going out, not driving, not doing… Just to assess: How do you feel? And you're looking for positive as well as negative effects. Is it doing anything for your symptoms? Or are you having any side effects?
And then if you do decide, you think, "Well, maybe this is something that might be helpful to me," give it a proper trial. Six months later, I often speak to patients and say, "Are you still using it?" "Yes." "And what is it doing for you?" "Well, I'm not really sure whether it's helping or not." Be definitive. Give it a defined period of time, and at the end of that time, take a decision. Is it helping, yes or no? And there is no justification to continue any medication unless you are quite sure that you're getting a good effect.
I think the other thing is: We must still acknowledge that certainly in the United States, it is federally an illegal product. So, patients must adhere to the rules and regulations within the individual state. Because, even if you're using the product medicinally, it will still be considered an illegal product federally if there is more than 0.3% THC.
Trina Wilcox: All right. Thank you so much. Well, every time we have a podcast coming up, we like to reach out on social media. And so, we asked: "If you have tried medical cannabis for your arthritis, what was the best benefit and biggest drawback?" We had a lot of responses. Dtm.fitness said, "If it weren't for cannabis, I would be in too much pain and anxiety to work out. An edible is the perfect pre-workout for me."
And then High Enough to Function said, "I use cannabis daily. It's a great alternative to narcotics. The biggest downside is stigma." Can you speak a little on that? I mean, stigma is a big reason a lot of people avoid getting help, even from narcotics.
Dr. Mary Ann Fitzcharles: Right. So, I think stigma is slowly going to reduce because it is an agent that is now more accepted recreationally. And I think that the public have become really aware that it might be an agent that is of use in people that are suffering. And a very important point is: Could cannabis really be a substitute or help people reduce opioid consumption? And we've talked a lot about the whole issue of the opioid epidemic.
And there are studies. There's a lovely cohort study from Kevin Boehnke indicating that many patients using cannabis report that they are able to substitute cannabis for some of their symptomatic treatments, including anti-inflammatories, opioids and even benzodiazepines. So, if cannabis could be a substitute for agents that potentially perhaps are more troublesome in the long term, that would be a very good thing. I just want to add one other little caveat of a disadvantage. The big disadvantage is cost.
Trina Wilcox: Yes. We have a few people that shared that.
Dr. Mary Ann Fitzcharles: Cannabis is costly, certainly in Canada. If our patients are using it, they're spending about a hundred dollars a month.
Trina Wilcox: Right. In fact, Butterfly Warrior on Instagram said, "Drawback: price and stigma. It helped me to need less pain meds and last longer before flaring," so that had an advantage for them. And then Quiet One said, "Unfortunately, it made me too anxious to function." And then someone, I am Trina Wilcox, might be my experience: "I had zero benefit, and it was expensive for me to find out that it didn't work."
I feel like it would be helpful for me to share my story. I have had stomach problems with a lot of NSAIDs. Some of the other pain medications, like anybody that is concerned with their health, you worry that: Is this going to take a toll on me? So, my rheumatologist did say, "You could look into this." He did say he was not educated on it. Like a lot of our medical professionals, they're not trained to know that much about it.
And before the state that I live in made it legal for recreational use, you had to get the medical card, which costs money, and then you have to go buy it. Like what you said, it is not cheap. The person there tried their best to help me, understanding my situation. I explained I have an autoimmune disease. I want minimal, you know, use that I could get away with. And they still told me to use a little more than I felt like I could handle.
I started out with half of what they suggested, and in fact, I felt achier than before. I just absolutely did not like the experience. And I think that's important for some people to know, too, that not everybody is going to respond with a wonderful euphoric experience, pain-free and la-di-da. And it does take trial and error in working with your medical professional.
Dr. Mary Ann Fitzcharles: You've really raised a very, very important point. And the point is that we are all different. Everyone responds to agents differently. There's some people that will take half a glass of wine and say, "I'm going to go to sleep now." And others, very differently. And clearly, some people actually have increased anxiety with cannabinoids. And even a tiny, tiny bit of THC can have psychoactive effects.
So, we need to be very, very careful in people who are sensitive, such as the older population or people who are on other medications that have some psychoactive effect, such as maybe some of the antidepressants, some of the sleep modulators and alcohol.
Trina Wilcox: Absolutely. All very important points. Do you have three takeaways from today's episode that you'd like to share with us?
Dr. Mary Ann Fitzcharles: I think we've really covered most of them. I think my first thing is: Always involve your health care professional. And I really love it when my patients will tell me, "You know, I want to discuss with you the use of some alternative medicine." Or, "I'd like to discuss with you something that I've heard." I think that there should be trust in the patient-doctor relationship, and always discuss with your health care professional.
Number two: Treat cannabinoids as you would treat any other medicine. So, it's not a brownie that you're going to take a few bites of. It's a medicine. Know the dose, know the effects and know the side effects. And I think the third thing is exactly as you've raised: It's not a magic agent; it's not the panacea for everyone. However, there are quite a number of patients or people that really do do very well.
Trina Wilcox: Thank you. I think my first takeaway goes right with yours. Talk to your rheumatologist, your medical professional, someone you know that you trust that knows your history with your condition. Number two: Throw stigma out the window. You shouldn't be ashamed of your condition. You shouldn't be ashamed of what works for you. And number three, again, I know people mean well, but please don't listen to someone that treats their recreational habit one way with your medical condition another way.
I did have someone say to me, "Oh, you shouldn't do that. You should," like you said, "smoke it." I knew that was not for me, and I did not; my little red flag went up. And so, I'm glad to hear you reiterate: That is not a safe way to get proper dosing, you know, so definitely do some research, talk to your doctor, and your friends might mean well, but they're not your doctor. (laughs)
Dr. Mary Ann Fitzcharles: And can I add just one little point?
Trina Wilcox: Yes, please.
Dr. Mary Ann Fitzcharles: Particularly for people being treated with disease-modifying agents for important inflammatory disease, cannabinoids should not replace your standard disease-modifying treatments. It's not a replacement. It would be an agent that could complement perhaps these disease-modifying agents, but it's a symptomatic treatment, not a treatment for the underlying disease process.
Trina Wilcox: Thank you for joining us. I hope you got some great takeaways. We'll be back next time with another compelling topic. You can get lots more information at arthritis.org.
Dr. Mary Ann Fitzcharles: Thank you, Trina. And thank you everyone.
PODCAST CLOSING: The Live Yes! With Arthritis podcast is independently produced by the Arthritis Foundation. Gifts from people like you make our podcast and other life-changing resources possible. You can donate at arthritis.org/donate. This podcast aims to help people living with arthritis and chronic pain live their best life. For a transcript and show notes, go to arthritis.org/podcast. Subscribe, rate and review us wherever you get your podcasts. If you subscribe through Spotify, leave a comment on their platform, letting us know what you think about this episode. And stay in touch!
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