More than 1 in 5 patients who go to orthopedic surgeons with chronic musculoskeletal pain are using or have used some form of cannabis to manage their pain, according to a new study published this month. Of those, almost two thirds said they felt cannabis was very or somewhat effective, while more than 9 in 10 said it was at least slightly effective.

“More than half (57%) claimed cannabis to be more effective than other analgesic medications, and 40% reported decreasing their use of other analgesic medications since starting cannabis use,” the research found, adding that only 26 percent reported a doctor recommended cannabinoids to them to treat their musculoskeletal (MSK) pain.

Notably, among those who said they used cannabis to manage pain, the most commonly used cannabinoid was CBD (39 percent), followed by a hybrid of multiple cannabinoids (20 percent). Almost a quarter (23 percent) said they were unaware of their cannabis’s composition.

Further, among patients who were not cannabis users, roughly two thirds (65 percent) said they were interested in using marijuana to manage their pain but reported barriers to use such as “lack of knowledge regarding access, use and evidence, and stigma,” although stigma was, contrary to previous research, not a primary concern.

“One in five patients presenting to an orthopaedic surgeon with chronic MSK pain are using or have used cannabis with the specific intent to manage their pain, and most report it to be effective.”

The paper, published in the Journal of Cannabis Research, didn’t seek to definitively determine whether marijuana effectively managed MSK pain symptoms—future double-blind, placebo-controlled trials are required to do that, it says—but instead intended to examine use and self-reported efficacy as well as potential obstacles to use among patients who are non-users.

The study was co-authored by six researchers from University Health Network, Sunnybrook Health Sciences Centre in Toronto, Canada. The 629 participants were adults 18 and older with chronic MSK pain “who were visiting the Orthopaedic Clinic at Toronto Western Hospital, University Health Network for a first-time consultation with an orthopaedic surgeon.”

Of the 23 percent of patients who said they had ever used cannabis to manage their MSK pain, 72 percent said it was part of their current treatment. The most frequent modes of use, meanwhile, were ingestion of oils (57 percent), smoking (36 percent) then vaporizing (32 percent).

While there were some commonly reported side-effects—dry mouth (43 percent), fatigue (23 percent) and a lack of motivation (15 percent)—about 2 in 5 (39 percent) said they experienced no side-effects.

“Many users indicated cannabis’s effectiveness in treating other symptoms,” the study adds, “primarily sleep disturbances (44%), anxiety (26%), and headaches (18%),” although 43 percent said they experienced no relief of other symptoms.

“Over 85% of cannabis users perceived it to be effective in managing their chronic MSK pain and improving their sleep and anxiety-related symptoms.”

As for where the patients obtained cannabis, many reported using multiple sources, “including a dispensary or compassion club (43% of users); a Health Canada licensed provider (34%), and from a friend or relative (33%).”

Despite the self-reported relief that cannabis users said the substance provided them, researchers also found that people who used cannabis also suffered more pain and a wider array of other ailments. But they stopped short of attributing those issues to cannabis use, instead suggesting that patients with a broader range of maladies might be more likely to seek out cannabis as an alternative or additional form of relief.

“It is noteworthy that cannabis users exhibited a constellation of comorbid conditions, including a higher prevalence of depression and pain, an increased number of painful bodily areas, longer pain durations, and more frequent visits to pain clinics/specialists when compared to non-cannabis users,” authors wrote. “This observation prompts us to consider the possibility that cannabis use may have arisen as a response to elevated levels of pain and dissatisfaction with existing therapeutic modalities. It is possible that a significant proportion of cannabis users turned to cannabis to seek relief from their heightened pain burden, which appears refractory to conventional treatments.”

“Furthermore, we observed that cannabis users, despite experiencing greater pain, tended to employ a broader array of medications, such as muscle relaxants, opioids, and antidepressants, in comparison to their non-cannabis-using counterparts,” they added. “This may also highlight that cannabis may have been sought as an alternative means of pain management, especially in situations where previous therapies yielded suboptimal results.”

Reinforcing that possibility was that one of the strongest predictors for cannabis use was having symptoms consistent with chronic pain syndrome, “suggesting that patients with chronic MSK pain are possibly unsatisfied with conventional treatments and seeking alternative pain management.”

The strongest predictor, however, was whether patients previously used cannabis recreationally.

“It was found that previous recreational cannabis use was associated with a more than tenfold increase in the odds of using cannabis to manage chronic MSK pain,” the study says, but it calls that finding “unsurprising as current cannabis use has been shown to strongly influence one’s perceptions of risk, stigma, and acceptability.”

Authors acknowledge that some of the perceived effectiveness may be due to a placebo effect, calling for more double-blind, placebo-controlled trials going forward.

The new research also cites past studies that found approximately 46 percent of patients “felt more comfortable discussing their cannabis use with their physician after legalization” and that “86% of orthopaedic patients that were characterized as cannabis users stated that they would be willing to stop consuming cannabis if their surgeon stated it would adversely impact their surgery.”

“These observations highlight the dire need for improved oversight and regulation of the medicinal cannabis industry,” the Toronto authors wrote.

The MSK pain study comes on the heels of a federal research meeting in the U.S. that brought together representatives of federal agencies to discuss the use of cannabis components to treat pain, with a special focus on minor cannabinoids and marijuana terpenes.

A federally funded study published in May indicated that terpenes could be “potential therapeutics for chronic neuropathic pain,” finding that an injected dose of the compounds produced a “roughly equal” reduction in pain markers when compared to a smaller dose of morphine. Terpenes also appeared to enhance the efficacy of morphine when given in combination.

Unlike with morphine, however, none of the studied terpenes produced a meaningful reward response, the research found, indicating that “terpenes could be effective analgesics with no rewarding or dysphoric side effects.”

Another recent study, published in the Journal of the American Medical Association, found that most marijuana consumers use the drug to treat health issues at least sometimes, but very few consider themselves medical marijuana users.

“Less than half the patients who used cannabis reported using it for medical reasons, even though the majority of patients reported cannabis use to manage a health-related symptom,” authors of that study wrote. “Given these discrepant findings, it may be more useful for clinicians to ask patients what symptoms they are using cannabis for rather than relying on patient self-identification as a recreational or medical cannabis user.”

“This aligns with another study that found that this type of cannabis use is clinically underrecognized,” they added, “and without specifically screening for medical cannabis use, clinicians may not ask and patients often do not disclose their use.”

Separately, a recent survey of marijuana consumers by the company NuggMD found that about a quarter use cannabis to manage their pain.

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