Introduction by Melinda Fontaine, article by guest bloggers Eloise Theisen, AGPCNP-BC and Timothy Byars
From Melinda:
For years, I have seen my patients using cannabis to treat a variety of conditions. A common complaint is the lack of guidance to do so. Recently, I found a medical professional who is not afraid to make specific recommendations. In fact, cannabis education, advocacy, and access are their specialty. I asked Eloise Theisen, AGPCNP-BC and Timothy Byars of Radicle Health in Walnut Creek, CA to teach us a little bit about cannabis for patients with pelvic pain.
From Eloise and Timothy:
Approximately one-third of the U.S. population suffers from debilitating chronic pain. 1 And while opioids are broadly accepted for treating acute pain, cancer pain, and end-of-life care, the use of opioids for managing chronic pain remains controversial and ineffective. In fact, the use of opioids for long-term chronic pain does not appear to improve patient conditions, health, and well-being.2
Approximately half of all Radicle Health patients are seeking relief from chronic pain. Many of these patients have spent years trying to manage their pain with pharmaceuticals, and for most, their current pharmaceutical regimen is no longer effective. Some patients have reported that their pain doctors are no longer willing to renew their opiate prescriptions and have not provided any alternatives. As more states legalize cannabis, clinicians should consider replacing opioid prescriptions with recommendations for cannabis.
The most common question that we receive from Radicle Health patients is “What type of cannabis would help with___?” For example, patients are seeking relief from sciatica, lower back pain, peripheral neuropathy, fibromyalgia, migraines, arthritis, and a host of other conditions and disease.
Our response, typically, is “it depends.” Pain is an individual experience and often requires an individualized approach. Fortunately, there are multiple combinations of cannabinoids and several routes of administration that healthcare professionals can recommend to treat chronic pain.
Which Cannabinoid?
The type of pain you want to treat will determine which cannabinoids you want to use:
CBD
CBD is not psychoactive in the same manner as THC, but it can positively influence mood and it can help manage the dysphoria associated with pain. 3 Additionally, CBD can boost opioid-based analgesic effects, enabling patients to achieve efficacy with lower doses of opioids, reducing the risk of addiction and overdose. 4
THC
THC is responsible for the psychoactive and euphoric effects of cannabis, but many patients want to use cannabis without these side effects. Small amounts of THC can provide pain relief, reduce inflammation, and relax muscles 5, 6 without producing powerful psychoactive effects. It may not be necessary for patients to experience psychoactivity in order to achieve relief when using THC.
THCa
THCa is a non-impairing cannabinoid that can help with inflammation and mild pain. 7 Research suggests that THCa is more water-soluble than THC 8, 9 , so patients can use lower doses of THCa to achieve relief, which reduces cost and adverse side effects. If THCa is exposed to heat or to prolonged UV light, it will convert to THC and produce psychoactivity. Always keep THCa in a cool, dark place to prevent it from converting to THC.
CBDa
CBDa is a non-impairing cannabinoid that has anti-inflammatory properties, which may be helpful for arthritic pain. While CBDa has not been studied as rigorously as CBD or THC, observational reports suggest that CBDa helps with mild pain and fatigue. CBD is more water-soluble than CBD, so patients can use lower doses of CBDa to achieve relief, which reduces cost and adverse side effects.
Always keep CBDa in a cool, dark place to prevent it from converting to CBD.
CBG
CBG is a non-impairing cannabinoid that can inhibit the uptake of the neurotransmitter GABA, which can decrease anxiety and muscle tension. Also, CBG has anti-inflammatory properties that might help patients suffering from intestinal bowel disease. Finally, CBG might offer therapeutic potential as an antidepressant, for the treatment of psoriasis, and as an analgesic. 11
Which Route?
After you identify the cannabinoids that might help treat your pain, which route should you use? There are a number of different delivery methods that you can use to consume cannabis and the benefits that you derive from cannabis are influenced by each method of administration. Each method provides a unique experience and set of effects.
Topical Administration
Topicals can provide local relief with few (if any) side effects. When applying a topical, patients can realize relief in minutes, and that relief can last several hours. Topicals can provide pain relief in the hands, neck, ankles, and feet (topical applications are more effective at treating painful joints that are closer to the skin surface). For example, many patients with arthritic pain and peripheral neuropathy should consider starting with a topical. Studies suggest that CBD penetrates the skin more effectively than THC, so Radicle Health recommends starting with a CBD-dominant topical for pain.
Topicals penetrate only the top layers of the skin, typically do not reach the bloodstream, and therefore will not provide systemic relief. For example, deep arthritic pain in the back, knees, or hips might not respond to topical applications and will likely require systemic treatments.
Ingestion
Ingesting cannabis can provide systemic relief for patients. The effects of ingested cannabis last longer and, over time, can reduce inflammation. Patients report that, when they use cannabis regularly and consistently, they can reduce the severity and intensity of their symptoms. Some patients are even able to decrease their overall cannabis intake over time without sacrificing the benefits.
Edible products can cause powerful full-body, psychoactive effects. Because the time of onset is variable and lengthy, edibles are difficult to dose and difficult to titrate. Many patients, and unfortunately, many first time patients, can over-medicate using edibles and experience very unpleasant side effects. 12
Sublingual Administration
Patients can use sublingual products to provide relief between edible doses and when inhalation is not an option. That said, there are few true sublingual products on the market. Cannabinoids are fat-soluble and, in their natural state, do not absorb well into the oral mucosa. Moreover, cannabis products are often extracted into an oil, and these products are not water-soluble. Patients often expect rapid onset when using tinctures, only to wait one to three hours for the dose to take effect. Many products marketed as tinctures will follow the pattern of ingestion, regardless of how long you hold them under your tongue. A true sublingual (a product in which the cannabinoids are formulated to be more water-soluble) absorbs rapidly into the mouth and can take effect within 15 minutes.
Transdermal Administration
If sublingual products are not available, you might consider a transdermal patch. Transdermal products are similar to topicals except that they have an added agent that helps the cannabinoids penetrate the skin and enter the bloodstream, mostly avoiding first-pass metabolism. A transdermal patch can provide eight to twelve hours of relief and are often more consistent and reliable than edible products. Long-lasting, time-released patches can be a good choice for patients when medication compliance is a concern.
Inhalation
If your pain is constant or if it fluctuates in intensity, inhalation may be the best way to control the pain. Inhaling cannabis can relieve pain quickly and can give you the most control over your dose. Inhalation remains the most common route of administration—this route provides immediate relief and is especially effective for patients treating nausea and who cannot ingest other forms of medication. Titrating a dose is easy as peak effects occur within ten minutes.
Rectal Administration
Some medical practitioners and cannabis manufactures suggest that rectal administration is advantageous because patients can take larger doses while avoiding psychoactivity. However, cannabinoids absorbed through the rectum should flow into the circulatory system, there should be detectable levels of THC in the plasma, and those levels should correspond to a discernible psychoactivity. Patients who use high THC products through rectal administration and who fail to feel any psychoactive side effects are likely not improving any systemic issues—the reason no psychoactivity is reported is that the cannabinoids have not been adequately absorbed into the bloodstream. While Radicle Health rarely recommends rectal administration, patients might consider this route if they suffer from conditions that can benefit from a topical cannabis administration, such as fissures or hemorrhoids.
You might need to use multiple routes to address chronic pain. For constant pain, you might need to apply a topical directly to the area, ingest cannabis to help treat the pain throughout the day, and inhale cannabis to treat breakthrough pain.
Of course, when using cannabis to treat chronic pain, working with a healthcare professional can be an effective way to save time and money. An experienced cannabis healthcare professional can get you started with a treatment plan that includes specific products, dosing, and frequency information, and can save you the heartache and expense of false starts and bad advice.
To stay connected with the folks at Radical Health: Facebook: @RadicleHealthcare
Twitter: @RadicleHealthcare
Instagram: RadicleHealth
An evaluation with a pelvic floor physical therapist is warranted when symptoms of pelvic pain, urinary, bowel, and sexual dysfunction arise. Pelvic floor physical therapy is almost always included in a patient’s treatment plan for pelvic pain. Cannabis can help reduce pelvic pain symptoms and working with a medical provider to help you explore if it is right you.Having the right team of professionals to help is important!
Would you like to read more about cannabis and pelvic pain? Check out these two blogs by Shannon Pacella, DPT of PHRC Lexington:
References:
- C.B. Johannes, T.K. Le, X Zhou, J.A. Johnston, and R.H. Dworkin, “The Prevalence of Chronic Pain in the United States Adults: Results of an Internet-based Survey,” Journal of Pain 11 (2010), 1230-39.
- B.D. Sites, M.L. Beach, and M. Davis, “Increases in the Use of Prescription Opioid Analgesics and the Lack of Improvement in Disability Metrics Among Users,” Regional Anesthesia and Pain Medicine 39:1 (2014), 6-12
- Leonardo BM Resstel, Rodrigo F Tavares,1,* Sabrina FS Lisboa,1,* Sâmia RL Joca, Fernando MA Corrêa, and Francisco S Guimarães, “5-HT 1A Receptors Are Involved in the Cannabidiol-Induced Attenuation of Behavioural and Cardiovascular Responses to Acute Restraint Stress in Rats,” Br J Pharmacol. 2009 Jan; 156(1): 181–188 via Blesching, Uwe, “Breaking the Cycle of Opioid Addiction.”
- Kathmann M., Flau K, Redmer A, Tränkle C, Schlicker E. “Cannabidiol Is an Allosteric Modulator at Mu- and Delta-Opioid Receptors,” Naunyn Schmiedebergs Arch Pharmacol. 2006 Feb;372(5):354-61. Epub 2006 Feb 18 via Blesching, Uwe, “Breaking the Cycle of Opioid Addiction.”
- Cannabis has demonstrated efficacy as an analgesic that is 20 times stronger than aspirin (D. Kosersky, et al) and twice as strong as hydrocortisone
- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3165946/
- “Is Juicing Raw Cannabis the Miracle Health Cure That Some of Its Proponents Believe It to Be?,” Martin Lee, originally published in O’Shaughnessy’s, http://www.alternet.org/personal-health/juicing-raw-cannabis-miracle-health-cure-some-its-proponents-believe-it-be
- https://www.sciencedirect.com/science/article/pii/S0378874107002401
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5510775/
- http://www.sciencedirect.com/science/article/pii/S0006295213000543
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3165946/
- http://www.nytimes.com/2014/06/04/opinion/dowd-dont-harsh-our-mellow-dude.html
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
I definitely agree that when using cannabis to treat chronic pain, working with a healthcare professional can be an effective way to save time and money. Superb post!