Using Cannabis to Treat Persistent Pelvic Pain

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:

1. 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.
2. 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
3. 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.”
4. 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.”
5. Cannabis has demonstrated efficacy as an analgesic that is 20 times stronger than aspirin (D. Kosersky, et al) and twice as strong as hydrocortisone
6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3165946/
7. “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
8. https://www.sciencedirect.com/science/article/pii/S0378874107002401
9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5510775/
10. http://www.sciencedirect.com/science/article/pii/S0006295213000543
11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3165946/
12. http://www.nytimes.com/2014/06/04/opinion/dowd-dont-harsh-our-mellow-dude.html