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Join L. Joseph Parker, a research physician, as we explore a recent study published in the Journal of Bone and Mineral Research. Discover how two compounds found in cannabis, cannabidiol (CBD) and cannabigerol (CBG), may revolutionize fracture healing and pain management. We’ll delve into the study’s findings, discuss the challenges doctors face in pain management, and explore the potential of these cannabinoids as alternatives to traditional medications.

L. Joseph Parker is a research physician.

He discusses the KevinMD article, “Cannabis compounds in fracture pain relief and healing.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Joseph Parker. He’s a research physician. Today’s KevinMD article is titled “Cannabis compounds in fracture pain relief and healing.” Joseph, welcome back to the show.

L. Joseph Parker: Thank you very much.

Kevin Pho: So Joseph has been on multiple times. Go to KevinMD.com/podcast, click the search icon in the upper right-hand corner, and search for his name to hear his story. But today we’re going to talk about a recent article in the Journal of Bone and Mineral Research about cannabis compounds and fracture healing. Tell us about the study and how your article came together.

L. Joseph Parker: It’s a very interesting study. Of course, cannabis has been used medicinally around the world for a long time. It’s been found in use 5,000 years ago in China, Egypt and Peru. There are a lot of alternative medications and herbal remedies, and I was very skeptical of them in the past, and we probably should be. I even objected to the term “alternative medicine.” There’s medicine that works, and then everything else: If it doesn’t work, it’s bunk. But when something’s used over that wide a geographical area, there’s probably a reason for it. And it was used medically in the United States until the 1900s.

So now things have loosened up a little bit, and the research can actually be done, because for the last 70 years the government restricted the research you were allowed to do on cannabis. They would grow it at a little place in Mississippi, what they grew was very substandard, and you could only do research if you agreed it was going to be negative research, looking at its bad effects.

The authors of this study were looking for something to treat fractures specifically, since opiate prescribing is no longer politically popular. You’ve got to find some way to treat pain, and a fracture is of course an extreme source of pain, and people around the world have fractures all the time. NSAIDs and Tylenol are often said to be adequate for treating pain, but that’s obviously not the case when it comes to a fracture, or at least for most people it’s not. Also, NSAIDs inhibit fracture healing. The inflammatory phase is very important for fracture healing; the callus formation and the changes that take place there are necessary. You can end up with a nonunion fracture, a fracture that never heals, if you use NSAIDs. And Tylenol is responsible for 50 percent of all liver failures. If you’re trying to treat fracture pain with Tylenol, you’re going to be using a lot of Tylenol, and then you end up causing other problems. And the NSAIDs cause GI bleeds, an increased incidence of heart attack, stroke, heart failure, renal failure and all that.

So they were looking for something else to use for pain and fractures, and they were hoping for something like CBD. Now, CBD is not THC. It doesn’t get you high, but it has shown some efficacy in treating pain, especially neurogenic pain, and some patients get some relief from it. So they were testing whether it could be used for fractures. They tested two compounds, cannabidiol, which is CBD, and cannabigerol, which is CBG. CBG is a lot less familiar to people. Less than 1 percent of the cannabinoids in most cannabis plants is CBG, because it gets converted into the other cannabinoids, but you can breed strains that have a higher amount.

What they found was that CBD and CBG don’t just improve pain equally to NSAIDs, which is what their study showed, but that they actually promote bone healing. So now you’ve got something that will treat the pain of a fracture at the same time that it improves the healing of the fracture and speeds it up. They were looking at how this happens, and there will be further studies done later, but it was a very interesting study, and I would say a very important one for us to start looking toward as we look for things other than opiates to treat pain. Some of these compounds seem to have a very good effect.

As a matter of fact, CBG was found to bind the alpha-2 receptors and the serotonin 5-HT2A receptors also, and of course increasing serotonin in the spinal cord increases the effects of the descending pain desensitization pathways. The reason antidepressants will sometimes help some people with pain appears to be that they increase these serotonin levels in the interneurons, and that turns down the volume of pain being reported up to the brain. Whereas CBD works on the cannabinoid receptors and potentiates the effects of our natural endocannabinoids, which are anandamide and 2-AG. So it increases the effectiveness of those, which are released when we’re injured to help us with pain, and it also has an effect on the immune system and all.

Kevin Pho: Sure. So to be clear, this is a study that was done in mice. Is it still early on in terms of this finding?

L. Joseph Parker: Very early on. And you see, cannabis is being used medically around the United States, and I, and probably several other people, would argue that rather than the high-THC strains, though THC does seem to help pain in some people, it might be better to go with the high-CBD, high-CBG strains, and perhaps drop the THC and reduce the risk of psychosis and all the other things that come with THC.

Kevin Pho: So give us a 30-second primer on what’s available legally in most states. I know there are some dispensaries that sell both CBD and THC, and I know that for CBD you can go to many drugstores that just sell CBD. So for a typical patient looking for cannabis-based pain options, what’s generally available to them?

L. Joseph Parker: They have THC by itself, and of course Marinol was approved in the 1980s for the treatment of nausea in chemotherapy. But THC by itself appears not to be a bright idea. It appears that CBD moderates the effects of THC, and THC has some very psychoactive effects that, except in very extreme cases, should probably be avoided. CBD is not considered a psychoactive substance by the World Health Organization, the CDC and most reasonable researchers, so it is available almost everywhere now.

There are some states that say that if THC is detectable at any level in your CBD, you can be prosecuted, and that’s important to know, because hemp oil, even if it comes from a federally legal plant, that is hemp with less than 0.3 percent THC by mass, will still have traces of THC in it. So there are companies that use filters to remove all the THC. If someone’s a pilot or a trucker, and probably for everyone, even in a state where THC is legal, if you get in a wreck and THC is detected in your system, there are a lot of consequences to that. So probably getting the filtered CBD, with no THC at all, is the best approach. Hemp oil with high CBD and CBG content that’s been filtered is probably the only reasonably safe way to go right now.

CBD has been approved in a purified form for the treatment of some forms of epilepsy in some children, but it doesn’t have to be that concentrated to have an effect. And over-the-counter medications like NSAIDs, ibuprofen and Tylenol have side effects too, and the side effects of these chemicals appear to be much less. I mean, over-the-counter NSAIDs kill about 15,000 people a year in the United States and send about 103,000 to the hospital, with GI bleeds and things like that. Tylenol kills quite a few people too, usually by intentional overdose.

Kevin Pho: So when you go to a drugstore and you’re looking for CBD compounds, and I know they come in different forms, tinctures, creams, gummies, do they all have the same absorption? What should patients generally look for?

L. Joseph Parker: About 40 percent of the supplements you buy are fake, and that includes those at big pharmacies and Walmart. Some research was done where they purchased a bunch of these and tested them, and 40 percent had none of what they were supposed to have. That’s for echinacea, coenzyme Q10, all these supplements. So I think CBD should be sourced from a manufacturer in Colorado or Nevada that specifically has pharmaceutical-grade product. Folium Biosciences is one that produces very high quality. It’s a husband-and-wife team; I think she has a doctorate in chemistry, and I think he has an MBA, he may not have a doctorate. They have a company that produces a very pure product that is federally legal, with less than 0.3 percent THC, so it should be able to ship across state lines. If it has no detectable THC, it should be legal in all states. I don’t think there’s any state that has banned CBD, though California at one time banned CBD made from hemp, while CBD made from marijuana was OK. Very strange. These markets are competing to keep each other out. I don’t know if that’s still the case in California, but it’s important to research your individual state’s laws.

Kevin Pho: Now, from a broader perspective, what do you see as the role of CBD in treating acute pain? Like you mentioned, NSAIDs and Tylenol have their own issues. CBD is becoming more popular, and we’re seeing very preliminary studies about the beneficial effects of cannabis-based products on acute fractures. Do you see a role for cannabis-based products in treating run-of-the-mill acute pain going forward?

L. Joseph Parker: Absolutely. I have seen patients who were able to stop strong prescription medications, even opiates, when they had access to alternatives like CBD. Now, that’s not going to be everybody, but even if it’s only 5 percent, and from what I saw it was about 15 percent, that’s a considerable number of people. About 40 percent of the American population will experience chronic pain at some point in their life. We’ve got 330 million people in this country, so we’re looking at about 120 million people who will experience chronic pain. If you can get by with something that’s over the counter and has a low risk of complications and side effects, that’s always better than even the over-the-counter stuff that has known dangerous effects. Nothing is without side effects except a vacuum. Even water has side effects, right? Some people die from drinking too much water. Anything can kill you if you get crazy about it, and almost everything is safe for you in moderation, in the right dose.

Kevin Pho: So tell us some of the side effects of CBD. I understand that you really shouldn’t drive while taking CBD products. Is that correct?

L. Joseph Parker: You should see how it affects you. You should never drive when a medication or a treatment or even a supplement makes you drowsy. You can take Benadryl and end up too drowsy to drive. So anytime you take something new, you should test its effects. With CBD, I would suggest that if people are going to take it, they take it at bedtime, and its effects will have worn off by morning. They make different preparations, and they make one with melatonin for nighttime use. I don’t recommend using melatonin at bedtime every time, because it’s kind of a clock reset, and you don’t need to reset your clock every night. It might be OK for a week or so. So anytime you start something, you should check and see what you’re getting.

You should avoid vaping anything. The vaporizers out there are not safe, unless they’re Scandinavian and medical grade, because they can have heavy metals in them, and a lot of people have suffered lung damage from aluminum poisoning and lead poisoning and things like that. So inhaling something into your lungs is probably a bad idea. They have hemp oil capsules, and that’s probably the best form as far as safety goes. And like I said, these can be ordered from companies in Colorado. Colorado has very strict laws: When something manufactured there says it has CBD, the state will go in, randomly select some, test them and make sure it has what it says it has. So that way you’re sure you’re getting what you’re supposed to be getting.

Kevin Pho: Now, the study we’ve been talking about looked at both CBD and CBG, and I’m actually not that familiar with CBG. Is that widely available?

L. Joseph Parker: No, you will not find CBG preparations right now. You probably will in the future, because it also binds the alpha-2 and the 5-HT2A receptors, and it may actually be better for pain than CBD. It’s just that there’s so little in most preparations that it’s not even tested. As they test these different cannabinoid structures, they’ll find something like this that has an anti-inflammatory, pain-relieving response without slowing bone healing. And there are probably other things. With any herbal or plant preparation, you’ve got hundreds if not thousands of chemicals in there, and when that plant has a beneficial effect, you might think it’s one thing doing it. Most people thought it was the THC, and it turned out, no, that’s actually not what’s doing most of what we consider the beneficial effects. It’s the CBD, and now we know CBG also.

Kevin Pho: Is there a habit-forming component to CBD products?

L. Joseph Parker: Not to CBD. It is considered a nonaddictive substance. I know that’s a scary thing to say, because they said that about OxyContin. Well, they said less addictive, not nonaddictive. Anything that causes a release of dopamine in the nucleus accumbens can lead to addiction, and there is no evidence that CBD does this. Now, THC does, so there can be addiction, and it’s argued whether it’s full addiction, or quote, true addiction. Addiction will upregulate the gene Delta FosB in the nucleus accumbens, and then things can get out of control. Whereas people mug their grandmothers to get methamphetamine, nobody really does that to get cannabis at this point. And if you take the THC out, it has no psychoactive effect and no dopaminergic effect, so it should have no addiction potential. Though something that makes you feel better will make you want to use it, and there’s often confusion between “I’m addicted to something because I can’t say no to it” and “I want something because it makes me feel better,” all right? Those are two different things, but they get conflated quite often.

Kevin Pho: What’s the general cost of over-the-counter CBD products? Compare that to a bottle of ibuprofen or Tylenol.

L. Joseph Parker: Cost is a consideration. The quality products will cost probably about the same as a supplement like coenzyme Q10, maybe $30 or $40 a month if you take it once or twice a day. It’s not as cheap as generic aspirin or generic ibuprofen, but because it appears to have a better side effect profile, it might be worth it. Of course, read up and do your own study. This is one very well-done study, and there are other studies that support it, but I’m sure there’s nothing out there without consequence, and they’ll find some situation. Just like they thought gabapentin didn’t have any addictive properties, and now they’re saying that people are using very large doses of it to get high. Just like dextromethorphan in very high doses is like LSD. There’s almost nothing that you can’t mess up if you put your mind to it and take a whole bunch of it. But so far there has been no serious consequence to these chemicals.

Kevin Pho: We’re talking to Joseph Parker. Today’s KevinMD article is titled “Cannabis compounds in fracture pain relief and healing.” Joseph, tell us some of the take-home messages that you want to leave with the KevinMD audience.

L. Joseph Parker: I would say that a lot depends on what you’re comfortable with and what your other problems are. You should discuss everything with your doctor. If you’re going to do something over the counter at home, you should read up on it in depth, and that includes over-the-counter medications like NSAIDs, Tylenol and Benadryl. Some people use Benadryl every night to sleep. That’s probably not a good idea, and you can look and read about why.

Kevin Pho: Joseph, thank you so much for coming back on the show and sharing your time and insight.

L. Joseph Parker: Thank you, sir.