Inside the usage of Cannabidiol & Kratom for pain management
Certain aspects of healthcare remain misunderstood, perhaps even among healthcare providers. Our new column addresses some misconceptions. This edition focuses on certain substances that are considered for chronic pain.
The longer that chronic pain remains a major healthcare issue, the more that the search for varied interventions exists. Chronic pain results in both physical and mental complications, and an estimated 50 million people in the United States reported experiencing chronic pain in 2016, according to the Centers for Disease Control and Prevention (CDC).
Among those 50 million individuals are nearly 11 million U.S. adults who experience “high impact chronic pain,” or pain that has been present for at least three months and is accompanied by at least one major activity restriction, such as being unable to perform household chores, according to the National Center for Complementary and Integrative Health. As more people live with pain, targeting of interventions becomes more challenging — sometimes to the point that research cannot yet keep up with anecdotal evidence.
Cannabidiol, commonly referred to as “CBD,” is a non-addictive substance that is the second-most prevalent active ingredient of cannabis (marijuana).1 An essential component of medical marijuana, cannabidiol is derived directly from the hemp plant and is readily obtainable in most parts of the U.S.,1 though some states have not legalized it. One CBD product, the prescription drug EPIDIOLEX,® is approved by the U.S. Food and Drug Administration (FDA) for the treatment of epilepsy.
Conversely, there are no FDA-approved uses for kratom (mitragyna speciosa), a plant that grows naturally in Thailand, Malaysia, Indonesia, and Papua New Guinea. The agency has gone as far as to warn against its use after receiving concerning safety reports.2 While FDA officials say they are actively evaluating all available scientific information on kratom and encouraging more research to better understand its safety profile, its use continues — as does that of CBD. There are also certain myths concerning both that some healthcare providers say could continue to cloud utilization, research, and legality.
Myth: Kratom is not addictive.
“We see kratom billed as a ‘pain reliever,’ but you don’t see a lot about how it acts on opioid receptors — it’s addictive,” said Aaron Weiner, PhD, ABPP, a licensed clinical psychologist who is an addiction treatment specialist. “There’s this myth that kratom is not harmful to anybody, but I’ve seen it with my own eyes – there are people in addiction treatment, and on buprenorphine and SUBOXONE® – the same treatments that people use for heroin – because of kratom.
“It is useful for pain because it is an opioid, but it’s not currently part of medicine. It’s an unregulated herbal supplement. More studies need to be conducted before recommendations can be made.”
Myth: Kratom can be used to wean patients off stronger opioids.
“We don’t know how the active ingredient, hydroxymitragynine, interacts with other substances, so there are many question marks,” said Weiner. “Even if it acts on the same receptors and its toxicity level isn’t as high, there is so much heterogeneity between the different strains.”
The different strains include red vein kratom (geared toward pain relief, sleep, and other physical discomforts), white vein kratom (physical relaxation, serenity, clear-minded energy), green vein kratom (providing a clear head, physical comfort, and energy), yellow kratom strains (relaxation and mood elevation), aged kratom strains (enhanced effects of various strains), and mixed strains.3
Myth: CBD is a bona fide “pain killer.”
“According to the research, when used for pain CBD is almost exclusively combined in low doses with tetrahydrocannabinol (THC) — so it’s difficult to determine if it’s a combination of the two that works, or if it is the THC or the CBD,” said Weiner. “Even still, the results aren’t always consistently positive.”4
Beyond that, Weiner said that there’s also the question of how to administer CBD. Oral, ingestion, and topical options exist, and different compounds are bioavailable in different ways through different administration routes. “And they’re definitely not all equal for the same reason there’s not much evidence about CBD being useful for pain on its own, especially when considering that it can enter the system in different ways,” he said.
Myth: Kratom is a synthetic drug.
“Since kratom and its use has become a hot topic during recent years, the internet is filled with individual opinions, marketing strategies, and various beliefs that might not be founded in fact,” said Nikola Djordjevic, MD, a family physician and medical advisor at LoudCloudHealth, an organization that promotes the use of cannabis and CBD. “Kratom comes from the leaves of the kratom tree. The leaves are handpicked, dried, and grounded to form a powder. It’s a completely natural process. But it shouldn’t be prescribed to patients yet, as it’s still not clear which possible harmful long-term effects it can have and it’s interaction with various health conditions.”
Myth: CBD can help to cure cancer.
“More research shows that it is effective in addressing chronic health conditions by relieving symptoms and addressing and modulating your body’s internal systems, but cannabis is not a cure-all for everything,” said June Chin, an integrative cannabis physician based in New York. “In a 2017 study published in JAMA,5 researchers ordered and tested 84 products sold online as CBD-containing products. Of those, only 26 were labeled accurately.”
Myth: CBD is only effective in high doses.
“The provider must understand the patient’s health history and current medications before prescribing CBD, but dangerous drug interactions are normally a problem only when CBD is prescribed at high doses (25-40 mg),” said Elaine Burns, NMD, a naturopath based in Avondale, AZ. “One of the known, although not common, side effects is for CBD to lower blood pressure, but you don’t need a high dose of CBD for it to be effective. You can dose lower and increase frequency.”
1. Grinspoon P. Cannabidiol (CBD) — what we know and what we don’t. Harvard Health Publishing. 2018. Accessed online: www.health.harvard.edu/blog/cannabidiol-cbd-what-we-know-and-what-we-dont-2018082414476
2. FDA and Kratom. FDA. 2019. Accessed online: www.fda.gov/news-events/public-health-focus/fda-and-kratom
3. Kratom 101. CBD Kratom Shops. 2020. Accessed online: https://cbdkratomshops.com/kratom
4. Weiner, A. Bridging the gap: insights on addiction and behavioral health. Weinerphd.com. 2020. Accessed online: www.weinerphd.com/blog
5. Bonn-Miller MO, Loflin MJE, Thomas BF, et al. Labeling accuracy of cannabidiol extracts sold online. JAMA. 2017;318(17):1708-1709. doi:10.1001/jama.2017.11909