By Mariano Garcia de Palau
Born in Barcelona, 17 February 1956. Graduated in medicine and surgery from the University of Barcelona in 1979. For 38 years has worked as an emergency physician in the area of occupational medicine. He became interested in cannabis by chance, and for the last 15 years has studied its therapeutic uses. He currently works at Kalapa Clinic, where he advises on treatments with cannabinoids, performs clinical work with patients and collaborates with different organisations and associations such as Catfac. He is a member of the Spanish Observatory for Medicinal Cannabis. He is a regular member of IACM.
Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease. It is characterised by affecting multiple joints simultaneously and by the presentation of diverse general non-specific symptoms and manifestations in other parts of the body. Without proper treatment, in its advanced phases, the disease can result in major physical limitations and a marked deterioration in quality of life.
RA is typically manifested through pain, swelling and stiffness or difficulty in moving different large and small joints. In some cases, the joints affected follow a characteristic pattern. The general symptoms, which sometimes precede manifestations of the disease in the joints and tend to persist throughout its development, basically include general tiredness, malaise, slight fever, loss of appetite and loss of weight. Extra-articular manifestations —which normally occur after the disease is fully established— mainly affect the skin, blood vessels, heart, lungs, eyes and blood.
RA is much more frequent among women than men and tends to appear in elderly patients, although it can begin at any stage of life and can affect anyone, regardless of race, sex or occupation.
The most frequent initial symptom is morning stiffness (especially in the joints of the hands and feet), experienced after night-time rest. This entails considerable difficulty in moving the joints accompanied by pain. Morning stiffness may be accompanied by tiredness, fever, loss of appetite and muscle weakness (which sometimes appear weeks or months before the pain) as well as indications of inflammation of the joints — swelling, warmth and redness of the affected joints.
The course of the disease varies greatly; in some people, advance of the lesions stops spontaneously, whereas in others it continues throughout their lives. In the most common scenario, the disorder develops over many years or throughout the patient’s entire life, alternating between periods of relative or complete calm and other periods –known as “flare-ups”– when symptoms are exacerbated. Flare-ups normally last a few weeks or even months.
During flare-ups, the joints affected become swollen and hot and are painful and difficult to move, especially on waking in the morning. Without proper treatment, these flare-ups tend to become more frequent and longer-lasting. As a result, the affected joints gradually lose mobility, with the appearance of very characteristic deformities which distinguish RA from other forms of arthritis. Without treatment, RA usually results in a significant deterioration in functionality and quality of life.
Treatment for RA consists of a series of general measures related to lifestyle, rest and exercise, combined with pharmacological therapy, in which a wide range of drugs may be used; in some cases, surgical intervention may be recommended. Unfortunately, there is still no cure for the disease. However, taken together, all the therapeutic measures currently available can alleviate the symptoms and improve the prognosis, with a very positive impact on the patient’s quality of life.
The best therapeutic results are achieved with early diagnosis and when treatment is established in the initial phases of the disease.
Autoimmune diseases constitute a major group of illnesses. For reasons that are not fully understood, the immune system, responsible for defending the body erroneously identifies certain tissues as being foreign and reacts against them as if they posed a threat.
Cannabinoids and rheumatoid arthritis
Cannabinoids such as THC and CBD can be useful for treating rheumatoid arthritis. RA is an autoimmune disease and we know that cannabinoids act by modulating the activity of the immune system. When the immune system over-reacts and its activity increases, autoimmune diseases may occur. The immune system erroneously identifies normal structures and tissues in the body as being foreign and rejects them. This is what happens after a transplant, and it is why immunosuppressant drugs are administered to prevent the tissue or organ from being attacked and destroyed by the patient’s own immune system.
Cannabinoids modulate the activity of the immune system. We know that the endocannabinoid system regulates activity of the immune system, and in autoimmune diseases, they have an immunosuppressive effect, reducing the activity of the system, and thus contributing to improvement in such pathologies.
Although cannabinoids are immunosuppressive, there is no evidence that already immunodepressed subjects (e.g. patients with HIV) suffer more opportunistic infections as a result of consuming cannabis. Indeed, cannabis is commonly used among HIV patients to alleviate symptoms, increase appetite and improve general quality of life.
Cannabinoids also have an analgesic effect which is mainly attributed to THC, but can be implemented by using different ratios of THC/CBD. By managing the relative proportions, it is possible to minimise the psychoactive effect of THC without reducing its analgesic effect.
In this way, the patient’s activity will not be limited by psychoactive effects (which many find unpleasant). In RA, the analgesic effect is very important, since the essential problem is inflammation, which causes varying degrees of pain, moderate or severe in some cases.
When working with RA patients, it is also important to treat the inflammation with the fewest possible side effects. We know that corticoids can be effective in acute phases of the disease. Nonsteroidal anti-inflammatory drugs, or NSAIDs (aspirin, ibuprofen, diclofenac, indometacin, etc.) can also be used. However, nearly all these drugs are gastrolesive and in the medium term can result in metabolic overload in the liver. In addition, they inhibit the action of THC when administered with it.
Lifetime treatment with corticoids or NSAIDs should therefore not be considered, given their side effects.
In analgesic doses, cannabinoids have never posed a metabolic problem in the liver, which is where they too are metabolised. Similarly, no problem of renal excretion or toxicity has ever been detected with such treatments.
Patients suffering chronic pain may also suffer sleep alteration. In the case of RA, nocturnal pain may also prevent proper rest and the structuring of the different sleep phases. The result is that sleep is non-restorative. Cannabinoids can be of use in improving sleep quality. By using THC and CBD, it is possible to induce sleep quite effectively, determining the night-time dose with different proportions of THC/CBD.
Proper rest is very important and for many patients, it is the first problem that needs to be addressed. Without restorative rest, little improvement can be expected in the other symptoms.
Appetite loss can also be a problem for many patients. Small doses of THC administered half an hour before meals increase appetite and ensure the patient does not suffer pathological weight loss. For some patients, THC/CBD treatment improves appetite. However, in some cases, it may be necessary to resort to THC on its own, administered before meals.
Because the doses of THC involved are low (around 5 mg), there is no limiting psychoactive effect, given that CBD is also being taken, which minimises any such effect.
Mood alteration is another issue for some people with RA, a chronic autoimmune disease, for which treatments are currently only available for the symptoms (pain and inflammation), but not the underlying cause. In such cases, the anxiolytic and anti-depressant effect of CBD may be very useful.
One of the great advantages of using cannabinoids is that many different symptoms can be treated with the same family of molecules. This aids better tolerance and makes management easier for the doctor as well.
Because of their low toxicity, cannabinoids have no potentially serious toxic side effects. This is another reason why they may be very useful for RA patients. Nonetheless, it should be noted that, the results of studies in this area with RA patients have not been as satisfactory as hoped, although they have been very positive for some patients. It is also important to remember that treatment may require therapeutic tools, as well as pharmaceuticals.
Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease. It is characterised by affecting multiple joints simultaneously and by the presentation of diverse general non-specific symptoms and manifestations in other parts of the body. Without proper treatment, in its advanced phases, the disease can result in major physical limitations and a marked deterioration
Medical Marijuana and Rheumatoid Arthritis: Pros and Cons of the Different Delivery Systems
Research is lacking, but some proponents say the effectiveness of medicinal cannabis treatments may vary in terms of RA joint pain. Which, if any, ones should you consider?
When it comes to medical marijuana, there are many more questions than answers. Even if you’ve discussed trying it for joint pain with your doctor — and gotten your documentation, and it is legal in your state — there’s still the issue of how to take it.
If you live in one of the 29 states that has decriminalized the use of marijuana for the treatment of certain medical problems, there are a lot of pain-relieving treatment options you haven’t heard much about. “Cannabis can be used as medicine in many ways, though not all types are equally effective,” says Jordan Tishler, MD, chief medical officer of InhaleMD, a holistic medical practice in the Boston area. “Low doses are also more effective and have fewer side effects, including intoxication,” he says, adding that in his opinion, cannabis can provide pain relief and an anti-inflammatory effect.
What Is the Best Way to Use Cannabis When You Have RA?
If you’re considering using cannabis for pain relief, you might be wondering how to take it. According to proponents, the delivery methods — that is, the ways in which one can use cannabis — don’t necessarily work equally. The delivery method you should use depends on your needs and what’s available to you. Here are the most common medicinal forms of marijuana, and the potential benefits and downsides of each.
Have dietary changes helped you manage your RA? Tip it forward and share with others!
Potential Pros and Cons of 7 Marijuana Delivery Methods for People With RA
1. Topical Ointments
Pros: They don’t make you high, and you get fairly immediate pain relief in a targeted area — like painful joints or low-back pain — for a couple of hours.
Cons: Some people complain of the odor, and the effects don’t last as long as inhaling or ingesting it. Tishler doesn’t believe that they’re worth the money; in his experience, they “seldom work as advertised.”
The Verdict: “The huge advantage here is that you don’t have any psychoactive effect,” says Rav Ivker, DO, a holistic family physician in Boulder, Colorado and author of Cannabis for Chronic Pain: A Proven Prescription for Using Marijuana to Relieve Your Pain and Heal Your Life. “I have seen very few downsides with the topicals. The effects have a short duration, but when it wears off, you can just apply the ointment again.” Dr. Ivker is a fan of pain-relieving creams that contain a combination of CBD — one of the active cannabinoids in marijuana — and arnica.
2. Pills and Capsules
Pros: Dosage is consistent, it doesn’t require inhaling, and the pain-relieving effects can last for up to eight hours.
Cons: They can be expensive, and sometimes the medicinal effect doesn’t take place until an hour or two after ingesting it. “But cannabis is fat soluable, and it can be absorbed more quickly if you ingest it with a fatty food,” says Ivker.
The Verdict: Pills and capsules may be the most consistent delivery system. “I like these primarily because of the consistent dosing,” notes Ivker. “Tablets and capsules last a long time like an edible, but you know exactly how much medicine you’re getting every time you do it.”
Pros: They are odorless, involve no smoke or vapor, and are easy to administer. And the medicinal effects can last up to eight hours. “This is good if your pain is constant and severe,” says Dr. Tishler. You can find medical marijuana candy, such as gummy chews.
Cons: They affect everyone differently, and the THC isn’t usually evenly distributed throughout the product. In other words, you can eat the same-size piece of an edible two days in a row and have a very different effect. Plus, there’s the calories.
The Verdict: “I don’t like edibles because they are way too inconsistent,” says Ivker. “If we talk about marijuana as a medicine, you need to be able to depend on it doing what it’s supposed to do. Most of the patients that I have worked with have had a previous bad experience with an edible.”
4. Transdermal Patches
Pros: Transdermal patches are adhesive patches containing cannabinoids. The medication is absorbed through the skin and enters the bloodstream, affecting the entire body. The effect lasts for a long time. It delivers slow release, long-duration, pain-relieving cannabis into the bloodstream without the need for ingesting or inhaling it.
Cons: This is one of the most expensive delivery systems, and isn’t as effective for severe pain as other medical marijuana options, says Ivker.
The Verdict: “The cannabinoids in patches are absorbed within a half an hour, and if you don’t want to feel the effect anymore, you can peel off an adhesive patch and the effect will dissipate,” says Ivker. “And if you only have it on for a short time, you can use it again.”
Pros: It’s nearly odorless, easier on the lungs than smoking, and has an immediate medicinal effect. “Vaporizers are like miniature ovens,” says Ivker. “You are basically cooking. The ideal temperature for most vaporizers is 375 degrees, just like your oven. It heats the plant and you inhale a vapor, and it provides relief within two to three minutes, just like smoking it does.”
Cons: The best kind of vaporizing machines — those that use the plant and not a fluid — can be pricey (between $250 and $300). And vaporizers that use oil cartridges get very hot, which can be irritating to the throat and lungs.
The Verdict: “I recommend vaping to my patients,” says Ivker. Adds Tishler: “Vaporizing cannabis flower (not concentrates) produces little to none of the dangerous chemicals associated with tobacco smoke, so it is likely safer than smoking.”
Pros: These liquids, usually administered with a dropper, have historical gravitas, since “through the first three decades of the 20 th century, tinctures were the only method of administration of medicinal cannabis in this country,” says Ivker. It is also easier for the user to experiment and determine the exact dosage that works best for their individual symptoms. And the pain-relieving effects last twice as long as inhaling, with none of the lung irritation.
Cons: The effect is not as immediate as inhaling; it can take as long as 45 minutes for the effects to kick in. Tishler doesn’t believe that they’re worth the money, either; as with the ointments, in his experience, they also “seldom work as advertised.”
The Verdict: While some people swear by tinctures, others don’t. Many argue that tinctures provide consistent and individualized dosing. “When you prescribe a prescription drug, you’re just guessing on the dosage. But here you can determine exactly how much works well for you,” says Ivker. He suggests starting by taking four or five drops under the tongue and waiting an hour to see how you feel. If after an hour and a half you don’t feel relief, you can take more.
7. Smoking a Joint or Pipe
Pros: It’s easy to get access to it, less expensive than other medical marijuana delivery systems, and inhaling cannabis has an immediate pain-relieving effect.
Cons: “It’s the most unhealthy method of administration because it irritates the respiratory tract, and smoke contains toxins that contribute to more inflammation throughout the body,” says Ivker.
Smoking is a risk for many diseases, including heart and lung disease. Women with rheumatoid arthritis already face an increased risk for progressive lung diseases, such as emphysema; any type of smoke is especially problematic for people with RA.
Another downside is that the duration of action is short, usually only two or three hours.
The Verdict: “It’s the most popular delivery system, but I discourage people from doing it,” says Ivker. Tishler agrees that any risks outweigh benefits for people with RA. “Cannabis smoke contains many of the same carcinogens and poisonous gases as tobacco smoke. There is every reason to believe that it would be just as harmful.”
Tishler notes that while studies have suggested there aren’t any irreversible negative effects of smoking cannabis, they are inconclusive. Don’t smoke, period.
Rheumatoid arthritis pain may be lessened by marijuana, but not all delivery methods are equal. Learn about the best and worst way to use medical marijuana to help ease RA pain.