Inhaled Cannabis More Effective Than Meds for Chronic Low Back Pain

By Pat Anson

Patients with chronic lower back pain who did not respond well to opioids and other pain medications showed “robust improvements” in pain and disability once they switched to inhaled cannabis, according to a new long-term study.

Researchers at Rabin Medical Center in Israel followed 241 patients with chronic lower back pain (CLBP) for five years – a period when they inhaled medical cannabis by smoking (91%) or vaporizing (9%).

Not only did participants report significant and steady improvement in their pain over the course of the study, many were able to stop or significantly reduce their use of opioids, non-steroidal anti-inflammatory drugs (NSAIDs), SSRI/SNRI antidepressants, and gabapentinoids such as pregabalin and gabapentin. 

“In a treatment-refractory CLBP cohort with five-year longitudinal follow-up, inhaled cannabis was associated with large, sustained, and statistically robust improvements in pain, disability, and pain interference, accompanied by near-total displacement of opioids, NSAIDs, antidepressants, and gabapentinoids,” researchers reported in the journal Biomedicines. 

Chronic lower back pain is the leading cause of disability worldwide, affecting about one in five adults at any given time. With so many people suffering, you'd think there would be a consensus on the best ways to treat it, but there isn’t. 

A 2018 review by The Lancet found that low back pain is usually treated with bad advice, inappropriate tests, risky surgeries and injections, and pain medications that provide only temporary relief.

2023 guidelines released by the World Health Organization (WHO) reached similar conclusions, recommending treatments such as exercise, physical therapy, and chiropractic care as alternatives to pain medication..

Neither WHO or The Lancet took a serious look at medical cannabis, so the new Israeli study breaks new ground as a treatment option.

The research team noted that randomized clinical trials are needed before causal claims can be made about cannabis, but the data so far ”support consideration of inhaled cannabis as a potentially clinically meaningful, opioid-sparing option for patients who have failed conventional multimodal therapy.” 

Another sign that inhaled cannabis was effective is that few participants dropped out of the study. After five years, nearly 93% of patients were still involved and only five dropped out due to side effects.

The THC content in the inhaled cannabis ranged from 4 to 22 percent, while the CBD concentration ranged from 2 to 22 percent. Researchers say they chose to study inhaled cannabis because of its rapid onset and patient preference. 

A 2019 survey of medical cannabis users in the U.S. found that smoking cannabis provides more pain relief than ingesting it. Over 3,300 people logged their symptoms on a mobile app while using a variety of cannabis products, including dried flower, edibles, tinctures and ointments. Smoking dried flower provided more pain relief than any other cannabis product.

Exercise Is Best Treatment for Low Back Pain, But Why?

By Pat Anson, PNN Editor

There has long been a consensus that the best way to treat chronic lower back pain (CLBP) – the world’s leading cause of disability – is by staying active and exercising. But a new study by Australian researchers failed to identify precisely why exercise is beneficial.

“A lot of treatments have stemmed from studies for people with CLBP, but the one with the most consistent evidence of benefit is exercise,” says senior author Matt Jones, PhD, an exercise physiologist, clinician and researcher at the UNSW Sydney School of Medical Sciences. “Despite decades of research in the area and more than 100 studies we analysed in our review, we still do not have a good idea of why exercise might be effective for CLBP.”

Jones and his colleagues recently reported their findings in the journal Musculoskeletal Science and Practice. They reviewed 110 research papers on CLBP conducted in Australia, United States, China, Brazil and Europe, and found little agreement on why researchers thought exercise relieved lower back pain.

“Researchers proposed common reasons as to why exercise was beneficial, including improvements in fitness – for example, core stability, aerobic fitness – and improvements in mood and confidence,” Jones said. “But the effects of these proposed reasons on outcomes for people with CLBP were seldom examined in the papers.

“There have been trends in research over time, where everyone focuses on a ‘flavour of the month’ – like motor control or McKenzie therapy, for example – but because the effects of exercise are broad and it impacts on many different systems in the human body, it’s difficult for researchers to pinpoint exactly why they think it might be benefiting people with pain.”

At any given time, over 500 million people worldwide are suffering from CLBP, which is “non-specific” back pain lasting three months or longer – not the severe back pain caused by degenerative disc disease, spinal injuries, arthritis and other chronic conditions. CLBP mostly affects adults of working age in lower socioeconomic groups, who often have physically demanding jobs.

A 2018 review published in The Lancet by an international team of researchers found that CLBP is often treated with bad advice, inappropriate tests, risky surgeries and painkillers. The authors said there was limited evidence to support the use of opioids for low back pain, and epidural steroid injections and acetaminophen (paracetamol) were not recommended at all.

“The majority of cases of low back pain respond to simple physical and psychological therapies that keep people active and enable them to stay at work,” said lead author Professor Rachelle Buchbinder of Monash University in Australia. “Often, however, it is more aggressive treatments of dubious benefit that are promoted and reimbursed.”

Jones said the aggressive treatments may not work because they don’t address underlying psychological reasons for back pain.

“Chronic pain is tricky and there are a lot of factors that can contribute to it – so, it's not simply biological aspects of tissue damage, but there are psychosocial elements at play, as well things like a person’s mood or confidence in their own abilities to do something,” he said. “Today’s evidence suggests CLBP likely comes from the brain and nervous system being a bit over-protective and generating a pain response – despite no obvious physical damage to the body.”

Although his review did not address what specific exercises were most effective for CLBP, Jones and his team recommended 33 “mechanisms” that people can use to relieve back pain, such as building muscle strength and flexibility or through social support and coping strategies.

“Many scientists have investigated this question before and the short answer is, there are no specific exercises recommended to alleviate CLBP,” he said. “But there are literally hundreds of studies on exercise for people with chronic pain, not only CLBP, and researchers consistently find exercise is one of the most effective treatments – it might not cause huge reductions in pain and disability, but it does help.”