Cannabis for Pain Management in Rheumatology

‘Cannabis has a long history of being used for pain management,’ says Physician Editor Bharat Kumar, MD, MME, FACP, FAAAAI, RhMSUS. ‘What does it mean for rheumatology patients moving forward? Read our article for one answer to this question.’

As cannabis becomes more widely legalized, both in the U.S. and internationally, its use for pain management in chronic conditions has expanded rapidly. For people with rheumatic and musculoskeletal diseases (RMDs), cannabis presents an intriguing option due to its analgesic and anti-inflammatory effects.

Chronic pain and inflammation are hallmark symptoms of such rheumatic conditions as rheumatoid arthritis (RA), osteoarthritis, fibromyalgia and lupus, and conventional treatments often fall short of providing complete relief.^1,2 Consequently, patients are turning to cannabis, either independently or with the hope of guidance from their rheumatologists.^3,4 However, as patients and providers navigate this evolving landscape, challenges related to knowledge gaps, physician comfort and evidence-based guidelines must be addressed.⁵

Patient-Driven Use

Rheumatology patients frequently report that cannabis offers relief not only for pain but also for secondary symptoms, including sleep disruption and anxiety, improving their quality of life with the additional benefit of reducing medications such as antidepressants, non-steroidal anti-inflammatory drugs (NSAIDs) and benzodiazepines.⁴

Fibromyalgia, characterized by widespread pain and notoriously resistant to conventional treatments, is one condition for which cannabis use has grown among patients.⁶ Patients with RA report reduced joint pain and improved mobility with cannabis, although scientific evidence remains limited and further research is needed to solidify these observations.⁷

Patients typically express interest in both THC and CBD, the two primary cannabinoids of more than 100, in the cannabis plant.⁸ These compounds interact with the body’s endocannabinoid system, which regulates pain perception, inflammation and immune responses.⁹ Although THC can provide potent pain relief and has anti-inflammatory effects, it is also psychoactive, which can be a barrier for some patients. CBD, on the other hand, offers anti-inflammatory benefits without psychoactivity, appealing to those who prefer symptom relief without altered cognition. It should be noted that CBD alone provides less pain relief than THC alone or when THC is combined with CBD.^10,11

Other minor cannabinoids, such as CBG, CBC, CBN and THCV, have been growing in popularity for sleep, pain and inflammation; however, these cannabinoids are not well studied.

Knowledge Gaps

A recent international survey of rheumatologists and allied health providers highlights the variations in knowledge, attitudes and practices around cannabis. Conducted November 2023 to April 2024, this cross-sectional survey included 215 respondents, of whom 86% were rheumatologists. The results reveal a community divided in comfort and confidence when discussing cannabis with patients.¹²

The survey revealed several key insights. Nearly 60% of respondents scored in the high-knowledge range regarding cannabis, yet 40% had notable gaps in understanding. These gaps affected rheumatologists’ comfort in discussing cannabis with patients and recommending it.

In this survey, respondents were clustered into three groups based on their attitudes toward cannabis: 1) progressive, 2) traditional and 3) unsure. Each group demonstrated distinct views on cannabis as a therapeutic tool:

1. Progressive group: Representing 32% of respondents, the progressive group was the most open to cannabis use. Nearly 90% believed in cannabis’s potential to replace opioids for chronic pain management, and 58% reported recommending CBD to patients for symptom relief.¹²
2. Traditional group: This conservative cluster (40% of respondents) was less likely to see cannabis as an opioid alternative, with only 49% supporting this use. Just 38% recommended CBD, reflecting a more cautious approach due to the lack of long-term evidence.
3. Unsure group: Making up 28% of the sample, the unsure group was marked by a high level of indecision; over half felt uncomfortable discussing cannabis, and most were undecided about its use as an opioid alternative.

This attitudinal divide affects clinical interactions. Without clear guidance, patients may resort to trial-and-error experimentation with cannabis, potentially choosing consumption methods and dosages without a firm understanding of what may work best for their condition, which could lead to over consumption of cannabis and/or cannabis use disorder. These findings underscore the importance of targeted cannabis education in medical training, as well as the need for more standardized recommendations in rheumatology.

Pharmacology

Cannabinoids, such as THC and CBD, modulate the body’s endocannabinoid system, which plays a role in pain perception, inflammation and immune function.¹³ THC binds to CB1 and CB2 receptors, reducing pain perception and inflammatory responses, which can benefit patients with inflammatory-driven conditions.^14,15

CBD, by contrast, indirectly enhances endocannabinoid activity, modulating pain and inflammation through additional receptor pathways without psychoactive effects.¹⁴

The prevailing theory is that cannabinoids may help reduce central sensitization, potentially easing widespread pain and fatigue.¹³

It is essential that those who provide patient care in rheumatology understand the nuances of cannabinoid pharmacology. Different methods of consumption, such as smoking, vaping and oral ingestion, vary in onset time and duration of effect, which may impact symptom management. For example, smoking and vaping provide rapid onset but come with respiratory risks, while oral products offer a prolonged effect with a slower onset.¹⁶ We need to be equipped with this knowledge to guide patients who may be considering cannabis as an adjunctive treatment.

Challenges & Safety

The primary challenges for rheumatologists and rheumatology health professionals advising on cannabis are related to safety, interactions with other medications and the lack of long-term data on its use in RMDs. Cannabis is known to have side effects—ranging from cognitive changes to potential dependency—that need to be considered, particularly for patients with chronic, long-term use.¹⁷ Further, many rheumatology patients use disease-modifying anti-rheumatic drugs (DMARDs) and immunosuppressants, raising concerns about possible drug interactions with cannabinoids.¹⁸ Although some preliminary studies suggest cannabis may be well-tolerated alongside other medications, further investigation is essential to confirm this in the context of specific rheumatic conditions.

Until rigorous, large-scale studies can establish definitive protocols, rheumatology should consider adopting a cautious, harm-reduction approach. This may include starting with low doses, avoiding inhaled products and closely monitoring patients for any adverse effects.

Foster Communication

Patients’ increasing interest in cannabis highlights the need for rheumatologists and rheumatology health professionals to create an open, non-judgmental space to discuss it. Although some may feel hesitant due to knowledge gaps, encouraging patient-provider dialogue can foster trust and ensure patients have access to accurate information on cannabis’ potential benefits and risks. Given that the survey indicated discomfort among certain rheumatology providers in discussing cannabis, this is a critical area in which professional education can improve the quality of care.

When discussing cannabis, we should be prepared to explain the differences between THC and CBD and emerging cannabinoids and the range of available products, from oils to topical creams, which may be relevant to individual patient needs. This information can empower patients to make more informed decisions that align with their lifestyle, pain management goals and safety considerations.

A Path Forward

As cannabis continues to gain acceptance, it holds the potential to become an adjunctive treatment for rheumatology patients struggling with pain and inflammation. However, to incorporate it safely and effectively, our field needs enhanced knowledge and evidence-based guidelines. The survey findings underscore that although some providers are comfortable discussing and recommending cannabis, a significant number remain uncertain or skeptical.

The future of cannabis in rheumatology hinges on high-quality research that can address these uncertainties, provide insights into long-term safety and explore interactions with conventional treatments. Until then, we are encouraged to approach cannabis with an evidence-informed perspective, focusing on patient-centered guidance that maximizes benefits while minimizing risks. By staying informed and fostering open communication with patients, rheumatology providers can contribute to a growing body of knowledge that may one day position cannabis as a respected and regulated option within the standard toolkit for managing RMDs.

In this evolving landscape, cannabis education and research will enable us to confidently support our patients’ pain management needs, helping us navigate the complexities of cannabis with greater clarity and understanding.

Joanna Zeiger, MS, PhD, works as a cannabis epidemiologist, one of the few in the U.S. She is the founder and CEO of Canna Research Foundation, a nonprofit organization whose goal is to understand the role of cannabis patterns of use and benefits/adverse effects in various populations to better understand the efficacy and safety of medical cannabis. She is also chief scientific officer and the epidemiologist and biostatistician Clinika Research, a CRO that focuses on health outcomes, pharmacokinetic studies and plant-based medicine, including cannabis.

Kaleb Michaud, PhD.
University of Nebraska Medical Center portrait taken on Thursday, September 15, 2022.

Kaleb Michaud, PhD, is a professor in the Division of Rheumatology and Immunology, University of Nebraska Medical Center, Omaha, and the director of FORWARD, The National Databank for Rheumatic Diseases. He is also the ARP secretary.

Disclosure

Dr. Michaud has received Innovative Research Award funding from the Rheumatology Research Foundation.

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