Further studies are needed relating to MS and cannabis, but the studies that have been published to date are encouraging and largely show that cannabis has a positive effect on MS. The fact that there is an approved medication (Sativex) available in some countries points to the efficacy of THC in treating MS related muscle spasms, and calls for FDA approval are mounting. Given the few known side effects, cannabis may be a worthwhile adjunctive treatment for patients with MS.
The Endocannabinoid System
The key to how cannabis may be beneficial as treatment is in the body’s endocannabinoid system (ECS). The ECS was discovered decades ago but has just recently garnered attention for its apparent role in treating conditions ranging from MS to diabetes. While more research is needed, there are at least a dozen relevant studies.
Understanding the ECS is crucial to understanding how cannabis may work in the body. There are three main parts to the ECS: endocannabinoids, neurons, and receptors. Endocannabinoids are produced naturally by the body, and neurons in the brain monitor the levels of endocannabinoids in the system. Receptors for the endocannabinoids are located throughout the central nervous system, including in the brain and in every major organ that researchers have sampled. The body contains an enzyme to break down extra endocannabinoids, which may be why it is incredibly difficult, if not impossible, to overdose on cannabis. The body is constantly trying to achieve balance, called homeostasis. More simply put, the body continually checks the levels of endocannabinoids and either will stimulate production or break down the excess, according to the body’s desired level.
In a study involving both live mice and human blood samples, the researchers concluded that the ECS is out of balance in patients with MS, and there is evidence the ECS is activated in central nervous system attacks. There seems to be an anti-inflammatory effect of endocannabinoids, indicating either the body tries to protect itself from attacks to the neural sheath (a key component of MS) or that the body tries to mitigate the damage by releasing endocannabinoids. Further studies are needed to determine the exact role of the ECS in MS and the potential mechanism of protection, but this is a promising avenue in understanding the disease.
Because the body produces endocannabinoids, some researchers believe that treatment with cannabinoids may have therapeutic value. Over the last 20 years, various studies have delved into the relationship between cannabis and MS, with results leaning towards a positive relationship.
Although the widely cited CAMS study found no objective improvement on the Ashworth Scale of spasticity, it did find that patients receiving cannabis treatments had improved self-reports of spasticity and decreased pain. A follow up of this study found continued improvement after one year, suggesting that long-term treatment with cannabinoids may be of benefit, although the authors are careful to note that further study is required.
A 2012 study in the UK using THC capsules found significant improvement in muscle stiffness in MS patients, with twice as many patients in the treatment group showing improvement — as compared to the placebo group.
A UCSD study involving smoked cannabis found that it was superior to placebo in reducing spasticity in MS patients.
A meta-analysis of various studies relating to cannabis and MS found that a majority of patients (77%) report they use fewer opioids for pain when they supplement their treatment with cannabis. There was also a reduction in the use of anti-anxiety medication (72%) and sleep medications (67%). Overall, the authors of the analysis suggest cannabis supplementation may help reduce potentially addictive prescription medication use. This encouraging result can potentially help fight the opioid epidemic playing out in the USA and many other countries, leaving tens of thousands dead in the USA each year.
Although these studies are promising, and surveys of MS patients have shown that between 25% and 50% use cannabis as a treatment for their symptoms, more robust trials would certainly allow us to gain greater insight as to how marijuana can be utilized in the treatment of MS.
Based on a large, double-blind clinical trial, the United Kingdom, Canada, and several European countries have approved nabiximols (Sativex®), a mouth spray containing THC and CBD in a 1:1 THC:CBD mixture. Sativex treats muscle control problems caused by MS, but it is not currently FDA-approved for use in the US.
CBD has been demonstrated to be well tolerated, both with continual use and in high doses of up to 1,500 mg a day, without significant impairment of psychological or bodily functions. However, a few studies linked CBD with some drug interactions and researchers note physician monitoring is warranted with elderly people, or with those with kidney and liver conditions.
Known and common side effects of THC usage are tiredness, confusion, and slowed motor control. Psychosis has also been known to be an adverse effect. It is worth noting that less than 5% of participants in any of the studies cited withdrew due to side effects.
THC seemingly has a low potential for addiction,with approximately 8.9% of long term users developing dependence. However, abrupt withdrawal from THC has been associated with cannabis withdrawal syndrome.
Worldwide, these countries have given regulatory and/or marketing approval for Sativex, available with a prescription: UK, Switzerland, Norway, Turkey, Canada, Australia, New Zealand, Israel, and Brazil.
As of 2019, the FDA has approved three prescription cannabis medications, including Epidolex (derived from CBD) to treat epilepsy and Dronabinol, a synthetic form of THC that has been approved to treat both nausea caused by chemotherapy and weight loss associated with AIDS. These are the only approved uses of these drugs, and any use for MS is off-label and unapproved.
Hemp is legal to cultivate in all states (Dec 2018 Farm Bill), which means that hemp-derived CBD is legal. THC-rich cannabis, with its associated psychoactive effects, may not be legal to grow or consume, even in a medical context, in some US states. It is illegal to sell products containing either THC or CBD as dietary supplements.
States that have a more comprehensive access to medical cannabis — including for MS:
Alaska, Arizona, California, Colorado, Connecticut, Washington D.C., Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota (albeit with the exclusion of dried flowers), Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, Vermont, and Washington.
A West Virginia medical cannabis card program went into effect in July 2019. It does not mention MS specifically, but the legislation states conditions that cause “severe or persistent muscle spasms” are covered.
States with severely limited access to medical cannabis — check for current laws and allowed conditions:
Alabama, Arkansas, Florida, Indiana, Iowa, Kentucky, Louisiana, Mississippi, Missouri (only hemp products, less than 3% CBD), North Carolina (strict pilot program), Oklahoma, South Carolina (CBD for epilepsy only with a doctor’s recommendation), Tennessee (seizures only), Texas, Utah (CBD and epilepsy only), Virginia (provides protection for some possessions for medical use against prosecution but not arrest), Wisconsin (CBD and seizure disorders with a physician’s recommendation), and Wyoming (CBD and seizures only).
States with no medical cannabis programs and therefore criminal charges may apply for possession:
Idaho, South Dakota, Kansas, Nebraska, and Indiana.
Multiple sclerosis, or MS, is a chronic and often progressive disease. If you have MS, it means that your immune system is attacking your own nervous system, specifically the myelin sheath that covers and protects the nerve fibers in your brain and spinal cord. As these nerve cells get damaged, they interrupt messages sent between your brain and the rest of your body, causing nerve damage which can lead to weakness, numbness, pain, and a host of other symptoms.
Multiple sclerosis is quite common. It’s estimated that over 2.3 million people around the world have MS, including nearly 1 million adults in the US. Interestingly, it occurs more in populations living further away from the equator. As we get closer to the equator, we see the prevalence of MS drop.
Because the symptoms of MS depend upon the rate of damage to the nerves, and which specific nerves are damaged, it can produce very different symptoms in different people. Some people with MS might have very few symptoms, while others quickly become unable to walk independently.
Common symptoms of MS include:
- Vision problems, like double vision, blurry vision, or partial loss of sight and eye pain, usually in one eye at a time
- Numb or weak muscles, frequently in one side of the body at a time
- Difficulty with balance or walking
- Sharp pain like an electric shock shooting down the body when moving the neck in certain ways
- Trembling, poor coordination, or unsteadiness, all of which can also affect mobility
- Poor memory and difficulty concentrating
- Fatigue and dizziness
- Tingling or pain in different parts of the body
- Slurred speech
- Difficulty controlling your bowels and/or bladder, and sexual problems
MS can also progress in different ways. Most people have relapsing-remitting MS, which is when they have periods of experiencing new symptoms, or feeling their previous symptoms get worse (replasing), followed by periods when they symptoms ease and they feel better remitting). This is usually followed by secondary progressive MS, which is when the symptoms get steadily and progressively worse, without remissions or relapses. It is much harder to treat at this stage.
Some people get primary progressive MS, when their symptoms get steadily worse from their onset, and they have no or barely any remissions or breaks between attacks.
Occasionally, people who are diagnosed with MS are diagnosed because an MRI scan revealed lesions in the brain and damage to the myelin sheath which matches the pattern of MS, but they haven’t yet experienced any symptoms.
Like a number of autoimmune disorders, it is not clear what causes MS. It seems to be a combination of genetics, environment, and other external factors.
Although we can’t identify specific causes for developing MS, there are a number of issues which make it more likely that you’ll get it. If you have a number of these risk factors, your chances of getting MS increases. You don’t need to worry if just a few risk factors apply.
- You already have an autoimmune condition such as thyroid disease, type 1 diabetes, or inflammatory bowel disease.
- You live in cooler climates further from the equator.
- If you move to a place where people are at higher risk of MS before puberty, you’ll also be at higher risk, which indicates that there’s something about your environment before puberty that affects the development of MS.
- In the US, white people are at greater risk than people from ethnic minorities.
- You’re a smoker. Smoking also causes MS to progress faster, once you’ve developed it.
- You have a close family member who has MS.
- Women are two to three times more likely to develop MS than men.
- Two viruses in the herpes family, including Epstein-Barr virus, are connected with MS, although it’s not clear if they cause MS or develop alongside MS.
- You have low levels of vitamin D and/or aren’t exposed to enough sunlight.
There’s no cure for MS, but there are many treatments currently, including new, highly effective ones over the past several years. Different treatments can help you to recover faster from attacks, slow down the progression of the disease, and manage your symptoms between and during attacks. Most people use a combination of lifestyle changes, medications, and alternative therapies.
Many of the therapies for MS can have serious side effects and health risks, so it’s important to discuss all the options with your doctor and make a careful and informed decision, based on the factors that matter most to you.
Practically all medications for MS modulate the immune system so it will be less effective. This is to prevent damage to the nervous system from the immune system in MS sufferers. As a result, they can potentially make the body less effective at fighting infections and increase the risk of getting sick from different types of bacteria or viruses that are body normally easily defends itself from.
Medications approved for MS
- Beta interferons are a common type of MS medication. They lower your immune response, but that can also make you vulnerable to other infections. They’re delivered by injection into the muscle. If you take beta interferons, you’ll need regular blood tests to monitor your liver, because they can cause liver damage.
- Glatiramer acetate (Copaxone, Glatopa) is also delivered by injection to prevent the immune system from attacking the myelin sheaths. It can cause a rash at the injection site, and other potential side effects, but is generally well tolerated.
- Teriflunomide (Aubagio) is a pill taken twice a day. It can cause liver damage and hair loss, and can be harmful to a developing fetus, so it’s not prescribed for women who could get pregnant.
- Fingolimod (Gilenya) is a daily pill that potentially reduces your relapse rate, but it also slows down your heartbeat so you’ll need to have your heart rate monitored for the first six hours. It can cause high blood pressure, blurred vision, headaches, and on rare occasions serious infections.
- Dimethyl fumarate (Tecfidera) is taken orally twice daily to reduce relapses. It can cause diarrhea, nausea, and a lower white blood cell count.
- Natalizumab (Tysabri) stops immune system cells from moving into your brain and spine where they can attack the myelin sheaths. It has potentially serious side effects, including a serious viral infection of the brain.
- Ocrelizumab (Ocrevus) is the only medication that works to treat primary-progressive MS as well as reducing the relapse rate in relapsing-remitting MS. It’s given intravenously, and it’s side effects can include a rash, low blood pressure, fever and nausea, and increased risk of breast cancer.
- Alemtuzumab (Lemtrada) and mitoxantrone (Novantrone) are chemotherapy drugs that can have very serious side effects, so they are only used as a last resort.
Medications for MS attacks
When you’re having an attack of MS symptoms, you might be given medication to help you recover from them faster.
There are two main ways to treat MS attacks. You might be prescribed corticosteroids, most often given by IV, which reduce inflammation in the affected parts of your body.
Alternatively, you could have plasma exchange (plasmapheresis), which is where your liquid blood (plasma) is removed, separated from the blood cells, mixed with a protein solution called albumin, and then replaced in your body. This takes out the antibodies your immune system produces that attack your own nerve cells.
Treatments for the symptoms of MS
As well as giving you medication to help you recover from attacks and to slow the progression of MS, your doctor will probably prescribe different medications to help deal with different symptoms of MS. These often include:
- Muscle relaxants and sedatives to help you deal with stiff muscles and muscle spasms
- Stimulants to help combat tiredness and fatigue
- Antidepressants to improve your mood
- Other medications to help control your bladder, deal with insomnia, sexual dysfunction, and pain
Other therapies for MS
Physical therapy and occupational therapy is recommended for people with MS. Physical therapists can show you gentle stretches and exercises to reduce pain in your muscles, and to keep them strong so that you can remain independent for as long as possible.
Acupuncture can help with symptoms of MS like bladder problems, stiff muscles, tiredness, pain, and numb or tingling limbs.
Vitamin D or other supplements like CBD can help people handle the symptoms of MS, like fatigue, pain, sore and aching muscles, and headaches.
As well as therapies and medications, there are a few lifestyle changes that are recommended to help slow down the progression of MS, and reduce the frequency and severity of attacks:
- Get plenty of sleep
- Take up mild to moderate exercise like swimming, biking, walking, yoga, or tai chi
- Try to avoid and reduce stress as much as possible
- Keep your body temperature cool, since some people find that MS symptoms get worse when they get too warm