Is CBD an Answer to Managing the Pain of Fibromyalgia?
Chronic pain could almost be considered the most epidemic non-infectious health condition in America. The Centers for Disease Control estimate that chronic pain affects at least 20 percent of all adults in the United States, but suggests the reality may be that as high as 40 percent. Those suffering from chronic pain outnumber individuals suffering from diabetes, heart disease, and cancer combined. While chronic pain may not give the external appearance of a debilitating health condition, it is more injurious than what meets the eye. It leads to loss of mobility and reduces the workforce, is a cause of the current opioid crisis, and provokes anxiety and depression – conditions whose gold-standard, pharmaceutical therapies cause additional challenges. The national health crisis caused by overutilization of opioid medications for pain has led to numerous, preventable deaths and forced the industry to discover alternative therapies to manage chronic pain. It is in the wake of this crisis that cannabidiol (CBD) found its opportunity for fame. But, is it all it claims to be?
Fibromyalgia – A Global Pain Disorder
Pain is most often the body’s response to inflammation and serves a positive role in alerting us of injury or infection. It frequently coexists with red and swollen areas of the body and its source can often be determined by applying pressure to the injured or infected area. Even the muscle aches that accompany a fever alert us of a disturbance in our body. Nonsteroidal anti-inflammatory agents (NSAIDs) such as aspirin and ibuprofen (Motrin®, Advil®) are commonly used to manage this temporary type of pain. Adjunct therapies such as hot/cold compresses, massage therapy, and acupuncture are also helpful for managing temporary or localized pain. Nature also provides us with anti-inflammatory botanicals such as willow bark and frankincense which are effective for controlling pain sourced from inflammatory processes.
Those suffering from classic fibromyalgia are no strangers to wide-spread chronic pain (partnered with chronic fatigue) because it is the hallmark feature of their condition. However, the pain experienced with fibromyalgia isn’t your standard pain. Unlike most pain which can be pinpointed to a certain locality, the pain of classic fibromyalgia is global, meaning it is perceived throughout the entire body. It is also unique in that the sensation of pain is a strong reality, but its source is a mystery. It may even make one wonder if their pain receptors are in overdrive since typical stimuli such as light touch, a breeze, clothing, loud noises, and even bright lights can elicit the sensation of pain.
The pain associated with fibromyalgia is distinct because it originates from dysfunction in the central nervous system. There is no inflammation-causing injury or infection responsible for producing the pain. Instead, the central nervous system is responsible for the pain of fibromyalgia. It is “confused” and processes normally nonpainful stimuli as painful. As a result, standard pain managing therapies don’t work well for those with fibromyalgia. Historically, conventional pharmaceutical therapies for managing pain associated with fibromyalgia have included NSAIDs and muscle relaxants but to no avail since fibromyalgia is not rooted in either inflammation or skeletomuscular disorders which these agents are designed to target. Interestingly, antidepressants, such as amitriptyline and the antiepileptic drug, pregabalin, have been shown to bring some relief to a small number of fibromyalgia sufferers; however, these pharmaceuticals have extensive side effect profiles that make their use less than optimal. It becomes evident that managing fibromyalgia pain is difficult since standard treatments fail and successful alternatives are lacking. Therefore, when CBD rose to the market and claimed to be a successful tool in managing pain, it aroused the curiosity of many fibromyalgia sufferers who wondered it if could be their gate to a better quality of life.
Phytocannabinoids – The Next Generation of Pain Therapy
Phytocannabinoids including CBD have flooded the market since the passage of the 2018 United States Farm Bill which legalized Cannabis species that contained less than 0.3 percent of the psychoactive phytocannabinoid, tetrahydrocannabinol (THC), and defined these unique species as hemp. Various species of the Cannabis plant deliver more than 100 phytocannabinoids which possess medicinal properties, but medical research has focused primarily on two cannabinoids, tetrahydrocannabinol (THC) and cannabidiol (CBD). Both act upon the endocannabinoid system of the human body, a signaling system laced throughout the central and peripheral nervous system and found in nearly all the path pathways. Activation of two of its primary receptors - CB1 (located in the brain and peripheral tissue) and CB2 (located in the immune and blood systems) - are linked to the health-promoting benefits of phytocannabinoids, including pain management.
Analgesia (pain relief) has been one of the larger areas of focus in cannabinoid research. These medicinal compounds seem to offer success where traditional pain management therapies have failed or they have been found to enhance the outcomes of traditional pain therapies. A systematic review of 13 randomized placebo-controlled trials involving cannabinoids for the treatment of chronic pain found Cannabis-based medicinal extracts provided effective analgesia in various conditions with chronic, nonmalignant, neuropathic pain which is similar to the type of pain experienced by those with fibromyalgia.
Evidence for Cannabinoid Use in Fibromyalgia
While this news sounds exciting, how does the research evidence stack up for the use of cannabinoids for fibromyalgia pain? First, it is important to note that many studies examining the application of Cannabis for fibromyalgia use synthetic THC (known as nabilone or medical marijuana). Many other studies will report results on subjects who smoke native Cannabis plants (marijuana) which contain various types and amounts of phytocannabinoids, including higher doses of THC. These studies are not useful for determining the pain-reducing effects of CBD, alone. After excluding these studies from inquiry, the remaining studies most often use a combination of THC and CBD in known ratios. Despite the inclusion of THC, they can still offer some assistance in understanding the potential impact of CBD on fibromyalgia.
In a 2019 randomized controlled trial, four Cannabis varieties with varying ratios of THC and CBD were tested on 20 individuals with fibromyalgia. Although most test groups revealed a reduction in pain after a single treatment, the decrease was not any greater than that reported by the placebo group, which annulled the potentially positive results. In an observational study published in 2019, 211 patients with fibromyalgia took various doses and ratios of cannabinoids reported a significant improvement in pain intensity, quality of life, and fibromyalgia-related symptoms after six months of therapy. Additionally, an average of 20 percent of the subjects were able to reduce or eliminate their pharmaceutical drugs taken for managing fibromyalgia symptoms. However, the most effective cannabinoid product in this study had high levels of both THC and CBD. It is impossible to make any conclusive evidence about the success of CBD based on these studies; however, they do allow for the possibility of CBD to help manage fibromyalgia pain when other modalities fail.
It is worth mentioning that studies of subjects who smoked and consumed the native Cannabis plant (marijuana) reported significant improvements in fibromyalgia symptoms. For example, in a 2018 report, 383 people with fibromyalgia in Israel (where Cannabis use is common) responded to a questionnaire that collected data about their Cannabis use and fibromyalgia-related symptoms. Nearly 94% of the respondents reported pain relief and significant improvement in other fibromyalgia-related symptoms.
Although the most recent literature doesn’t seem to offer much assistance in determining the success of CBD as a solo agent, it is indicative of the potential power of targeting the endocannabinoid system for pain relief. It is also useful in understanding the synergistic effect of the collection of phytocannabinoids that can be utilized by harvesting the entire plant rather than extracting a single agent. This principle is crucial when choosing a potentially effective CBD product from within the market and may help ensure greater clinical success, if success is to be found in the CBD-rich phytocannabinoids harvested from hemp.
Not All CBD is Created Equal
Although hemp is a Cannabis species with a controlled amount of THC that is far lower than the native Cannabis (marijuana) species used in most clinical studies, anecdotal evidence combined with our understanding of the role of the endocannabinoid system in pain pathways suggests that some people may find pain relief from a high-quality CBD product. But, not all CBD products on the market will offer the same degree of effectiveness. Most CBD products are classified as full-spectrum, broad-spectrum, or an isolate. Each of these forms delivers a different therapeutic outcome, making it important to choose the right one.
Also known as purified CBD, this form is manufactured by isolating CBD and eliminating all other compounds present in the hemp plant. Although this may seem beneficial at first, studies have shown that the extracted compounds provide synergistic value. In fact, in an observational data meta-analysis comparing purified CBD and CBD extract in the treatment of refractory epilepsy, not only was a greater quantity of purified CBD isolate necessary to reach the desired outcome, but it resulted in more adverse side effects compared to the CBD extract.
Often considered the “Cadillac” of CBD products, full-spectrum CBD retains all the original compounds of the hemp plant including additional phytocannabinoids, aromatic terpenes, and essential oils. These compounds have been found to act synergistically, enhancing the therapeutic effect of CBD in a phenomenon known as the “entourage effect,” and delivering the greatest therapeutic potential. Since growing conditions impact the constituents of full-spectrum CBD products, it is important to know the Cannabis variety and strain selected, sourcing, and the method of extraction. A reputable CBD manufacturer will provide this information.
Like full-spectrum CBD, broad-Spectrum CBD products contain additional phytocannabinoids, terpenes, and essential oils; however, the THC component has been completed removed from the product. This form of CBD is most often recommended for individuals who must avoid all traces of THC for personal, religious, or medical reasons.
Successful pain management is paramount to living with fibromyalgia. Unfortunately, the success rate of conventional therapies is far too low because of the unique nature of fibromyalgia pain. However, as we discover more about the role of the endocannabinoid system in pain pathways and the therapeutic potential of targeting this system for managing centrally-mediated pain, phytocannabinoids such as CBD may become a promising tool for managing fibromyalgia pain in some individuals. The research is still inconclusive, but the possibility is welcoming and should be entertained by those struggling to find solutions to their pain.
- David Brady