Acupuncture

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Author: SCIRE Community Team | Reviewer: Amrit Dhaliwal | Published: 5 July 2019 | Updated: ~

Acupuncture is a common complementary therapy used for various symptoms and conditions. This page outlines what acupuncture and dry needling are and their uses after spinal cord injury (SCI).

Key Points

  • Acupuncture is a treatment where small thin needles are inserted into specific points on the body to treat health conditions. Acupuncture is a complementary and alternative medicine treatment based on traditional Chinese medicine.
  • Acupuncture has been studied as a treatment for pain, bladder problems, and to aid functional recovery after SCI.
  • Scientists are not entirely sure how acupuncture might work. Its effects on pain, bladder function, and functional recovery after SCI are likely related to influences on the nervous system and/or circulation.
  • Overall, there is moderate evidence suggesting that acupuncture (including electroacupuncture) may be effective for treating neuropathic pain and bladder problems after SCI; and may aid functional recovery after SCI. The evidence for treating shoulder pain is unclear. Further studies are needed to confirm these findings.
Thin acupuncture needle inserted into cloth.

Acupuncture needles are thin needles that are inserted into acupuncture points on the body.1

Acupuncture is a complementary and alternative medicine (CAM) practice that has been used for thousands of years as a component of traditional Chinese medicine (TCM). Acupuncture involves the insertion of small thin needles into specific points on the body called acupuncture points or acupoints.

Acupuncture is used to treat many different symptoms and conditions. For people with SCI, acupuncture is used to treat pain, manage bladder problems, and possibly aid functional recovery.

 

Dry needling

Dry needling, also known as intramuscular stimulation (IMS), involves the use of similar thin needles that are inserted into trigger points. Trigger points are tight, irritable bands in the muscles and fascia that are a common cause of musculoskeletal pain. Dry needling typically elicits a small muscle twitch that may help to reduce muscle tension. Acupuncture and dry needling differ in both the theories that underlie their use and in how they are practiced.

Acupuncture is performed by health providers such as physiotherapists, physicians, chiropractors, and acupuncturists. In many regions, health providers need special training and a license to practice acupuncture.

Before the treatment

If you are considering trying an acupuncture treatment, it is important to discuss with your health providers to make sure that acupuncture is safe for you. Before starting a treatment, your health provider will perform an assessment and provide information about the treatment, its risks, and any other information you need to decide whether to proceed with an acupuncture treatment.

During the treatment

Person's lower leg with several acupuncture needles inserted into the skin

Acupuncture points are located at very specific points on the body.2

Acupuncture needles are thin, single-use, sterile needles that are solid and cannot be used to inject or withdraw fluids from the body. The needles are inserted into the surface of the skin at locations called acupuncture points. Acupuncture points are specific points on the body that are thought to influence the body systems. When the needles are inserted into the skin, they can cause minimal pain and/or bleeding.

Once the acupuncture needles are inserted, they may be left in for a specific amount of time determined by the therapist (usually 20 minutes or longer) before removal. Your response will be monitored during and after the treatment. While the needles are inserted, some practitioners choose to twist or shallowly plunge the needles into the skin or apply other stimulation in the form of heat or electricity to the needles. Acupuncture treatments are usually scheduled anywhere from a few days to a week apart.

Traditional Chinese medicine explanation

ancient illustration of man with acupuncture meridian labelled on his body

Ancient illustration of the acupuncture meridians based on Traditional Chinese Medicine.3

Traditional Chinese medicine (TCM) is based on the belief that illness happens because of imbalances in energy flow in the body. This energy flow is known as Qi (pronounced ‘chee’) and is thought to flow along lines of energy in the body called meridians. Traditional acupuncture points are located where these lines are believed to pass close to the surface of the skin. Thus, stimulating acupuncture points with needles is thought to promote balance of the body’s energy and treat health conditions.

Modern explanations

Traditional explanations for how acupuncture works do not align well with modern science. Scientists are not entirely sure how acupuncture might work, but its effects are likely related to influences on the nervous system and/or circulation.

Pain

Scientists have proposed several possible explanations for how acupuncture could work to reduce pain:

  • By blocking pain from traveling in the nerves
  • By causing the body to release substances that prevent pain (such as endorphins)
  • By altering blood circulation in important areas of the body
Bladder problems

Acupuncture may affect bladder function by influencing nerve signals or control centers for urination in the brain and spinal cord.

Functional recovery

Acupuncture has been proposed as a treatment to improve recovery of function after SCI. This is not well understood, but some scientists have proposed that it may be related to reducing damage caused by the after-effects of the injury.

There are certain situations in which acupuncture may not be safe to use. This is not a complete list; please consult a health provider for detailed safety information before using this treatment.

Acupuncture should be used with caution in the following situations:

Hand inserting a thin acupuncture needle into another person's arm.

It is important to consider whether acupuncture will be safe for you.4

  • By certain groups of people, such as children, pregnant women, and people with medical conditions (such as heart conditions, osteoporosis, or weakened immune systems)
  • Near major organs (such as certain places on the torso or neck)
  • By people who are prone to fainting or have a fear of needles
  • By people who are prone to autonomic dysreflexia
  • By people who are at risk of bleeding (including people taking anticoagulants)
  • By people who are unable to follow instructions or provide accurate feedback

Acupuncture should not be used in the following situations:

  • By people with metal allergies
  • In areas with open, infected, inflamed skin or recent surgery
  • Near tumors

Even for people who are not restricted from using acupuncture (see above), there may be risks and side effects with the use of this treatment. The common side effects of acupuncture are usually mild and serious complications are rare. However, it is important to discuss these possibilities in detail with your health provider before using this treatment.

Common risks and side effects of acupuncture may include:

  • Bruising, bleeding, and skin irritation
  • Nausea, vomiting, and diarrhea
  • Headaches
  • Sweating
  • Dizziness and fainting
  • Worsening of symptoms (like increased pain or muscles spasms)

For people with SCI (especially those with injuries above the level of T6), acupuncture needles may be a cause of irritation to the body if they are placed below the level of injury. This could increase the risk of autonomic dysreflexia in some people.

Rare complications of acupuncture may include:

  • Puncture of the lung (pneumothorax) or other internal organs
  • Nerve injury
  • Infection or spread of infectious diseases (such as Hepatitis B)
  • Needles breaking after they are inserted and becoming embedded in the skin
  • Convulsions

Many of the rare complications of acupuncture can result from improper acupuncture technique. Technique is a very important part of ensuring safety, and there can be major risks if acupuncture is performed incorrectly. For example, improper needle placement and not using properly sterilized needles or sterile technique can put a person at risk of complications. Because of these risks, it is important that acupuncture is only performed by a trained health provider.

Acupuncture for pain after SCI

White computer generated figure with a red spot representing pain over their back.

Acupuncture is a common alternative treatment for pain, although research is currently limited.5

Research has studied acupuncture for the treatment of several different types of pain after SCI, including neuropathic pain and shoulder pain.

Shoulder pain

The evidence is unclear about whether acupuncture helps to reduce shoulder pain after SCI. Two studies have compared acupuncture to other treatments, including a sham treatment and a movement therapy called Trager therapy. Although both of these studies found that acupuncture helped with shoulder pain after SCI, it was not more effective than the comparison treatments. Further research is needed to determine effectiveness.

Neuropathic pain

Moderate evidence from three studies suggests that acupuncture may reduce neuropathic pain after SCI. However, two of these studies were low quality so further research is needed to confirm this.

Acupuncture for bladder problems after SCI

Three studies have studied acupuncture as a treatment for bladder problems after SCI. These studies provide moderate evidence that electroacupuncture used together with conventional therapies may help people with SCI to develop effective bladder management earlier after injury.

Another small study provides weak evidence that regular needle acupuncture may help with bladder incontinence caused by hyperreflexic bladder.

Acupuncture for improving functional recovery after SCI

One study has investigated acupuncture for improving functional recovery after SCI. It provides moderate evidence that acupuncture helps to improve functional recovery early after SCI. However, other researchers have debated the quality of the study and whether its conclusions were accurate. More studies are needed to confirm whether acupuncture has any effects on the recovery of function after SCI.

Overall, there is moderate evidence suggesting that acupuncture (including electroacupuncture) may be effective for treating neuropathic pain, bladder problems, and possibly for improving functional recovery after SCI. The evidence for shoulder pain is unclear. Further studies are needed to confirm these findings.

There have not been any studies on whether dry needling is effective for treating people with SCI.

Acupuncture needs to be used with caution in certain situations, but overall is a safe treatment when performed by a trained practitioner. Until more research is done, it is best to discuss this treatment with your health provider to find out more about if it is a suitable treatment option for you.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Parts of this page has been adapted from SCIRE Project (Professional) “Pain Management”, “Bladder Management”, and “Upper Limb” Chapters:

Mehta S, Teasell RW, Loh E, Short C, Wolfe DL, Hsieh JTC (2014). Pain Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-79.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/pain-management/

Hsieh J, McIntyre A, Iruthayarajah J, Loh E, Ethans K, Mehta S, Wolfe D, Teasell R. (2014). Bladder Management Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-196.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/bladder-management/

Connolly SJ, McIntyre A, Mehta, S, Foulon BL, Teasell RW. (2014). Upper Limb Rehabilitation Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-77.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/upper-limb/

Evidence for “Acupuncture for pain after SCI” is based on:

Shoulder pain

[1] Dyson-Hudson TA, Shiflett SC, Kirshblum SC, Bowen JE, Druin EL. Acupuncture and trager psychophysical integration in the treatment of wheelchair user’s shoulder pain in individuals with spinal cord injury. Arch Phys Med Rehab 2001;82:1038-46.

[2] Dyson-Hudson TA, Kadar P, LaFountaine M, Emmons R, Kirshblum SC, Tulsky D et al. Acupuncture for chronic shoulder pain in persons with spinal cord injury: a small-scale clinical trial. Arch Phys Med Rehab 2007;88:1276-83.

Neuropathic pain

[1] Norrbrink C, Lundeberg T. Acupuncture and massage therapy for neuropathic pain following spinal cord injury: An exploratory study. Acupunc Med 2011;29:108-15.

[2] Rapson LM, Wells N, Pepper J, Majid N, Boon H. Acupuncture as a promising treatment for below-level central neuropathic pain: A retrospective study. J Spinal Cord Med 2003;26:21-6.

[3] Nayak S, Shiflett SC, Schoenberger NE, Agostinelli S, Kirshblum S, Averill A et al. Is acupuncture effective in treating chronic pain after spinal cord injury? Arch Phys Med Rehab 2001;82:1578-86.

References for Acupuncture for bladder problems after SCI:

[1] Cheng P-T, Wong M-K, Chang P-L. A therapeutic trial of acupuncture in neurogenic bladder of spinal cord injured patients-A preliminary report. Spinal Cord 1998;36(7):476-480.

[2] Honjo H, Naya Y, Ukimura O, Kojima M, Miki T. Acupuncture on clinical symptoms and urodynamic measurements in spinal-cord-injured patients with detrusor hyperreflexia. Urol Int. 2000;65(4):190-5.

[3] Liu Z, Wang W, Wu J, Zhou K, Liu B. Electroacupuncture improves bladder and bowel function in patients with traumatic spinal cord injury: results from a prospective observational study. Evid Based Complement Alternat Med. 2013;2013:543174

[4] Gu XD, Wang J, Yu P, Li JH, Yao YH, Fu JM, Wang ZL, Zeng M, Li L, Shi M, Pan WP. Effects of electroacupuncture combined with clean intermittent catheterization on urinary retention after spinal cord injury: a single blind randomized controlled clinical trial. Int J Clin Exp Med. 2015 Oct 15;8(10):19757-63.

References for Acupuncture for functional recovery after SCI:

[1] Wong AM, Leong CP, Su TY, Yu SW, Tsai WC, Chen CP. Clinical trial of acupuncture for patients with spinal cord injuries. Am J Phys Med Rehabil. 2003 Jan;82(1):21-7.

Other references:

Ma R, Liu X, Clark J, Williams GM, Doi SA. The Impact of Acupuncture on Neurological Recovery in Spinal Cord Injury: A Systematic Review and Meta-Analysis. J Neurotrauma. 2015 Dec 15;32(24):1943-57.

Dorsher PT, McIntosh PM. Acupuncture’s Effects in Treating the Sequelae of Acute and Chronic Spinal Cord Injuries: A Review of Allopathic and Traditional Chinese Medicine Literature. Evid Based Complement Alternat Med. 2011;2011:428108.

Wang J, Zhai Y, Wu J, Zhao S, Zhou J, Liu Z. Acupuncture for Chronic Urinary Retention due to Spinal Cord Injury: A Systematic Review. Evid Based Complement Alternat Med. 2016;2016:9245186.

Shin BC, Lee MS, Kong JC, Jang I, Park JJ. Acupuncture for spinal cord injury survivors in Chinese literature: a systematic review. Complement Ther Med. 2009 Oct-Dec;17(5-6):316-27.

NIH consensus conference. Acupunc JAMA 1998;280:1518-24.

Pomeran ZB. Scientific basis of acupuncture. In: Stux G, Pomeran (Eds.). Basis of acupuncture (pp. 6-72). 4 Rev Ed. Springh-Verlag. 1998.

Wong JY, Rapson LM. Acupuncture in the management of pain of musculoskeletal and neurologic origin. Phys Med Rehab Clin North Am 1999;10:531-45.

Zhang T, Liu H, Liu Z, Wang L. Acupuncture for neurogenic bladder due to spinal cord injury: a systematic review protocol. BMJ Open. 2014 Sep 10;4(9):e006249.

Lee MHM, Liao SJ. Acupuncture in physiatry, in Kottke FJ, Lehmann JF (eds). Krusens Handbook of Physical Medicine and Rehabilitation, ed. 4. Philadelphia: Saunders 1990:402-32.

Chung A, Bui L, Mills, E. Adverse effects of acupuncture. Which are clinically significant? Canadian Family Physician. 2003;49:985–989.

White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med. 2004 Sep;22(3):122-33.

Ansari NN, Naghdi S, Fakhari Z, Radinmehr H, Hasson S. Dry needling for the treatment of poststroke muscle spasticity: a prospective case report. NeuroRehabilitation. 2015;36(1):61-5.

Salom-Moreno J, Sánchez-Mila Z, Ortega-Santiago R, Palacios-Ceña M, Truyol-Domínguez S, Fernández-de-las-Peñas C. Changes in spasticity, widespread pressure pain sensitivity, and baropodometry after the application of dry needling in patients who have had a stroke: a randomized controlled trial. J Manipulative Physiol Ther. 2014 Oct;37(8):569-79.

Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014 Aug;19(4):252-265.

Averill A, Cotter AC, Nayak S, Matheis RJ, Shiflett SC. Blood pressure response to acupuncture in a population at risk for autonomic dysreflexia. Arch Phys Med Rehabil. 2000 Nov;81(11):1494-7.

Gattie E, Cleland JA, Snodgrass S. The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther. 2017 Mar;47(3):133-149.

 

Image credits:

  1. ‘Acupuncture’, ©Magali M , CC BY-NC-ND 2.0
  2. By thepismire, ‘her handiwork’, CC BY-NC-ND 2.0
  3. Acupuncture meridian illustration: This image is in the public domain in its country of origin and other countries, and is identified as being free of known restrictions under copyright law, including all related and neighboring rights.
  4. Acupuncture on an arm: Released into the public domain (by the author). There is no copyright associated with this file, and the website has released all ownership to the public domain.
  5. Stock image of back pain, ©3dman_eu, CC0.

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Cannabis (Marijuana) and Cannabinoids

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Authors: SCIRE Community Team | Reviewer: Andrea Townson and Janice Eng | Published: 2 April 2019 | Updated: Apr 20, 2020

Cannabis (marijuana) is an alternative treatment option for pain and spasticity after spinal cord injury (SCI). This page outlines basic information about cannabis and its use after SCI.

Key Points

  • “Cannabis” refers to products derived from the cannabis plant, such as marijuana. The natural cannabinoids or compounds found in cannabis can also be made synthetically.
  • Cannabis may be inhaled as a smoke or vapour or taken by mouth as a capsule or spray.
  • Smoking cannabis is not recommended due to the risks associated with inhaling smoke.
  • The safety of cannabis products for use after SCI is not known. Please consult your health providers for detailed safety information.
  • Research on cannabis use after SCI is in its early stages. Studies done so far show that cannabis products may have beneficial effects on pain and are unclear about its effects on spasticity. More research is needed to establish if cannabis is a safe and effective treatment after SCI.
A photograph of leaves of a cannabis plant

Leaves of a cannabis plant.1

Cannabis is a term that refers to the products of cannabis (hemp) plants, a group of plants from central Asia that are now cultivated around the world. Cannabis sativa, Cannabis indica, and Cannabis ruderalis are three well-known types of cannabis, but many strains or varieties exist, both pure and hybrid types. Common preparations of cannabis include marijuana, which is the dried leaves and flowering tops of the plant, and hashish, which is its condensed resin. Cannabis has been used for thousands of years as a medicine and recreational drug.

Currently, cannabis is a controlled substance in most regions because of its psychoactive effects. However, exceptions are made in some places for approved medical or spiritual uses. In addition to medical use, in Canada recreational use of cannabis has also been made legal as of October 2018. Here, the sale of recreational cannabis was originally limited to dried cannabis and oils, but as of October 2019 edibles and concentrates are also legal for sale.

Cannabis has been studied as a treatment for conditions as diverse as nausea associated with cancer chemotherapy, loss of appetite in people with HIV, and spasticity associated with multiple sclerosis.

Cannabis has its unique properties because of naturally-occurring chemical compounds within the plant called cannabinoids. Cannabinoids act on receptors on the surface of cells called cannabinoid receptors, causing effects on body processes like pain, memory, appetite, and immune responses.

Diagram categorizing cannabinoids into endocannabinoids (produced in the body), phytocannabinoids (produced by the cannabis plant), and synthetic cannabinoids (synthesized in a lab)

There are various sources of cannabinoids, both natural and synthetic.2

Cannabinoids occur naturally within the body (endocannabinoids), in cannabis plants (phytocannabinoids), and can also be synthesized in a lab (synthetic cannabinoids). There are more than 60 cannabinoids present in cannabis, with the most well-known being Delta-9-tetrahydrocannabinol (commonly known as THC), which is responsible for many of the psychoactive effects for which cannabis is known such as creating a “high” or sense of euphoria. Other cannabinoids, like Cannabidiol (also known as CBD), are not psychoactive and may have different effects such as improving mental health concerns and preventing oxidative damage although evidence for this is currently not conclusive. Because of these benefits over THC as well as the reduced health risks, CBD is believed to be the component of cannabis that gives rise to its medicinal potential and opposes the negative psychiatric effects associated with THC.

The chemical structures of THC and CBD

The chemical structures of THC and CBD.3

Cannabis/Cannabinoids, whether plant-derived or human-made, may be used for medicinal or recreational purposes in a variety of ways.

Medical cannabinoid products

Medical cannabis

The laws and regulations required to get approval for medical marijuana differ by country and region. In Canada, use of medical cannabis requires authorization for use from a physician.

Prescription synthetic cannabinoids

In some countries, certain synthetic cannabinoids are available for therapeutic use and require a prescription from a physician. Like other medications, these products are registered with a Drug Identification Number (DIN) in Canada or with the Food and Drug Administration (FDA) in the United States. Prescription synthetic cannabinoids are carefully regulated and monitored for their composition and effects on the body and are developed to minimize accompanying intoxication.

Recreational cannabis products

An indoor grow op with rows of cannabis plants in pots.

There are various environmental and health risks associated with unlicensed grow-ops.4

Recreational use of cannabis is legal in Canada, but still subject to provincial or territorial restrictions. Recreational use outside these restrictions is illegal. Like medical cannabis, the production and distribution of recreational cannabis is regulated to ensure safety and quality. There are various concerns with the use of cannabis that is not regulated or produced legally. These cannabis products may include harmful contaminants (e.g., mold, bacteria, and pesticides) or have much greater variation in their chemical composition than cannabis products intended for medical use. It can be difficult to know exactly what dose you are receiving and the risks and side effects for using these products may be unknown. Another issue with cannabis sourced from illegal grow-ops include its negative impact on the environment as these sites may misuse toxic pesticides and may divert water supply away from lakes or rivers, threatening plant, wildlife, and human health. Unregulated cannabis products are not recommended for treating symptoms of SCI.

Illegal synthetic cannabinoids

A hand holding a jar of synthetic cannabinoids mixed with shredded cannabis plant material.

Illegal synthetic cannabinoids may be sold to look like cannabis.5

Even though synthetic cannabinoids act on the same receptors as the phytocannabinoids found in the cannabis plant, they may produce different effects on the body. Some non-prescription synthetic cannabinoids are made to imitate the psychoactive effects of THC, making them potentially dangerous especially since their actions on the body can be unpredictable. Known by names like “Spice” and “K2,” these compounds are often combined with plant-based products and sold as “alternatives” to marijuana. However, all activities associated with non-prescription synthetic cannabinoids (e.g., production, distribution, use) are illegal in Canada. Besides the fact that illegal synthetic cannabinoids have not been tested in humans, their product composition can vary greatly and may be laced with other unknown and potentially deadly substances. Synthetic cannabinoids also more potent than plant-derived THC. This means that they bind more strongly to the cannabinoid receptors, increasing the risk of overdose.

Cartoon image showing different dosage forms of cannabis (vape pen, capsules, cream, and oil).

Photograph of a female smoking a joint.

Smoking is not a recommended method of using cannabis.10

Cannabis products are usually inhaled or taken by mouth. Smoking is the most common method among the general population as well as within the SCI population. However, there are serious concerns about the negative health effects to the user and those nearby associated with inhaling and exhaling smoke, which contains many of the same harmful compounds as tobacco smoke. People with SCI, in particular, should avoid smoking cannabis as respiratory issues including compromised breathing and pneumonia are already prevalent in the SCI population. Vaporization is another method where the cannabis leaves are heated to form a vapour that is then inhaled. While vaping prevents the cannabinoids from burning which decreases the amount of toxic by-products produced compared to smoking, it is not without risks and has recently been associated with vaping-associated pulmonary injury (VAPI). After a sharp increase in VAPI cases in August and September of 2019, emergency department visits continue to decline. This is thought to be due to the removal of vitamin E acetate from most products, increased public awareness of the risks associated with THC containing e-cigarettes or vaping devices, and law enforcement actions related to illicit products in the US. Canadian extracts for vaping that contain THC are not allowed to have any added vitamins, minerals, nicotine, sugars, flavouring or colouring agents.

Cannabis can also be taken by mouth in the form of food items or other products like oils, capsules, and mouth sprays. Other less common methods cannabis may be delivered include through the skin (e.g. creams, lotions, balms, patches, etc.), through the rectum, or into the veins


A bottle of CBD oil with a dropper above.

Cannabis can be prepared by extracting the cannabinoids from the plant and dissolving it in oil.11

Cannabidiol oil

CBD oil is becoming more popular among people who wish to gain the health benefits of cannabis and avoid the psychoactive effects of THC. Although many people use CBD oil for a range of ailments, there is limited safety and efficacy data (and no research in SCI) to support its use for these conditions. Recently, positive results from three clinical trials with strong evidence have led the Food and Drug Administration (FDA) in the United States to approve the use of CBD oil for two rare forms of epilepsy in June 2018.

Prescription synthetic cannabinoids

Prescription synthetic cannabinoids often use isolated cannabinoid compounds or combinations of cannabinoids. This includes products such as:

  • Nabilone (Cesamet), a synthetic cannabinoid similar to THC that is taken by mouth as a capsule.
  • Dronabinol (Marinol), synthetic THC that is taken by mouth as a capsule. Please note that dronabinol is no longer available in Canada.
  • Nabiximols (Sativex), a mix of cannabis plant-derived THC and CBD that is taken as a mouth spray.
A jar of dried marijuana including the flowers and leaves.

Marijuana is the dried flowers and leaves of cannabis.12

There are currently no standard cannabis dosing regimens for SCI-related conditions. Dosing for medical cannabis varies based on factors such as method of delivery, past cannabis use, and the medical condition being treated. Additionally, the amount of THC and CBD in marijuana is not always the same. Thus, the effects of different marijuana products are not always the same. Levels of THC and CBD in a product can change based on the strain of the plant used as well as how the plant was grown and prepared.

Especially for those who have never used cannabis in the past, it is recommended that they start on low doses before slowly increasing the dose until their therapeutic goals are met. To minimize negative side effects related to THC and maximize symptom control, a strain with low THC and high CBD may be used initially. Immediately discontinue use if any intolerable side effects occur.

People who use cannabis for medicinal purposes consume an average of 1-3 g/day or 10-20 g/week. Even with equal grams of the same cannabis strain, the amount of cannabis the body actually absorbs differs depending on the method of delivery. For example, people who wish to switch from inhaling cannabis to taking cannabis by mouth may need to increase in their daily cannabis use by 2.5 times to get an equivalent dose. Each different form and method of cannabis use will change how quickly the drug produces an effect and how long it lasts in the body. For example, inhalation of cannabis will generally lead to a faster onset of action and longer-lasting effect than oral ingestion.

Inhalation Oral ingestion
Onset of action Few minutes 30 minutes (up to 3-4 hours)
Peak of effect 30 minutes 3-4 hours
Duration of effect 2-4 hours (up to 24 hours) 8 hours (up to 12-24 hours)

It is important that you closely follow the directions of your health providers and consult with them before making any changes to your cannabis use. Speak to your health provider for more detailed information.

The safety of medical cannabis use after SCI is not yet known. However, a number of risks and side effects of cannabis use in the general population are known. Many of the short-term side effects of cannabis have been reported to be mild to moderately severe and related to the dose of the drug taken. Uncommon but serious adverse effects may also exist. Furthermore, the risks to long-term users are not well known and some side effects may be related to regular use over time.

This is not a complete list. Speak to your health provider for detailed information about the risks and side effects of cannabis use.

Short-term side effects of cannabis may include:

Diagram of the human body showing the different side effects cannabis can have on the body.

Cannabis can cause many side effects to different body systems.13

  • Dizziness and lightheadedness
  • Dry mouth, throat irritation, and cough
  • Drowsiness
  • Altered judgment and attention
  • Anxiety and agitation
  • Hallucinations
  • Disorientation and confusion
  • Increased heart rate
  • Impaired coordination and balance
  • Impaired short-term memory
  • Headache
  • Paranoia and psychosis
  • Reddening of the eyes
  • Decreased intra-ocular pressure (pressure within the eyes)
  • Muscle relaxation
  • Interactions with other medications

Because cannabis lingers in the body long after use, task performance may be impaired for up to 24 hours. It is recommended to avoid operating heavy machinery or performing dangerous activities for 3-4 hours after inhaling cannabis, 6 hours after oral ingestion of cannabis, and 8 hours if a “high” is experienced. Examples of high-risk activities may include performing transfers and participating in physical therapy sessions.

Long-term cannabis use may be associated with:

  • Addiction and withdrawal
  • Airway problems like chronic bronchitis
  • Possible increased risk of mental disorders like anxiety, depression, schizophrenia, and psychosis in people at risk for these conditions
  • Possible increased cancer risk with long term smoking, although this is not yet clear

An emerging concern is the effects that cannabis use may have on adolescents and young adults. Studies have suggested that cannabis use early in adolescence may alter brain development and could be related to the development of psychotic disorders as adults.

Overdosage of cannabinoids

A cartoon cannabis leaf with an up arrow on the top left and a warning sign on the bottom right.Overdoses of cannabis, although not common, have been reported. The risk increases when both oral and inhaled forms of cannabinoids (prescription or recreational) are combined. The signs and symptoms of overdose are generally tolerable and overlap with the effects of THC such as dizziness, drowsiness, and sensory impairment. More severe complications including psychosis and convulsions occur rarely.

Unlike cannabis, synthetic cannabinoids carry a greater risk of overdose because they are more potent than THC. The clinical presentation of toxicity will depend on the specific synthetic cannabinoid used, but can be severe and even result in death. Since its introduction into the United States in 2008, there have been cases of adverse reactions in all 50 states. There is currently no antidote to synthetic cannabinoids, making the illegal use of these drugs an emerging public health threat. If you or someone you know experiences an overdose, seek medical attention immediately.

A cartoon cannabis leaf with a thumbs up and thumbs down above.

Studies show that cannabis is mostly used by patients with SCI for (chronic) pain and spasm relief, as well as for anxiety, stress and depression, bowel and bladder management, nausea, to increase appetite, to improve sleep, to decrease other medication use and for pleasure, recreation and relaxation. However, research has only studied the use of cannabinoid products in the treatment of pain and spasticity after SCI.

Pain

Early research provides moderate evidence that smoked and vapourized cannabis may help to reduce neuropathic pain. There is also weak evidence that oral plant-derived cannabinoid sprays may help to reduce neuropathic pain. Moderate evidence from two other studies indicates no benefit with synthetic cannabinoids. In one, dronabinol was no different than diphenhydramine (an anti-allergy medication with no pain-relieving properties) for reducing neuropathic pain. In the other, a synthetic cannabinoid called Normast showed no benefit. These last two studies were specific to people with SCI, while the other studies above also included people with other neurological conditions. Further research specific to people with SCI is needed to determine if cannabis and synthetic cannabinoids are safe and effective for pain after SCI.

 

Hear Matt describe his experience with synthetic and non-synthetic marijuana for pain management.

Spasticity

Research on cannabinoid products for spasticity after SCI has been conflicting. Four studies provide moderate evidence that synthetic cannabinoids and vapourized cannabis may help with spasticity after SCI. However, two other studies with moderate evidence have been inconclusive about whether cannabinoid products helped.

Overall, these studies show that cannabinoid-based treatments may have benefits in the treatment of spasticity, but further research through larger and more rigorous studies are needed before conclusions can be drawn about how effective they are.

There is early evidence that cannabinoid products may help to treat neuropathic pain after SCI and conflicting evidence about whether they help to treat spasticity after SCI. More studies are needed to confirm these findings.

It is not known whether cannabis is safe to use after SCI, especially over the long term, since cannabis use is associated with a number of potential risks and side effects. Until more research is done, it is important that you discuss this treatment option with your health providers in detail to find out if it is a suitable and safe treatment option for you.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Parts of this page has been adapted from SCIRE Project (Professional) “Pain Management” and “Spasticity” Chapters:

Mehta S, Teasell RW, Loh E, Short C, Wolfe DL, Hsieh JTC (2014). Pain Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-79.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/pain-management/

Hsieh JTC, Wolfe DL, Townson AF, Short C, Connolly SJ, Mehta S, Curt A, Foulon BL (2012). Spasticity Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan V, Mehta S, Sakakibara BM, Boily K, editors. Spinal Cord Injury Rehabilitation Evidence. Version 4.0.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/spasticity/

 

Evidence for “What is cannabis” is based on:

Atakan, Z. (2012). Cannabis, a complex plant: different compounds and different effects on individuals. Therapeutic Advances in Psychopharmacology, 2(6), 241–254. https://doi.org/10.1177/2045125312457586

Baker, D., Pryce, G., Croxford, J. L., Brown, P., Pertwee, R. G., Huffman, J. W., & Layward, L. (2000). Cannabinoids control spasticity and tremor in a multiple sclerosis model. Nature, 404(6773), 84–87. https://doi.org/10.1038/35003583

Ben Amar, M. (2006). Cannabinoids in medicine: A review of their therapeutic potential. Journal of Ethnopharmacology, 105(1–2), 1–25. https://doi.org/10.1016/j.jep.2006.02.001

Birdsall, S. M., Birdsall, T. C., & Tims, L. A. (2016). The Use of Medical Marijuana in Cancer. Current Oncology Reports, 18(7), 40. https://doi.org/10.1007/s11912-016-0530-0

Evidence for “What are cannabinoids?” is based on:

Aizpurua-Olaizola, O., Elezgarai, I., Rico-Barrio, I., Zarandona, I., Etxebarria, N., & Usobiaga, A. (2017). Targeting the endocannabinoid system: future therapeutic strategies. Drug Discovery Today, 22(1), 105–110. https://doi.org/10.1016/j.drudis.2016.08.005

Zerrin 2012

Crippa, J. A., Guimarães, F. S., Campos, A. C., & Zuardi, A. W. (2018). Translational Investigation of the Therapeutic Potential of Cannabidiol (CBD): Toward a New Age. Frontiers in Immunology, 9, 2009. https://doi.org/10.3389/fimmu.2018.02009

National Academies of Sciences, Engineering, and Medicine. 2017. The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. Washington, DC: The National Academies Press. doi: 10.17226/24625.

Whiting et al. (2015) Cannabinoids for Medical Use. A Systematic Review and Meta-Analysis. JAMA 313(24): 2456-2473.

Mücke M, Phillips T, Radbruch L, Petzke F, Häuser W.(2018) Cannabis-based Medicine for chronic neurophathic pain in adults. Cochrane Database of Systematic Reviews, Issue 3. Art. No: CD012182 DOI: 10.1002/14651858.CD012182.pub2

Evidence for “How are cannabinoids used?” is based on:

Drossel, C., Forchheimer, M., & Meade, M. A. (2016). Characteristics of Individuals with Spinal Cord Injury Who Use Cannabis for Therapeutic Purposes. Topics in Spinal Cord Injury Rehabilitation, 22(1), 3–12. https://doi.org/10.1310/sci2201-3

Sheel, A. W., Welch, J. F., & Townson, A. (n.d.). Respiratory Management Following Spinal Cord Injury. Retrieved from www.scireproject.com

Health Canada (2018) Information for health care professionals. Cannabis (marihuana, marijuana) and the cannabinoids. Ottawa; Health Canada publications.

Center for Disease Control (2020) Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products. Retrieved on 13-02-2020 from: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html

Evidence for “Cannabidiol oil” is based on:

Devinsky, O., Cross, J. H., Laux, L., Marsh, E., Miller, I., Nabbout, R., … Wright, S. (2017). Trial of Cannabidiol for Drug-Resistant Seizures in the Dravet Syndrome. New England Journal of Medicine, 376(21), 2011–2020. https://doi.org/10.1056/NEJMoa1611618

Devinsky, O., Patel, A. D., Cross, J. H., Villanueva, V., Wirrell, E. C., Privitera, M., … Zuberi, S. M. (2018). Effect of Cannabidiol on Drop Seizures in the Lennox–Gastaut Syndrome. New England Journal of Medicine, 378(20), 1888–1897. https://doi.org/10.1056/NEJMoa1714631

Thiele, E. A., Marsh, E. D., French, J. A., Mazurkiewicz-Beldzinska, M., Benbadis, S. R., Joshi, C., … Wilfong, A. (2018). Cannabidiol in patients with seizures associated with Lennox-Gastaut syndrome (GWPCARE4): a randomised, double-blind, placebo-controlled phase 3 trial. The Lancet, 391(10125), 1085–1096. https://doi.org/10.1016/S0140-6736(18)30136-3

Shannon, S., & Opila-Lehman, J. (2016). Effectiveness of Cannabidiol Oil for Pediatric Anxiety and Insomnia as Part of Posttraumatic Stress Disorder: A Case Report. The Permanente Journal, 20(4), 16-005. https://doi.org/10.7812/TPP/16-005

Evidence for “What is the suggested dosing of cannabis?” is based on:

Health Canada. (2013). Information for Health Care Professionals Cannabis (marihuana, marijuana) and the cannabinoids. Retrieved from https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/dhp-mps/alt_formats/pdf/marihuana/med/infoprof-eng.pdf

Evidence for “What are the risks and side effets of cannabis? Is based on:

Grant, I., Atkinson, J. H., Gouaux, B., & Wilsey, B. (2012). Medical marijuana: clearing away the smoke. The Open Neurology Journal, 6, 18–25. https://doi.org/10.2174/1874205X01206010018

Volkow, N. D., Baler, R. D., Compton, W. M., & Weiss, S. R. B. (2014). Adverse health effects of marijuana use. The New England Journal of Medicine, 370(23), 2219–2227. https://doi.org/10.1056/NEJMra1402309

Zhang, M. W., & Ho, R. C. M. (2015). The Cannabis Dilemma: A Review of Its Associated Risks and Clinical Efficacy. Journal of Addiction, 2015, 1–6. https://doi.org/10.1155/2015/707596

Health Canada. (2013). Information for Health Care Professionals Cannabis (marihuana, marijuana) and the cannabinoids. Retrieved from https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/dhp-mps/alt_formats/pdf/marihuana/med/infoprof-eng.pdf

Evidence for “What are cannabinoids used for after spinal cord injury?” is based on:

Cardenas DD, Jensen MP. (2006) Treatments for chronic pain in persons with spinal cord injury: A survey study. The journal of spinal cord medicine 29:109-117.

Shroff FM. (2015) Experiences with Holistic Health Practices among Adults with Spinal Cord Injury. Rehabilitation Process and Outcome 4:27-34.

Drossel C, Forchheimer M, Meade MA. (2016) Characteristics of Individuals with Spinal Cord Injury Who Use Cannabis for Therapeutic Purposes. Top Spinal Cord Inj Rehabil;22:3-12.

Government of Canada (2019) Final regulations: Edible cannabis, cannabis extracts, cannabis topicals. Retrieved on 13-02-2020 from: https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/resources/regulations-edible-cannabis-extracts-topicals.html

Andresen SR, Biering-Sorensen F, Hagen EM, Nielsen JF, Bach FW, Finnerup NB. (2017) Cannabis use in persons with traumatic spinal cord injury in Denmark. J Rehabil Med 49:152-160.

Bruce D, Brady JP, Foster E, Shattell M. (2018) Preferences for Medical Marijuana over Prescription Medications Among Persons Living with Chronic Conditions: Alternative, Complementary, and Tapering Uses. Journal of alternative and complementary medicine (New York, NY) 24:146-153.

Hawley LA, Ketchum JM, Morey C, Collins K, Charlifue S. (2018) Cannabis Use in Individuals With Spinal Cord Injury or Moderate to Severe Traumatic Brain Injury in Colorado. Archives of physical medicine and rehabilitation 99:1584-1590.

Evidence for “Pain” is based on:

[1] Wilsey, B., Marcotte, T., Tsodikov, A., Millman, J., Bentley, H., Gouaux, B., & Fishman, S. (2008). A Randomized, Placebo-Controlled, Crossover Trial of Cannabis Cigarettes in Neuropathic Pain. The Journal of Pain, 9(6), 506–521. https://doi.org/10.1016/j.jpain.2007.12.010

[2] Wilsey, B., Marcotte, T. D., Deutsch, R., Zhao, H., Prasad, H., & Phan, A. (2016). An Exploratory Human Laboratory Experiment Evaluating Vaporized Cannabis in the Treatment of Neuropathic Pain From Spinal Cord Injury and Disease. The Journal of Pain, 17(9), 982–1000. https://doi.org/10.1016/j.jpain.2016.05.010

[3] Wade, D. T., Robson, P., House, H., Makela, P., & Aram, J. (2003). A preliminary controlled study to determine whether whole-plant cannabis extracts can improve intractable neurogenic symptoms. Clinical Rehabilitation, 17(1), 21–29. https://doi.org/10.1191/0269215503cr581oa

[4] Rintala, D. H., Fiess, R. N., Tan, G., Holmes, S. A., & Bruel, B. M. (2010). Effect of Dronabinol on Central Neuropathic Pain After Spinal Cord Injury. American Journal of Physical Medicine & Rehabilitation, 89(10), 840–848. https://doi.org/10.1097/PHM.0b013e3181f1c4ec

Andresen, S.R., Bing, J., Hansen, R.M., Biering-Sørenson, F., Hagen, E.M., Rice, A.S., Nielsen, J.F., Bach, F.W., Finnerup, N.B., (2016) Ultramicronized palmitoylethanolamide in Spinal Cord Injury Neuropathic Pain: A Randomized, Double-blind, Placebo-controlled Trial. Pain. 157(9): 2097-103.

Evidence for “Spasticity” is based on:

[1] Pooyania, S., Ethans, K., Szturm, T., Casey, A., & Perry, D. (2010). A Randomized, Double-Blinded, Crossover Pilot Study Assessing the Effect of Nabilone on Spasticity in Persons With Spinal Cord Injury. Archives of Physical Medicine and Rehabilitation, 91(5), 703–707. https://doi.org/10.1016/j.apmr.2009.12.025

[3] Maurer, M., Henn, V., Dittrich, A., & Hofmann, A. (1990). Delta-9-tetrahydrocannabinol shows antispastic and analgesic effects in a single case double-blind trial. European Archives of Psychiatry and Clinical Neuroscience, 240(1), 1–4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/2175265

[4] Hagenbach, U., Luz, S., Ghafoor, N., Berger, J. M., Grotenhermen, F., Brenneisen, R., & Mäder, M. (2007). The treatment of spasticity with Δ9-tetrahydrocannabinol in persons with spinal cord injury. Spinal Cord, 45(8), 551–562. https://doi.org/10.1038/sj.sc.3101982

[6] Grao-Castellote, C., Torralba-Collados, F., Gonzalez, L. M., & Giner-Pascual, M. (2017). [Delta-9-tetrahydrocannabinol-cannabidiol in the treatment of spasticity in chronic spinal cord injury: a clinical experience]. Revista de Neurologia, 65(7), 295–302. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/28929471

[2] Wilsey, B., Marcotte, T. D., Deutsch, R., Zhao, H., Prasad, H., & Phan, A. (2016). An Exploratory Human Laboratory Experiment Evaluating Vaporized Cannabis in the Treatment of Neuropathic Pain From Spinal Cord Injury and Disease. The Journal of Pain, 17(9), 982–1000. https://doi.org/10.1016/j.jpain.2016.05.010

[5] Kogel, R. W., Johnson, P. B., Chintam, R., Robinson, C. J., & Nemchausky, B. A. (1995). Treatment of Spasticity in Spinal Cord Injury with Dronabinol, a Tetrahydrocannabinol Derivative. American Journal of Therapeutics, 2(10), 799–805. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11854790

Other references

Allan, G. M., Ramji, J., Perry, D., Ton, J., Beahm, N. P., Crisp, N., … Lindblad, A. J. (2018). Simplified guideline for prescribing medical cannabinoids in primary care. Canadian Family Physician, 64(2).

National Center for Environmental Health. (n.d.). Synthetic cannabinoids: What are they? What are their effects? | HSB | NCEH. Retrieved March 29, 2019, from https://www.cdc.gov/nceh/hsb/chemicals/sc/default.html

Villan, S. (2008). Use of Δ9-tetrahydrocannabinol in the treatment of spasticity in spinal cord injury patients. Spinal Cord, 46(6), 460–460. https://doi.org/10.1038/sj.sc.3102149

Image credits

  1. Marijuana ©United States Fish and Wildlife Service, CC0 1.0
  2. Image by SCIRE Community Team
  3. Cannabidiol and THC Biosynthesis ©Madkamin, CC BY-SA 4.0
  4. Weeds ©The Other Dan, CC BY-NC 2.0
  5. ‘Spice’ — a designer synthetic cannabinoid ©G.W. Pomeroy, CC0 1.0
  6. Vape Pen ©Aly Dodds, CC BY 3.0 US
  7. Cannabis Pills ©Mooms, CC BY 3.0 US
  8. CBD Oil ©Mooms, CC BY 3.0 US
  9. Cannabis Cream ©Mooms, CC BY 3.0 US
  10. When in Amsterdam… ©ashton, CC BY 2.0
  11. CBDistillery-OIL-benefits ©Robert Fischer, CC BY-NC 2.0
  12. Hmmmm cannabis ©Steven Schwartz, CC BY 2.0
  13. Bodily effects of cannabis ©Mikael Häggström, CC0 1.0
  14. Marijuana side effect ©dDara, CC BY 3.0 US
  15. Marijuana side effect ©dDara, CC BY 3.0 US


Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.