Characterizing cannabis use in a sample of adults with multiple sclerosis and chronic pain: An observational study

Pain is a common and often disabling symptom in people with multiple sclerosis (PwMS), affecting 50–63% of adults with the disease (O'Connor et al., 2008). Not only is pain highly prevalent in PwMS, but the quality, severity, and characteristics of pain can greatly vary from person to person (O'Connor et al., 2008; Brola et al., 2014). This variability poses a challenge for pharmacological treatments, which are not are not always effective in managing or reducing pain intensity and may cause adverse effects (Urits et al., 2019). In recent years, alternative pharmacological and non-pharmacological treatments have become more common, including the use of cannabis (Cofield et al., 2017; Weinkle et al., 2019).

Despite the increasing availability of cannabis products, there remains a paucity of information regarding the types of cannabis being used for symptom management by PwMS. While previous randomized controlled trials (RCTs) suggest potential benefits of cannabis for MS symptoms such as pain and spasticity (Nielsen et al., 2018; Turcotte et al., 2015; Ware et al., 2010), it is unclear how similar the standardized, research-grade preparations evaluated in such trials are to the cannabis products being used by PwMS, who are often using cannabis purchased from dispensaries or obtained from other people and without the guidance of healthcare providers (Braley et al., 2020). There are also potential adverse effects of cannabis use in people with neurologic disorders, including impaired cognition, dizziness, increased fatigue, and interactions with other medications (Brown and Winterstein, 2019; Koppel et al., 2014). Further, as the legal status of cannabis has changed nationwide, the diversity of products has increased. Cannabis products vary in terms of their ratio of THC to CBD, their potency, and their route of administration (e.g., smoked/vaped, topical products, edibles, tinctures, etc.). The few studies that have investigated the types of cannabis products used by PwMS have had limitations in geographic scope (Rice et al., 2021; Santarossa et al., 2022; Schabas et al., 2019) or in timing of the studies relative to changes in legality of cannabis products (Chong et al., 2006) that limit their generalizability in present-day circumstances. For these reasons, it is important to explore the types of cannabis products currently being used by PwMS. This will advance knowledge of real-world patient experiences and help to inform clinicians’ understanding of how their patients may be using cannabis for symptom management.

The use of cannabis for MS pain management may be influenced by various demographic and disease-related factors. While previous studies of PwMS have found factors such as younger age (Rice et al., 2021; Gupta et al., 2019) and male sex (Cofield et al., 2017; Gupta et al., 2019) to be associated with higher odds of cannabis use, others have shown conflicting findings (Schabas et al., 2019; Chong et al., 2006). Along with their mixed results, these samples were not exclusive to PwMS experiencing pain, furthering the need for investigation within a chronic pain population. It is also not well understood how disease-related factors may relate to cannabis use for pain management. While previous studies have found greater cannabis use to be associated with relapsing-remitting MS (Gupta et al., 2019), others have failed to detect a relationship between cannabis use and MS phenotype (Banwell et al., 2016).

Cannabis represents one of many avenues that PwMS might take to manage their pain, although the use of cannabis for pain management in PwMS who have pain has not been well studied. Prior research has explored other avenues more extensively, such as the use of pain medications (Burkill et al., 2019; Kratz et al., 2021), engagement in non-pharmacologic approaches (Alschuler et al., 2021; Ehde et al., 2015; Jensen et al., 2011), and the ways in which patients’ thoughts, beliefs, and coping strategy use intersects with their pain experience (Arewasikporn et al., 2018). How – and in what ways – cannabis use intersects with these other important areas in people living with MS has been the topic of a limited body of research. Outside of MS, a modest number of studies have found associations between cannabis use and psychological aspects of the pain experience, including higher pain interference (Degenhardt et al., 2015; Kerlin et al., 2018; Kosiba et al., 2020) and higher pain catastrophizing. (Sturgeon et al., 2020). Thus, in addition to understanding patterns of cannabis use and demographic and disease-related differences in cannabis use, there is also value in understanding how cannabis use intersects with other key areas of MS pain management.

Given the gaps in knowledge regarding the use of cannabis for pain management in PwMS, an assessment of its use in a nationwide sample of PwMS is warranted. This study examined the use of cannabis for pain management in a nationwide sample of people with MS and chronic pain in the United States who were enrolled in a RCT comparing telehealth mindfulness-based cognitive therapy (MBCT), cognitive-behavioral therapy (CBT), and usual care for pain. The study aims were to (1) describe the prevalence of cannabis use and the routes of administration of cannabis products in adults with an existing chronic pain condition and MS, (2) to examine differences in demographic and disease-related variables between cannabis users and non-users, and (3) to examine differences between cannabis users and non-users in pain-related variables, including pain intensity, pain interference, neuropathic pain, pain medication use, and pain-related coping.

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