Marijuana (Cannabis) for Fibromyalgia
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Fibromyalgia (FM), one of the most common chronic pain syndromes, is characterized by diffuse musculoskeletal pain, in addition to extreme fatigue and mood and sleep disturbances. The cause(s) of fibromyalgia is not known but it usually affects women more than men, it has a genetic predisposition and its prevalence in the general population is approximately 7%.
Effective treatment for the pain and other symptoms of fibromyalgia has remained elusive, despite three FDA-approved prescription medication. These prescription medications as well as opioids are often ineffective or not well tolerated leaving many patients suffering from significant impairment in the quality of their lives to turn to alternative medications.
The recent changes in access to medical marijuana and marijuana-based medication offers hope for a new alternative treatment for many of the symptoms associated with FM.
Over-the-Counter Cannabinoid Medications:
Prescription Cannabis-Based Medications:
Clinical Applications of Cannabis:
Cannabis – Anxiety (coming soon)
Cannabis – Headaches (coming soon)
Cannabis – Inflammatory Bowel Disease (coming soon)
Cannabis – Neuroinflammation (coming soon)
Cannabis – Pain (coming soon)
Cannabis – Sleep (coming soon)
The Medical Science of Cannabis:
Cannabinoids and Terpenes:
Cannabinoids & Terpenes – An Overview (coming soon)
Key to Links:
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This section is frequently edited for accuracy and completeness.
Mariuana (Cannabis) – Fibromyalgia (FM)
In 2003 one of the leading marijuana researchers, Ethan B. Russo, published a paper that explored the concept that a clinical endocannabinoid deficiency (CECD) underlies the pathophysiology of migraine, fibromyalgia, irritable bowel syndrome and other functional conditions that have been found to symptomatically respond to treatment with medical cannabis. Since then, investigation has found that cannabinoids can block spinal, peripheral and gastrointestional mechanisms that promote pain in these conditions. Subsequent research has confirmed that underlying endocannabinoid deficiencies indeed does play a role in migraine, fibromyalgia, irritable bowel syndrome and a growing list of other medical conditions.
Cannabis Research Regarding Treatment of Fibromyalgia
The current state of medical marijuana research, especially in the field of fibromyalgia, is based mostly on studies using the cannabis plant, whether smoked, vaped or ingested, in which virtually nothing is known about the dosages associated with use, i.e. how much THC, CBD and other constituents were used and how often. This leaves a serious weakness in applying the findings to the use of marijuana-based products which have fixed amounts and ratios of constituents. Most cannabis research is in the form of observational studies with very few randomised controlled trials to guide management of fibromyalgia with specific cannabis-based treatments.
Observational studies are those in which data is reviewed by an investigator who observes individuals without manipulation or intervention and draws inferences from a population where no independent variables are under the control of the researcher. Observational studies can determine if there are associations between an activity and an outcome but cannot identify or confirm cause and effect. This is in contrast to randomised controlled trials (RCTs) where investigators do intervene and look at the effects of the intervention on an outcome. RCTs are useful in determining causal relationships between treatment and outcome such as whether a medication actually works for a particular conditi0n.
Fibromyalgia Treatment with Cannabis
A 2014 online survey of over 1,300 fibromyalgia patients conducted by the National Pain Foundation and published in the National Pain Report indicated that while over 70% of the people who responded to the survey indicated they had not tried medical marijuana, but of those who did try medical marijuana said it was far more effective than any of the FDA-approved prescription medications for fibromyalgia (Cynbalta, Lyrica, Savella).
Sixty-two percent of respondents who had tried cannabis considered it very effective for treating their fibromyalgia symptoms and another 33% said it helped a little, while only 5% said it did not help at all. Some responders reported that nothing had worked for them apart from marijuana. Adverse effects reported included brain fog with use of medical marijuana.
A 2018 study of 26 patients with FM treated for an average duration of 10 months, with a median duration of 3 months. No patient ceased cannabis treatment. All the patients smoked or inhaled cannabis but the study did not identify an analysis of the cannabis content. In the study group, 13 patients (50%) ceased taking any medication other than cannabis. Twelve patients (~46%) reduced the dose/number of medications they had been taking for their FM, including opioids, Lyrica and benzodiazepines, by at least 50% as compared with the dose/number of medications prior to cannabis treatment. In some cases, the improvement was so marked that the patients completely ceased treatments they had taken previously.
The main finding of the study was that cannabis treatment was associated with significant favorable outcomes in every item evaluated, including pain, sleep, energy and quality of life. It was noted that the patients expressed dramatic improvements such that the researchers commented that they “Very rarely encountered such responses in real-life medicine.”
Examples of the patients’ responses included: “I wish I had received this treatment when I was first diagnosed with fibromyalgia,” “I returned to be the same person as before,” “I regained my health,” and “This is a miraculous treatment.”
There were no serious adverse effects in this study. The patients reported a few mild adverse effects, including dry mouth, redness of the eyes, and feeling hungry. These symptoms appeared at the start of the treatment but were usually transient, lasting only a few weeks, and were mainly associated with smoking the cannabis. Many patients adapted to feeling hungry by eating prior to the use of cannabis.
Safety and Efficacy of Medical Cannabis in Fibromyalgia – 2019
Perhaps the most helpful study that supports the potential benefit for medical marijuana is a 2019 Israeli stody evaluating 298 patients with fibromyalgia who were treated with medical cannabis for six months. Of these, only 211 responded with the follow-up questionnaire. although out of the 87 patients who did not respond to the six months questionnaire, 76 patients (87.3%) were still using cannabis at six months.
The majority of the patients in this study were 40–60 years old (181 patients, 49.3%) and female (301 patients, 82.0%). Patients had reported previous experience with recreational cannabis in the past in 45.2% of cases. The median length of fibromyalgia symptoms was 7 years, and 320 (87.2%) patients reported constant daily pain. In 283 patients (77.1%), fibromyalgia was the primary pain-related indication to initiate medical cannabis therapy. Fibromyalgia was the secondary indication to initiate cannabis therapy in 35 (9.5%) patients with the primary pain condition of cancer, 22 (6.0%) patients, post-traumatic stress disorder (PTSD) in 27 (7.4%) patients and others with other indications.
The route of administration was oil in 74 patients (20%), inhalation of marijuana flower (vaped or smoked) in 247 patients (67%) both oil and inhalation in44 patients (12%). The actual dosing employed in this study is, unfortunately, confusing. The median cannabis plant dosage was 670 mg/day at initiation of the study and 1000 mg/day at six months. The calculated median THC and CBD dosages at six months were 140 mg/day (ranging from 90–200 mg) for THC and 39 mg/day (ranging from 10–69 mg) for THC. When comparing dose at six months between patients with fibromyalgia as a primary or secondary indication, the primary fibromyalgia patients utilized the similar THC and CBD dosages as the secondary patients. However, it is not clear at all how these doses were calculated and no comparism was provided between oil vs. inhalation doses. Therefore, applying these doses as a means of recommending doses to patients with FM appears to be very speculative.
Overall, treatment was successful in 194 out of 239 patients (81.1%), defined as at least moderate improvement in their condition while receiving medical cannabis without experiencing serious adverse events. The likelihood of treatment success was reduced in patients who expressed concerns about cannabis treatment, whereas spasticity at treatment initiation and previous use of cannabis were variables associated with increased likelihood of treatment success.
Regarding pain intensity, prior to treatment initiation 193 patients (52.5%) reported a high level of pain scale (8–10). However, after six months of follow-up, only 19 patients (7.9%) reported similar pain intensity. Overall pain intensity reduced from a median of 9.0 at baseline to 5.0 (range 4.0–6.0) after six months.
Regarding quality of life (QOL) assessment, prior to treatment initiation only 10 patients (2.7%) reported good or very good QOL, whereas after six months of treatment 148 patients (61.9%) reported their QOL to be good or very good. When analyzing QOL components, sleep quality, appetite, and sexual activity significantly improved at six months while other components (e.g., mobility, dressing, and concentration) did not improve. The sleep problems reported by 196 patients (92.9%) at intake improved in 144 patients (73.4%) and disappeared in 26 patients (13.2%). Depression-related symptoms reported by 125 patients (59.2%) at the baseline improved in 101 patients (80.8%).
The patients in this study used 14 different strains of cannabis, which prevented evaluation of a comparison between THC and CBD strains and products in terms of effectiveness or side effects. Of the regimens used by the patients in this study, 56% used THC-rich regimens compared to 22% who used CBD-rich regimens. This suggests that a THC-rich regimen was more popular and therefore more effective, but no direct analysis was performed comparing effectiveness of one regimen vs. the other nor did the study offer an analysis of side-effects comparing the two regimens. Furthermore, no comparism was made between inhaled regimens vs. oral or buccal regimens either related to dosing, effectiveness or side effects.
Regarding the use of other drugs for the treatment of fibromyalgia after six months, most patients ceased, reduced, or at least did not change the dosage of their chronic drugs for fibromyalgia while receiving medical cannabis. At six months, 28 out of 126 patients (22.2%) stopped or reduced their dosage of opioids, and 24 out of 118 (20.3%) reduced their dosage of benzodiazepines. When stratifying the analysis to patients with fibromyalgia as the primary vs. secondary pain source, both groups showed the same improvement at six months in terms of pain intensity and overall quality of life.
With respect to side effects, the most commonly reported adverse events after six months were dizziness (7.9%), dry mouth (6.7%), and vomiting/nausea (5.4%). This is consistent with the findings of other studies.
The final conclusion of this study is therefore limited to the fact that the use of cannabinoids appears to offer significant benefit for those with fibromyalgia on multiple levels but no specific recommendations can be made for route of administration or dosing regarding THC or CBD.
Fibromyalgia Treatment with Pharmaceutical Cannabinoids
Pharmaceutical Cannabinoids – THC
THC (delta-9-tetrahydrocannabinol), the major cannabinoid constituent of cannabis, has only limited research as a singular agent for treating fibromyalgia. A 2006 study evaluated just nine fibromyalgia (FM) patients who received a daily dose of 2.5-15 mg of THC, starting with a 2.5mg/day dose with a weekly dose increase of 2.5 mg up to a maximum 15 mg/day dose, as long as no side effects were reported. Daily-recorded pain of the FM patients was significantly reduced but researchers recommended further studies be done prior to concluding definitive effectiveness.
In 2009 a multicenter survey was performed evaluating 172 patients treated with an average of 7.5 mg/day of THC over 7 months. Of these, 48 patients prematurely withdrew due to side effects, insufficient analgesia, or expense of therapy. In the end, 124 patients were assessed for changes in pain intensity, quality of life, anxiety and depression. Pain intensity improved significantly with the THC treatment. Opioid doses were reduced and patients perceived THC therapy was effective with tolerable side effects. About 25% of the patients, however, did not tolerate the THC treatment.
Pharmaceutical Cannabinoids – Nabilone (Cesamet)
Nabilone is a synthetic cannabinoid intended for oral use that is different from THC, but is structurally similar. Nabilone is FDA-approved in the United State but indicated only for the treatment of the nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond adequately to conventional antiemetic treatments. Nabilone is also approved for use in Canada, Mexico, and the United Kingdom for the treatment of severe nausea and vomiting associated with chemotherapy.
Evidence is emerging for the use of nabilone in the management of different pain conditions including fibromyalgia. A systematic review of the Cochrane Library databases (updated July 23, 2015) identified eight randomized controlled trials, two prospective cohort trials, and one retrospective chart review evaluating cancer pain, chronic noncancer pain, neuropathic pain, fibromyalgia, and pain associated with spasticity. Nabilone was most commonly used as adjunctive therapy but overall nabione treatment led to small but significant reductions in pain. The most common side effects included euphoria, drowsiness, and dizziness but nabilone was rarely associated with severe side effects that required discontinuation of use. The likelihood of abuse was considered low. Although the optimal role of nabilone in the management of pain is yet to be determined, nabilone is generally considered to be a third-line agent.
A Cochrane review article published in 2016 reviewed randomised controlled trials of at least four weeks’ duration that evaluated any formulation of cannabis products used for the treatment of adults with fibromyalgia. Highest quality evidence was obtained from studies with at least 200 participants and of eight to 12 weeks duration. Lesser quality evidence was obtained from smaller studies that were considered at some risk of bias. The primary outcomes in the review were participant-reported pain relief of 50% or greater.
Nabilone was compared to placebo and to amitriptyline in two small studies with 32 and 40 participants and study duration of four to six weeks. Nabilone was provided with a bedtime dosage of 1 mg. Neither study reported participants experiencing at least 30% or 50% pain relief or who were very much improved.
Some studies, though of very low quality, provided evidence of greater reduction of pain and limitations of health-related quality of life compared to placebo. There were no significant differences to placebo found for fatigue and depression. Better effects of nabilone on sleep than amitriptyline (Elavil) were reported. More participants dropped out due to adverse events in the nabilone group (4/52 participants) than in the control groups (1/20 in placebo and 0/32 in amitriptyline group). The most frequent side effects were dizziness, nausea, dry mouth and drowsiness (six participants with nabilone). There were no reported serious side effects.
The authors of the Cochrane review concluded that there is no convincing, unbiased, high quality evidence that nabilone is of value in treating people with fibromyalgia and the tolerability of nabilone was low.
National Academy of Sciences
This website appears to be good resource for exploring medical marijuana.
Cannabis – Fibromyalgia
- Clinical Endocannabinoid Deficiency (CECD): Can this Concept Explain Therapeutic Bene ts of Cannabis in Migraine, Fibromyalgia, Irritable Bowel Syndrome and other Treatment-Resistant Conditions?-2004
- Clinical endocannabinoid deficiency (CECD) revisited: can this concept explain the therapeutic benefits of cannabis in migraine, fibromyalgia, irri… – PubMed – NCBI – 2014
- Clinical Endocannabinoid Deficiency Reconsidered- Current Research Supports the Theory in Migraine, Fibromyalgia, Irritable Bowel, and Other Treatment-Resistant Syndromes – 2016
- Cannabinoids for fibromyalgia. – 2016 PubMed – NCBI
- Association of Herbal Cannabis Use With Negative Psychosocial Parameters in Patients With Fibromyalgia – 2012
- Cannabinoids in the management of difficult to treat pain – 2008
- Cannabis Use in Patients with Fibromyalgia – Effect on Symptoms Relief and Health-Related Quality of Life – 2011
- Efficacy, tolerability and safety of cannabinoids in chronicpain associated with rheumatic diseases (fibromyalgia syndrome, back pain, osteoarthritis, rheumatoid arthritis) – 2016
- Medical Cannabis for the Treatment of Fibromyalgia. – PubMed – NCBI – 2018
- Safety and Efficacy of Medical Cannabis in Fibromyalgia – 2019
Cannabis & Fibromyalgia – Nabilone
- Nabilone for the Management of Pain. 2016 – PubMed – NCBI
- Nabilone for the treatment of pain in fibromyalgia. 2008 – PubMed – NCBI
- The effects of nabilone on sleep in fibromyalgia: results of a randomized controlled trial. – PubMed – 2010 NCBI
Cannabis – THC
- Delta-9-THC based monotherapy in fibromyalgia patients on experimentally induced pain, axon reflex flare, and pain relief. 2006 – PubMed – NCBI
- Tetrahydrocannabinol (Delta 9-THC) Treatment in Chronic Central Neuropathic Pain and Fibromyalgia Patients – Results of a Multicenter Survey – 2009
Cannabis – Pain
- It is premature to expand access to medicinal cannabis in hopes of solving the US opioid crisis – 2018
- Patterns of medicinal cannabis use, strain analysis, and substitution effect among patients with migraine, headache, arthritis, and chronic pain in a medicinal cannabis cohort – 2018
- Patterns and correlates of medical cannabis use for pain among patients prescribed long-term opioid therapy. – PubMed – NCBI
- Associations between medical cannabis and prescription opioid use in chronic pain patients – A preliminary cohort study – 2017
- Medical Marijuana for Treatment of Chronic Pain and Other Medical and Psychiatric Problems – A Clinical Review – 2015
Cannabis – Misc.
- A tale of two cannabinoids: the therapeutic rationale for combining tetrahydrocannabinol and cannabidiol. – PubMed – NCBI
- Taming THC – potential cannabis synergy and phytocannabinoid-terpenoid entourage effects – 2011
- The Cannabis sativa Versus Cannabis indica Debate – An Interview with Ethan Russo, MD – 2016
- Review of the neurological benefits of phytocannabinoids – 2018
- Cannabis and cannabis extracts – greater than the sum of their parts? – 2001 I
- Cannabis-conclusions – 2017 National Academy of Sciences
- Cannabis-chapter-highlights – 2017 National Academy of Sciences
- Cannabis-report-highlights – 2017 National Academy of Sciences
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