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Journal of Cannabis Research volume 5 , Article number: 38 Cite this article. Metrics details. Medical cannabis MC is increasingly used for chronic pain, but it is unclear how it aids in pain management. Previous literature suggests that MC could holistically alter the pain experience instead of only targeting pain intensity. However, this hypothesis has not been previously systematically tested. A retrospective internet survey was used in a sample of Finnish chronic pain patients 40 MC users and opioid users. The patients evaluated statements describing positive and negative phenomenological effects of the medicine. The two groups were propensity score matched to control for possible confounding factors. MC and opioids were perceived as equally efficacious in reducing pain intensity. Ratings of individual statements were exploratively examined in a post hoc analysis. MC and opioids were perceived to be equally efficacious in reducing pain intensity, but MC additionally positively affected broader pain-related factors such as emotion, functionality, and overall sense of wellbeing. This supports the hypothesis that MC alleviates pain through holistically altering the pain experience. Chronic pain refers to pain that has pertained for at least three consecutive months. Both opioids and medical cannabis MC are commonly used for pain alleviation Schlag et al. Opioids are known to efficiently alleviate pain both acutely and chronically Meske et al. While the side effects of MC are mainly non-severe Deshpande et al. Another possible reason for the inconsistencies in previous research is the complex effects of cannabis on the psyche, which is our focus in the present study. Previous research has mainly focused on the analgesic effect of MC i. John Smith It is well-known that cannabis can alter the state of consciousness, but not much attention has been paid to the question whether this could constitute a part of the therapeutic effect of MC on pain. In a previous qualitative interview study of seriously and terminally ill patients in California Chapkis , the psychoactive effects of MC were associated with feelings of wellness, increased acceptance of the pain, being able to ignore the pain and do other things, uplifting of the spirit, increased focus, as well as psychological and spiritual insights. On the other hand, unwanted side-effects, such as disturbed memory processes, tolerance, and dependence were also reported. In addition, the use of MC was also described by many patients as having a holistic effect that enabled them to function better in their daily lives, including increased ability to sleep, focus, and function ibid. In addition to these qualitative studies, there is quantitative research supporting the notion that MC has therapeutically relevant positive effects beyond pain intensity per se. A systematic review of placebo-controlled studies on the effects of cannabis on acute experimentally induced pain in healthy participants found that cannabis did not affect perceived pain intensity, but instead made the pain feel less unpleasant and more tolerable De Vita et al. Further, a cross-sectional study on chronic pain patients found that MC users experienced substantially less depression and anxiety than opioid users Feingold et al. The use of MC in chronic pain has also been associated with improved physical and social functioning and overall quality of life Haroutounian et al. On the neurocognitive level the pain-alleviating effects of MC have been associated with changes in connectivity between brain regions associated with emotional regulation and lower somatosensory areas, suggesting that cognitive-emotional modulation may mediate the effects of MC on pain Weizman et al. There is also evidence that THC reduces the perceived unpleasantness of experimentally induced pain, correlated with amygdala activity and reduced sensory-limbic functional connectivity Lee et al. Overall, feeling high was associated with symptom relief across most of the patient subgroups, including those who used MC for pain relief, but feeling high also predicted more negative side effects ibid. The previous research thus supports the hypothesis that MC may exert its therapeutic effect on pain through altering the pain experience in a more holistic way than traditional analgesics. That is, in addition to having an antinociceptive effect i. On this account, the consciousness-altering psychoactive effects of MC could be a part of its therapeutic mechanism, instead of merely negative side effects. This hypothesis has not, however, been systematically tested. We asked the patients to rate how they experienced the effects of the medicine opioids or MC , using a questionnaire. The preregistered hypothesis was that whereas opioids mainly affect the intensity of the pain, MC affects the pain experience in a more holistic way, affecting factors such as functionality, emotion and mood, and mindfulness. Our focus was on the perceived effects of MC, while the opioid group mainly served as controls. Neither MC nor opioids are first-line treatments for chronic pain, but both are commonly used when other treatments fail to provide sufficient pain relief. This could render the opioid and MC users similar in relevant background characteristics such as severity of pain and the underlying diagnosis, enabling better control of confounding factors. A cross-sectional survey study was employed on Finnish patients suffering from chronic pain who used MC or opioids for pain management. All the questions are listed in Appendix A. The diagnosis underlying the pain condition was assessed with a multiple-choice question and the answers were recoded based on the open reports about the type of pain as well as the reported ICD codes into the following categories: 1 Chronic musculoskeletal pain; 2 Chronic neuropathic pain; 3 Other specified chronic pain e. The whole questionnaire is included as Appendix B. The survey was distributed through email lists of Finnish chronic pain patient organizations, the Finnish Medical Cannabis Association, social media e. The survey link led to a landing page including information about the study and eligibility criteria, which was that the patient suffers from chronic pain and uses opioids or medical cannabis to treat it. The eligibility was checked by examining the responses to the survey questions about pain duration minimum three months , description of the pain diagnosis and symptomology, and types of medication used to treat it. Recreational users of cannabis or opioids and those who use the substances to treat other types of symptoms than chronic pain were explicitly asked not to partake in the study. Problematic items were deleted following the 0. To account for background characteristics that may confound the results, we used propensity score matching PSM for a general introduction, see Harder et al. Psychiatric variables such as anxiety and depression were not used as covariates, as they could be affected by the treatment Feingold et al. The matching was conducted with the Matchit package Ho et al. The preregistered analyses method for group comparisons was t-tests, but Mann—Whitney U-tests were used instead due to normality violations. Multiple comparisons were corrected by Bonferroni correction. Rank-Biserial Correlation was used as a non-parametric estimate of standardized effect size. Additionally, to see whether there are interactions between the experience factors and group, repeated ANOVAs were used. In addition to frequentist p-values, Bayes factors were calculated to estimate the strength of evidence for the alternative in contrast to the null hypothesis. The Bayes factor BF 10 indicates the likelihood of the observed data if the alternative hypothesis holds, in proportion to its likelihood if the null hypothesis is true. The testing was conducted by using an anonymous online survey that was distributed through patient organizations, social media and other social networks e. No compensation was given for participation. We included in the study even the MC patients without prescription, given the substantial practical difficulties in getting prescription for MC in Finland see Discussion. Demographic information and pain type with tests of group differences are described in Table 1. Opioids were used in this group on average 9. Lifetime duration of MC use was on average 7. Average single dose was 0. Based on the scree plot, four factors were extracted. Before proceeding in the analysis, we examined the factor structure for face validity. The fourth factor included only two items i. Next, 13 problematic items were deleted due to violating the 0. The final 30 items and their factor loadings are presented in Table 2. We determined that the first factor 13 items included negative side effects, including cognitive disturbances, emotional problems, as well as functional and somatic problems. The questions were averaged to gain factor scores. Before comparing the perceived effects of the medicine between the groups, matching was conducted for the relevant covariates see Methods. Data was missing about the duration of pain for ten participants one in MC group and nine in the opioid group and was imputed by the respective group means. Moreover, education data was missing from six participants in the opioid group and was imputed with the respective group mode two corresponding to vocational school. Comparison of the matched vs. Although no ideal match was attained on all covariates, the match between the groups was substantially improved. Note : The standardized mean difference SMD indicates the extent to which the groups differ on a given covariate; smaller values are desired. The highlighted vertical line at. For information regarding how the background variables were assessed, see Table 1. The standardized effect size was large 0. The results are summarized in Table 3 and Fig. Regarding the perceived efficacy of MC and opioids in reducing pain intensity, the average rating to the intensity-related items 9 and 10 was 5. Raincloud plots of the group differences in the three factor scores, indicating most pronounced differences in Positive emotional effects, with higher ratings in the medical cannabis MC group. As an additional group comparison, we examined if there is group difference in the average rating to the items 34 and 36 tapping on psychotic symptoms which were omitted from the factor analysis see above. Finally, to get a deeper insight into the experienced differences between the two medications, we conducted a non-planned analysis of the differences between the matched groups in ratings to all the questions from the final factor solution, summarized as a forest plot in Fig. All items with means and standard deviations for the matched groups are summarized in Table 4. Explorative between-group comparisons of all the variables included in the final factor model, ordered by standardized effect size Rank Biserial Correlation from largest to smallest. Note : Larger effect size indicates higher rating in the medical cannabis group. Full item descriptions as well as group means and standard deviations for all the items can be found in Table 4. Items where the confidence interval does not overlap with the vertical line can be considered as significant. It could be argued that recent opioid use in the MC group and recent MC use in the opioid group is a confounding factor in the analysis. Thus, a post hoc analysis was run to investigate whether the main group effects remain after excluding those in the groups who had used the other medication i. Previous research indicates that MC may exert its therapeutic effect on pain through altering the pain experience holistically. That is, in addition to reducing pain intensity, MC may positively affect pain-related factors such as emotion and mood, functionality, and overall sense of well-being. By contrast, we hypothesized that the effect of opioids on pain is narrower, mainly targeting its intensity. We tested this hypothesis quantitatively in a survey study by assessing the perceived effects of MC or opioids in a group of Finnish chronic pain patients. The main group comparison, based on the factor scores of the experience questions, indicated that MC and opioids did not differ in Negative Side Effects, but the effects of MC were rated as more positive in terms of the factors Positive Emotional and Positive Holistic Effects. Both MC and opioids were perceived to reduce pain intensity equally well. The group differences support the hypothesis that the effects of MC on pain are more holistic than those of opioids. Moreover, the results corroborate previous data that MC alleviates pain-related negative emotion and increases pain tolerance De Vita et al. The group differences were further examined by looking at the individual items exploratively Fig. The strongest group differences were, in order or magnitude, for relaxation, improved sleep, improved mood, and being able to feel pain without reacting to it. These items could reflect a broad range of cognitive-emotional processes. Second, pain is commonly associated with sleep disturbances, and sleep disturbance in turn can lead to worsening of pain and mood problems Herrero Babiloni et al. Thus, sleep is a central node in the holistic network of pain-related experience factors. Third, mood disorders and pain frequently go together, and through acutely improving mood, MC could also decrease the unpleasantness of the pain sensation cf. Tang et al. It is noteworthy that the participants perceived MC and opioids as equally effective in reducing pain intensity. Given that opioids are known to be effective analgesics Meske et al. These inconsistencies could stem from the wide range of cannabis-based medicines examined in previous research. It is possible that whole-plant cannabis flower, which was predominantly used by the patients in the present study, is more effective on pain intensity than isolated or synthetic cannabinoids. To illustrate, in the review of Fisher et al. Likewise, in Gedin et al. By contrast, in both studies, the results concerning isolated and synthetic cannabinoids were mixed. Thus, the present results contribute to the cumulating evidence that whole-plant cannabis flower may be an effective analgesic. There were no indications that MC, despite its holistic effects on consciousness, was experienced to distort cognitive processes, but instead was perceived to improve memory, focus, and clarity of thought see items 28—33 and 35, Table 4. This is in line with previous findings from a longitudinal study where MC use was associated with improved neurocognitive performance Sagar et al. The results of the present study underline that the psychoactive effects of MC can be therapeutically positive and have beneficial effects on mood and functioning. However, this conclusion would require more robust testing, ideally in randomized controlled trials RCT. A central limitation of the present survey study pertains to the special status of MC in Finland. Although legal in principle, prescription for MC is very difficult to attain. In the first half of there were less than 50 prescriptions Harmaala For these reasons, we decided already in the preregistration to include in the study even those MC patients without prescription. This could increase the risk of recreational users participating in the survey. Another risk related to the special status of MC in Finland is that, due to the negative perceptions about MC of medical doctors and authorities as well as severe difficulties in receiving a MC prescription, the patients may exaggerate the benefits of MC. However, systematic exaggeration of the benefits of MC would arguably also lead to underrating negative side effects, which was not the case here. Moreover, there was a differential effect in the two positive factors, supported by the ANOVA analysis, with the group difference being larger for the emotional factor than for the holistic factor. It is unlikely that this interaction effect would be due to systematic exaggeration of positive effects. The small sample size is an obvious limitation of the present study and is mainly due to the very small MC population in Finland. This limits the generalizability and reliability of the results and motivates replication in a larger, independent sample in a country where the MC population is larger. However, it can be argued that the present sample is relatively representative of the larger population of chronic pain patients that use MC to manage the pain. In sum, the present sample corresponds to some degree to the larger population of MC users, but there are also differences, motivating the use of a larger and more representative sample in future studies on this topic. Another limitation of the present study pertains to the experience questionnaire, which has not been previously validated. Although the present results indicate that it has good psychometric properties in terms of factor structure and reliability, the questionnaire should be tested for construct and convergent validity, which was not within the scope of the present paper. In general, there are inherent limitations to survey studies, pertaining to factors such as insufficient control, non-experimental design, and possible confounding factors. On the other hand, survey studies on existing patient populations can also be considered as a more ecologically valid approach compared to RCTs Schlag et al. Survey studies should not be seen as competing with RCTs, but instead the two approaches can be seen as mutually supportive. The present results highlight the importance of considering the holistic effects of MC on the pain experience also in RCT research. The results of the present study support the hypothesis that the effects of MC on pain experience are more holistic than those of opioids. MC may alleviate pain through affecting a broad range of pain-related experience experiental factors such as relaxation, improved sleep and mood, being able not to react to the pain, as well as a sense of control. These holistic effects of MC could explain the inconsistencies in clinical trials, where focus has mainly been on pain intensity instead of broader pain phenomenology. The results highlight the importance of taking these holistic effects into account in treating patients with MC, considering them as part of the therapeutic process. Aviram J, Samuelly-Leichtag G. Efficacy of cannabis-based medicines for pain management: a systematic review and meta-analysis of randomized controlled trials. Pain Physician. Using self-report assessment methods to explore facets of mindfulness. Article PubMed Google Scholar. College student mental health: an evaluation of the DSM-5 self-rated level 1 cross-cutting symptom measure. Psychol Assess. 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Front Psych. John Smith E. Advances in understanding nociception and neuropathic pain. J Neurol. Front Pharmacol. Prognostic score-based balance measures can be a useful diagnostic for propensity score methods in comparative effectiveness research. J Clin Epidemiol. Effects of mood on pain responses and pain tolerance: an experimental study in chronic back pain patients. Associations between medical cannabis and prescription opioid use in chronic pain patients: a preliminary cohort study. PLoS One. Vihervaara M, Hupli A. Helsinki: Basam Books; J Pain. Cannabis analgesia in chronic neuropathic pain is associated with altered brain connectivity. The prevalence of opioid analgesic use in people with chronic noncancer pain: systematic review and meta-analysis of observational studies. Cannabinoids for medical use: a systematic review and meta-analysis. Scale development research: a content analysis and recommendations for best practices. Couns Psychol. Download references. The authors are deeply grateful to the Finnish patient organizations that enabled the data gathering. This work has been supported by the Kone Foundation grant number The funder had no role in the design of the study, data collection and analysis, interpretation of data, or in writing the manuscript. You can also search for this author in PubMed Google Scholar. JJ conceptualized and coordinated the study, took part in preparing the materials and data gathering, analyzed the data and wrote the first draft of the manuscript. AH took part in data gathering and writing of the manuscript. AN, SA, AB, and SL took part in planning the experiment, preparing the materials, data gathering, analysis, and commented on the manuscript. AK took part in the analysis. ML-A took part in writing the manuscript. OK took part in planning the experiment, data gathering, analysis, and writing the manuscript. Informed consent was acquired from all participants. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Reprints and permissions. The holistic effects of medical cannabis compared to opioids on pain experience in Finnish patients with chronic pain. J Cannabis Res 5 , 38 Download citation. Received : 19 March Accepted : 25 October Published : 09 November Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search. Download PDF. Abstract Background Medical cannabis MC is increasingly used for chronic pain, but it is unclear how it aids in pain management. Method A retrospective internet survey was used in a sample of Finnish chronic pain patients 40 MC users and opioid users. Conclusion MC and opioids were perceived to be equally efficacious in reducing pain intensity, but MC additionally positively affected broader pain-related factors such as emotion, functionality, and overall sense of wellbeing. Background Chronic pain refers to pain that has pertained for at least three consecutive months. Materials and methods A cross-sectional survey study was employed on Finnish patients suffering from chronic pain who used MC or opioids for pain management. Table 1 Background information with between-group differences. Group is determined by the medicine the participants evaluated in the experience questions Full size table. Table 2 Final items and extracted factors, with problematic items deleted Full size table. Full size image. Table 3 Group differences in the three experience factors Full size table. Discussion Previous research indicates that MC may exert its therapeutic effect on pain through altering the pain experience holistically. Limitations A central limitation of the present survey study pertains to the special status of MC in Finland. Conclusion The results of the present study support the hypothesis that the effects of MC on pain experience are more holistic than those of opioids. Google Scholar Honkasalo V. Google Scholar Jeffreys H. Article Google Scholar St. Article Google Scholar Download references. Acknowledgements The authors are deeply grateful to the Finnish patient organizations that enabled the data gathering. Funding This work has been supported by the Kone Foundation grant number View author publications. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary Information. Additional file 1. Additional file 2. About this article. Copy to clipboard. Contact us Submission enquiries: nikki.

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