What Every Person With Arthritis Needs to Know About Cannabis
For people with arthritis pain, medical marijuana can bring relief without the side effects caused by traditional treatments. But it’s still not legal everywhere—yet.
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“I actually don't remember what it was like not to be in pain,” says Bridget Seritt, who has dealt with chronic illness since she was a small girl. “I have both types of arthritis — rheumatoid and osteoarthritis. I have Sjogren's syndrome. I have lupus, and I have Ehlers-Danlos syndrome, which is a genetic collagen disorder that affects all of my joints, ligaments, and tendons.”
When she lived in Georgia, her treatment centered on methotrexate, a drug used to slow down the progression of rheumatoid arthritis.
Unfortunately, Seritt experienced all three of the drug’s most common side effects — nausea, stomach upset, and fatigue — and, for a time, she used black-market cannabis to alleviate those symptoms. (Georgia didn’t have a medical marijuana program at the time.) Seritt moved to Colorado in 2013, still taking “a handful of opiates and a whole bunch of prescription medications,” and quickly realized that, as a chronic-pain patient requiring high doses, the growing war on opioids might affect her options for relief sooner rather than later.
It didn’t take long: Her new pharmacy wasn’t always able to fill her full oxymorphone prescription on time. “I was consistently running out,” she says, which led to muscle seizures. Since cannabis was legal in Colorado, “I decided to see if it would help with pain and withdrawal. I smoked a couple of joints, but it didn’t do anything except help my insomnia.” That was good enough, and eventually she replaced smoking pot with making her own cannabis butter and topicals.
It wasn’t until about three months later that Seritt noticed another change: “I could walk better. I could be active for longer periods of time, and I didn't need as long to recover.” Between 2014 and 2015, she went from being able to walk just 200 feet to hiking several miles. She credits medical cannabis.
Location, Location, Location
If Seritt still lived in Georgia, she wouldn’t have achieved this level of relief without breaking the law. Currently, the state allows only cannabis oil with less than 5% THC — the chemical that causes most of pot’s psychoactive effects. In Colorado, however, some form of medical marijuana has been legal since 2000, and patients aren’t limited to low-THC oils. Instead, patients like Seritt have access to a seemingly endless variety of cannabis products with a wide range of potency, along with professional staff equipped to answer medical questions. Colorado also allows home cultivation of up to six plants per patient, so they can grow the specific strains they need to get results.
Though medical marijuana programs exist in 33 states, cannabis is still illegal in the eyes of the federal government. As a Schedule I drug according to the Controlled Substances Act (CSA), it’s considered a dangerous substance with "no currently accepted medical use." That means that doctors and patients complying with state laws still operate as federal outlaws, risking fines, arrest, even prison time.
Several bills in congress aim to erase cannabis from the CSA. Among them, Oregon Sen. Ron Wyden’s cleverly-titled S.420 Marijuana Revenue and Regulation Act; Hawaii Rep. Tulsi Gabbard’s March reintroduction of the Ending Federal Marijuana Prohibition Act; New Jersey Sen. Cory Booker’s Marijuana Justice Act; and New York Sen. Charles Schumer’s Marijuana Freedom and Opportunity Act. Passing any of these bills would allow millions of American arthritis patients to legally benefit from the plant’s therapeutic properties.
The Power of (Medical) Pot
Traditional arthritis treatments are rife with potentially dangerous side effects. Cases in point: Tylenol and non-steroidal anti-inflammatory drugs, or NSAIDs, can exacerbate liver and bleeding issues. Disease-modifying anti-rheumatic drugs (DMARDs) and biologics can interfere with the immune system's ability to fight infection. And, if those categories don’t work, patients are left with opioids, which are highly addictive.
“If you put the opioids head-to-head with cannabis for mild to moderate pain, what we find is that they're about equal,” says Jordan Tishler, M.D., a Boston cannabis physician at Inhale MD, Harvard instructor of medicine, and president of the Association of Cannabis Specialists. “In that situation, cannabis may be equally effective, but it's a lot safer.”
Scientific evidence confirming Dr. Tishler’s experience continues to grow, showing cannabis to be “remarkably helpful as a pain medication, interacting with receptors in multiple locations throughout the body,” he says. It also impacts pain processing in the spinal cord and brain. Preclinical data suggest that cannabinoids have particular therapeutic potential for rheumatic diseases like rheumatoid arthritis and osteoarthritis (plus systemic sclerosis and fibromyalgia, too).
Here’s how it works: Cannabis contains dozens of cannabinoids, chemicals that interact with our body’s own endocannabinoid system, which regulates inflammation and pain. THC is the most well-known (it’s what gets you high) and CBD is another. “The THC in cannabis is the primary pain reliever, so what I do as a doctor is find the smallest dose of the THC or cannabis that will do the job with the minimum side effects,” Dr. Tishler says. The most common side effect, unsurprisingly, is getting stoned. “All pain medications have side effects and cannabis is no different,” he says.
Like any other clinician, Dr. Tishler helps arthritis patients manage side effects through dosing, timing, and route of delivery. For example, for chronic pain, he might recommend an edible with 5 mg THC twice a day for long-lasting coverage, and a vaporizer for acute relief on an as-needed basis.
“One cannabinoid called THC-A — which is different from THC — is a better anti-inflammatory than THC or CBD,” he says. “When I treat somebody with an autoimmune disease like rheumatoid arthritis, I often try to add THC-A to the THC so that we're covering the underlying inflammation as well as deriving pain control.” Dr. Tishler supplements THC-A through an extract; Seritt gets her dose of THC-A and THC from a paste made from fresh plants that she grows herself.
Why Medical Programs Matter
When it comes to CBD for arthritis, Dr. Tishler is unconvinced that the extract is particularly useful for pain at the available doses. (The most compelling research so far has been in rodents, not humans.)
“There's also the issue of how harmful hemp-derived CBD oils may be. Not because of the CBD, but because of whatever else might be in that bottle,” says Dr. Tishler, who cites traces of everything from pesticides and heavy metals to fentanyl.
The 2018 Farm Bill loosened regulations on hemp-derived CBD by removing hemp products from the list of Schedule 1 drugs. There’s only one CBD drug that’s been approved by the U.S. Food and Drug Administration (FDA) — Epidiolex for severe epilepsy — and the FDA doesn’t regulate supplements, so scams are rampant. Recent research from Penn Medicine revealed that 70% of CBD products available online mislabeled their CBD content. These are precisely the types of shenanigans medical marijuana laws are meant to prevent, and why medical programs are important, even for states with legal recreational cannabis.
“Medical patients are not the same as recreational cannabis users,” says Dr. Tishler. An arthritis patient wants medicine that’s easy to take, precisely dosed, and provides reliable results with the least intoxication. (Not exactly a recreational user’s idea of a party.)
Having a medical system in place allows physicians to follow up on what patients are purchasing through the registry system. Medical dispensaries and dual-licensed shops are best equipped to answer patient questions about how to dose cannabis or what contraindications there might be.
“It’s completely inappropriate to have this type of advice coming out of the mouth of a budtender,” says Dr. Tishler.
There are other advantages to medical-marijuana programs. In states like Colorado, patients pay standard sales tax on cannabis, but not high excise taxes or additional state taxes applied to recreational cannabis sales. Minors with qualifying conditions can also register as medical marijuana patients, which isn’t addressed by the recreational model.
Advocating for Access
There are many reasons to keep an eye on upcoming cannabis bills, both federal and in your specific state. Even putting the overarching problem of federal prohibition aside, the state laws are a messy patchwork of contradicting rules. For example, cannabis is straight-up illegal — for any reason — in Idaho, Kansas, Nebraska, and South Dakota. There are 33 states offering medical marijuana, but only seven list arthritis as a qualifying condition (Arkansas, California, Connecticut, Hawaii, Illinois, New Mexico, and New York).
Some states allow physicians more leeway by letting them determine “other medical conditions” at their discretion. In some states, even CBD oil is a no-go. In Kentucky, only people participating in a clinical trial or an expanded access program are legally allowed to possess it; in Mississippi, only people with a debilitating epileptic-seizure disorder qualify.
The laws are constantly evolving. If access is important to you, contact your state legislators and congress members and let them know. There are dozens of pending marijuana bills and resolutions on the state and federal level right now. (Check out this list from NORML to see which ones affect you and the arthritis patients in your life. Then refresh your browser and do it again, as cannabis laws can rapidly change.)
Having a medical-marijuana program in place doesn’t necessarily guarantee unfettered access. Seritt, who makes her own cannabis medicine from homegrown plants, laments the passing of House Bill 1220, which lowered the number of plants one residence could grow from 99 to a dozen, max. Her belief? “If your state program doesn’t allow access to fresh plants or cultivation, you don’t have real medical access.”
Dr. Tishler shares more about the politics surrounding medical cannabis for treating arthritis in this recording of a Facebook Live conversation with Lene Andersen, HealthCentral contributor and social ambassador for our rheumatoid arthritis community group. Click the video to hear their conversation.