CBD AND OPIOID USE FOR CHRONIC PAIN 1

The Effects of CBD and Opioid Use on Chronic Pain

Myriah Merten, Mitzie Martin, Caitlyn Howe, Hannah Hassett, Grayson Zinni

Bitonte College of Health and Human Services, Youngstown State University

NURS 3749: Nursing Research

Ms. Randi Heasley

April 09, 2023

CBD AND OPIOID USE FOR CHRONIC PAIN 2

The Effects of CBD and Opioid Use on Chronic Pain?

CBD and opioid use are effective ways to manage chronic pain. CBD is claimed to be a

nonpharmacologic, non-intoxicating, non-addictive substance that can relieve chronic pain,

whereas opioids are a group of medications that interact with receptors on cells within the body

that help alleviate the feeling of pain and replace it with feelings of pleasure. This mechanism of

action can be detrimental for specific populations predisposed to addiction, such as those

suffering from chronic pain. With the growing opioid crisis resulting in growing opioid

dependence, CBD has emerged as a non-pharmacological method of pain relief. Nurses must be

aware of the medication and supplemental use for chronic pain relief for proper nursing care.

They are responsible for educating and evaluating the effects of pain management.

PICO

This literature review explored ways to relieve chronic pain while considering the

benefits and disadvantages of each method. The following PICOT question was developed: “For

patients with chronic pain, how does the use of CBD as an alternative medicine benefit the

patient compared to traditional pharmacological methods?”

Search Strategy

Using EBSCOhost a search using the terms CBD or cannabinoids, and opioids or opiates,

and pain or pain management. The databases used were Health and Medicine (Gale OneFile),

Health Source: Nursing/Academic Edition (EBSCO), MEDLINE (PubMed), MEDLINE with

Full Text (EBSCO), and Nursing & Allied Health (Gale OneFile). The literature to be selected

had to be published between 2018-2023. Criteria for inclusion were also to be written in English,

as well as in peer-reviewed academic or E-journals. The initial search yielded 1,598 articles.

Abstracts and conclusions were reviewed to identify relevance to our topic. We refined our
CBD AND OPIOID USE FOR CHRONIC PAIN 3

search by adding the keywords chronic pain, and cancer or fibromyalgia or arthritis to further

specify different examples of chronic pain. This narrowed the search results to 794 articles.

Abstracts, conclusions, and titles were reviewed and resulted in the 11 articles used in this

literature review.

Literature Review

Four themes are outlined in the literature review that reflects the effects of CBD and

opioid use on chronic pain. These four themes include the benefits and disadvantages of both

CBD and opioids. Showing the differences between the use of alternative medicine and

pharmacological medicine for chronic pain.

Alternative Medicine: CBD

Benefits of CBD

Chronic pain is very prevalent around the world today. Many people often turn to opioids

and believe that is the only way to find relief. In the article “Evaluation of the effects of CBD

hemp extract on opioid use and quality of life indicators in chronic pain patients: a prospective

cohort study,” they introduce to their audience that CBD can work as an opioid and have fewer

complications than opioids. The study aims to see how effective CBD can be against chronic

pain. They sampled 131 patients from pain management centers aged anywhere from 30 to 65

years of age with chronic pain and who have been on opioids for at least one year (Capano,

2020). They were set to be checked four and eight weeks after being on CBD. After this study,

they found that over half of the patients decreased or eliminated their use of opioids within eight

weeks of starting CBD. Most patients had reported a better quality of life while on the CBD

hemp extract. This study shows CBD's significance for those suffering from chronic pain. Those

who have been on opioids for over a year were able to decrease their use after being on CBD for
CBD AND OPIOID USE FOR CHRONIC PAIN 4

two months. In addition to stopping their prescribed opioids, their quality of life and sleep

improved while being on CBD because of reduced pain. There is room for research regarding the

use of CBD early on in a pain management regime.

The article “Promising Health Benefits of Adjuvant Acmella and Zingiber Extracts

Combined with Coenzyme Q10 Phytosomes, Supplementation in Chronic Pain Treated with

Medical Cannabis: A Prospective and Open-Label Clinical Study” also shows the effects of CBD

with patients dealing with chronic pain. This article also states, “several drugs comprising of

medical cannabis are utilized for chronic pain relief” (Poli, 2022, p. 1) as well as improved sleep

and mental health. In this study, 48 participants on medical cannabis were given a “dietary

supplement, combining standardized extracts in phytosome (Mitidol), coenzyme Q10 phytosome

(Ubiqsome), and group B vitamins (B1, B6, and B12), twice daily for 90 days” (Poli, 2022, p. 1).

The pain intensity, quality of life, and mental well-being were measured, “by the visual analogue

scale (VAS), the pain type, and quality, evaluated by the Italian Pain Questionnaire” (Poli, 2022,

p. 1). The results showed that 70% of the subjects had significant pain alleviation and comfort–A

statistically significant reduction in pain as VAS mean was detected after three months

supplementation in 70.8% of subjects” (Poli, 2022, p. 3). Participants who implemented the

dietary CBD supplement had decreased pain from their chronic condition. The Q10 phytosome

showed to reduce stress from chronic pain and reduce inflammation. Many “subjects with

chronic inflammatory pathologies like rheumatoid arthritis benefited from the adjuvant

supplement” (Poli, 2022, p. 3). This CBD dietary supplement showed many positive results in

those who have chronic arthritis.

In the article “Cannabidiol (CBD) in Cancer Management,” O’Brien (2022) discusses the

use of CBD in cancer patients regarding the management of various afflictions caused by the
CBD AND OPIOID USE FOR CHRONIC PAIN 5

cancer treatment or the disease itself. A cross-sectional study of 926 cancer patients located in

Seattle found that over half of the participants had used cannabis previously, and a third had used

cannabis in the last year. The most common symptoms that cannabis was used to help alleviate

were “stress, anxiety and depression, poor sleep, nausea and vomiting (associated in particular

with chemotherapy), pain, neuropathy (e.g., associated with chemotherapy and radiation

therapy), oral mucositis (e.g., associated with chemotherapy and head/neck radiation therapy),

cancer-related fatigue, cachexia, and anorexia” (O’Brien, 2022). These factors contribute to an

individual's quality of life and pain perception.

In a majority of research that studies the relationship between pain relief and CBD in

cancer patients, a formulation that combines CBD and THC is used. One of these combinations

is called Nabiximols. O’Brien (2022) references a study in which 263 participants with late-stage

cancer or refractory opioid pain were given either a placebo or nabiximols. There was a reported

decrease in their daily level of pain. O’Brien (2022) references another study composed of 108

cancer patients that compared these formulations of CBD and THC, with the options being

dominantly THC, dominantly CBD, and a mix. There were generally no differences in pain

levels, but all were improved from the baseline.

Fibromyalgia is a chronic pain condition that causes those afflicted with widespread

musculoskeletal pain, fatigue, and trouble concentrating. A study by Boehnke et al. (2021)

examines the use of CBD in those dealing with the condition. They used a survey to collect data

from 878 participants, including socio-demographic information, preferred type of CBD, why

they are using CBD, and how many could use it as a substitute for other pain management

medications. Over 70 percent of participants reported that they could substitute their prescription

medications, most commonly opioids and NSAIDs, with CBD products.

CBD AND OPIOID USE FOR CHRONIC PAIN 6

This study is one of the first to directly examine the relationship between fibromyalgia

and CBD use. Many of the medications currently used for these individuals do not adequately

decrease their pain and often come with substantial side effects. Switching to CBD has helped

many study participants find an alternative that worked better for them in controlling their

condition. There were limitations to this study, however, as they were unable to control many

factors due to it being a survey. A more rigorous study on the relationship between fibromyalgia

and CBD could have considerable clinical significance.

There needs to be a push for CBD to treat/relieve chronic pain. Opioids are not the only

option, and many people believe that opioids are the only thing that will bring them relief. Those

who take CBD will not only have reduced pain but can also live their everyday life. Their quality

of life will improve, as shown in these studies, as well as their mental well-being. This will not

affect their lives like opioids. They will not have to depend on opioids to relieve their pain, just

implementing this CBD dietary supplement into their life.

Disadvantages of CBD

With the rise in public interest and usage of CBD, the question of safety, regulation, and

disadvantages comes to light. The research article “Content versus Label Claims in Cannabidiol

(CBD)-Containing Products Obtained from Commercial Outlets in the State of Mississippi”

found that most claims from product labels incorrectly reflect the actual CBD content analyzed.

This study utilizes 25 hemp oil products commercially available across Mississippi and applies

gas chromatography/flame ionization detection (GC/FID) to determine the amount of

tetrahydrocannabinol (THC) and CBD within the product. In addition to the GC/FID, full scan

gas chromatography/mass spectrometry (GC/MS) was utilized to detect the presence of synthetic

cannabinoids within the products. All products were purchased by the Mississippi Bureau of
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Narcotics officers to adhere to DEA regulations and guidance. Products were purchased from

retailers readily available to the public, including convenience stores, CBD shops, and health

food stores. (Gurley et al. p. 601)

The results of this study conclude that only 20 products made label claims for CBD, and

of those 20 products, only three were within ±20% of their CBD content claim. 13 of those

products contained less than 50% of their CBD content claim. Three products contained levels of

THC exceeding 0.3%, and one contained 45% THC with 0.3% being the legal limit of THC to be

within a product. Four of the 25 products were marketed as vaping liquids and found to contain

synthetic cannabinoids. After analysis of all 25 products, only two did not contain THC or

synthetic cannabinoids and were within ±20% of their label claims. The discussion following

explains the questionable quality of CBD products and the uncertainty surrounding their

regulation. Findings confirm that the majority of CBD products have discrepancies between the

label claims and the content of the products. The inaccurate contents of THC and the adulteration

of synthetic cannabinoids can pose a serious risk to consumers. The researchers and their

findings vouch for further development of regulations and manufacturing processes for CBD

products. (Gurley et al. p. 602)

An increase in real-world evidence (RWE) and clinical studies influencing healthcare

decisions was acknowledged for the research study titled “Cannabinoid Profiles in Medical

Cannabis Users: Effects of Age, Gender, Symptoms, and Duration of Use.” This observational

study aims to “describe patterns of medical cannabis use, associated changes in symptom

severity over time, and to evaluate change in cannabis dose over time for pain-related

symptoms” (Kalaba & Ware, 2022, para 1). 629 participants recorded data through an

application called Strainprint which is compliant with HIPAA, PIPEDA, and PHIPA.
CBD AND OPIOID USE FOR CHRONIC PAIN 8

Participants recorded the products used, the administration method, the dosage, and their

symptoms before and after cannabis use. The products used were categorized based on content

and documented as THC and CBD levels. The most frequently reported medical conditions

included back pain and chronic pain. (Kalaba & Ware, 2022)

Results found that CBD users showed an increase in dosage over time while THC users

showed less of an increase in comparison, suggesting tolerance. It also concluded that THC-

dominant products were often chosen for pain treatment, while CBD-dominant products were

often chosen for mental health conditions, suggesting that THC may be more effective than CBD

in treating or managing pain. Researchers explain that there is weak evidence for cannabinoids

being effective in managing symptoms, that a placebo effect may create a bias for those with

chronic conditions, and that there is a need for additional trials to examine the effects of these

products. It is also concluded in their research that only THC-dominant products provided a

statistically significant relationship between dose and effectiveness over time. This study

provides a basis for more research on the “safety, efficacy, pharmacokinetics, and therapeutic

indications for medical cannabis” (Kalaba & Ware, 2022, para. 38).

Pharmacological Medicine: Opioids

Benefits of Opioids

Chronic pain is becoming more common due to the aging population, and it is one of the

most common reasons people seek medical attention. Due to the uprising in the condition,

physicians commonly turn to pharmacological methods to relieve pain. In the research study,

"Comparative benefits and harms of individual opioids for chronic non-cancer pain: a systematic

review and network meta-analysis of randomized trials," it is found that opioids are effective in

managing chronic, non-cancer pain (Noori, 2021). This study used a network meta-analysis of
CBD AND OPIOID USE FOR CHRONIC PAIN 9

randomized controlled trials to compare the effects of various opioids on chronic non-cancer

pain. A total of 22,619 participants and 14 different opioids were utilized and closely monitored

over four weeks. Each participant was given a specific opioid or placebo and was monitored for

effects such as pain relief, physical function, vomiting, constipation, and nausea. It was reported

that opioids were more effective in pain relief than the placebo. Additionally, oxycodone,

fentanyl, and morphine were more effective in relieving pain and physical functioning than other

opioids. However, those who received the placebo reported fewer GI side effects than those who

received an opioid.

Because opioid use was proven successful in relieving pain, it also helps improve the

quality of life of those suffering from this symptom. This enables affected individuals to

participate in daily life activities and improve their overall well-being. Although the authors'

findings expressed successful results in relieving pain, they emphasized the need for careful

evaluation of the risks and benefits of opioid therapy before administration due to the possibility

of addiction, overdose, and other adverse effects.

In an article by Chapman et al. (2020) titled “Practice review: Evidence-based and

effective management of pain in patients with advanced cancer,” they looked at studies using a

scoping review approach to examine the current pain management recommendations for pain in

cancer patients. In patients with moderate to severe pain, a potent opioid is a suggestion, with

morphine often being the initial medication. If there is inadequate pain relief or undesirable side

effects, it is next suggested to switch opioids. Half of the patients who switch medications report

decreased side effects and better pain control. Patients with continual inadequately controlled

pain are often referred to palliative care at an earlier stage in their disease. Treatment with
CBD AND OPIOID USE FOR CHRONIC PAIN 10

palliative care leads to “Improved quality of life indicators” (Chapman et al., 2020, p. 5) with

more access to opioids.

Opioids can be used for various non-cancer chronic pain conditions such as neuropathic

and musculoskeletal pain. Neuropathic pain is defined as pain affecting the nervous system. It is

common for individuals with neuropathic pain to be prescribed an opioid to help manage their

chronic pain. In the research study, “Opioids for chronic non-cancer neuropathic pain. An

updated systematic review and meta-analysis of efficacy, tolerability, and safety in randomized

placebo-controlled studies of at least four weeks duration,” it was found that opioids are effective

in managing neuropathic pain. This study compared the effects of placebo and opioids on

individuals diagnosed with neuropathic pain conditions by analyzing randomized control trials

over four to twelve weeks. Participants were men and women of all ages with at least one

neuropathic pain condition for at least three months. There were eight different types of opioids

administered with a variety of doses. Out of 2,199 participants, it was concluded that most taking

opioids reported at least 50% pain relief after the study and reduced disability. Additionally, it

was found that those taking opioids improved their mood and mental health.

Opioid use for chronic pain is effective in pain relief as long as it is taken as prescribed.

Other benefits of opioids for chronic pain relief include the rapid onset of action, the long

duration of therapy, and accessibility. It is crucial to take opioids under the supervision of an

individual healthcare provider to monitor for adverse effects and dependency.

Disadvantages of Opioids

Pharmacotherapies, such as opioids, are widely used for the treatment of chronic pain. As

a vast portion of the population is battling with chronic pain daily, it is important to look at the
CBD AND OPIOID USE FOR CHRONIC PAIN 11

disadvantages of one of the biggest classes of chronic pain medications prescribed; opioids. The

research article “Swallowing the pill of adverse effects: A qualitative study of patients’ and

pharmacists’ experience and decision-making regarding the adverse effects of chronic pain

medications” examines both perspectives of chronic pain medication use in further depth. This

research study took place as 12 online focus groups (FG), consisting of 26 people battling

chronic pain daily, and 19 pharmacists. “Chronic pain is a major public health issue affecting one

in five adults in North America 1–3 and leading to significant negative impacts on patients' daily

living.3,4 Pharmacological therapies are prescribed to a majority of patients (62%–84%)”

(Dassieu et al., 2022, para 2). It is imperative to identify the relationship between the population

of those suffering from chronic pain, and those prescribed pharmacologic analgesics.

Important elements to examine in patients being treated are the quality of life using

opioid analgesics and the overall adverse effects of using opioids both short and long-term. It

was stated that the negative impacts or adverse effects in this study are defined as “any

unfavorable, unpleasant or harmful outcome following the intake of an analgesic drug or the

interaction between an analgesic drug and other medications” (Dassieu et al., 2022, para 6).

The first perspective involved is the pharmacists, as they are responsible for deciding if

the medication is of the appropriate indication on a person-by-person basis. This is so because

opioids can be an effective chronic pain reliever for some, but can be a detriment to others. There

are an abundance of facets to take into consideration when deciding if opioid analgesics are

appropriate drugs to prescribe to patients. Details noted by pharmacists about analgesic

candidates include: age and how the body tolerates drugs with increasing age, coexisting

conditions or diseases, polypharmacy, history of drug dependence, abuse or overdose, and the

desired lifestyle of the patient.

CBD AND OPIOID USE FOR CHRONIC PAIN 12

In some instances, the decision that has to be made by the provider becomes an ethical

predicament. If a patient in severe pain takes an opioid that may alter their alertness, balance, and

decision-making skills, but has to go to work- it turns into a safety issue. This person may cause

harm to himself or others due to altered alertness caused by an opioid. Now the issue becomes if

the prescriber stops prescribing the medication so the patient can lead their normal life without

any ailments caused by the medication, the patient would still be suffering from chronic pain. If

the prescriber continues to provide the medication, this potentially puts the patient or others at an

increased risk of bodily injury. If the prescriber tells the patient they are unable to work because

of the dangers it poses, this may cause financial stressors. Each one of these scenarios poses a

risk versus reward. Of course, the goal is to have the patient able to perform daily activities of

living with chronic pain at bay, however, repercussions may pose a larger threat. The

pharmacists in this study conclude that the quality of life of a patient living with some degree of

chronic pain poses a lesser threat than the adverse effects of some of the pharmacological

treatments used in the management of chronic pain. Some of the adverse effects that could be

detrimental to patients long term are: organ damage caused by long-term use of analgesic

opioids, bodily harm due to the altered alertness, and the result of dependence or abuse of these

substances.

The concentration of the patients enduring chronic pain lies more in relief. It can be noted

that the patient's in this study state that the benefit of being able to comfortably function in their

day-to-day lives matters more to them than the possible long-term consequences of utilizing

opioid analgesics. These patients often note some adverse effects but alleviate them by methods

such as altering their own doses of drugs. This is not a recommended method of solving adverse

effects, however, some patients are unwilling to forfeit the relief provided by the analgesics. By
CBD AND OPIOID USE FOR CHRONIC PAIN 13

taking these opioid analgesics other than prescribed, the patient risks experiencing opioid abuse,

overdose, dependence, and mortality.

The research article titled “Trends of Opioid Use Disorder Among Hospitalized Patients

With Chronic Pain” covers the topic of abuse and dependence on opioid analgesics in greater

detail. This National Inpatient Sample examines the correlation of opioid use disorder (OUD) in

patients managing chronic pain. It is identified that within the past decade, the incidence of OUD

in patients suffering from chronic pain rose exponentially. Orhurhu et al. (2019) state: “Between

2011 and 2015, approximately 10.3 million patients with chronic pain were identified. Of this

cohort, 680,631 were diagnosed with OUD”(para 12). Of the people affected by OUD, there

appears to be a trend among certain demographics. This study shows patients with a higher

affinity for acquiring OUD are those of white ethnicity, females, those in poverty, people using

tobacco, and people on Medicare Insurance (Orhurhu et al., 2019, para 1). With these numerical

increases and having such a large population of people at a higher risk of OUD, it is imperative

for providers to thoroughly educate patients, evaluate risk factors, and carefully evaluate if the

treatment plan is the most appropriate. (Orhurhu et al., 2019, para 24)

Conclusion

Chronic pain is a condition affecting millions of individuals due to various diseases and

ailments. While opioids have been the main way of treating chronic pain for decades and are

shown to help with pain management, dependency and addiction to these medications have been

on the rise. Side effects and the risk of overdose have left individuals to look for an alternative.

The rise in popularity of CBD has made it a prominent choice for many seeking a different route

than pharmacological methods. While CBD is less addictive than opioids and has helped some to

quit using their prescribed medications, it is not FDA-approved and lacks adequate regulation.
CBD AND OPIOID USE FOR CHRONIC PAIN 14

The stigma and laws around CBD and other cannabis products have made research difficult to

complete. As more states are changing their laws, it opens up more opportunities for in-depth

research to be done on cannabidiol.

CBD AND OPIOID USE FOR CHRONIC PAIN 15

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