cbd oil spinal cord injuryDecember 15, 2021
CTP users endorsed greater disruptions of daily life by pain, and CTP may represent a complementary route to pain management for the majority of its users. Extending the literature, the current data show that the use of CTP did not mitigate prescriptions for other potentially SCI-related pain medications33 but rather appeared to fulfill a supplementary function. Because cannabinoid use by itself carries risks for adverse events,34–36 clinicians should encourage patients to disclose their patterns of CTP use to allow close monitoring for adverse drug or drug interaction effects.
Background: People with spinal cord injury (SCI) are accessing cannabis for therapeutic purposes (CTP), the use of which has been legalized in more than 20 states. In the past, illicit marijuana use had positive correlations with other health risk behaviors. It is not known whether access to CTP has shifted patterns of use and altered health outcomes. Objective: To describe the self-reported patterns of CTP use among individuals with SCI and correlations with health behaviors and health indicators. Method: Secondary analysis of data from a cross-sectional study involving community-dwelling individuals with chronic SCI and neurogenic bladder and bowel, at least 5 years post injury. Data were collected via structured interviews. Results: 92.2% of the current sample ( n = 244) lived in states that, at the time of the study, permitted the use of CTP. 22.5% reported using CTP at least monthly to relieve pain (70.4%) and spasticity (46.3%). Of those 54 participants, 52.7% were daily users. Whereas 23.0% of non-CTP users endorsed having prescriptions for at least one opioid-based medication, 38.1% of CTP users did so, suggesting that CTP use does not mitigate opioid use. Users were more likely to be single and live alone, report more bladder complications, and perceive their psychosocial functioning as more compromised than non-users. Conclusion: A relatively large percentage of individuals with chronic SCI appear to use CTP on a regular basis. Results suggest that they may be more vulnerable to complications and to risk factors for substance use disorders in SCI, such as social isolation. Although the generalizability of these findings is limited by the sampling strategies and the eligibility criteria of the larger study, CTP use should be assessed and considered when planning health interventions.
In addition, the degree of perceived social and instrumental support was assessed with a subscale of the Quality of Caregiving (QoC)30 measure (ie, relationship with the primary caregiver, 4 items) among those persons receiving caregiver services. The Working Alliance Inventory (WAI)31 was used to gauge the client-provider relationship. The WAI short-form is a 12-item measure that produces 3 subscales of 4 items each (alliance in terms of tasks, the client-provider bond, and the client’s goals). Items are presented on a Likert scale (1–7, where 7 represents a greater alliance).
The purpose of the current cross-sectional study was to describe the characteristics of individuals with chronic SCI who self-reported use of cannabinoid-based products and to examine their stated reasons for use, self-reported SCI-related complications and health behaviors, and relationships with health care providers. When sample size allowed, comparisons were made between CTP users and non-users within this sample.
Human use of cannabis goes back thousands of years, but the discovery of its mechanism of action – the endocannabinoid system – occurred fairly recently, with the cloning of the first receptor in 1990.1 Since then, our basic understanding of the endocannabinoid system has grown considerably, and its participation in immune, metabolic, and cognitive functioning as well as pain modulation and sleep has been established.2 Neuroprotective effects of cannabinoids have been shown preclinically when administered within hours following cerebral or spinal lesions3–6 and have been broadly publicized.7,8 While creating visions of novel therapeutic potential, the basic neuroscience of cannabinoids raises significant concerns: The cannabinoid system is complex and exerts direct and indirect actions upon a wide range of fundamental physiological processes. The clinical impact of chronic use of cannabis-based products is not known, especially when users’ central nervous system is already compromised.9.
This work was developed under the University of Michigan Spinal Cord Injury Model System (SCIMS) grant 90SI5000-0103 from the National Institute on Disability and Independent Living Rehabilitation Research (NIDILRR), US Department of Health and Human Services (HHS). The contents of this article do not necessarily represent the policy of NIDILRR, HHS, and you should not assume endorsement by the Federal Government. None of the authors have a financial or other relationship that might signify a conflict of interest.
Cannabis use was self-reported by participants during the interview (“Have you ever used marijuana to make you feel better? All responses are kept absolutely confidential.”). “Yes,” “no,” and “refuse to say” answers were recorded by interviewers, who did not probe further about whether use occurred in legal or illicit contexts (eg, the status of marijuana card holders was neither assessed nor verified). Instead, the interview focused on purpose and mode of administration. Specifically, interviewees were asked if they used cannabis for bladder or bowel management, spasticity, pain, anxiety, or other purposes, including recreational use. If they answered “other,” they were asked to provide the reason. Participants were able to endorse more than one purpose and more than one mode of administration. Recreational use of cannabis was not independently assessed nor were alcohol use and other illicit drug use (eg, stimulants).
Further investigation of the patterns of CTP use showed no clear relationship between self-reported life disruption by pain and frequency of CTP use. Individuals who indicated a severe disruption of their lives by pain used cannabinoids monthly, weekly, or daily. A number of participants ( n = 12) reported daily use of CTP with no to mild disruption of their lives by chronic pain.
Regarding health behavior management, CTP users did not significantly differ from non-users as assessed by the SCILS (cardiovascular: x ̄ CTP = 8.71, x Non-user = 8.95; genitourinary: x ̄ CTP = 12.96, x ̄ Non-user = 12.30; skin: x ̄ CTP = 23.22, x ̄ Non-user = 22.54; psychosocial: x ̄ CTP = 7.54, x ̄ Non-user = 7.49; neuro: x ̄ CTP = 17.38, x ̄ Non-user = 18.34; total: x ̄ CTP = 69.87, x ̄ Non-user = 69.61; all P values < .15).
The current study was limited by its relatively small sample size, its cross-sectional and descriptive nature, and the lack of information about past history of substance use and mental health history and related measures. Of note, participants were not recruited to participate in a study of cannabis use in SCI; rather, recruitment occurred for an ongoing large investigation of the relationship between bowel and bladder functioning and QOL. Thus, the characteristics of the sample reported were directly affected by the inclusion criteria of the study in the context of which these data were collected (ie, chronic SCI and at least 5 years post injury, with neurogenic bladder and bowel). Because of sampling strategies (more than 90% of the current participants were recruited from SCI research registries and SCI clinics) and the eligibility criteria of the larger study, the current sample may not be representative of the population of individuals with SCI as a whole. It may be that some individuals with SCI who use cannabis for therapeutic or recreational purposes were reluctant to admit their use (particularly those 19 individuals who lived in states that had not legalized the use of CTP at the time of the study) or to participate in a clinical research study; thus it appears likely that the figure of 22.5% is actually an underestimation of the prevalence of cannabinoid use in SCI.
Of all the individuals included in the sampling pool so far for the ongoing larger study on bowel and bladder functioning and QOL, about half met inclusion criteria and were eligible to participate and about one-third were enrolled. The total sample of the current secondary data analysis included 246 participants with chronic SCI and neurogenic bowel and bladder at least 5 years post injury. Most of these participants (93.9%) were recruited via the SCI Research Registry of a large medical center in the Midwest region of the United States ( n = 138), from SCI outpatient clinics at that medical center ( n = 86), and from research registries at other centers ( n = 7). Fifteen participants were recruited from other sources: advertisements in SCI-related newsletters and lectures at rehabilitative settings ( n = 14) and via social media ( n = 1). The sample consisted of 182 men (74%) and 64 women (26%). They were on average 49.7 years old (range, 21–94 years old). Average age at injury was 31.1 years old (range, 2–83). One hundred and thirty-five participants (54.9%) had tetraplegia and 111 (45.1%) had paraplegia. The data from 2 individuals were excluded from further analysis because of the extent of missing data and refusal to provide information related to cannabis use.
Comparison of demographic characteristics.
The current study replicates results from previous studies in finding that almost a quarter of individuals with chronic SCI self-report being users of CTP. Pain tended to be the most frequently cited reason for use, followed by spasticity, anxiety, and other non-specified uses. The current study further suggests that CTP users differ from non-users along distinctive demographic and functional domains.
Measures included demographic information (gender, age, race/ethnicity, education, vocational status, marital status, primary living situation) and characteristics of the SCI (years since injury, neurological status, level of injury).
It has long been known that individuals with SCI tend to subjectively perceive cannabinoids as an effective alternative treatment for pain.21 A 2006 study on pain management in SCI found that CTP had been “tried by 32% and was being used currently by 23% of the sample.”22 (p115) Whereas some users report reduction in SCI-related pain and potentially spasticity for hours after administration, evidence for the efficacy of CTP use in clinical trials is mixed and complicated by the lack of methodological consistency (eg, in administration and dosing). Further challenging the interpretation of CTP use in SCI is the circumstance that many individuals with SCI have clinically significant substance use histories, just as the general users of CTP described previously.23 The use of cannabinoid-based products may be a continuation of preexisting behavior patterns that can result in increased vulnerability to adverse health effects following SCI, such as bladder and bowel complications.24,25 However, little is known about complications and potential correlations with CTP use in particular.
Recent conceptualizations of substance use from a behavioral science perspective have emphasized a crucial role for lack of social support.39 In these models, the progressive narrowing of alternative, meaningful relationships and activities is characteristic of situations that give rise to and support the use of mood-altering substances. Accordingly, relationship status has been shown to correlate with increases in the risk for the use of mood-altering substances in SCI.23,40 In addition, one might speculate that increased anxiety after SCI, including fear of bowel and bladder accidents, could lead to a long-term spiral of social withdrawal, a narrowing range of activities with concurrent lack of distraction from pain, and a general perception of a decreased ability to master everyday social roles. Based upon these findings, future studies should focus on the link between social support, anxiety sensitivity and pain,41 and CTP use in SCI.
(d) Spinal Cord Injury Multidimensional Quality of Life (SCI-QOL)28: Computerized adaptive test that produces T-scores for bladder complications, distress due to bladder management, distress due to bowel management, and ability to participate in social roles and activities. Higher T-scores reflect higher levels of the concepts measured (eg, if distress due to bowel management is measured, higher scores present greater disruption with functioning; if ability to participate is measured, higher scores present less disruption).
It will be important for future studies about CTP to gather more information including duration of use, perceived effectiveness of use, and many other factors. As such, both qualitative studies as well as clinical research that incorporates objective assessments of health variables will be important to provide insights into who uses CTP, how it is used and why it is used and – as such – better inform the clinical conversations that need to occur around this issue.
Functional status and QOL were assessed with the following instruments:
(c) The SF-Qualiveen27: 8-item questionnaire that assesses the interference of urinary problems with QOL, with 2 items addressing each of the following areas: feeling bothered by limitations, frequency of limitations, fears, and feelings. Item scores range from 0 to 4, and lower average scores indicate less interference. The total score is the mean of the subscales means scores.
Percentage of participants reporting at least one prescription from each drug category (n = 241).
Because of the wide gap between clinical evidence and practice, it is important to know about the characteristics of current users of CTP as well as their self-reported reasons for use. Cross-sectional studies have repeatedly shown that chronic pain and associated conditions are the main reasons cited for cannabinoid use among medical populations.14 In the United States and the United Kingdom, younger age, male gender, and previous recreational use predict the use of CTP.15 A study of applicants for the medical marijuana card in the United States found that only a minority (<10%) of first-time applicants were naïve to cannabis.16 In an international sample of users, this number rose to 23.5%,17,18 suggesting that cultural differences exist in the acceptance of CTP and consideration for first-time use. In the United States, a significant percentage of CTP users have past19 or current20 substance use disorders. However, these data do not describe individuals with spinal cord injury (SCI) specifically.
CTP users in our study reported more bladder complications and fear of urinary accidents than non-users. Previous studies of complications in SCI have suggested that a history of alcohol problems with subsequent abstinence is associated with an increased risk of urinary tract infections.24,25 Hawkins and colleagues related these bladder complications to histories of poor self-care and continuing deficient self-management.24 Our data suggest that the health behavior management of individuals with current CTP use does not significantly differ from that of non-users, yet users appear to experience a higher rate of complications. While there are studies on the role of CTP in managing urge incontinence in multiple sclerosis,37 only 3 participants in the present study linked their CTP use to bladder management. Conversely, there are currently no data available that would predict bladder complications from CTP use, and adverse events related to CTP may differ in aging individuals with already chronically compromised central nervous system functioning.38 Because other studies have shown that CTP use tends to correlate with a history of alcohol and other drug use,23 which were not assessed in this study, it is unclear whether the reported complications reflect the effects of other substances.
The most common mode of administration was smoking (80%, n = 44), followed by eating (27.3%, n = 15) and vaporizing (20%, n = 11). Note that 16 individuals endorsed more than one administration method. One person (1.8%) endorsed the use of tinctures.
(b) Medication use, self-reported and recorded by interviewers as part of the Bowel and Bladder Treatment Index (BBTI): Two authors of the study (C.D., M.F.) independently coded opioids, with 97% interrater agreement. Other drug classes were coded by C.D.
However, considering all of the drug classes shown in Figure 1 , this difference was not statistically significant [χ 2 (4) =3.81, P = .4323]. Additionally, there was no difference in the number of drug classes that were spanned by the reported prescriptions [range, 0 to 5; x ̄ CTP = 1.7 ( SD = 1.2); x ̄ Non-user = 1.4 ( SD = 1.2); t (239) = −1.63, P = .104].
Measures of social and instrumental support assessing quality of caregiving and the client-provider alliance (WAI) showed that individuals who used CTP generally did not significantly differ from non-users in their evaluation of the relationships. Typically, working alliance with providers was described as positive [ x ̄ CTP = 66.22, x ̄ Non-user = 69.56; t (240) = −1.810, P = .072]. Those participants who received formal or informal assistance (n CTP = 33 [60%], n Non-user = 103 [54.5%]) generally characterized the relationship with their primary caregiver as close (range, 4 to 16; x ̄ CTP = 12.94 [ SD = 3.02]; x ̄ Non-user = 14.10 [ SD = 2.10], z = −1.9, P = .057); very few participants (3 CTP users vs 6 non-users) reported negative or non-supportive relationships with their caregivers. Users and non-users also did not differ in terms of the years elapsed since they had last seen their provider [ x ̄ CTP = .17 ( SD = .54), x ̄ Non-user = .21 ( SD = 1.07); t (211) = .293, P = .77]. The most common primary care provider specialties identified by participants ( n = 196) were family medicine (41.3%) followed by physiatry (32.1%). A greater percentage of CTP users than non-users reported prescriptions for medications in drug classes that target SCI-related pain, spasticity, and neuropathy—such as opioids, sedative-hypnotics, anticonvulsants, and antidepressants ( Figure 1 ).
(e) Life Satisfaction Index, Form Z (LSI-Z)29: 13-item measure that assesses life satisfaction in retrospective. Responses take on values 0 ( disagree ), 1 ( unsure ), and 2 ( agree ) and total scores range from 0 to 26, with higher scores reflecting greater life satisfaction.
Descriptive statistics, including frequency, means ( x ̄ ), standard deviations ( SD ), and percentages, were computed for relevant variables using IBM SPSS Statistics, Version 23 (IBM, Armonk, NY). The quality and quantity of data available specified the type of analyses performed. Because of the small number of participants, categories of some demographic variables were combined when possible to facilitate statistical analysis. When not limited by the small sample or cell sizes, differential statistics were used, including chi-square tests and tests of means ( t tests, Mann-Whitney U tests). Because the current study is exploratory in nature, multiple test corrections for experiment-wise error rates were not conducted. The significance level was set at P < .01.
Table 2 summarizes SCI characteristics and factors related to functional status of the 2 groups within our sample. Most individuals sustained their injury more than 20 years ago (40% and 38.1% for CTP users and non-users, respectively). There was no difference between users and non-users of CTP in neurological status or the amount of bowel assistance needed.
it’s helped my whole health and helped the pain everything, my mental pain, physical pain the whole lot you know, ever since I’ve been on it. (Participant 2)
There’s some [high CBD cannabis] out there that’ll relax your body, which is the one that helps me relax my mind, get out of that state of pain, or there’s the one that’s makes you go to sleep [high THC]. Those are the two simple breeds really. I’m fortunate sometimes to get the one that makes me live through the day and not sleep through the day. (Participant 5)
In Theme three we describe why participants chose to use cannabis, and more specifically how and why they chose the particular type of cannabis product. Participants’ reported using cannabis products because the prescribed pain medication was ineffective and/or the side-effects caused frustration and exhaustion. When making the decision to use cannabis products one participant (who trialled a high CBD/low THC oil) reflected:
Several participants described that their use caused them to review their view of on cannabis in society:
Participants reported a fundamental difference between being ‘high’, and effectively managing one’s pain.:
Theme four: negotiating an unfamiliar illegal context.
Eight individuals participated in this study. We interpreted six themes that captured the participants’ perspectives regarding their choice to, and perceptions of, using cannabis to manage SCI pain. Participants were motivated to use cannabis when other pain management strategies had been ineffective and were well-informed, knowledgeable cannabis consumers. Participants reported cannabis reduced their pain quickly and enabled them to engage in activities of daily living and participate in life roles without the drowsiness of traditional prescribed pain medication. Despite the positive aspects, participants were concerned about the irregularity of supply and inconsistent dosage.
Just to make it legal so we don’t have to look over our shoulders all the time and think about what’s gonna happen and consequences. (Participant 5)
It just takes over your, your life. I mean when you have the pain you can’t do anything, you know? You can barely talk, um, and, um, it just, the pain just overtakes everything. (Participant 6)
I come from a family where I, yah know, we’ve, my parents taught me a few morals and, with right and wrong, I mean, um, I was never really into cannabis and just for taking it for getting high. (Participant 4)
Participants were invited to contribute to an interview, either in person at a location of their choosing or by internet-based videoconference. Two researchers (JB and VC) conducted the interviews, which were audio recorded and transcribed. Field notes were completed after each interview. Interview questions were informed from the literature, as well as clinical and consumer members on the research team. Questions were ordered from the broad (e.g. Can you tell us about your experience of pain?) to the more specific (e.g. What percentage of THC and CBD were you using?). For all participants, we also collected basic demographic information (e.g. age, gender and spinal injury level).
This study shows that for our participants cannabis produced important and meaningful outcomes along with reducing pain. Campbell et al. . highlight that research examining the efficacy of cannabinoids in managing pain has traditionally focused on a change in pain scores rather than examining clinically meaningful outcomes of function and participation. Our research supports the suggestion that cannabis might not eliminate pain intensity per se, but instead enables those with pain to tolerate it more effectively . Participants in our study described improved sleep, and increased participation in family, and community life—outcomes which might contribute to any reduced pain scores . The contribution of qualitative research and lived experience provides unique insights, particularly during cannabis health policy development.
Family were often able to see the beneficial effects of using cannabis products which in turn reduce the family member’s own discomfort of seeing a loved one in pain:
It is critical that clinicians, researchers, and individuals who may choose to use cannabis are informed of the benefits—and risks—of using cannabis to manage their pain. Research exploring the use of cannabis to treat non-cancer chronic pain is still in its infancy with the findings, and opinions, being inconsistent and polarising [10, 18–22]. Research exploring the user perspectives of cannabis to manage pain following SCI almost always utilise questionnaires [13–15, 23, 24], apart from one focus group conducted by Hawley et al. . Few in-depth qualitative research exploring user perspectives are available. The perspectives of individuals with SCI who use cannabis for their pain, should contribute to the clinical, social, and political discussion. The aim of this study was to understand why individuals with SCI choose to use cannabis to manage their pain and their experiences of doing so.
All authors apart from WM were involved in the study design. JN, JB and VC were responsible for the data collection. All authors were involved in the data analysis. JB was responsible for the first draft the paper and all authors contributed to further edits and iterations of the paper.
Analytic rigour was pursued in several ways. First, researchers regularly referred to the original interview transcripts to ensure their analysis was connected to the participants’ voice. Second, theme development was discussed at each team meeting and regularly via email. Third, a complete record of the data collection and data analysis process was kept so that an independent researcher could audit the research process. Finally, the research team included a person with SCI, rehabilitation clinicians, a pain researcher, a pain consultant, a medical doctor, and an adviser with the lived experience of SCI of using cannabis to manage pain. The researchers conducting the interviews had no prior relationship with research participants.
Feeling trapped by pain inhibited the participants’ ability to engage in meaningful activities of daily life, family interactions, social situations, or employment. The all-consuming nature of pain eclipsed all other experience until the pain subsided:
[my suppliers] live in isolated areas, you can’t get a hold of them by cell phone or anything like that, it’s only when they might come into town and I might receive a message (Participant 6)
The authors declare that they have no conflict of interest.
Participants in our study were motivated to use cannabis, often as a last resort, when other pain management strategies were ineffective or the negative side-effects of prescribed medication, such as drowsiness, fatigue, and of being in a dysphoric ‘zombie’ state, became intolerable. Participants in our study found these side effects limited basic communication and their ability to focus, whereas using cannabis helped without these side-effects. Similar findings were identified in qualitative analysis of a single focus group in the USA where participants preferred using cannabis over prescribed medications as cannabis had fewer negative side-effects, and cannabis use had enabled their participants to discontinue narcotic and anti-anxiety medication . Our participants reported increased cognitive clarity associated with reducing their prescription medications, enabling them to feel they could engage in activities and with social connections. Furthermore, for many participants in this study, cannabis use reduced the use of prescribed medications, and a feeling of overall improvement in physical health, with fewer secondary complications (e.g. fatigue, constipation, and sleep disruption).
Once participants chose to use cannabis, and despite having to negotiate an often unfamiliar illegal context, almost all participants described cannabis effectively helping them to the extent they felt less disabled and could participate in the community again.
Internationally, increasing research is beginning to explore the use and potential therapeutic effects of cannabis for individuals with SCI [13–15]. While legal access to cannabis varies throughout the world, the New Zealand government passed a Misuse of Drugs (Medicinal Cannabis) Amendment Act in 2018, setting a Medicinal Cannabis Scheme to commence in early 2020 . Certain medical cannabis products are available on prescription in New Zealand, however this route is a time-consuming, expensive process and excludes prescription use of cannabis plants. In the 2012/2013 New Zealand Health Survey, 11% of adults (397,000) reported using cannabis in the last 12 months, with 42% (167,000) of these individuals reporting they used cannabis for medicinal purposes .
Why spend a fortune going back to your doctor when I can grow something out in my backyard that would do the same thing… why go to a doctor when all they’re going to do is refer you on and then it’s going to be eight months down the track before you know. (Participant 3)
As such, personal experimentation, research through online forums and groups, and discussion with peers all contributed to determining products that worked for them. One participant described experimenting with a variety of methods and monitoring changes in their pain levels:
I started to eat it raw. The leaves, the stalks, I started chopping it up and putting it into my salads and things like that. Um, I don’t know exactly what it was doing then, but the pain would come and go, and the burning sensations were all starting to change, and with a mixture of eating it, the stalks, the leaves and smoking, um, it, the pain started to subside. (Participant 2)
With no educated health professional to guide administration, participants reported having to trial products within an unregulated, and often unfamiliar, environment. Participants described themselves as well-informed consumers of cannabis products over time, with different products creating unique subjective effects. Several participants reported wanting something that effectively managed pain but did not create dysphoria which had a detrimental effect on participants’ mind and ability to participate within the community:
Since day dot I’ve tried everything and you know nothing has seemed to work. (Participant 1)
In the absence of professional advice, participants relied on their own research to determine dosage and chemical make-up of cannabis. This places people at risk of adverse effects of cannabis use such as interactions with pharmaceutical medications. An international survey of clinicians  who care for individuals with SCI ( n = 153) reported that 52% of clinicians believe they should be able to offer patients cannabis, yet only 13% were employed by a facility who prescribed medicinal cannabis, suggesting a discrepancy between clinicians interest in medicinal cannabis and policy. As more Medicinal Cannabis Schemes are introduced it is critical that clinicians have adequate education about medicinal cannabis products, and the benefits and risks, in order to provide informed advice to their patients.
The most common participant management strategy reported for their pain was prescription medication, which presented certain drawbacks.
Participants described many positive implications of using cannabis for pain, highlighting a range of meaningful outcomes on quality of life, sleep, and community participation.
I just have to stop and learn to breathe and just sit there and do nothing and just hopefully that, um, eases off basically. (Participant 4)