How did you become interested in the field of chronic pain?

Through my own lived experience. In 2008, I started having pain symptoms with pain largely in my hands and my wrists. It quickly moved into my elbows, back, shoulders, and hips. After about 13 months of time, I finally received a diagnosis of fibromyalgia. Through that experience, I realized that there are a lot of limitations in the options that are typically offered for pain management and I learned about what things were helpful for me. Once I started educating myself, including with the help and support of the physician who diagnosed me, I started learning the science behind these limitations. I decided to do my PhD in public health instead of water quality.

I did a survey study on how people use cannabis for chronic pain and I found that a lot of people reported decreasing their opioid consumption after using cannabis. At that point, I switched fields and started studying cannabis and pain. Originally I was studying water quality transmission of Helicobacter pylori which causes stomach cancer. Then I moved into the pain space where I had no official training, but a lot of lived experience.

What has helped you the most with managing your fibromyalgia?

In some way, it’s being open enough to develop a toolkit of approaches. For example, I found early on that medications were very helpful. If I was having an acute flare-up, I knew which medications to take at which time. Then I found that cannabis was more helpful than pretty much any of the prescribed medications, which is one of the things that sparked my interest in cannabis.

Similarly, this toolkit extends to non-pharmacologic interventions like acupuncture and massage. There are also lifetime practices that I do myself such as practicing yoga and I actually completed yoga teacher training in 2017, which was really a great way to deepen my practice. I got into meditation and now I teach meditation as well. It’s a combination of all those things to manage symptoms as they arise. I also like to think holistically about what is related to some of these symptoms getting worse. How can I be both proactive as well as reactive in the most appropriate way when things are tough? 

What are studies showing us with the use of cannabis to treat chronic pain?

Quite a few people use it for pain. In the US 38 states have legal medical cannabis at this point. The most common reason that people get a medical cannabis license is for chronic pain. We’re talking about over 1,000,000 people in those state registries.

There is a subset of people who have started substituting cannabis for pain medications like opioids, gabapentin, SSRIs, and NSAIDs. That’s a trend we’re seeing, but it doesn’t apply to everyone. 

There are also people who add cannabis to their treatment regimen and nothing changes. Some of them still report a very poor quality of life. It does not work for everyone. This is a given for any medication, but there are so many polarized narratives about cannabis. Some people say that it works for everything and other people say that it is poison and it doesn’t work at all.

That’s the most common reason that people discontinue cannabis and the second most common reason is the expense. It’s not covered by insurance. That can be a big barrier for people being able to use this as a medicine.

The way people use cannabis for pain management is very different than all the clinical trials that have been done with cannabis-based medicines. I live in Michigan and it’s legal for adult and medical use. As a scientist, I cannot study the things I can buy at dispensaries. I could go buy a topical product of vaporizer, some cannabis flower, and a sublingual tincture and use all of those things to manage my pain, but I cannot use those in a clinical trial. Typically we use a formulation with a specific cannabinoid content delivered in a specific way. The flexibility that exists in a naturalistic use context is much different than what you see in clinical trials. It’s really hard to compare what is found in clinical trials to what people are actually doing.

I’d also like to note that quite a few people don’t tell their doctor when they’re using cannabis. Even when they change their medication regimen due to cannabis, they often do not disclose this to their doctor.

People often notice an improvement in their insomnia when they are on cannabis. Once their sleep is better, their pain often gets better.

At this point in time, do we have an understanding of how cannabis works on the body?

There are a lot of potential mechanisms. People typically think that THC, CBD, and other things in the cannabis plant work on the body’s endogenous cannabinoid system. We know that the endocannabinoid system is involved in a lot of various different functions related to homeostasis. Pain is in part modulated by the endocannabinoid system and so are sleep, behavior, feeding, and several other things. It’s the interaction with that system and potentially some other systems where you see cannabis exerting its effects. Endocannabinoid receptors are found throughout the body. These receptors are CB1 and CB2. CB1 is one of the most common receptors found in the central nervous system. There is so much going on with the endocannabinoid system and its interplay with the many other systems in the body. 

It’s very hard to give a simple answer to that question. There are so many different options there.

What is the difference between cannabis and CBD (cannabidiol)?

In some ways, this is a definitional issue. Cannabis is the plant that CBD, THC, and other cannabinoids are extracted from. Cannabis has over 100 active compounds that are called cannabinoids. These are things like CBD, THC, CBN, delta-8-THC, CBG, and CBC. There’s a whole alphabet soup of cannabinoids that are found in the plant. When you buy a cannabis flower that you smoke or make an extraction from- it contains all of that stuff.

CBD is just one of those compounds that has been extracted and then suspended in oil. CBD is different in the sense that CBD is non-intoxicating and doesn’t get you high. It’s a very potent anti-convulsant. The FDA has approved CBD for orphan epileptic conditions like Lennox-Gastaut syndrome and that’s been approved since 2018.

There is some evidence that CBD might be helpful with anxiety and it may even reduce pain, potentially in the inflammatory context. We still need more human studies to help figure out more definitively the benefits of CBD.

At this point in time, what are studies telling us about psychedelics?

At this point, it’s not too much because the research on psychedelics has been heavily restricted for decades, and it’s just since 2006 when this second wave of psychedelic renaissance started, that people started looking at the therapeutic potential of psychedelics. That being said, there are very few clinical trials of people using psychedelics for any kind of pain.

There were two small pilot proof-of-concept studies where tiny numbers of people were heavily screened. These studies included 10 to 14 people with migraines and cluster headaches. Those studies showed that psilocybin, the active component in magic mushrooms, combined with psychotherapy might reduce pain related to cluster headaches and migraines. The studies were so small and selective so it’s still pretty early to make a definitive pronouncement. There is a lot of excitement that they could be helpful for a number of different things. For example, there are studies that have been published in very high-profile journals like the Journal of Medicine or the Journal of the American Medical Association that focused on things like treatment-resistant depression, for example. It’s remarkable. It’s exciting and we need to pursue that further. I think there’s a lot of work to be done to see how that translates into people with chronic pain because treatment-resistant depression is not the same thing.

Where do you see the direction of future psychedelic research going?

I think we should look at the path of cannabis. I published an article last year that argued that if we want to look at the future of psychedelics, we should look at where cannabis is now. Cannabis set the stage for Schedule I drugs to be legalized. The same states that first legalized cannabis for medical use are now looking into decriminalizing psychedelics. Oregon and Colorado have both passed laws that decriminalize the use of psychedelics. They are setting up treatment centers so that any adult can go and seek psilocybin-assisted treatment for any reason. 

There are a few startup companies or fairly mature pharmaceutical companies that are funding clinical trials.

I think there’s a lot of momentum here that will likely continue to build unless there is some kind of comprehensive federal action to shut it down. It seems unlikely because if it was going to happen, it probably would have happened already. What’s illegal at the federal level could still be implemented and made legal in the states that choose to pass the laws.

 In Ann Arbor, Michigan we have decriminalized psychedelics and there is a local advocacy event called Ethiopia Fest that has happened in the past few years on the University of Michigan campus. People give talks about the therapeutic potential of psychedelics, why they should be decriminalized, and that people should no longer face jail or prison sentences for using these potentially therapeutic substances. 

What advice do you have for individuals who are considering using cannabis to treat chronic pain?

That’s a great question. We’re actually doing a study right now where we’re trying an intervention to teach people how to use cannabis for pain symptoms. So stay tuned for those results. For right now, there are some guiding principles.

You have to think about what symptoms you are specifically trying to target. For example, people with chronic pain have sleep issues. A lot of people who try out cannabis improve their sleep and their pain. Then you have to consider the cannabinoid content or whether you need CBD or THC. If we’re talking about sleep problems, there is more evidence suggesting that THC could be helpful. That being said, you don’t want to take too much so you have to think about the dose. People should start low and go slow.

We also need to consider the method of administration. Smoking doesn’t give you the same effect as eating which doesn’t give you the same effect as rubbing cream on your elbow. Smoking will usually take effect almost immediately and then it takes about two hours to give you the full effect.

It’s also important to do this with a thoughtful mindset. Cannabis should be approached as a medication. People need to check their symptoms and give it a real test to see if it helps with the symptoms. Cannabis use will most likely need to be individualized for each person.

Are there any doctors or organizations that work with chronic pain patients and can instruct them on the use of cannabis?

There are some out there, but it depends on the institution. There are some institutions that tend to be quite friendly towards cannabis. They treat cannabis just like any other medicine and see what helps and then they’ll learn from their patients. They’ll teach their patients about safe usage. It’s a mutual growing process.

In other situations, doctors won’t engage with cannabis at all because they know nothing or they’re scared about it. Some doctors will stop prescribing medications if their patient is on cannabis. There’s a lot of work to be done in this area.

Takeaways:

• Have a toolkit of approaches when managing your pain. Focus on more than one treatment option.

• Cannabis has the potential to improve sleep in a lot of people. An improvement in sleep can lead to a reduction in pain.

• CBD has the potential to reduce pain and you do not get high while using it.

• More research is needed on psychedelics, but the few studies that have been done have shown promising results.

Thank you so much to Dr. Kevin Boehnke for doing this interview with me. He is doing amazing work for the chronic pain community. I am so excited to see where his research takes us in the treatment of chronic pain.