Abstract
Objectives
Cannabis legalisation in North America has led to increased use of medical cannabis (MC) among patients with inflammatory rheumatic diseases (IRDs). In Europe, there are still no epidemiologic data on the patterns of cannabis consumption in this population. Thus, this study aimed to assess the prevalence of cannabis consumption among patients with IRD in Germany just after legalisation and to analyse its associations with demographic and clinical factors, acceptance, and physician experience with prescription.
Methods
Two surveys were performed on patients with IRD at 2 centres and on physicians treating these diseases. Patients and physicians were questioned about cannabis use, disease-related factors, treatments, and their experience with MC prescription.
Results
Of 651 patients, 3% reported current and 12% past cannabis consumption. Cannabis use was higher among young men (P < .001) and patients with spondyloarthritides (relative risk [RR]: 1.78; 95% CI: 1.18-2.72; P = .006) and was associated with higher pain (P < .001), more frequent analgesics use (P = .012), and risk behaviours, eg, smoking and illicit drugs use (P < .001). Active users reported high efficacy of cannabis on pain, but only 17% declared ever being prescribed MC, and 97% denied ever seeking medical counselling. Among 127 physicians, only 20% had experience with MC prescription. Openness to MC was high overall, with greater acceptance among patients than physicians (62% vs 54%).
Conclusions
The high acceptance and reported efficacy of cannabis among patients with IRD likely anticipate an increase in MC consumption in Europe. Our data highlight the need for dedicated trials to define the indications of MC and to improve the education of physicians and patients.
WHAT IS ALREADY KNOWN ON THIS TOPIC
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Previous studies have shown that medical cannabis has analgesic and possibly anti-inflammatory efficacy in inflammatory rheumatic diseases (IRDs). However, the evidence on cannabis applications in IRDs is still quite limited, and there are no guidelines defining indications and dosages.
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The legalisation of cannabis in North America has led to a significant increase in the use of medical cannabis among patients with IRD. Germany has been the first European country to legalise recreational cannabis while also abolishing the requirement for narcotic prescription forms for medical cannabis. Still, there are no epidemiologic data on the consumption of cannabis-based products among patients with IRD in Europe.
WHAT THIS STUDY ADDS
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Despite high openness, use of cannabis-based products is still relatively low among German patients with IRD at the time of legalisation.
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Cannabis use is higher among young men with spondyloarthritides and was also associated with higher reported pain, greater reliance on other analgesic therapies, and risk behaviours such as smoking and illicit drugs use.
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The rate of prescription of medical cannabis is very low, even among cannabis users, and the vast majority of patients with IRD have never received medical counselling on cannabis.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY
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This study points to the high acceptance and reported efficacy of cannabis for pain management among patients with IRD, likely anticipating an increased demand for medical cannabis in Europe in the coming years. Thus, there is an emerging need for dedicated clinical trials and for improved education to ensure an evidence-based use of medical cannabis in IRDs.
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INTRODUCTION
Cannabis and its derivates, such as cannabidiol (CBD) and delta-9-tretrahydrocannabinol (THC), have shown efficacy in the treatment of neuropathic and chronic pain in several clinical trials [1]. Among inflammatory rheumatic diseases (IRDs), beneficial effects of cannabis on pain and functional indices have been observed in fibromyalgia and osteoarthritis [2]. A few preliminary and exploratory studies suggested positive effects of cannabis on pain and on the reduction of analgesic drugs including opioids in rheumatoid arthritis (RA) and in spondyloarthritides (SpA) [3,4]. A randomised double-blind trial on nabiximols, a combination of CBD and THC, in patients with active RA reported significant improvements in pain and DAS28 with no major concerns for safety [3].
Nonetheless, there is still no current recommendation in international guidelines on the use of cannabis-based medications for pain management in IRDs [5] due to a lack of high-quality evidence. Paucity of clinical trials can be attributed to the strict regulations on cannabis prescription, as well as to its abuse potential and physician reticence [2]. A recent survey conducted in Canada and the USA, where cannabis is legal for both medical and recreational use, observed frequent and increasing consumption among patients with IRDs since legalisation [6]. Several European countries permit cannabis use; however, Germany is the only country that recently legalised its recreational use while also streamlining prescription for medical purposes by eliminating the requirement for narcotic prescription forms [7]. This is particularly relevant for rheumatic patients, who are more likely to use cannabis than the general population [6].
Therefore, Germany currently serves as a notable case study on this topic to understand the current practices and attitudes of both patients and physicians towards MC that will help in planning healthcare services accordingly. To do so, we conducted a survey on patients with IRDs to assess the following: (i) the frequency and patterns of cannabis consumption, (ii) patient openness to MC for pain management, and (iii) associations of cannabis use with demographic and clinical characteristics. We also conducted a survey among German physicians treating IRDs to assess their perspectives and knowledge of MC.
METHODS
Recruitment and surveying
Only adult individuals with an adequate understanding of the German language were included. Patients were recruited from the outpatient clinic of the Department of Rheumatology and Immunology of the University Hospital of Erlangen and from the Department of Rheumatology and Clinical Immunology of the Charité University Hospital of Berlin between July and September 2024. Patients with the following diagnoses were included in the study: RA, SpA including psoriatic arthritis (PsA), connective tissue diseases (CTDs) including systemic lupus erythematosus (SLE), systemic sclerosis (SSc), Sjogren syndrome, and polymyositis (PM)/dermatomyositis (DM). All patients received information about the survey from a rheumatologist and gave informed consent to participate. Participating patients were asked to anonymously complete a paper questionnaire, and anonymity was ensured by returning the completed surveys to a sealed drop box.
Participants for the physician survey were recruited during the 2024 congress of the German Society of Rheumatology. Potential participants were randomly approached for an interview by 2 interviewers (GC and AK). The questionnaire was digitally administered and completed anonymously upon agreeing to a digital informed consent form. The study was approved by the ethics committee of the Friedrich-Alexander University of Erlangen-Nürnberg.
Questionnaire
The patient questionnaire included 29 open and multiple-choice questions. The questions covered general demographics (n = 2), disease-related information (n = 4), current treatments and pain management (n = 5), current pain levels by visual analog scale (VAS, 1-10 cm), and perceived efficacy of analgesics and cannabis on a VAS (n = 3). Patients were also asked to describe their experience and current or past use of cannabis for medicinal or recreational purposes, routes of cannabis administration, side effects, and whether they received counselling from a physician (n = 6); their awareness of the recent cannabis legalisation, knowledge on the therapeutic uses of cannabis, and openness to cannabis-based therapies (n = 6); and their use of other substances with potential abuse risk (ie, alcohol, tobacco, and other psychoactive drugs) (n = 3).
The physician questionnaire included 12 open and multiple-choice questions regarding their medical specialty and position (n = 2), the number and type of IRDs treated (n = 2), openness to the medical use of cannabis and awareness of the recent regulatory changes (n = 2), habits and form of cannabis prescription (n = 3), first-hand experience with MC for treating pain (n = 2), and IRDs considered more likely to benefit from treatment with MC (n = 1). The complete patient and physician questionnaires are provided in the supplementary materials.
Statistical analysis
We used summary statistics to describe characteristics as per data type. We used chi-square or Fisher’s exact test to compare the frequency of categorical variables across categories and Wilcoxon rank-sum or Kruskal-Wallis test for continuous variables. To evaluate the association between cannabis use and participant diagnosis, we estimated risk ratios using generalised linear regression with a binomial log link function which also enables adjustment for covariates.
RESULTS
Patient characteristics
A total of 651 patients were enrolled (n = 251 RA, n = 245 SpA, and n = 155 CTD), the majority of whom were women (64%) and aged >50 years (68%). Most patients (76%) reported chronic pain, which was significantly more frequent in RA (81%) and SpA (78%) compared with CTD (66.9%) (P = .006). The median (IQR) reported VAS pain level was 4.0 cm (2.0-6.0 cm) and did not significantly differ between diagnoses. About one in 4 patients (27%) used analgesics once or more daily, with no significant difference across diagnoses. Patients denying use of on-demand analgesics were overrepresented in the CTD group, with 46% (n = 72) reporting no on-demand medications (P < .001). The frequency of intake of analgesics did not significantly differ between groups. The VAS on the perceived efficacy of analgesics was similar between the diagnosis groups with a median of 6.0 cm (4.0-8.0 cm). Detailed results are reported in Table 1 and in Supplementary Table S1.
Table 1.
Patient demographic and clinical characteristics and prevalence of cannabis use
| Overall N = 651 |
RA N = 251 |
SpA N = 245 |
CTD N = 155 |
P value | |
|---|---|---|---|---|---|
| Sex (male/female) | 232/415 | 80/168 | 122/122 | 30/125 | <.001a |
| Age, y, N (%) | <.001a | ||||
| 18-30 | 30 (4.6%) | 8 (3.2%) | 15 (6.1%) | 7 (4.5%) | |
| 31-50 | 181 (27.9%) | 43 (17.2%) | 85 (34.9%) | 53 (34.4%) | |
| >50 | 438 (67.5%) | 199 (79.6%) | 148 (60.7%) | 94 (61.0%) | |
| Reported chronic pain, N (%) | 493 (75.9%) | 198 (80.5%) | 192(78.2%) | 103 (66.9%) | .006a |
| Visual analog scale pain (0-10), median (IQR) | 4.00 (2.00-6.00) | 4.00 (2.00-6.00) | 4.00 (2.00-6.00) | 5.00 (2.00-6.00) | .8 |
| Analgesic therapy on demand, N (%) | |||||
| None | 214 (33.0%) | 61 (24.5%) | 81 (33.3%) | 72 (46.4 %) | <.001a |
| Paracetamol | 13 (2.0%) | 5 (2.0%) | 2 (0.8%) | 6 (3.9%) | .12 |
| Metamizol | 76 (11.7%) | 31 (12.4%) | 21 (8.6%) | 24 (15.5%) | .091 |
| NSAIDs | 304 (47.0%) | 129 (51.8%) | 125 (51.4%) | 50 (32.2%) | <.001a |
| Weak opioids | 23 (3.5%) | 13 (5.2%) | 6 (2.4%) | 4 (2.6%) | .2 |
| Strong opioids | 4 (0.6%) | 2 (0.8%) | 2 (0.8%) | 0.0 (0%) | .7 |
| Others | 52 (8.0%) | 24 (9.6%) | 16 (6.5%) | 12 (7.7%) | .2 |
| Frequency of analgesics intake, N (%) | .5 | ||||
| Several times a day | 99 (15.9%) | 37 (15.2%) | 43 (18.5%) | 19 (12.8%) | |
| Once a day | 72 (11.5%) | 35 (14.3%) | 24 (10.3%) | 13 (8.8%) | |
| Several times a week | 104 (16.7%) | 43 (17.6%) | 35 (15.1%) | 26 (17.6%) | |
| Once a week | 64 (10.3%) | 26 (10.7%) | 24 (10.3%) | 14 (9.5%) | |
| less often than once a week | 285 (45.7%) | 103 (42.2%) | 106 (45.7%) | 76 (51.3%) | |
| Visual analog scale, reported efficacy of analgesic therapy (0-10), median (IQR) | 6.00 (4.00-8.00) | 6.00 (4.00-8.00) | 6.00 (4.00-8.00) | 6.00 (4.00-8.00) | .6 |
| Cannabis use | .035a | ||||
| No use ever | 548 (84.2%) | 221 (88.0%) | 193 (78.8%) | 134 (86.5%) | |
| Previous use | 81 (12.4%) | 26 (10.4%) | 40 (16.3%) | 15 (9.7%) | |
| Current use | 22 (3.4%) | 4 (1.6%) | 12 (4.9%) | 6 (3.8%) |
IQR, interquartile range.
Percentages are calculated with respect to the total of responses for each item.
significantly different, p ≤ 0.05.
Prevalence of cannabis use and characteristics of users
A total of 548 of the 651 patients (84%) reported no current or past use of cannabis. Eighty-one patients (12%) reported previous use, and 22 patients (3%) were current users. Patients with SpA showed the highest proportions of both previous (16%) and current use (5%) compared with RA and CTD, where the ever-users cumulatively amounted to 12% and 14%, respectively (P = .035). The relative risk (RR) of engaging in cannabis consumption in the SpA group was 1.78 (95% CI: 1.18-2.72; P = .006) compared with RA. However, after adjusting for sex and age, the RR was reduced (1.13, 95% CI: 0.66-1.90) (Table 1).
Cannabis consumption was significantly more frequent in men (P < .001), 22% of whom (n = 50) reported previous or current use of cannabis products, compared with just 12% of women (n = 51). Individuals aged < 50 years were also significantly more likely to engage in cannabis use (P < .001): 50% of patients aged <30 (n = 15) and 25% of patients aged between 31 and 50 years (n = 45) reported cannabis consumption, as opposed to 10% of those aged >50 years (n = 42). Regarding antirheumatic therapies, cannabis users were prescribed more biological disease-modifying anti-rheumatic drugs (bDMARDs) (P = .4, n.s.) and significantly less conventional (cs)DMARDs (P = .014) compared with nonusers (Table 2).
Table 2.
Demographic and clinical characteristics and use and perceived efficacy of analgesics by cannabis use
| Overall N = 651 |
No use ever N = 548 |
Previous use N = 81 |
Current use N = 22 |
P value | |
|---|---|---|---|---|---|
| Sex (male/female) | 232/415 | 182/364 | 36/43 | 14/8 | .002a |
| Age, y, N (%) | <.001a | ||||
| 18-30 | 30 (4.6%) | 15 (2.7%) | 11 (13.7%) | 4 (18.2%) | |
| 31-50 | 181 (27.9%) | 136 (24.9%) | 33 (41.3%) | 12 (54.6%) | |
| >50 | 438 (67.5%) | 396 (72.4%) | 36 (45.0 %) | 6 (27.2%) | |
| Type of disease | .035a | ||||
| Rheumatoid arthritis | 251 (38.6%) | 221 (40.3%) | 26 (32.1%) | 4 (18.2%) | |
| Spondyloarthritides | 245 (37.6%) | 193 (35.2%) | 40 (49.4%) | 12 (54.5%) | |
| Connective tissue diseases | 155 (23.8%) | 134 (24.5%) | 15 (18.5%) | 6 (27.3%) | |
| Ongoing DMARD therapy | |||||
| csDMARDs | 300 (46.1%) | 266 (48.5%) | 26 (32.1%) | 8 (36.4%) | .014a |
| bDMARDs | 326 (50.1%) | 270 (49.3%) | 42 (51.9%) | 14 (63.6%) | .4 |
| tsDMARDs | 69 (10.6%) | 57 (10.4%) | 10 (12.3%) | 2 (9.1%) | .9 |
| Reported chronic pain, N (%) | 493 (75.9%) | 405 (74.9%) | 64 (80.0%) | 22 (100%) | .018a |
| Visual analog scale pain (0-10), median (IQR) | 4.00 (2.00-6.00) | 4.00 (2.00-6.00) | 5.00 (3.00-6.00) | 6.00 (5.00-7.00) | <.001a |
| Analgesic therapy on demand, N (%) | |||||
| None | 214 (33.0%) | 193 (35.3%) | 18 (22.8%) | 3 (13.6%) | .012a |
| Paracetamol | 13 (2.0%) | 9 (1.6%) | 3 (3.8%) | 1 (4.5%) | .2 |
| Metamizol | 76 (11.7%) | 61 (11.2%) | 12 (15.2%) | 3 (13.6%) | .5 |
| Other NSAID | 304 (47.0%) | 248 (45.4%) | 48 (60.8%) | 8 (36.4%) | .038a |
| Weak opioids | 23 (3.5%) | 16 (2.9%) | 5 (6.3%) | 2 (9.1%) | .077 |
| Strong opioids | 4 (0.6%) | 1 (0.2%) | 2 (0.3%) | 8 (36.4%) | .012a |
| Others | 52 (8.0%) | 40 (7.3%) | 4 (5.0%) | 0 (0.0%) | <.001a |
| Frequency of analgesic therapy intake, N (%) | <.001a | ||||
| Several times a day | 99 (15.9%) | 74 (14.1%) | 12 (15.2%) | 13 (61.9%) | |
| Once a day | 72 (11.5%) | 63 (12.0%) | 7 (8.9%) | 2 (9.5%) | |
| Several times a week | 104 (16.7%) | 85 (16.2%) | 19 (24.0%) | 0 (0%) | |
| Once a week | 64 (10.3%) | 57 (10.9%) | 7 (8.9%) | 0 (0%) | |
| less often than once a week | 285 (45.7%) | 245 (46.8%) | 34 (43.0%) | 6 (28.6%) | |
| Visual analog scale, reported efficacy of analgesic therapy (0-10), median (IQR) | 6.00 (4.00-8.00) | 6.00 (4.00-8.00) | 6.00 (4.00-8.00) | 6.00 (4.00-7.00) | .7 |
| Visual analog scale, reported efficacy of cannabis (0-10), median (IQR) | - | - | 5.00 (3.00, 7.00) | 8.00 (7.00, 10.00) | <.001 |
| Awareness of new Cannabis Act, N (%) | <.001a | ||||
| Yes | 365 (56.3%) | 286 (52.5%) | 59 (72.8%) | 20 (90.9%) | |
| Unsure | 142 (21.9%) | 127 (23.3%) | 14 (17.3%) | 1 (4.5%) | |
| No | 141 (21.6%) | 132 (24.2%) | 8 (9.9%) | 1 (4.5%) | |
| Awareness of potential analgesic effect of cannabis, N (%) | .002a | ||||
| Yes | 507 (78.0%) | 416 (76.3%) | 69 (86.2%) | 22 (100%) | |
| No | 140 (21.6%) | 129 (23.7%) | 11 (13.8%) | 0 (0%) | |
| Openness to medical cannabis, N (%) | <.001a | ||||
| Yes | 403 (62.7%) | 315 (58.2%) | 66 (82.5%) | 22 (100%) | |
| Unsure | 171 (26.6%) | 162 (29.9%) | 9 (11.3%) | 0 (0%) | |
| No | 69 (10.7%) | 64 (11.8%) | 5 (6.2%) | 0 (0 %) | |
| Purpose of cannabis use, N (%) | <.001a | ||||
| Recreational | 55 (53.9%) | 0 (0%) | 51 (63.0%) | 4 (19.0%) | |
| Medical | 29 (28.4%) | 0 (0%) | 18 (22.2%) | 11 (52.4%) | |
| Both | 18 (17.6%) | 0 (0%) | 12 (14.8%) | 6 (28.6%) | |
| Physician counselling on medical cannabis ever received, N (%) | 19 (2.7%) | 4 (0.7%) | 6 (6.2%) | 9 (36.4%) | <.001a |
| Consumption of cannabis products without prescription, N (%) | - | - | 35 (43.2%) | 11 (50.0%) | <.001a |
| Previous or current tobacco smoking history, N (%) | 392 (62.0%) | 311 (58.7%) | 61 (76.3%) | 20 (90.9%) | <.001a |
| Alcohol consumption, N (%) | .3 | ||||
| Occasionally (max. twice a week) | 345 (54.5%) | 295 (55.3%) | 43 (54.4%) | 7 (33.3%) | |
| Regularly (twice a week) up to daily | 64 (10.1%) | 55 (10.3%) | 6 (7.6%) | 3 (14.3%) | |
| Never | 224 (35.3%) | 183 (34.4%) | 30 (38.6%) | 11 (52.4%) | |
| Previous or current use of illicit substances, N (%) | 28 (4.3%) | 8 (1.6%) | 16 (19.8%) | 4 (18.1%) | <.001a |
cs/b/tsDMARD, conventional, biological, targeted-synthetic disease-modifying anti-rheumatic drugs; NSAID, non steroidal anti-inflammatory drugs; IQR, interquartile range.
Percentages are calculated with respect to the total of responses for each item.
significantly different, p ≤ 0.05.
All 22 patients (100%) who were currently using cannabis reported chronic pain, which was significantly more prevalent than in previous users (n = 64, 80%) and never-users (n = 405, 75%) (P = .018). These patients also reported more severe pain with a median (Q1-Q3) VAS of 6.0 cm (5.0-7.0 cm) compared with 5.0 cm (3.0-6.0 cm) of previous users and 4.0 cm (2.0-6.0 cm) of never-users (P < .001). On-demand analgesic use was more common in cannabis users: only 3 cannabis users (14%) reported no need for on-demand analgesics, as opposed to 18 (23%) of previous users and 193 (35%) of never-users (P = .012). The use of weak and light opioids was particularly more common in ever-users. Overall, 7% of ever-users (n = 7) needed weak opioids compared with 3% of never-users (n = 16) (P = .074, n.s.). Similarly, the use of strong opioids was significantly more frequent in ever-users (n = 3, 3%) than never-users (n = 1, 0.2%) (P < .001).
Non steroidal anti-inflammatory drugs were significantly less prescribed in current cannabis users (n = 8, 36%) compared with previous (n = 48, 59%) and never-users (n = 248, 45%) (P = .038). Multiple daily intake of analgesics was reported in 62% of current cannabis users as opposed to 14% of nonusers. There were no significant differences in the perception of conventional analgesic efficacy between ever-users and nonusers. Cannabis users reported a high efficacy of cannabis products on pain (median VAS reported efficacy of cannabis: 8.0 cm [7.0-10.0 cm]), which was higher than previous users (P < .001) and higher than the effect of conventional analgesics (median VAS reported efficacy of cannabis of conventional analgesics: 6.0 cm [4.0-7.0 cm]). Previous cannabis users reported similar efficacy of cannabis (5.0 cm [3.0-7.0 cm]) and conventional analgesics (6.0 cm [4.0-8.0 cm]) (Table 2).
Openness to MC, patterns of cannabis use, and prescription
Among the 548 patients who reported no current or past use of cannabis, 315 (58%) were open to cannabis, 162 (30%) were uncertain, and 64 patients (12%) opposed. Ever-users were more commonly aware of the analgesic effects of cannabis (88%) than those who never used cannabis (76%) (P = .004), but it was still high in both groups. Nonetheless, never-users were significantly less informed about the new German law, with only 53% (n = 365) reporting being aware of the new law compared with 73% (n = 59) of previous users and 91% (n = 20) of current users (P < .001).
More than half (n = 11, 52%) of the cannabis users declared consuming cannabis solely for medical purposes, whereas for 19% (n = 4), the use was merely recreational. Among patients who reported consuming cannabis at least once daily, 43% had a diagnosis of SpA. When asked about the routes of administration of cannabis products, most users (n = 40, 49%) declared to smoke cannabis, whereas the rest mainly resorted to oils and edibles. Side effects of cannabis were reported in (n = 48) 47% of all users and significantly more frequently in ex-users (n = 33, 59%) than in active users (n = 15, 31.8%) (P < .001). Although alcohol consumption did not differ significantly by use of cannabis, the overwhelming majority (91%) of current users reported a previous or ongoing smoking habit, which was significantly more than the other groups (P < .001). Furthermore, past or current use of other illicit substances was reported with an about 11-fold higher frequency in ever-users of cannabis (P < .001).
Prescription rates of MC were very low: out of 103 patients who previously or currently used cannabis, only 17 (17%) declared a prescription from a physician, whereas 46 (45%) reported having no medical prescriptions, and the rest did not provide further information. Remarkably, the quasi-totality of patients (n = 607, 97%) declared to have had no consultation with a physician about cannabis. Even between active users, among whom consultation rates were significantly higher (P < .001), only 36.4% declared having sought consultation (Table 2).
Physicians survey
A total of 127 physicians participated in the survey, the vast majority of whom (n = 118, 93%) were rheumatologists. Little more than half (n = 68, 54%) declared to be open to MC, whereas about one in 4 (n = 35, 28%) was unsure, and the remaining 19% (n = 24) positioned themselves against it. Although 85% (n = 108) were aware that narcotic prescription forms are no longer required to prescribe cannabis, only 20% (n = 25) had ever prescribed cannabis, and a minority (n = 29, 23%) had direct experience with MC for pain management. When asked about which groups of patients would benefit the most from MC, participants overwhelmingly indicated fibromyalgia (n = 79, 62%) as the primary target group, followed by osteoarthritis (n = 45, 35%), RA (n = 40, 32%), and SpA (n = 36, 28%), suggesting a preference for noninflammatory conditions and forms of arthritis with a high burden of pain. Detailed results are reported in Table 3 and Supplementary Table S2.
Table 3.
Characteristics of participating physicians and disposition towards cannabis
| Overall N = 127 |
|
|---|---|
| Specialty, N (%) | |
| Rheumatologists | 118 (92.9%) |
| Internist | 28 (22.0%) |
| Other | 6 (4.8%) |
| Role, N (%) | |
| Specialist | 95 (74.8%) |
| Resident | 27 (21.3%) |
| Other | 5 (3.9%) |
| Awareness of no required narcotic prescription for cannabis, N (%) | 108 (85.0%) |
| Openness to cannabis for medical use, N (%) | |
| Yes | 68 (53.5%) |
| No | 24 (18,9%) |
| Unsure | 35 (27.6%) |
| Experience in the use of cannabis for pain, N (%) | 29 (22.8%) |
| Physician opinion on the efficacy of cannabis for chronic pain | |
| Positive, medical cannabis is effective | 12 (41.4%) |
| Negative due to inefficacy | 6 (20.7) |
| Negative due to adverse events | 0 (0.0%) |
| Unsure | 11 (37.9%) |
| Cannabis ever prescribed, N (%) | 25 (19.7%) |
| Rheumatic disease in which cannabis could be useful, N (%) | |
| Fibromyalgia | 79 (62.2%) |
| Osteoarthritis | 45 (35.4%) |
| Rheumatoid arthritis | 40 (31.5%) |
| Spondyloarthritis, incl. psoriatic arthritis | 36 (28.3%) |
| Autoimmune connective tissue diseases | 12 (9.4%) |
| Other | 15 (11.8%) |
Percentages are calculated with respect to the total number of participants.
DISCUSSION
The use of cannabis-based medications to manage chronic pain is increasing worldwide [2,6,8]. A recently conducted survey in North America highlighted a substantial prevalence of cannabis use among patients with IRDs, reaching up to 78% [6]. To our knowledge, our study represents the first epidemiologic investigation on this topic in Europe, revealing a significantly lower rate of cannabis use among German patients compared to Canada. This disparity is primarily attributed to the several-year gap in legalisation between the 2 countries. However, lessons from the Canadian experience—along with German patients’ high openness to these therapies and the high reported analgesic efficacy—suggest that an increase in cannabis use in Germany following the Cannabis Act and the simplification of MC prescription should be anticipated [8].
Our findings indicate a notable lack of counselling and cannabis prescription by healthcare professionals in Germany, which may contribute to uncontrolled consumption and reliance of patients on the recreational market. Our analysis suggests that patients with IRD—and particularly younger men with SpA and those experiencing chronic pain—exhibit a higher prevalence of cannabis use. This result is most likely due to the higher rates of cannabis consumption in males and younger individuals, which are already known for the general German population, rather than a disease-specific effect of SpA [9]. Indeed, the current rate of cannabis use in our SpA cohort (4.9%) was comparable with the 12-month prevalence of cannabis use in the German general population (4.6%) [9]. As such, targeted counselling should prioritise vulnerable demographics over specific disease groups. Still, patient openness to MC was independent of demographic and clinical factors, meaning that information about cannabis-based treatments should be offered to the broadest possible patient base.
It is also worth noting that cannabis users were also more likely to engage in high-risk behaviours such as smoking, use of opioids, and use of illicit substances, highlighting the need for caution to minimise the risk of abuse when considering such therapies.
The physicians’ survey revealed that most physicians have a positive attitude towards MC. However, about one in 3 still expressed uncertainty about its utility. Most notably, only a small minority of participants reported having direct experience with MC prescription. This is likely due to the very limited amount of high-quality evidence and consequently to the insufficient education of healthcare professionals about its indications.
Few studies have explored the use of MC in IRDs. However, existing research suggests that cannabis could also elicit some anti-inflammatory effects besides analgesia. Several murine models suggest that this could be linked to the downregulation of proinflammatory cytokines, probably by acting on CB2 receptors expressed on myeloid immune cells [[10], [11], [12]]. Some clinical observations seem to substantiate these preclinical findings, as synthetic and phytocannabinoid-based medications were shown to be effective in treating digital ulcers in SSc and skin manifestations in PM/DM [[13], [14], [15]]. Furthermore, lower IL-23 levels were observed in cannabis users with PsA compared with nonusers [16]. However, the cited studies are limited in scale and methodological quality, providing only low-level evidence; therefore, further research is needed to better understand both the analgesic and potential anti-inflammatory effects of cannabis in the context of IRDs.
Moreover, long-term data on the broader health and social impact of MC use among patients with IRDs are lacking, raising concerns similar to those already observed with opioid use; namely, the risk of prolonged use, dependency, and the absence of reduction in major adverse cardiovascular events compared with non steroidal anti-inflammatory drugs [[17], [18], [19]].
Our study has some limitations. First, the patient survey was conducted in 2 centres, which could affect the generalisability of our findings to the entire German IRD population. Second, because participation in the survey was voluntary, we have no data on the number of individuals who chose not to participate due to a lack of interest or because of prejudice against this topic. This could introduce a bias, leading to an overestimation of the acceptance of MC.
In conclusion, our findings indicate that patients and physicians are mostly open to the use of cannabis. Still, the prevalence of cannabis use is relatively low among patients with IRDs, and only a minority of users obtain cannabis products through prescription.
The interest and consumption of cannabis-based medications to treat rheumatic pain is expected to substantially grow in the coming years. Therefore, there is an emerging need for dedicated clinical trials to better define the indications of MC in rheumatologic clinical practice. Additionally, there is a need to standardise substances, administration methods, and dosages more clearly. To achieve this, the commitment of both institutional authorities and pharmaceutical companies to support clinical research, as well as promoting education for patients and healthcare professionals, will be crucial.
Competing interests
None to declare.
Acknowledgments
Acknowledgements
The present work was performed in fulfilment of the requirements for obtaining the degree ‘Dr med. dent.’ (Doctor medicinae dentariae) at Friedrich-Alexander University Erlangen-Nuremberg (FAU) by AK.
Contributors
GC and FF designed the study. GC, AK, IM, and DS collected the data. KT conducted the statistical analysis. GC, AK, KT, DS, IM, AK, GS, and FF wrote the original draft. GC, KT, and FF worked on Tables and Figures. All authors have read and agreed to the published version of the manuscript.
Funding
The study was supported by the Deutsche Forschungsgemeinschaft (DFG-FOR2886 PANDORA—405969122 and the CRC1181 Checkpoints for Resolution of Inflammation—261193037; Leibniz Award to GS). Additional funding was received by the Bundesministerium für Bildung und Forschung (project MASCARA), the ERC Synergy grant 4D Nanoscope, and the Emerging Fields Initiative MIRACLE of Friedrich-Alexander University Erlangen-Nürnberg. GC and FF were funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation)—493624887 (Clinician Scientist Program NOTICE).
Patient consent for publication
All patients provided informed consent before participation in the survey.
Ethics approval
The conduction of this study was approved by the ethics committee of the University Hospital of Erlangen.
Provenance and peer review
Not commissioned; externally peer reviewed.
Data availability statement
Data from this study can be requested from the corresponding author upon reasonable request.
Footnotes
Handling editor Gerd R. Burmester.
Editor Disclosure: The peer review process did not involve Editorial Board Member David Simon and Editorial Board Member Arnd Kleyer, and the editorial decision making was led by editors not involved in the creation of this manuscript.
Supplementary material associated with this article can be found in the online version at doi:10.1016/j.ero.2025.07.005.
Appendix. Supplementary materials
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data from this study can be requested from the corresponding author upon reasonable request.