Point/Counter

How do you address patients’ questions on use of CBD oil for treatment of musculoskeletal pain?

Click here to read the Cover Story, "Cannabinoids may complement rehabilitation physical therapy joint or spinal injections."

POINT

Lack of scientific data

Thomas R. Hickernell

CBD is one of the most recognized, and certainly one of the most heavily marketed, cannabinoids or cannabis-derived compounds. It is non-psychotropic. In other words, it does not produce a “high” and is reported to have anti-inflammatory and anxiolytic properties. The only current FDA-approved CBD formulation is Epidiolex (Greenwich Biosciences), which is for treatment of epilepsy associated with Lennox-Gastaut or Dravet syndrome. Most patients, however, come into our offices asking about the use of unregulated CBD-containing products that are available on the open market, such as topical oils. I counsel my patients firstly by informing them these unregulated products are exactly that—unregulated by the FDA and not generally held to any federal testing standards to ensure products contain what the labels claim. Furthermore, there is little scientific data at this point to support the myriad claims of CBD’s anxiolytic and anti-inflammatory properties that are advertised in the lay press. The FDA, in fact, has issued dozens of warning letters to various American manufacturers regarding false advertising and illegal interstate marketing of CBD as an unapproved drug.

That said, there is a growing body of anecdotal evidence supporting CBD’s use for musculoskeletal pain. The existing safety data, including from testing of Epidiolex, show that CBD has a broad spectrum of safe dosages with seemingly few side effects. If patients are willing to pay out of pocket for CBD oils and are aware and accepting of the current lack of scientific data, then I encourage them to try them as a non-opioid, seemingly safe musculoskeletal pain control option.

Thomas R. Hickernell, MD, is an assistant professor of orthopedic surgery at Columbia University Irving Medical Center and New York-Presbyterian Hudson Valley Hospital in New York.

Disclosure: Hickernell reports no relevant financial disclosures.

COUNTER

Todd J. Albert

Substances need further study

We have seen a significant increase in patients asking about the use of CBD as an adjunct to pain control for their musculoskeletal problems. Like many things, we are studying this first by conducting a survey to identify the numbers/percent of patients utilizing these substances. We will then work to create guidelines and recommendations for usage. In general, I am in favor of these methodologies given their decreased chance of habituation and adequate efficacy in pain diminution. Certainly, given the problems the industry has had with classic opioid treatment (habituation, overuse, addiction and repurposing of medicine), we would do a service to our patients to develop a well thought out and studied protocol using these substances as adjuncts in our pain control. Appropriate stewardship would then recommend we study these substances further in terms of frequency of use, adverse events, secondary effects and ease of withdrawal. This can serve as a model for future responsible introduction of substances by a specialty whose diseases and interventions are more pain producing than any other specialty.

Todd J. Albert, MD, is surgeon-in-chief emeritus at Hospital for Special Surgery in New York and is an Orthopedics Today Editorial Board Member.

Disclosure: Albert reports no relevant financial disclosures.

Click here to read the Cover Story, "Cannabinoids may complement rehabilitation physical therapy joint or spinal injections."

POINT

Lack of scientific data

Thomas R. Hickernell

CBD is one of the most recognized, and certainly one of the most heavily marketed, cannabinoids or cannabis-derived compounds. It is non-psychotropic. In other words, it does not produce a “high” and is reported to have anti-inflammatory and anxiolytic properties. The only current FDA-approved CBD formulation is Epidiolex (Greenwich Biosciences), which is for treatment of epilepsy associated with Lennox-Gastaut or Dravet syndrome. Most patients, however, come into our offices asking about the use of unregulated CBD-containing products that are available on the open market, such as topical oils. I counsel my patients firstly by informing them these unregulated products are exactly that—unregulated by the FDA and not generally held to any federal testing standards to ensure products contain what the labels claim. Furthermore, there is little scientific data at this point to support the myriad claims of CBD’s anxiolytic and anti-inflammatory properties that are advertised in the lay press. The FDA, in fact, has issued dozens of warning letters to various American manufacturers regarding false advertising and illegal interstate marketing of CBD as an unapproved drug.

That said, there is a growing body of anecdotal evidence supporting CBD’s use for musculoskeletal pain. The existing safety data, including from testing of Epidiolex, show that CBD has a broad spectrum of safe dosages with seemingly few side effects. If patients are willing to pay out of pocket for CBD oils and are aware and accepting of the current lack of scientific data, then I encourage them to try them as a non-opioid, seemingly safe musculoskeletal pain control option.

Thomas R. Hickernell, MD, is an assistant professor of orthopedic surgery at Columbia University Irving Medical Center and New York-Presbyterian Hudson Valley Hospital in New York.

Disclosure: Hickernell reports no relevant financial disclosures.

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COUNTER

Todd J. Albert

Substances need further study

We have seen a significant increase in patients asking about the use of CBD as an adjunct to pain control for their musculoskeletal problems. Like many things, we are studying this first by conducting a survey to identify the numbers/percent of patients utilizing these substances. We will then work to create guidelines and recommendations for usage. In general, I am in favor of these methodologies given their decreased chance of habituation and adequate efficacy in pain diminution. Certainly, given the problems the industry has had with classic opioid treatment (habituation, overuse, addiction and repurposing of medicine), we would do a service to our patients to develop a well thought out and studied protocol using these substances as adjuncts in our pain control. Appropriate stewardship would then recommend we study these substances further in terms of frequency of use, adverse events, secondary effects and ease of withdrawal. This can serve as a model for future responsible introduction of substances by a specialty whose diseases and interventions are more pain producing than any other specialty.

Todd J. Albert, MD, is surgeon-in-chief emeritus at Hospital for Special Surgery in New York and is an Orthopedics Today Editorial Board Member.

Disclosure: Albert reports no relevant financial disclosures.