In the age of the opioid crisis, it is crucial to explore nonpharmacologic and pharmacologic alternatives for pain management in patients with rheumatic diseases. Strong opioids are not effective for fibromyalgia-related pain, and their use in this context is discouraged.1 A few randomized controlled trials have investigated the effects of cannabis on fibromyalgia symptoms with mixed results.2,3 Recent systematic reviews found low-quality data showing cannabinoid therapeutics may be a safe and effective option for short-term pain control in fibromyalgia patients. These studies also show improved quality of life measures among patients with fibromyalgia treated with cannabinoids, including improved mood and sleep quality.4,5 Studies that focus on the role of cannabinoids in the treatment of rheumatoid arthritis-related pain are scarce, and there is no consensus regarding their use specifically for rheumatoid arthritis.6
In this issue of Baylor University Medical Center Proceedings, Shrestha et al seek to clarify the potential role of cannabis in the management of rheumatoid arthritis.7 The authors analyzed 5 years of retrospective data using inpatient ICD-10 codes to compare rheumatoid arthritis patients who were cannabis users to those who were nonusers. Using a multivariate logistic regression analysis to adjust for age, gender, and race, the authors found that patients who used cannabis had lower rates of mortality, depression, chronic pain, and anxiety.
The role of cannabinoid therapeutics in pain management for patients with longstanding rheumatoid arthritis remains uncertain. It is not clear from the study whether lower rates of mortality, depression, chronic pain, and anxiety apply specifically to rheumatoid arthritis. Fibromyalgia and secondary osteoarthritis are common comorbidities among patients with rheumatoid arthritis and could be confounding the data. Other limitations to this study should also be acknowledged. As the authors indicate, ICD-10 codes do not give insight into the frequency of cannabis use, nor do they delineate between recreational and physician-directed use. Furthermore, it is hard to correlate cannabis use with hospital mortality rates since cannabis is not given in the inpatient setting.
The authors theorize about the antiinflammatory properties of cannabinoid therapeutics to decrease joint pain and potentially reduce joint destruction. It should be clarified that cannabinoids are not currently known to be disease-modifying antirheumatic drugs and have not been studied in this manner. Further studies, including randomized controlled trials, are needed to delineate the role of cannabinoids in both reducing rheumatoid arthritis disease activity and as a possible adjunct for the management of comorbid osteoarthritis and fibromyalgia. Future studies need to clarify the specific formulation, dosage, length of treatment, and dependence concerns before cannabinoids can realistically be used for rheumatic disease–associated chronic pain.
—Brooke Mills, MD http://orcid.org/0000-0003-1001-9402
Division of Rheumatic Diseases, Internal Medicine,
University of Texas Southwestern Medical Center,
Dallas, Texas, USA
brooke.mills@utsouthwestern.edu
Disclosure statement/Funding
The authors report no funding or conflicts of interest.
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