Residual Limb Pain – Medical Marijuana Research Overview

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Residual limb pain is pain isolated at the site of an amputation. Studies have shown cannabis effectively reduces pain and may also help address some of the pain’s underlying causes.

Overview of Residual Limb Pain

Residual Limb PainResidual limb pain (RLP) is pain that develops at the site of an amputation. It’s different from phantom pain, which is felt in the amputated part of the limb that is no longer part of the body. The pain associated with RLP, which is also commonly referred to as “stump pain,” can feel like cramping, aching, burning, or sensations of hot and cold.

There are numerous potential causes of residual limb pain. The most common cause, according to Amputee Coalition, is an underlying condition that is either related to the surgical procedure or that was present prior to the amputation. From the surgery, skin problems, infections can develop. From diabetes or other circulatory problems, neuropathy can arise and cause residual limb pain. Trauma caused from the surgery, such as a decrease in blood supply or a loss of tissue covering and protecting the end of the bone can also cause residual limb pain. In addition, the formation of neuroma, bone spurs, or the entrapment of nerves in scar tissue are not uncommon and can be causes.

Following a lower limb amputation, because of altered gait pattern, decreased weight load, disuse atrophy and lack of muscular action, it’s not uncommon for those with residual limb pain to also develop osteoporosis, or a loss in bone density (Yazicioglu, et al., 2008).

While pain medications are commonly used to help manage discomfort, treatments for residual limb pain also focus on managing the underlying cause of the pain. For pre-existing conditions like diabetes, treatment focus is on managing the condition through medications and lifestyle changes. When a loss of tissue or the development of bone spurs is the cause, additional padding and prosthetic adjustments may help, but in some causes surgery may be necessary to revise the residual limb or remove the extra bone. To treat residual limb pain caused by neuromas, non-steroidal anti–inflammatory, antidepressant and anticonvulsant medications, as well as ultrasound, massage, vibration, percussion, acupuncture and transcutaneous electrical nerve stimulation are traditionally effective for reducing pain.

Findings: Effects of Cannabis on Residual Limb Pain

Studies have shown that cannabis and its cannabinoids have analgesic, anticonvulsant and antidepressant effects, which means it could potentially help manage residual limb pain. This is significant, as one study found that 67.7% of amputees experienced residual limb pain and a quarter of those reported that the pain they experienced was “extremely bothersome” (Ephraim, et al., 2005).

Tetrahydrocannabinol (THC) and cannabidiol (CBD), two major cannabinoids found in cannabis, have been shown to effectively reduce pain caused by cancer, neuropathy, spasticity, headache, migraines, and other acute pain and chronic pain conditions (Jensen, Chen, Furnish & Wallace, 2015) (Baron, 2015). THC and CBD are agonists of the two main cannabinoid receptors (CB1 and CB2) of the endocannabinoid system within the body. These receptors regulate the release of neurotransmitter and central nervous system immune cells to manage pain levels (Woodhams, Sagar, Burston & Chapman, 2015). As a result, the cannabinoids have demonstrated the ability to significantly lower neuropathic and nociceptive pain, and has even shown it can help manage pain that has proven refractory to other treatments (Boychuck, Goddard, Mauro & Orellana, 2015) (Wallace, et al., 2015) (Lynch & Campbell, 2011).

Cannabis can also help those whose residual limb pain is caused from diabetes. Cannabis use has been found to have an inverse association with diabetes (Alshaarawy & Anthony, 2015). In addition, in animal trials, CBD was shown to significantly reduce both pro-inflammatory cytokines in the bloodstream and the incidence of diabetes in non-obese mice (Weiss, et al., 2006). Later, those same researchers found that CBD was effective at curtailing the manifestations of the disease. Only 30% of the CBD-treated mice in a latent diabetes stage or with initial symptoms of diabetes ended up developing diabetes (Weiss, et al., 2008).

Cannabis also can reduce the risk of those with residual limb pain from developing osteoporosis. THC’s activation of the CB2 receptor has been shown to stimulate bone formation and inhibit bone breakdown (Bab, Zimmer & Melamed, 2009). Even low concentrates of cannabinoids have been shown to be effective at activating human osteoclasts, thus boosting bone density and offering therapeutic benefits to bone disease (Whyte, et al., 2012).

States That Have Approved Medical Marijuana for Residual Limb Pain

No states have approved medical marijuana specifically for the treatment of residual limb pain. However, in Washington D.C., any condition can be approved for medical marijuana as long as a DC-licensed physician recommends the treatment. In addition, a number of other states will consider allowing medical marijuana to be used for the treatment of residual limb pain with the recommendation from a physician. These states include: California (any debilitating illness where the medical use of marijuana has been recommended by a physician), Connecticut (other medical conditions may be approved by the Department of Consumer Protection), Massachusetts (other conditions as determined in writing by a qualifying patient’s physician), Nevada (other conditions subject to approval), Oregon (other conditions subject to approval), Rhode Island (other conditions subject to approval), and Washington (any “terminal or debilitating condition”).

Also, several states have approved medical marijuana specifically to treat “chronic pain.” These states include: Alaska, Arizona, California, Colorado, Delaware, Hawaii, Maine, Maryland, Michigan, Montana, New Mexico, Ohio, Oregon, Pennsylvania, Rhode Island and Vermont. The states of Nevada, New Hampshire, North Dakota, Ohio and Vermont allow medical marijuana to treat “severe pain.” The states of Arkansas, Minnesota, Ohio, Pennsylvania and Washington have approved cannabis for the treatment of “intractable pain.”

Recent Studies on Cannabis’ Effect on Residual Limb Pain
      • For most, using cannabis improves mood, pain, muscle spasms, and sleep.A survey of cannabis (marijuana) use and self-reported benefit in men with chronic prostatitis/chronic pelvic pain syndrome. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4277530/)
      • Cannabinoids found in cannabis shown to be effective at reducing pain that had proven refractory to other treatments.The effectiveness of cannabinoids in the management of chronic nonmalignant neuropathic pain: a systematic review.(http://www.ncbi.nlm.nih.gov/pubmed/25635955)

References

Alshaarawy, O., and Anthony, J.C. (2015, July). Cannabis Smoking and Diabetes Mellitus: Results from Meta-analysis with Eight Independent Replication Samples. Epidemiology, 26(4), 597-600.

Bab, I., Zimmer, A. and Melamed, E. (2009). Cannabinoids and the skeleton: from marijuana to reversal of bone loss. Annals of Medicine. 41(8), 560-7.

Baron, E.P. (2015, June). Comprehensive Review of Medicinal Marijuana, Cannabinoids, and Therapeutic Implications in Medicine and Headache: What a Long Strange Trip It’s Been… Headache, 55(6), 885-916.

Boychuck, D.G., Goddard, G., Mauro, G., and Orellana, M.F. (2015 Winter). The effectiveness of cannabinoids in the management of chronic nonmalignant neuropathic pain: a systematic review. Journal of Oral & Facial Pain and Headache, 29(1), 7-14.

Ephraim, P.L., Wegener, S.T., MacKenzie, E.J., Dillingham, T.R., and Pezzin, L.E. (2005, October). Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Archives of Physical Medicine and Rehabilitation, 86(10), 1910-9.

Jensen, B., Chen, J., Furnish, T., and Wallace, M. (2015, October). Medical Marijuana and Chronic Pain: a Review of Basic Science and Clinical Evidence. Current Pain and Headache Reports, 19(10), 524.

Lynch, M.E., and Campbell, F. (2011, November). Cannabinoids for treatment of chronic non-cancer pain; a systematic review of randomized trials. British Journal of Clinical Pharmacology, 72(5), 735-744.

Management of Residual Limb Pain. (n.d.) Amputee Coalition. Retrieved from http://www.amputee-coalition.org/limb-loss-resource-center/resources-for-pain-management/management-of-residual-limb-pain/.

Wallace, M.S., Marcotte, T.D., Umlauf, A., Gouaux, B., and Atkinson, J.H. (2015, July). Efficacy of Inhaled Cannabis on Painful Diabetic Neuropathy. Journal of Pain, 16(7), 616-27.

Weiss, L., Zeira, M., Reich, S., Har-Noy, M., Mechoulam, R., Slavin, S., and Gallily, R. (2006, March). Cannabidiol lowers incidence of diabetes in non-obese diabetic mice. Autoimmunity, 39(2), 143-51.

Weiss, L., Zeira, M., Reich, S., Slavin, S., Raz, I., Mechoulam, R., and Gallily, R. (2008, January). Cannabidiol arrests onset of autoimmune diabetes in NOD mice. Neuropharmacology, 54(1), 244-9.

Whyte, L.S., Ford, L., Ridge, S.A., Cameron, G.A., Rogers, M.J. and Ross, R.A. (2012, April). Cannabinoids and bone: endocannabinoids modulate human osteoclast function in vitro. British Journal of Pharmacology. 165(8), 2584-97.

Woodhams, S.G., Sagar, D.R., Burston, J.J., and Chapman, V. (2015). The role of the endocannabinoid system in pain. Handbook of Experimental Pharmacology, 227, 119-43.

Yazicioglu, K., Tagcu, I., Yilmaz, B., Goktepe, A.S., and Mohur, H. (2008, June). Osteoporosis: A factor on residual limb pain in traumatic trans-tibial amputations. Prosthetic and Orthotics International, 32(2), 172-8.

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