Should I try cannabis for my back pain?
It's a question spine surgeon Richard Price says he gets at least several times a day from patients who come into his clinic.
When Price finally dived into the evidence several years ago, he found there were not many high quality studies, even though chronic pain is one of the most common reasons people turn to medical marijuana.
"Anecdotally, [people] say cannabis works great," says Price, an assistant professor of neurological surgery at UC Davis. "It's the only thing that helps them sleep at night, the only thing that takes the edge off."
This is why findings from a pair of major clinical trials in Europe that evaluated cannabis for low back pain — the leading cause of disability worldwide — have caught the attention of Price and others who are investigating the plant's potential in pain management.
The first, published in the journal Nature Medicine, showed that a blend of cannabis oil, containing the psychoactive compound THC, as well as CBD and other natural compounds in the plant, outperformed a placebo.
The other compared that same proprietary cannabis tincture with opioids. Here, patients were much less likely to have gastrointestinal side effects like constipation, and cannabis offered better relief over 6 months than their painkillers.
Price believes the new studies are "groundbreaking" and will be a "cornerstone" of the growing evidence base on cannabis and chronic pain.
Because cannabis remains a Schedule 1 drug — a category reserved for substances with no accepted medical use — and is heavily regulated, this type of large-scale clinical trial is tough to pull off in the U.S.
Vertanical, the German company that funded the trials, expects to win approval to market their full-spectrum cannabis oil, called VER-01, to patients in several European countries in a matter of months.
Meanwhile, the Food and Drug Administration is requiring the company replicate this research in the U.S., meaning it could be years before the drug has a chance to win approval here.
"If politicians or the FDA want to speed up the process, we are ready," says Dr. Clemens Fischer, the founder of Vertanical.
The FDA wouldn't comment on the future of VER-01, but a spokesperson told NPR in a statement that it supports "rigorous, science-based research to evaluate these products."
A pain relief alternative
The findings from the European trials are "remarkable," particularly the fact that cannabis outperformed opioids in terms of pain relief and sleep, says Kevin Boehnke, an assistant professor of anesthesiology at the University of Michigan who studies cannabis and chronic pain.
The opioid trial had close to 400 participants — about half the size of the other study comparing cannabis and a placebo — and patients knew which drug they were receiving.
While these are limitations, Boehnke says the study was also more "reflective" of the real world and validates previous research indicating "many people deliberately use cannabis in place of opioids" because they find it more effective and doesn't come with the same side effects.
Though Vertanical's cannabis tincture may not be available in the U.S. anytime soon, Boehnke says for people seeking treatment for low-back pain, the study suggests it may be worth trying a similar cannabis product instead of opioids.
"It might not be exactly the same," he says. "But I think this provides a lot of useful evidence for patients."
Others in the field are more circumspect, though.
This is the kind of rigorous study that's sorely needed, says Simon Haroutounian, who has decades of experience in this area and directs research at the Washington University Pain Center in St. Louis.
But he thinks the findings are specific to this particular compound that was tested.
In the trial, those in the cannabis group had, on average, about a 30% drop in pain after 12 weeks compared to their baseline. Meanwhile, those who took the placebo had around a 20% reduction.
Haroutounian says it's likely the actual treatment effect is the difference between the two.
Another way to look at the efficacy is that the number of people who need to take the drug for one person to get clinically meaningful pain relief is around seven.
"Most of the medications that we have at our disposal for treating chronic pain are in that range," Haroutounian says. "So it's not panacea, it's not a compound that is going to treat all chronic pain."
Proponents of medical cannabis are quick to point out the drug's safety profile is a clear upside. Unlike opioids, it doesn't come with the same concerns around overdose and addiction.
Fischer of Vertanical notes there were no signs of dependency or withdrawal. In fact, he says the participants usually didn't feel high, particularly if they'd taken it for a longer stretch of time.
"You're not stoned," he says. "They go to work, they drive cars, they use machinery, all possible and legal in Europe."
In the study, however, those on opioids and cannabis did experience about the same rate of side effects, and about 13% ultimately dropped out.
Over the years, Haroutounian, a clinical pharmacist, has seen successes and failures with his own patients.
One patient had suffered a horrific motorcycle injury and eventually tapered off opioids with the help of cannabis. On the other hand, he recalls the case of an older woman who tried cannabis for knee pain.
"With the first dose, she felt dizzy. She fell and broke her hip," he says, "The next six months she spent in and out of hospital."
Pain patients want cannabis options
Currently there's only one cannabis-derived medication with FDA approval, the seizure treatment Epidiolex, and it doesn't contain any THC.
While it's not entirely clear, experts like Boehnke say THC seems to be one of the "primary" compounds responsible for cutting down pain and improving sleep.
"There is no silver bullet chronic pain medication, pretty much for anything," he says, "It's often like, 'oh, I got a little benefit here and a little there,' you're kind of piecing together the puzzle."
Although most Americans live in a state where marijuana is legal, either recreationally or medically, there are well-documented concerns about the quality and consistency of these products.
Ellen Lenox Smith, who's with the U.S. Pain Foundation, says FDA approval of a cannabis product would not only make it available in all states – but also give patients with chronic pain confidence in what they were using.
"I wish it was our country that was putting this out right now," she says.
As a patient advocate, she's frustrated that there isn't better research she can direct others to.
"It's unfortunate because a lot of people are kind of just on their own," says Lenox Smith, who has used medical marijuana for nearly two decades to treat her own pain.
Her condition, known as Ehlers-Danlos syndrome, has led to more than two dozen surgeries, including on her neck and spine. Still, a spoonful of her homemade cannabis oil gives her relief and helps her sleep through the night.
UC Davis surgeon Richard Price thinks it's a reasonable option for his patients who are not getting an operation, though he'd like to see the findings from Europe replicated in the U.S., before he promotes cannabis more broadly.
"It's really challenging to tell somebody, 'I know you're in pain, but there's nothing I can do for you, and a lot of patients do not want to go on opioids,'" he says.
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