Chronic Back Pain

The Frequently Overlooked and Undertreated Symptom of Multiple Sclerosis (MS) – Could Cannabis Medicine be the Answer?

What causes back pain in MS?

Multiple sclerosis (MS) is a lifelong condition, which primarily affects the brain and the spinal cord. It is often described as an immune-mediated, degenerative progressive, neurological disorder (Stokes, 2004). MS is characterised by unpredictable inflammation and scarring of the central nervous system (CNS) (Bhasker, Young, Khan 2017). The immune system malfunctions and starts to no longer recognise myelin sheaths. Myelin is a lipid rich substance, which covers and protects nerve fibres in the CNS (brain and spinal cord). Because the immune system mistakes myelin for a foreign substance, it attacks and destroys the myelin sheaths.
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This process is known as demyelination. Demyelination causes recurrent lesions in the neuronal network. Subsequently electrical signals carrying messages from the brain to the rest of the body are severely disrupted.

Despite advances in acute MS management, it remains one of the most common causes of neurological disability in young adults, affecting 1.3 million people worldwide (WHO 2008).

MS is a complex and personal condition. Rarely are two patients experiences identical which makes treating the condition all the more difficult. The most common symptoms include; fatigue, muscle stiffness and spasm, spasticity (increased muscle tone), problems with cognition, neuropathic pain (experienced as burning, pins and needles, squeezing, hugging or pressure), problems with balance and co-ordination and back and joint pain (www.nhs.uk).

Back pain experienced by individuals living with MS is often an indirect symptom resulting from the condition. The disrupted messaging causes mobility difficulties which, in combination with muscle spasms and muscle tone changes, puts pressure on the lower back causing stiffness and pain. Back pain can also be a result of the disrupted or misdirected pain signalling (Khan, 2011).

Pain in MS comes from different symptoms and often for different reasons. Everyone has a different set of symptoms, lifestyles and coping strategies. There are a number of different technique combinations that can be curated in order to obtain optimum symptom management.

Newly Available Medicines

Through advocacy campaigns led by patients, such as those living with MS, cannabis medicines became legal to prescribe in November 2018. These medicines are currently available primarily via private clinics, although Sativex is available on the prescription via the NHS for spasticity in MS.

Integro is one of these pioneering clinics currently prescribing cannabis medicines in the UK. At Integro we treat patients who find cannabis medicines to be an effective symptom management tool when added to their care regime.

Cannabis flowers grow tiny hairs called trichomes that themselves contain hundreds of different chemicals compounds. The most common are two of a family of compounds called cannabinoids; THC and CBD. These two compounds are the most researched and are each known to have a multitude of medical actions and both play a role in treating pain.

These cannabinoids interact with our body’s own endocannabinoid system (ECS). The ECS is a system of receptors, situated on certain cells throughout the body. To date we have identified two key ECS receptors; CB1 and CB2. Humans naturally produce their own endo-cannabinoids. Two examples of this are anandamide and 2-AG. These receptors and endo-cannabinoids make up the ECS (Blenheim, 2016)

The ECS is involved in regulating numerous physiological functions including (but not limited to) motor coordination, neuroprotection, pain control, appetite stimulation and regulating our immune systems (Herhenham et al, 1990).

Endocannabinoids such as anandamide are produced through activities such as exercise, but for those living with chronic conditions, this is more difficult to produce naturally. It is more difficult to regulate all body systems, and cannabis medicines can be useful supplements to these essential naturally produced compounds.

THC has been proven to alleviate both neuropathic and inflammatory pain caused by Multiple Sclerosis (Russo, 2008) by causing a reduction in pain signalling and acting as an anti-inflammatory.

CBD is an effective muscle relaxant (Biles, 2020) making movement more comfortable and therefore enabling individuals to be able to engage with physiotherapy exercises, or complementary therapies such yoga, all of which contribute to maintaining muscle strength and tone.

Better pain management, with fewer side effects than opioid medications, can result in higher quality sleep. This, coupled with the mood stabilisation effect of some cannabis medicines, can help build emotional resilience and empower individuals to manage symptoms such as anxiety and even enable them to engage with mindfulness or meditation techniques as part of a holistic approach to back pain management.

The goal of carefully planning and sticking to an effective and varied care regime, is to help the patient regain a sense of control over their symptoms. In order for this regime to be sustainable, it has to be right for their lifestyle.

When considering how best to manage back pain, or other symptoms associated with Multiple Sclerosis, it is always important to do this in collaboration with your clinical care team.