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Research Article

Prevalence of Cannabinoid Use in Patients With Hip and Knee Osteoarthritis

Deckey, David G. MD; Lara, Nina J. MD; Gulbrandsen, Matthew T. MD; Hassebrock, Jeffrey D. MD; Spangehl, Mark J. MD; Bingham, Joshua S. MD

Author Information
JAAOS: Global Research and Reviews: February 2021 - Volume 5 - Issue 2 - e20.00172
doi: 10.5435/JAAOSGlobal-D-20-00172

Abstract

State legalization and widespread marketing efforts have increased the accessibility and consumption of off-label, non–FDA-approved, cannabinoid (CBD) products. Subsequently, these products have been promoted for the treatment of numerous ailments, including joint pain. Although clinical evidence is largely absent for the treatment of musculoskeletal pain, patients are experimenting with these products in efforts to relieve joint pain.1-6 If proven effective, these medications could provide multimodal pain control in the treatment of arthritis-related pain.

Surgeons should be aware of the effects of over-the-counter medications, especially non–FDA-approved medications that their patients are consuming. Given the increased availability of CBD products, investigations into the prevalence and perceived efficacy of CBD for treatment of osteoarthritis (OA) are warranted. To our knowledge, data evaluating the prevalence and perceived efficacy of CBD products for the treatment of OA are limited. Therefore, the purpose of this study was to report the prevalence and subjective efficacy of CBD products in patients with symptomatic hip and/or knee OA presenting for an initial orthopaedic surgery consultation.

Methods

After institutional review board approval, 200 consecutive patients presenting with painful hip or knee OA were surveyed at their initial arthroplasty clinic evaluation at a single high-volume academic center. As part of the initial intake screening, patients were asked to complete a 21-question survey. Questions concerning function and perceived efficacy of treatments were assessed using Single Assessment Numeric Evaluation (SANE) on a 1 to 100 point scale, with a score of 100 indicating the highest perceived benefit (SANE).7,8 In addition, medical chart review was undertaken for background demographic factors.

After completion of questionnaires (see appendix for questionnaire example, Appendix 1, http://links.lww.com/JG9/A108), answers were categorized and tabulated. Average SANE scores for interventions were calculated as well. Questions results were binary (yes/no), numeric (SANE/visual analogue scale [VAS]), or free text (ex “Question 14: ‘How did you hear about CBD?’”). Free text answers were manually reviewed for each respondent and categorized into nominal reviewable outcomes (Table 5). Radiographs for every patient were reviewed by two independent reviewers. Descriptive statistics were performed to characterize the population; T-tests were used to compare the variation of continuous variables. Comparison of proportions for sample populations was performed with z-tests. All statistical analysis was performed with JMP statistical software (SAS Institute).

Results

Of the 200 consecutive patients, 100% completed the survey. Sixty-six percent were female, and the average age was 67 years. Knee OA was the most common complaint (n = 108) followed by hip OA (n = 80), and a minority of patients had symptoms in both joints at presentation (n = 12). Thirty-seven percent of these patients were symptomatic on the right side, 31% on the left side, and 32% presented with bilateral complaints. Knee OA had an average Kellgren-Lawrence OA grade of 2.7 (range 0 to 4). Average Tönnis scale grading of the affected hip OA was 1.8 (range 0 to 3) (Table 1).

Table 1 - Demographic and Radiographic Variables of Arthroplasty Clinic Sample Population
No. of patients, n 200
Age (y) (±SD) 67.21
Female, n (%) 112 (56)
Joints, n (%)
 Knee 108 (54)
 Hip 80 (40)
 Both 12 (6)
Laterality, n (%)
 Left 62 (31)
 Right 74 (37)
 Both 64 (32)
Knee osteoarthritis gradea (n = 159), n (%)
 0 2 (1.1)
 1 29 (18.3)
 2 34 (21.4)
 3 42 (26.4)
 4 52 (32.7)
Hip osteoarthritis gradeb (n = 107), n (%)
 0 7 (6.5)
 1 36 (33.6)
 2 31 (29.1)
 3 33 (30.8)
aKellgren-Lawrence grading scale for knee osteoarthritis.
bTönnis grading scale for hip osteoarthritis.

Twenty-four percent (48/200) of patients endorsed use of CBD products before their presentation. The average presenting SANE score (range 0 to 100) for non-CBD users was 50.8 compared with 41.3 among CBD users (P = 0.012). The average VAS score (range 0 to 10) for non-CBD users was 5.7 compared with 6.6 among CBD users (P = 0.036). No difference in the asymptomatic contralateral joint SANE score (range 0 to 100) was found when comparing non-CBD users with CBD users (81.9 versus 75.9, respectively, P = 0.129) (Table 2).

Table 2 - SANE and VAS Scores Among Non-CBD and CBD Users, Respectively
Factor Non-CBD Users (n = 152), n (%) CBD Users (n = 48), n (%) P Value
Symptomatic joint SANE (average) 50.8 41.3 0.012
Contralateral unaffected joint SANE (average) 81.9 75.9 0.129
VAS pain rating (average) 5.7 6.6 0.036
CBD = cannabinoid, SANE = Single Assessment Numeric Evaluation, VAS = Visual Analogue Scale

Among non-CBD users, 73% had tried NSAIDs for symptomatic relief compared with 90% among the CBD using group. A statistically higher percentage of patients in the CBD group had used NSAIDs for symptomatic relief compared with non-CBD users (P = 0.017). No significant difference was found in the number of patients who had tried bracing treatment, steroid injections, or viscosupplementation injections between the two groups. A significantly higher percentage of marijuana use was found among the CBD group compared with non-CBD users (31% versus 1%, respectively, P < 0.001) despite similar rates of “Other” recreational drug use (15% CBD users versus 11% non-CBD users) (Table 3).

Table 3 - Frequency of Alternative Treatments for Symptomatic Osteoarthritis Used by Study Sample Population Non-Cannabinoid (CBD) and CBD Users, Respectively
Factor Non-CBD Users (n = 152), n (%) CBD Users (n = 48), n (%) P Valuea
NSAID 111 (73) 43 (90) 0.017
Bracing treatment 43 (28) 26 (54) 0.289
Steroid injection 79 (52) 28 (58) 0.119
Viscosupplementation injection 30 (20) 11 (23) 0.575
Marijuana 2 (1) 15 (31) <0.001
Recreational “other” drug use 16 (11) 7 (15) 0.928
aComputed using z-test for difference in proportions.

A significant difference was seen after NSAID use; non-CBD users reported an improvement with an increase in the average SANE to 52.7, whereas CBD users decreased to a SANE of 39.0 (P = 0.012). Otherwise, the differences in SANE scores between the two groups after bracing treatment, steroid injection, viscosupplementation injection, or marijuana use were not statistically significant (Table 4).

Table 4 - SANE Score Averages Among Two Groups After Nonsurgical Treatments
Average SANE Scores Non-CBD Users (n = 152), n CBD Users (n = 48), n P Value
Baseline 50.8 41.3 0.012
Post-NSAID 52.7 39.0 0.012
Post–bracing treatment 40.2 37.6 0.727
Post-steroid 54.9 45.9 0.205
Post-viscosupplementation 55.0 43.4 0.225
Post-marijuana 25.0 47.0 0.319
CBD = cannabinoid, SANE = Single Assessment Numeric Evaluation

Among CBD users, 60% of patients learned about CBD through friends, and 67% purchased CBD directly from a dispensary. Oral tinctures (43%) and topical applications (36%) were the most commonly used forms of CBD. Twenty-two percent of all the patients in this sample reported ongoing CBD utilization (Table 5).

Table 5 - Characterization of CBD Use and Procurement Among the Sample Population
Descriptor N
Referral source
 HCP 7
 Friend 31
 Advertisement 13
 Work 1
Purchasing location
 HCP 1
 Friend 3
 Online 10
 Store 29
CBD type
 Capsule 5
 Topical 16
 Oil tincture 19
 Edible 4
Frequency of use
 Daily 13
 Twice daily 6
 Three times daily 2
 As needed 19
 Only once 4
CBD = cannabinoid, HCP = healthcare provider

Discussion

In this prospective cohort of 200 consecutive patients, 24% (48 patients) reported trying CBD-containing products for relief of their arthritis-related pain before their initial orthopaedic surgical consultation. Although CBD use has not been previously characterized in this population, its prevalence is similar to the reported 15% to 22% of the general US population that reported marijuana use.9,10 However, this reported CBD use is much higher compared with marijuana use in an older population. Han and Palamar11 found that 9% of adults aged 50 to 64 years and 2.9% of adults aged 65 years and older reported marijuana use, which was similar to the 9% of patients who reported marijuana use in our study. This large difference in CBD and marijuana usage in a similarly aged population demonstrates the growing trend and popularity of CBD utilization. Given that more and more patients will arrive in clinic having tried or wanting to try these products, it is crucial that the orthopaedic surgeon is aware of CBD products and current trends in utilization. In addition, in the setting of the opioid crisis, it is imperative that we continue to identify new and potentially less-addictive modalities for pain relief. The goal of this study was to characterize and analyze CBD usage and perceived effectiveness in patients presenting for primary consultation with hip and/or knee OA.

To understand why CBD has become such a rapidly growing trend, a brief history is helpful. The passage of the US Hemp Farming Act of 2018 removed hemp (defined as cannabis with less than 0.3% tetrahydrocannabinol [THC]) from Schedule I Controlled Substances.12 CBD can be derived from cannabis, which comes from the plant Cannabis sativa. Virtually overnight, a new US industry was created. This industry brought with it a legal, unregulated product with broad claims of treating anxiety, insomnia, PTSD, and reducing pain and inflammation. Although not containing high percentages of THC, hemp can still contain CBD, which augments the body's endogenous CBD system primarily through CB1 and CB2 receptors in both the central and peripheral nervous system. These receptors have been shown to play roles in modulating nociception and inflammatory pathways.13 However, the full effects of CBD are still not fully understood. Although animal models have shown CBD to decrease OA-related pain,14-19 its efficacy in humans has not been fully supported.18,20,21

As the stigma surrounding THC and CBD use decreases and these products become more readily available, the prevalence of their use will likely increase. Previously, research has been hampered by lack of funding and the Schedule I classification of cannabis. Given the wide availability of CBD in the United States at present and movements to remove cannabis from the Schedule I classification, it is believed that more knowledge about how THC/CBD functions will come to light. A study using National Inpatient Sample database showed that marijuana/THC use was associated with decreased mortality in patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA), total shoulder arthroplasty (TSA), and traumatic femur fixation.22 In addition, two previous, recently published studies in the orthopaedic literature have explored the use of CBD and THC in arthroplasty.4,5 Hickernell et al4 examined the use of dronabinol, a synthetic form of THC, in a multimodal pain regimen after THA and TKA surgery. In their study, the group taking a prescribed dose of drocannabinol had significantly shorter stays and significantly fewer total morphine equivalents. However, this was a small (81 patients) retrospective study and warrants further studies to fully support this trend. Runner et al5 found that 16.4% of patients following TKA or THA reported use of CBD or THC in the perioperative period. Compared with nonusers, no significant difference was observed in the length of narcotic use, total morphine equivalents used, postoperative pain scores, or the length of stay. Patients in this study were self-medicating without uniformity, which is in contrast to the prescribed dose of drocannabinol used in the Hickernell study.

Our study, however, showed no significant perceived benefit of CBD use compared with nonuse, and patients who used CBD actually reported significantly worse SANE and VAS scores at baseline than nonusers. The symptomatic joint(s)' SANE score significantly differed between CBD users and nonusers at initial presentation (41.3 versus 50.8, P = 0.012). Previous literature has suggested that the minimally clinically important difference for knee injury interventions is approximately 7 to 19, suggesting that perhaps baseline presentation SANE scores may have been statistically different but not clinically measurable.23 In addition, VAS pain rating for CBD users was significantly higher at baseline than nonusers (6.6 versus 5.7, P = 0.036). Interestingly, patients who used CBD products were also significantly more likely to use NSAIDs. This finding suggests that the patients taking CBD products may have had more symptomatic OA or more prone to self-medicating. Patients who reported CBD use were also significantly more likely to report marijuana use.

Several limitations of this study must be acknowledged. Although this was a prospective study, recall bias may be present as patients were asked to recall use of treatment and its effectiveness leading up to their first visit. In addition, only patients presenting for primary hip and knee arthroplasty consultation were included in this study. This restriction limits the generalizability of our findings to other orthopeadic specialties. Future studies are warranted in other subspecialties, such as sports medicine, where injuries are more acute. The perceived efficacy of CBD products may be different for acute pain than for chronic pain. The source of CBD product and route of administration was also not standardized, which may play a role in its effectiveness. In addition, this study had a limited sample size of 200 patients and as such may be subject to type 2 error when concluding no difference. Therefore larger, multicenter studies are needed to fully evaluate CBD use in this population and to enhance generalizability as well as a randomized controlled trial with placebo and a controlled dose of CBD. Finally, a substratification of severity of OA in either group would be useful in future studies attempting to determine the efficacy of CBD in symptomatic relief.

Conclusion

To our knowledge, this is the first prospective study to evaluate the usage of over-the-counter CBD products in a hip and knee OA population. A 24% incidence of CBD usage was found among these patients. We found no significant perceived benefit of CBD use compared with nonuse, and patients who used CBD actually reported significantly worse SANE and VAS scores than nonusers.

References

1. Fitzcharles MA, Clauw DJ, Hauser W: A cautious hope for cannabidiol (CBD) in rheumatology care. Arthritis Care Res (Hoboken). 2020 Mar 7. doi: 10.1002/acr.24176. Epub ahead of print. PMID: 32144889.
2. Korsh J, Marvil S, Guttmann D: Cannabinoids Can Serve As Alternatives To Narcotic Pain Medication For Fracture Healing. Rosemont, IL, American Academy of Orthopaedic Surgeons. https://www.southpalmorthopedics.com/pdfs/edu-cannabinoids-can-serve-as-alternatives-to-narcotic-pain-medication-for-fracture-healing.pdf. Accessed on June 25, 2020.
3. Ware M, Beaulieu P: Cannabinoids for the treatment of pain: An update on recent clinical trials. Pain Res Manag 2005;10:27A-30A.
4. Hickernell TR, Lakra A, Berg A, Cooper HJ, Geller JA, Shah RP: Should cannabinoids be added to multimodal pain regimens after total hip and knee arthroplasty? J Arthroplasty 2018;33:3637-3641.
5. Runner RP, Luu AN, Nassif NA, et al.: Use of tetrahydrocannabinol and cannabidiol products in the perioperative period around primary unilateral total hip and knee arthroplasty. J Arthroplasty 2020;35:S138-S143.
6. Klein TW, Newton CA: Therapeutic potential of cannabinoid-based drugs. Adv Exp Med Biol 2007;601:395-413.
7. Austin DC, Torchia MT, Werth PM, Lucas AP, Moschetti WE, Jevsevar DS: A one-question patient-reported outcome measure is comparable to multiple-question measures in total knee arthroplasty patients. J Arthroplasty 2019;34:2937-2943.
8. Sueyoshi T, Emoto G, Yato T: Correlation between Single Assessment Numerical Evaluation score and Lysholm score in primary total knee arthroplasty patients. Arthroplasty Today 2018;4:99-102.
9. Baron EP, Lucas P, Eades J, Hogue O: Patterns of medicinal cannabis use, strain analysis, and substitution effect among patients with migraine, headache, arthritis, and chronic pain in a medicinal cannabis cohort. J Headache Pain 2018;19:37.
10. Kondrad EC, Reed AJ, Simpson MJ, Nease DE: Lack of communication about medical marijuana use between doctors and their patients. J Am Board Fam Med 2018;31:805-808.
11. Han BH, Palamar JJ: Marijuana use by middle-aged and older adults in the United States, 2015-2016. Drug and Alcohol Dependence 2018;191:374-381.
12. Comer J: Hemp Farming Act of 2018. 2018. https://www.congress.gov/bill/115th-congress/house-bill/5485/text. Accessed on June 25, 2020.
13. Zuardi AW: Cannabidiol: From an inactive cannabinoid to a drug with wide spectrum of action. Braz J Psychiatry 2008;30:271-280.
14. Philpott HT, O'Brien M, McDougall JJ: Attenuation of early phase inflammation by cannabidiol prevents pain and nerve damage in rat osteoarthritis. Pain 2017;158:2442-2451.
15. Gamble L-J, Boesch JM, Frye CW, et al.: Pharmacokinetics, safety, and clinical efficacy of cannabidiol treatment in osteoarthritic dogs. Front Vet Sci 2018;5:165.
16. Hammell DC, Zhang LP, Ma F, et al.: Transdermal cannabidiol reduces inflammation and pain-related behaviours in a rat model of arthritis. Eur J Pain 2016;20:936-948.
17. Malfait AM, Gallily R, Sumariwalla PF, et al.: The nonpsychoactive cannabis constituent cannabidiol is an oral anti-arthritic therapeutic in murine collagen-induced arthritis. Proc Natl Acad Sci U S A 2000;97:9561-9566.
18. O'Brien M, McDougall JJ: Cannabis and joints: Scientific evidence for the alleviation of osteoarthritis pain by cannabinoids. Curr Opin Pharmacol 2018;40:104-109.
19. Schuelert N, McDougall JJ: The abnormal cannabidiol analogue O-1602 reduces nociception in a rat model of acute arthritis via the putative cannabinoid receptor GPR55. Neurosci Lett 2011;500:72-76.
20. Richardson D, Pearson RG, Kurian N, et al.: Characterisation of the cannabinoid receptor system in synovial tissue and fluid in patients with osteoarthritis and rheumatoid arthritis. Arthritis Res Ther 2008;10:R43.
21. Fitzcharles MA, Baerwald C, Ablin J, Häuser W: Efficacy, tolerability and safety of cannabinoids in chronic pain associated with rheumatic diseases (fibromyalgia syndrome, back pain, osteoarthritis, rheumatoid arthritis). Schmerz 2016;30:47-61.
22. Moon AS, Smith W, Mullen S, et al.: Marijuana use and mortality following orthopedic surgical procedures. Subst Abus 2019;40:378-382.
23. Winterstein AP, McGuine TA, Carr KE, Hetzel SJ: Comparison of IKDC and SANE outcome measures following knee injury in active female patients. Sports Health 2013;5:523-529.

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