Journal of Opioid Management 16:3 n May/June 2020
Cannabidiol (CBD) as a treatment of acute and chronic back pain:
A case series and literature review
Jonathan P. Eskander, MD, MBA; Junaid Spall, BS; Awais Spall, BA;
Rinoo V. Shah, MD, MBA; Alan D. Kaye, MD, PhD
Objective: Two patient case reports are presented describing the use of canna-
bidiol (CBD) for the symptomatic relief of a lumbar compression fracture and in
the mitigation of thoracic discomfort and dysesthesia secondary to a surgically
Discussion: CBD appears to have antisnociceptive and anti-inflammatory
effects on opioid-naive patients with neuropathic and radicular pain. Of note,
the patients in this case series used the same CBD cream: Baskin Essentials Body
Wellness Cream (400 mg CBD per two oz.)
Conclusion: Hemp-derived CBD in a transdermal cream provided significant
symptom and pain relief for the patients described in this case series. Based on
these results, we believe further investigation is warranted to see if CBD-containing
products should have a more prominent role in the treatment of acute and chronic
Cannabidiol (CBD) is a phytocannabinoid and
one of the most abundant 113 identified cannabi-
noids as well as 432 other chemical compounds
found in the cannabis plant.1,2 Its mechanism
of action has not been determined; however, it
may interact with numerous targets. However,
the Food and Drug Administration (FDA) has
approved the CBD drug Epidiolex® for the treat-
ment of two forms of rare childhood epilepsy
disorders: Dravet syndrome and Lennox-Gastaut
syndrome.3 Based on previous research, cannabi-
noids seem to possess antinociceptive responses
stemming from nociceptive neuron inhibition and
Cannabinoid (CB) receptors decrease excita-
tory neurotransmission, modulate psychotrophic
effects, as well as ventral tegmental dopamine neu-
ronal activity critically associated with addiction.2
Cannabinoids exert their effects via the activation of
the G-protein coupled receptors, cannabinoid CB1
and CB2. Additionally, it is possible that there are still
more cannabinoid receptors still unknown to us. CB1
receptors are found predominantly along the pain
pathways of the central nervous system4 as well as in
the ocular, cardiovascular, and gastrointestinal sys-
tems.5 The CB2 receptor, which has a significantly
lower affinity for THC compared to CB1,5 is found
primarily in the immune system.6-8 Some authors sug-
gest that CB1 and CB2 agonists might induce antino-
ciception via the release of endogenous opioids and
low back pain
thoracic back pain
© 2020 Journal of Opioid Management,
All Rights Reserved.
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Journal of Opioid Management 16:3 n May/June 2020
possibly by increasing opioid precursor gene expres-
sion.8 Emerging research suggests that cannabi-
noids may be promising treatments for neuropathic,
inflammatory, and oncologic pain.8
Endocannabinoids, a family of bioactive lipids,
are derived from arachidonic acid metabolism. They
are structurally like arachidonic acid and chemi-
cals that interact with the endocannabinoid system
are believed to diminish inflammation. Arachidonic
acid metabolite regulation is also part of the mech-
anism by which nonsteroidal anti-inflammatory
drugs (NSAIDs) reduce pain and inflammation. This
includes cyclooxygenase-2 (COX-2) inhibition and
fatty acid amide hydrolase (FAAH). Regulation of
these pathways leads to increased endocannabinoids
anandamide (AEA), as well as decreased arachidonic
acid and prostaglandin levels. Endocannabinoid
production is also increased by the conversion of
omega-3 fatty acids which possess anti-inflamma-
tory and vasodilatory properties.9,10 It is believed
that endocannabinoids activate previously described
cannabinoid receptors and modulate neural trans-
mission.8 This suggests that endocannabinoids par-
ticipate in a variety of cerebral and systemic functions
including pain perception, mood-enhancement, anti-
inflammatory effects, and more.11
Encouraging results in the treatment of chronic
pain in animal models have recently been demon-
strated by compounds with multiple mechanisms.12
CBD treatment in diabetic mice showed a reduc-
tion in tactile allodynia, which suggests an effect
on neuropathic pain. Additionally, CBD has shown
antinociceptive and anti-inflammatory properties
without known adverse effects to the central nerv-
Regarding neuropathic pain, CB1 agonists work
alongside a set of receptors known as transient
receptor potentials (TRPs). TRPs refers to groups
of ion channels located across plasma membranes
of various organ systems and nerve cells. These ion
channels have nonselective permeability for cati-
ons, the regulation of which, can alter inflammatory
responses.14 As Lowin and Straub note, TRPs induce
the sensation of pain but also support inflamma-
tion via secretion of pro-inflammatory cytokines.14
An important subgroup within this receptor super-
family includes the TRP Vanilloid receptors, which
have been studied to bind to various cannabi-
noids.15 Upon activation, via entrance of calcium
and magnesium, the TRPV1 channel undergoes
desensitization, which has a considerable impact on
nerve-affiliated nociceptive transduction.16 These
hyperalgesic effects of TRPs are critical for under-
standing the physiological dynamics of chronic
nerve injury and pain. Furthermore, nerve injury
also triggers an immunological response initiating
the production of inflammatory macrophages that
retract sympathetic nerve fibers.14 Hypothalamic
norepinephrine thus falls under the threshold for
anti-inflammatory beta-2 receptor activation and this
favors pro-inflammatory effects, via alpha-adrener-
gic signaling.17 Further down in the cascade, this can
lead to an increase of nerve fiber signaling to the
CNS that triggers nociception. In chronic inflamma-
tory conditions, pro-inflammatory cytokines, such
as TNF and IL-10, can over-sensitize TRPV1 recep-
tors.18 Inhibiting TRPV1 function via CB1 activation
and FAAH inhibition reduces intracellular calcium
that can initiate analgesia by reducing the inflamma-
tory cytokine cascade often associated with pain.19
The immunomodulatory component of cannabi-
noids is indirectly accompanied by the antihyper-
algesic effects initiated by the ionotropic regulation
The route of administration of CBD in the two
patients discussed in this report is transdermal.
Previous studies, using animal models, describe the
steady-state plasma concentrations of transdermal
CBD in guinea pigs did reach potentially therapeu-
tic levels (6.3 ng/mL) which was reached 15 hours
after application. Enhancers did increase absorption
3.7-fold.20 Of note, some CBD creams for sale use
proprietary technology to enhance the absorption
of CBD via the transdermal route. Another study
involved mice and transdermal ethosome CBD.
After application, CBD levels lasted at least 72 hours
and notably there was significant accumulation of
CBD as measured in underlying muscle.21
Some potential side effects of cannabinoids
include increased bleeding risk via suppression of
platelets and anticoagulants.22 In addition, CBD can
interact with warfarin and increase the risk of bleed-
ing complications. Like warfarin, CBD is metabo-
lized through the hepatic P450 enzyme system.
Both share the same isoforms in their metabolism.
CBD acts on CYP1A1, CYP1A2, CYP2C9, CYP2C19,
CYP2D6, CYP3A4, and CYP3A5.
A 40-year-old African American man pre-
sented with 8/10 low back pain secondary to an
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Journal of Opioid Management 16:3 n May/June 2020
L3 compression fracture suffered after a fall. His
medical history is significant for an epidural abscess
requiring evacuation and subsequent posterior
instrumentation and fusion of the lumbar spine
10 years ago. He does not take any medications.
After it was determined by his healthcare provid-
ers that he was not a candidate for a kyphoplasty,
he began conservative therapy using a combination
of acetamenophen and NSAIDS; neither of which
provided significant relief. Beginning on week two
status-post L3 vertebral compression fracture, he
began applying CBD cream twice daily to his lower
back. He applied a small amount of cream over the
affected area. He endorsed approximately 10 hours
of pain reduction to a 1/10 or 2/10. Pain from low
back muscle spasms as well as radiating pain to his
sacrum were mitigated. After 4 weeks of treatment,
he stopped using all medications as his low back
A 61-year-old Caucasian woman presenting with
thoracic sensory disturbance and dysesthesia for
over 2 years following a surgical resection of a spi-
nal meningioma at the T6-7 level involving the lat-
eral intradural extramedullary compartment of the
vertebral canal. Her medical history is significant for
rheumatoid arthritis, cervical degenerative disc dis-
ease with left-sided radiculopathy, and obesity. Her
medications include methotrexate and simvastatin.
After using CBD cream applied to the affected area
of her thoracic spine, she endorsed approximately
7-8 hours of relief from sensory disturbance and
DISCUSSION AND CONCLUSION
The CBD has multiple theoretical targets includ-
ing CB2 receptors, alpha-2 adrenergic receptor ago-
nism, indirect stimulation of opioid receptors, and
mediators of the inflammatory processes and noci-
ceptive pathways. Modulation of the noradrenergic
system and indirect stimulation of opioid receptors
via CB2 receptors can be important in the treat-
ment of pain, anxiety, depression, and opioid with-
drawal. This could help explain why CBD appears
to be an effective antinociceptive compound. This
case series suggests that CBD may have antinocicep-
tive and anti-inflammatory effects on opioid-naive
patients with neuropathic and radicular pain. Due
to lack of evidence, it is unknown which products
containing CBD have a similar effect. Since CBD
creams are not regulated by the Food and Drug
Administration (FDA) it is difficult to determine the
efficacy and potency of each product in the market.
Interestingly, both of the aforementioned patients
used the same CBD cream: Baskin Essentials Body
Wellness Cream. Hemp-derived CBD in a topical
cream provided significant symptom and pain relief
for the patients described in this case series. It should
be noted that these products are third-party labora-
tory tested to ensure that the active ingredients are
as stated on the label. Based on these results, we
believe further investigation is warranted to see if
these products have a role in the treatment of acute
and chronic pain. A high-powered study involving
patients afflicted by either chronic and acute pain
conditions is warranted in order to examine to what
extent CBD can mitigate pain.
No funding was received for this manuscript.
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Jonathan P. Eskander, MD, MBA, Department of
Anesthesiology and Pain Medicine, Portsmouth Anesthesia
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Junaid Spall, BS, Department of Chemistry, University of
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Awais Spall, BA, Department of Chemistry, University of
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Rinoo V. Shah, MD, MBA, Department of Anesthesiology,
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Alan D. Kaye, MD, PhD, Department of Anesthesiology
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