Cannabis, pain, sleep and navigating daily life and training

Awesome pain control and psychedelic insights

From Wikipedia

Since this pain emerged as a constant, intense, and independent annoyance, around May or June 2020, it has changed. Even the image showed that, but nobody was knowledgeable here to read the MRI. I didn’t send it to my orthopedist in Brazil. From it being symptomatically characterized by a disabling radiation of the pain on the left leg, it evolved into an also excruciating pain concentrated on the lower back, one of the changes. It has been at its lowest intensity (except now), and frequently manifests itself involving the quadratus lumborum and the iliopsoas. The flare-ups are still the same, very intense.

Another thing that changed is that it is now much more responsive to cannabis. In a clinical context, I used cannabis before as an adjunct painkiller, and also to help with sleep (which it does paradoxically). It helps me a lot, much more than gabapentinoids, for example.  Now, my pain is highly responsive to cannabis, or at least to the formulation I use (with a CBD: THC ratio of 1:1), at the dose I use (100 mg). This is the same preparation I used before, so what changed is the drug responsiveness of the pain.

The effect of cannabis on pain is poorly understood, and difficult to test. There is suggestive data in favor of both analgesic and antiinflammatory action by cannabinoids, but not conclusive, and much less dose-informative. 

Lötsch and colleagues reviewed preclinical and human experimental studies and summarized their findings: the activation of CB1 cannabinoid receptors by endogenous or exogenous cannabinoids throughout the nociceptive system is evidenced in preclinical (animal) models of pain. Cannabis-based medications available for humans mainly comprise Δ9 -tetrahydrocannabinol (THC), cannabidiol (CBD), and nabilone. Studies done during the last decade showed an effect on nociceptive processing that could be translated to the human setting in functional magnetic resonance imaging studies, which pointed to a reduced connectivity within the pain matrix of the brain. The results are not consistent, and the cannabinoids could have heterogeneously influenced the perception of the experimentally induced pain, including a reduction in only the affective but not the sensory perception of pain, only moderate analgesic effects, or occasional hyperalgesic effects. This extends to the clinical setting. While controlled studies showed a lack of robust analgesic effects, cannabis was nearly always associated with analgesia in open-label or retrospective reports. 

All reviews that I read agree on the inconclusiveness of data about human analgesia.

However, a careful look at the studies’ methods suggests something else: institutional research is not succeeding in designing effective experimental strategies to measure and explain the analgesic effect of cannabis, and it is also failing to design methods to investigate the actual user setting where there is much information to be obtained. 

While meta-analyses of clinical studies on cannabis claim that the evidence for analgesia is inconclusive in many experimental settings, studies about pain management strategies adopted by actual chronic pain patients (“in the field”) show a prevalent willingness to substitute prescribed opioids for cannabis, as well as a great deal of self-medication. Boehnke and colleagues reported their results from:

“an ongoing, online survey of medical cannabis users with chronic pain nationwide about how cannabis affects pain management, health, and pain medication use. They also studied whether and how these parameters were affected by concomitant recreational use, and duration of use (novice: <1 year vs experienced: ≥1 year). There were 1,321 participants (59% female, 54% ≥50 years old) who completed the survey. Approximately 80% reported substituting cannabis for traditional pain medications (53% for opioids, 22% for benzodiazepines), citing fewer side effects and better symptom management as their rationale for doing so. This confirms what other studies have found. Medical-only users were older (52 vs 47 years old; P < .0001), less likely to drink alcohol (66% vs 79%, P < .0001), and more likely to be currently taking opioids (21% vs 11%, P < .0001) than users with a combined recreational and medical history. Compared with novice users, experienced users were more likely to be male (64% vs 58%; P < .0001), take no concomitant pain medications (43% vs 30%), and report improved health (74% vs 67%; P = .004) with cannabis use. Given that chronic pain is the most common reason for obtaining a medical cannabis license, these results highlight clinically important differences among the changing population of medical cannabis users.”

Of the many studies showing evidence of opioid substitution for cannabis, I chose this one for relatedness: I have the experience these people have, and I can put myself in their situation. 

Anyone who suffers from chronic pain knows that a placebo will not be preferred to hydrocodone or oxycodone. If these patients are dropping their legally obtained opioids in favor of cannabis, citing fewer side effects and better pain control as factors, there is absolutely no doubt that cannabinoids have analgesic effect for these people. 

The results of these on-ground studies of cannabis use (and perception of use) among actual chronic pain patients provide data that the scientific community and the regulatory organisms are struggling to incorporate because they rely exclusively on randomized clinical trials. These will have to wait for better experimental designs.

Despite all the “inconclusive” meta-analyses, that speak more to research methodological failures, the International Association for the Study of Pain (IASP) established a Taskforce on Cannabis and Cannabinoid Analgesia, to systematically examine the evidence on analgesic pharmacology of cannabinoids. Guidelines are being developed for cannabis use among the chronic pain community because patients will use it, whether properly educated or not: legal marijuana is a reality in more than half of the US today. 

People use cannabis for pain because it works. How, in which circumstances, and what determines it are the unknowns. I am one of the lucky people who respond well to cannabis.

My pain is extremely intense. A pain clinic where I had epidural steroid injections that didn’t help referred me to surgery, and that is something I will not pursue in the US. First, because I really don’t trust health care here, and I have seen too many malpractice cases in surgeries among family and friend circles. Second, because I have reasons to suspect that I might be in the group of patients who manifest/are diagnosed with ME/CFS late in life and succeed in significantly improving their symptoms. Even remission is statistically meaningful. I have been improving (I think). Why not bet all my money on this outcome, do everything within my reach to increase its chances, or at least not get in the way? More later on recovery and remission.

I wrote four speculative lines about possible reasons for cannabis to be much more effective against my pain now, compared to earlier in the history of this chronic condition, and this particular orthopedic pathology. I deleted everything because I have no idea, and will probably remain ignorant: this answer cannot be obtained from the content of the current literature on cannabis and pain, or the current body of knowledge on it. The question now is how to use this resource in my favor. 

I have another reason to be enthusiastic about cannabis: for me, it is the only substance that counteracts the “sickness sensation” caused by sleep deprivation. The burning eyes, heavy, aching head, the sluggishness, and, most of all, the dark mood, are just gone when cannabis hits. I can more or less function the day after a sleep-deprived night thanks to cannabis. I tested whether cannabis could affect my sleep negatively, and it does not. Of course, I’m a big fan: although I am sleeping better than a few weeks ago, sleep disruption has been with me forever, and I don’t expect to ever be free from it. Whatever help I can get, I’ll take. 

Cannabinoids are substances that I feel more comfortable experimenting with because they have fewer adverse side effects than any other class of painkiller, the risk of overdose is irrelevant, and although one can develop tolerance and eventually dependence on them, they are considered much less addictive than other classes of substances like opioids, benzodiazepines, or amphetamines. Like most users in the studies I mentioned before (and others), I am substituting other drugs for cannabis. Addictive potential is not a great concern of mine, but I know it is for many people, so here it is, presented in context. 

There is one problem: at this dose (100 mg per capsule), a lot of things happen intensely, including getting high (and slow, distracted, slightly uncoordinated, etc.), and the munchies. 

Munchies are the least relevant of problems, but they are annoying and a potential risk to the diet. I have pretty strong self-control, but munchies are munchies, and sometimes it’s really hard to resist. Food tastes wonderful when I’m high. I remember eating a mango over the counter, in my kitchen, and thinking that it was the most delicious food ever to come into existence, in the history of deliciousness. I love the experience and usually leave the fruits to eat when I’m high and munchie-driven. I don’t think it’s easy, and it may be very hard for people with any binging response. I’m not that concerned about the munchies also because I am not so worried about the calorie deficit at this point, as long as I keep it at around 15-20%. 

I am concerned, at least a little, with being chronically high. It can be fun, I’ll admit. Great for art, drawing, and music, but it makes the day confusing. Reading can get slow and inefficient. Problem-solving ability (certainly agility) can be compromised, although creative solutions increase. Talking is confusing, but sometimes fun. And memory gets shuffled in my case: sometimes I don’t know if something happened that day, or some other day. But I remember tripping high on the cryptogams in one of the greenhouses of the Biosciences Institute, when I was a sophomore in college, in field class, and I don’t remember cannabis ever interfering with my performance. Maybe I’m lucky in this respect.

Of course, it also means not having to drive, and I’m lucky in that respect, too.

I am surprised at how fast I got used to being for long periods in this state, now, during this flare-up. I work (I even work better on repetitive tasks), I write coherently, I take care of my house, I care for my cats (a lot, they are trippy), and I follow my routine according to the items on the list. I do depend on lists. The only thing I’m still not entirely confident with is lifting, but I’m getting there, with caution.

Taking more than 100mg in one day strongly affects intestine motility and digestion. At 200mg and 300mg, I need a mild laxative, and I bloat more. That sucks, but using more than 100mg in a day is also rare, fortunately.

Should I worry? About side effects? About tolerance? About living a slower, less productive life? 

I don’t know. For now, there are so many more positives, that I am just watchfully waiting.