In 2019, the Annals of Internal Medicine published a set of recommendations and commentary on cannabinoid use for chronic pain management from two University of Michigan Medical School Researchers, Kevin F. Boehnke, Ph.D., and Daniel J. Clauw, MD. The researchers’ concern primarily revolved around providing appropriate context and methodology for patients and fellow physicians who are interested in using cannabinoids for pain relief, considering that there is such a limited number of clinical trials to provide information. They recognize both that patients who are looking for alternatives will often try cannabinoids on their own without guidance, and doctors too often don’t know how to discuss cannabinoid options or dosing. Here’s what they had to say.

Clinical analysis of THC and CBD

Most studies to date focus largely on the therapeutic potential of THC-centric synthetic pharmaceutical cannabinoids (like dronabinol) as well as inhaled cannabis options. While the studies have found some evidence of resulting pain relief, they have also highlighted concerning side effects like intoxication, addiction, and mental or physical impairment. CBD, however, does not cause intoxication, and its broader effects are milder than its THC counterparts. The Drug Enforcement Administration even categorized the CBD-based prescription drug Epidiolex as a Schedule V drug—a.k.a. the least restrictive classification noting the lowest potential for abuse. While there is not a lot of clinical data for CBD, preclinical analysis shows great possibility for its anti-inflammatory and pain-relieving properties. Further, CBD has a balancing effect on THC’s side effects, thereby broadening the scope of use for cannabinoids and potentially reducing harm when taken together.

Recommendations for use

The researchers provided the following suggestions for determining appropriate dosage when using cannabinoids as chronic pain treatment:

  • Not cannabinoids alone: Use cannabinoid products in conjunction with other medicines and holistic treatment plans and necessary therapies. Talking to your physician about how this can be achieved is very important in maximizing your overall healthcare experience.
  • Must be verified safe: Only use products with verified third-party testing and analysis.
  • Use oral forms: Take capsules or edibles for long-term treatment, oils and tinctures for breakthrough pain (abrupt pain while already on long-acting painkillers), and for those who prefer inhalation, vaporize flower instead of smoking. Vaping concentrates is concerning, given the ongoing outbreak of vaporizing-related illness.

“Start low, go slow”

The researchers really emphasize the importance of building up slowly, starting with the least disruptive form and amount of cannabinoid products, so that patients can find their optimal dosage, and whether or not that means products with THC or CBD.

They suggest beginning with CBD oil, taking 5-10mg twice a day, increasing the dose weekly over the span of one to two months until they experience pain relief. If CBD alone doesn’t bring relief, then you can add in THC in small amounts, 1-2.5mg per day, and slowly titrate up methodically from there, taking the same amount of time they would with increasing doses of CBD.

Boehnke and Clauw noted that because it is known that taking high doses of opioids for extended periods of time can damage regulatory functions of our internal opioid system, they worry that excessive dosing of THC could cause similar issues. So, it’s very important to approach dosing mindfully as either a patient or a medical professional, and it’s even more important for current physicians to educate themselves on cannabinoids and other non-pharmaceutical treatment alternatives so they can appropriately guide patients who want to explore those options.

Chronic Pain and Fatigue Research Center, Anesthesiology Department, University of Michigan Medical School

Improving the understanding and management of disorders distinguished by symptoms of chronic pain and fatigue

See all posts by Chronic Pain and Fatigue Research Center, Anesthesiology Department, University of Michigan Medical School

Research Papers