Fibromyalgia is poorly understood and as a result the development of treatment has been challenging. Treatments are often not effective and patients go from one therapy to another, accumulating disappointments and side effects. Unfortunately, people living with fibromyalgia often have adverse reactions to medication further limited treatment options.
There is increasing interest in medical cannabis as a treatment for fibromyalgia. Cannabis has been used to treat cramps and pain as far back as 5,000 years ago in ancient China. This is not just due to its effects on pain (analgesic properties) but also due to its potential to help with other associated symptoms such as insomnia, anxiety and depression.
The Endocannabinoid System
Cannabis contains over 500 active compounds including at least 140 cannabinoids—the number has been gradually growing in the past few years due to new research—that can affect the body by interacting with and activating the endocannabinoid system (ECS). The ECS is divided into three main parts: receptors that are distributed throughout the body, cannabinoid molecules that combine with and activate the receptors and metabolic enzymes. There are particularly high concentrations of cannabinoid receptors found in the nervous system, immune system, bones and joints, which is where the ECS has its main functions. The central role of the enzymes is to synthesize the molecules that activate the ECS or to break them down and stop them activating the receptors.
Cannabinoid molecules that activate the ECS can be found in three different environments: within the body, in the cannabis plant, and in pharmaceutical preparation.
When naturally-occuring in the body they are called endocannabinoids (“endo” means inside in Greek) and play an important role in the bodies “homeostasis,” or balance. Endocannabinoids are produced by the body in reaction to different types of stress including physical and psychological. The exact functions of the ECS are still in the process of being understood.
The other naturally-occurring cannabinoids are present in the plant Cannabis sativa and are known as phytocannabinoids. The most-studied phytocannabinoid molecules are tetrahydrocannabinol (THC) and cannabidiol (CBD). These phytocannabinoids have similarities to the endocannabinoids in their ability to activate the ECS.
Finally cannabinoids have also been synthesized as pharmaceutical preparations. Most of the pharmaceutical preparations are synthesized cannabinoid molecules that are analogues of (similar or almost identical to) THC, for example Nabilone, which has been approved by the FDA for use in the United States.
There have been two cannabinoid receptors identified to date, and it’s likely that more receptors will be identified through future research. Both cannabinoid receptor 1 (CB1) and cannabinoid receptor 2 (CB2) can be activated by combining with cannabinoid molecules—whether endocannabinoids, phytocannabinoids or synthetic cannabinoids. The combination of the cannabinoid molecules and the cannabinoid receptor activates specific signalling pathways within cells. One of the central results of these signalling pathways in cells is to decrease neurotransmitter release. Neurotransmitters are the primarily signals of the nervous system, which are involved in many processes including pain perception and other brain functions such as sleep and anxiety. CB1 receptors are mainly located in the nervous system in both the brain and peripheral nerves that extend from the spinal cord. CB2 receptors, on the other hand, have been found mainly located on cells of the immune system and different types of musculoskeletal cells. It is these effects on pain and sleep and anxiety that may be helpful in fibromyalgia.
Fibromyalgia & Cannabis
Research into medical cannabis is relatively new, mainly due to its legal status—it’s impossible or at least very difficult to perform medical studies on illicit substances. Since regulations have changed there is increasing interest and an increasing number of trials being performed. However, this area of research is still relatively young and therefore there is still not a lot of data regarding the effects of cannabis in fibromyalgia.
A recent high quality but very small study (randomized placebo-controlled trial) examined the analgesic (pain control) effect of pharmaceutical grade cannabis in 20 patients with fibromyalgia. The four groups received either cannabis high in THC content with minimal CBD, equal THC and CBD, high CBD with minimal THC or placebo (no THC or CBD). After treatment patients measured spontaneous pain levels (meaning pain that is present without any obvious trigger) and underwent pain tests (pain that as elicited by a trigger). Patients receiving the combination of CBD and THC had statistically improved pain scores in the induced pressure pain test—30% decreased pain score compared to placebo. None of the treatments had an effect on spontaneous pain levels. CBD without THC cannabis did not demonstrate any effects of pain levels.
Two other randomised controlled trials looked at the effect of the synthetic cannabinoid Nabilone on fibromyalgia. One trial compared treatment with Nabilone to placebo and the other trial compared Nabilone to Amitriptyline (a tricyclic antidepressant used in fibromyalgia). The trial comparing Nabilone to placebo provided low-quality evidence that the cannabinoid provided improvement in pain control and measure of quality of life. No effect on fatigue or depression was seen. The study that examined Nabilone vs Amitriptyline found low quality evidence of improved sleep with cannabinoid treatment. In contrast to the previous trial there was no effect on pain or quality of life.
A larger observational trial of 367 patients was recently published examining plant-based medical cannabis that may have been either THC or CBD rich. Eighty percent of patients reported an improvement in their symptoms such as sleep and depression. There were also significant improvements in pain and quality of life. In terms of side effects, the most frequent were dizziness (8%), dry mouth (7%), nausea & vomiting (5%) and hyperactivity (5%). Hallucinations was reported in 1% of the participating patients. The results of this trial seem very encouraging; nonetheless it is important to recognize that this is an observation trial. That means in terms of the methodology there are many issues where the results may have been affected by factors other than the treatment.
Regarding the side effects of cannabinoid treatment: the most significant include immediate effects on motor and cognitive function that may last up to 5 hours. Additionally, smoking cannabis may be a risk factor for developing respiratory disease. Cannabis use has also been associated with psychosis, paranoia and anxiety especially related to THC.
So far, the current research demonstrates low- to medium-quality evidence that treatment with cannabinoids, either plant based or synthetic, have a beneficial effect on people living with fibromyalgia. The strongest evidence is that this effect is produced by THC in contrast to limited evidence of the effectiveness of CBD in fibromyalgia. Clinical research into treatment with cannabinoids is relatively new and the majority of the described trials are small. It is likely that with larger high-quality trials the effects of cannabinoid treatment in fibromyalgia will become clearer.
There are known associations between fibromyalgia, migraines and irritable bowel syndrome (IBS). It has been suggested that these diseases/syndromes share a similar underlying cause and that they may all be treated with cannabis. The proposed cause is endocannabinoid deficiency. There is some research that has found decreased endocannabinoid levels in patients with migraines and decreased levels in a study of mouse models with pain hypersensitivity. There is also increasing data showing that the ECS may play a role in the development of altered gastrointestinal function. However, currently there are no studies examining endocannabinoid levels in fibromyalgia or IBS. Thus endocannabinoid deficiency is still a theory, there is little data and it is an area of ongoing research.
Fibromyalgia is a debilitating disease with limited treatment. Medical cannabis may provide a new treatment option. Despite limited data the research increasingly seems to demonstrate beneficial effects. The decision to start treatment should be taken with the treating physician having been discussed and considered the pros and cons.
Although cannabis is federally illegal in the United States the majority of states have legalized cannabis for medical use. States have legalized medical cannabis with varying degrees of restrictions. In the following states fibromyalgia or chronic or intractable pain is a valid indication for prescribing medical cannabis: Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Vermont, Virginia, Washington, West Virginia.
Other countries in which fibromyalgia or chronic pain are a legal indication for prescription include Australia, Chile, Colombia, Canada, Czech Republic, Germany, Greece, Israel, Italy, The Netherlands, Norway, Poland, Romania, and Uruguay.
Fibromyalgia is a long-term and chronic condition that often causes widespread pain and tenderness over much of the body. It is considered common and approximately affects 2-8% of the population, with women affected about twice as often as men.
Symptoms of fibromyalgia may be confused with those of arthritis, or joint inflammation. However, unlike arthritis, fibromyalgia has not been found to cause joint or muscle inflammation and damage. It is seen as a condition that causes only soft tissue or myofascial pain. Patients often suffer immensely from fibromyalgia and end up getting many ineffective treatments and therapies, and go from one doctor to another seeking a solution. It severely impacts quality of life and may often lead to depression, anxiety and a host of other conditions.
Symptoms of fibromyalgia tend to differ from one person to another. Nevertheless, one of the main symptoms is widespread pain. This may be felt throughout the body but could be worse in certain areas, such as the back or the neck. The pain can fluctuate in intensity and change in location but it is often chronic and debilitating.
Notable symptoms of fibromyalgia include:
- Extreme sensitivity to pain all over the body
- Muscle stiffness
- Muscle spasms
- Extreme tiredness (fatigue) that can range from a mild, tired feeling to exhaustion
- Cognitive difficulties, often described by patients as a “fibro fog,” can disrupt focus, attention, and concentration
- Poor sleep quality or difficulty falling asleep. Sleep might also be disturbed because of an urgent need to urinate, especially at night
Fibromyalgia often coexists with other painful conditions, such as:
- Irritable bowel syndrome
- Migraine and other types of headaches
- Temporomandibular joint disorders
- Depression and anxiety
- Sleep problems
Other less common symptoms of fibromyalgia are problems with vision, nausea, dizziness, skin problems and breathing problems. As a result of poor quality of life, patients also report symptoms of depression and anxiety.
Physicians don’t yet know exactly what causes fibromyalgia, but research suggests that there may be an interaction between physical, neurological and psychological factors. It seems that a combination of pain, sleep disturbance and anxiety or depression can turn into a vicious circle that leads to fibromyalgia, and vice versa.
Other risk factors are a result of personal medical history, such as:
- Infections—Prior illnesses may trigger fibromyalgia or worsen the symptoms
- Trauma—The condition has been linked with post-traumatic stress disorder (PTSD) after being observed among people who experienced physical or emotional trauma
- Stress—High-stress levels have been linked to hormonal disturbances that could contribute to fibromyalgia
- Age—Fibromyalgia may present at any age, but symptoms most often begin around age 30 and get worse over time and under stress, so most people are diagnosed in their 40s. The risk of developing fibromyalgia also increases with age.
- Gender—Women are twice as likely to have fibromyalgia as men
- Other related conditions— such as lupus or rheumatoid arthritis
Some patients also report that “flare-ups,” in which their symptoms are more intense, can be triggered or aggravated by several factors, including weather changes, overexertion, traveling, and hormonal changes among others.
There is no single test that can fully diagnose fibromyalgia, and scientists debate whether an objective diagnosis is possible. However, physicians usually diagnose fibromyalgia using the patient’s history, physical examination, X-rays, and blood work.
The most widely used criteria for the diagnosis of fibromyalgia are:
- The patient either has severe pain in 3 to 6 different areas of his/her body, or he/she has milder pain in 7 or more different areas
- The symptoms have stayed at a similar level for at least 3 months
- No other reason for the symptoms has been found
There is no lab test to confirm a diagnosis of fibromyalgia, so the purpose of the blood work is to rule out other conditions that may have similar symptoms. In fact, fibromyalgia is a diagnosis that is given when many other conditions are ruled out. Blood tests may include complete blood count, erythrocyte sedimentation rate, cyclic citrullinated peptide test, rheumatoid factor, and thyroid function tests.
The physician may also ask about your medical history, specifically looking for the level of severity of these symptoms:
- Waking unrefreshed
- Cognitive (memory or thought) problems
Patients living with fibromyalgia are usually treated by rheumatologists or pain specialists. Rheumatologists specialize in treating diseases of an overactive immune system that causes damage to the patients. There is no strong evidence that fibromyalgia is a disease of the immune system (autoimmune or inflammatory disease). However, there is a significant association of fibromyalgia and rheumatological diseases. Patients with rheumatological diseases like rheumatoid arthritis and systemic lupus are likely to develop fibromyalgia than the general population. This is very suggestive that the immune system may play a role in the development of fibromyalgia. Nonetheless, the majority of patients with fibromyalgia do not have a rheumatological disease.
There’s no cure for fibromyalgia, but there are ways of maintaining quality of life by managing the symptoms, including medication, alternative therapies, and lifestyle changes. No one treatment works for every symptom.
A variety of therapies can help reduce the pain that accompanies fibromyalgia. Common forms of therapy are:
- Physical therapy—A physical therapist can teach exercises, especially water-based, that will improve the patient’s strength, flexibility, and stamina
- Occupational therapy—An occupational therapist may recommend adjustments to the work environment that would lessen the stress on the patient’s body
- Psychological therapy—Speaking to a counselor can boost self-esteem and offer support in dealing with stressful situations. This may be either cognitive behavioral therapy (CBT) or psychotherapy. Support groups can also be useful.
Medications can help reduce the pain of fibromyalgia and improve sleep. Physicians mostly prescribe:
- Painkillers—Medications that don’t require a prescription include acetaminophen (Tylenol, Paracetamol), ibuprofen (Advil, Motrin IB) or naproxen sodium (Aleve). Stronger medications are codeine or tramadol, but these are considered addictive and their effect tends to weaken over time
- Antidepressants—Duloxetine (Cymbalta) and milnacipran (Savella) can ease the pain and fatigue associated with fibromyalgia. Amitriptyline or the muscle relaxant cyclobenzaprine may also improve sleep quality, by relaxing the muscles. However, antidepressants can cause many effects, including dizziness, weight gain, and constipation
- Anti-seizure drugs—Medications such as Gabapentin (Neurontin) or pregabalin (Lyrica) are mostly prescribed to treat epilepsy but may be proven useful in reducing different types of pain. They also have a host of side effects which may cause tolerability issues in many patients.
- Antipsychotics— Quetiapine is sometimes given to help with sleep and when many other medications have failed. Side effects may include drowsiness, tremors (shaking) and restlessness.
Other forms of treatment:
- Water-based activities—swimming, sitting or exercising in a heated pool or warm water (known as hydrotherapy or balneotherapy)
- Exercise—an individually-tailored exercise program. Unfortunately, exercise often exacerbates pain in those suffering from fibromyalgia.
- Alternative therapy—acupuncture, meditation, yoga, massage therapy, mindfulness may help with relaxation.
- Dietary program—maintaining a balanced, healthy diet, rich with fruits and vegetables. Drinking plenty of water, eating more plants than meat and reducing sugar intake can also help to reduce symptoms.
Living with Fibromyalgia
People with fibromyalgia need to maintain balance—this means knowing when to be active and when to rest, and never overdo it or push too hard since it might make symptoms worse. It’s also important to manage stress levels since stress might worsen symptoms and even lead to depression. Patients can practice relaxation techniques by physical exercises or by mental routine, taught by relevant books, tapes, and webinars.
One of the most difficult aspects to manage is the quality of sleep. Fibromyalgia is known for making it difficult to sleep or fall asleep, also known as insomnia. To get better sleep, try to create a bedtime routine (such as taking a bath before heading to bed), get up at the same time every morning. Also, try to relax before going to bed, avoid caffeine, nicotine, and alcohol, and avoid eating late at night.