CBD for Pain: Is Cannabidiol a Natural Alternative to Opioid Drugs?

The statements mentioned in this content have not been evaluated by the FDA, and are not intended to prevent, diagnosis, or treat any disease. Always work with your personal healthcare provider.

By Chris D. Meletis, N.D.

The increased dependence upon opioid medications to treat pain has become alarming given the potential to grow dependent upon and overdose on these medications. More than 130 individuals die every day due to opioid overdose.1 This includes prescription opioid pain killers, heroin, and synthetic opioids such as fentanyl. In 2017, more than 47,000 people in the U.S. died from overdosing on one of these medications.1 This has created what has been commonly termed “the opioid crisis.”

In the 1990s, pharmaceutical companies assured physicians that opioid drugs were not addictive, and doctors began to prescribe these medications.2 Since then widely, clinical experience and science has shown that this class of medications is indeed highly addictive.2,3 Furthermore, a paper published in the journal Pain found that 21% to 29% of individuals using opioids for chronic pain misuse the drugs.4 Despite the awareness of the addictive nature of opioids, the number of prescriptions written for this class of medications has skyrocketed by 300% since 1991.5

A safe and natural alternative to opioids is needed, and accumulating evidence indicates that alternative is cannabidiol (CBD) oil. 

The Endocannabinoid System and Pain

CBD is a phytocannabinoid derived from hemp. Unlike the primary cannabis-derived phytocannabinoid known as tetrahydrocannabinol (THC), CBD has no psychoactive effects. It interacts with the endocannabinoid system, which is integrally involved in pain perception. CBD indirectly acts upon CB1 and CB2, along with type 1 vanilloid receptors (TRPV), which regulate pain perception and inflammation.6 CBD also boosts levels of the endogenous cannabinoid anandamide, which is involved in controlling pain through the CB1 receptor.7,8 

Shared Pathways Between Opioids and CBD

The endocannabinoid and opioid systems are intertwined. CB1 receptors and opioid receptors are found in many of the same regions of the brain.5 Modulating CB1 receptors can influence the rewarding properties of opioids, and opioid administration can also alter the effects of cannabinoids.5 Further corroborating this endocannabinoid-opioid connection was a human study that determined CB1 was upregulated in the reward pathway of opioid users.5 Additionally, blocking CB1 receptors in the amygdala interferes with opioid withdrawal in rats.

Due to these shared pathways, CBD has been shown to demonstrate properties that may make it beneficial for people withdrawing from opioids. In people with addictions, the recall of memories related to a drug experience can lead to craving and relapse. Research indicates memories related to the use of a drug are reactivated due to environmental cues and are strengthened through a process known as reconsolidation. This can lead to the cycle of addiction. However, rodent studies indicate CBD can disrupt reconsolidation of drug-related memories and reduce the risk of relapse.10 Furthermore, in other rodent studies, CBD has ameliorated the rewarding effects of several drugs of abuse including cocaine and amphetamine.5,11A double-blind pilot study in humans found that in people who had recently abstained from heroin, CBD inhibited heroin cravings.12 The reduction in cravings was noted as soon as 1 hour after administration of the CBD and lasted for as long as 7 days. CBD also reduced anxiety in the subjects. 

One group of researchers concluded, “Because CBD is neither intoxicating nor rewarding and has an extremely large therapeutic window and impressive safety profile, the use of CBD to inhibit opioid craving has great therapeutic potential.”5

CBD and Abdominal Pain 

CBD’s role in ameliorating opioid addiction extends beyond its ability to ease withdrawal and reduce cravings. CBD may also have a role to play in supporting the health of people who are suffering from pain—the main reason many people turn to opioids in the first place. The endocannabinoid system has been studied for its role in pain perception in various areas of the body. One example is the relationship between gut, pain, and endocannabinoids. The endocannabinoid system can regulate the perception of visceral pain13,14 and may also be the bridge linking stress to abdominal pain.14

There is a cross-talk between the endocannabinoid system and the gut microbiota that plays a role in the regulation of visceral pain. The probiotic Lactobacillus given orally to rodents inhibited visceral pain while also upregulating CB2 receptors in the intestinal epithelium.15 Blocking CB2 canceled out the probiotic’s beneficial effects. Furthermore, in a model of chronic colonic hypersensitivity, Lactobacillus acidophilus produced analgesia.15 This study also observed that CB2 receptors may play a role in the correlation between gut microbiota and visceral hypersensitivity.

CBD and Other Forms of Pain

CBD has been directly studied in different forms of pain in humans. Seven kidney transplant patients suffering from pain were given an initial dose of up to 100 mg/day of CBD.16 Two subjects experienced complete resolution of pain, four had a partial improvement in the first 15 days, and one subject did not have any improvement. Additionally, cannabinoid-rich hemp oil was associated with less body pain and alleviated other symptoms in girls who had suffered from an adverse reaction to the human papillomavirus (HPV) vaccine.17 Another study observed that the oil of cannabis seeds reduces pain in people with chronic musculoskeletal inflammation.18 It was thought this effect was due to the ideal omega-3/omega-6 ratio content in the oil. In a survey of 484 women using various strategies for their endometriosis pain, hemp/CBD oil was one of the supportive measures rated as most effective.19 The hemp/CBD oil had a mean effectiveness of 6.33 on a 10-point scale. In rats, local CBD treatment reduced joint inflammation, and prophylactic administration of CBD blocked the development of osteoarthritis.20 

Conclusion

An alarming number of patients have suffered the consequences of the opioid crisis. The addictive nature of these drugs indicates that a natural alternative to opioids is needed. Based on accumulating evidence, CBD oil may be that alternative. Studies have pointed to the potential effectiveness of CBD in pain related to endometriosis and osteoarthritis as well as abdominal pain and other disorders. 

References:

  1. National Institute on Drug Abuse. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis Accessed May 14, 2019
  2. Van Zee A. The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy. Am J Public Health. 2009 Feb;99(2):221-7.
  3. Kraus L, Seitz NN, Schulte B, et al. Estimation of the Number of People With Opioid Addiction in Germany. Dtsch Arztebl Int. 2019 Mar 1;116(9):137-43. 
  4. Vowles KE, McEntee ML, Julnes PS, et al. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015 Apr;156(4):569-76. 
  5. Wiese B, Wilson-Poe AR. Emerging Evidence for Cannabis’ Role in Opioid Use Disorder. Cannabis Cannabinoid Res. 2018;3(1):179-89. 
  6. O’Hearn S, Diaz P, Wan BA, et al. Modulating the endocannabinoid pathway as treatment for peripheral neuropathic pain: a selected review of preclinical studies.Ann Palliat Med. 2017 Dec;6(Suppl 2):S209-14.
  7. Elmes MW, Kaczocha M, Berger WT, et al. Fatty acid-binding proteins (FABPs) are intracellular carriers for Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD). J Biol Chem. 2015 Apr 3;290(14):8711-21.
  8. Manzanares J, Julian MD, Carrascosa A, et al. Role of the Cannabinoid System in Pain Control and Therapeutic Implications for the Management of Acute and Chronic Pain Episodes. Curr Neuropharmacol. 2006 Jul;4(3):239-57. 
  9. Wills KL, DeVuono MV, Limebeer CL, et al. CB₁ receptor antagonism in the bed nucleus of the stria terminalis interferes with affective opioid withdrawal in rats.Behav Neurosci. 2017 Aug;131(4):304-11.
  10. de Carvalho CR, Takahashi RN. Cannabidiol disrupts the reconsolidation of contextual drug-associated memories in Wistar rats. Addict Biol. 2017 May;22(3):742-51.
  11. Parker LA, Burton P, Sorge RE, et al. Effect of low doses of delta9-tetrahydrocannabinol and cannabidiol on the extinction of cocaine-induced and amphetamine-induced conditioned place preference learning in rats. Psychopharmacology (Berl). 2004 Sep;175(3):360-6.
  12. Hurd YL, Yoon M, Manini AF, et al. Early Phase in the Development of Cannabidiol as a Treatment for Addiction: Opioid Relapse Takes Initial Center Stage. Neurotherapeutics. 2015 Oct;12(4):807-15. 
  13. Sakin YS, Dogrul A, Ilkaya F, et al. The effect of FAAH, MAGL, and Dual FAAH/MAGL inhibition on inflammatory and colorectal distension-induced visceral pain models in Rodents.Neurogastroenterol Motil. 2015 Jul;27(7):936-44.
  14. Sharkey KA, Wiley JW. The Role of the Endocannabinoid System in the Brain-Gut Axis.Gastroenterology. 2016 Aug;151(2):252-66. 
  15. Rousseaux C, Thuru X, Gelot A, et al. Lactobacillus acidophilus modulates intestinal pain and induces opioid and cannabinoid receptors. Nat Med. 2007 Jan;13(1):35-7.
  16. Cuñetti L, Manzo L, Peyraube R, et al. Chronic Pain Treatment With Cannabidiol in Kidney Transplant Patients in Uruguay. Transplant Proc. 2018 Mar;50(2):461-4.
  17. Palmieri B, Laurino C, Vadalà M. Short-Term Efficacy of CBD-Enriched Hemp Oil in Girls with Dysautonomic Syndrome after Human Papillomavirus Vaccination. Isr Med Assoc J. 2017 Feb;19(2):79-84.
  18. Shaladi AM, Crestani F, Tartari S, et al. [Cannabinoids in the control of pain]. [Article in Italian, Abstract in English]. Recenti Prog Med. 2008 Dec;99(12):616-24.
  19. Armour M, Sinclair J, Chalmers KJ, Smith CA. Self-management strategies amongst Australian women with endometriosis: a national online survey. BMC Complement Altern Med. 2019;19:17. 
  20. Philpott HT, O’Brien M, McDougall JJ. Attenuation of early phase inflammation by cannabidiol prevents pain and nerve damage in rat osteoarthritis. Pain. 2017 Dec;158(12):2442-51.