CBD and Pain (2/3): Therapeutic Applications of CBD by Type of Pain

Therapeutic Applications of CBD by Pain Type

Research on CBD has covered various types of pain, from musculoskeletal inflammatory conditions to neuropathies. Below, we analyze the most recent findings (mainly since 2020) in different pain categories:

Chronic Non-Cancer Pain

Chronic pain (long-lasting, not cancer-related) is one of the most common indications for which the use of cannabinoids has become popular. Many patients with refractory chronic pain have turned to cannabis or CBD seeking relief when standard treatments fail. In recent years, clinical studies have specifically explored CBD (without THC) to evaluate its analgesic efficacy.

• A 2020 prospective study with 131 chronic pain patients who received a CBD-rich oil formulation (oral dose of 60 mg daily) observed a significant improvement in pain and quality of life, along with a reduction in opioid use in this patient group. In this study (open-label design but with high methodological quality), CBD was associated with a decrease in pain scores and allowed for the reduction or discontinuation of opioid analgesics in many cases, suggesting a beneficial opioid-sparing effect. These results indicate that CBD could be an effective and safe analgesic for chronic pain, complementing or partially replacing opioids, with the potential benefit of fewer adverse effects.

• In contrast, a randomized clinical trial in 2021 investigated CBD for acute low back pain. This study (called the CANBACK trial) included 143 patients who presented to the emergency room with acute low back pain; they were administered a single oral dose of 400 mg of CBD or placebo along with standard treatment. The results showed no significant differences in pain relief between the CBD and placebo groups in the short term. That is, CBD was not superior to placebo as a complementary medication for acute low back pain in a context of intense pain treated with conventional analgesics. The authors point out that in severe acute conditions (where opioids or other high-potency drugs are often used), it may be difficult to detect the added benefit of CBD. This finding suggests that CBD alone may not be sufficient for intense acute pain, or at least not at the dose and in the context evaluated.

• Another relevant application is in chronic orofacial and muscular pain disorders. A 2024 clinical trial evaluated CBD in patients with temporomandibular disorder (TMD) associated with bruxism and mandibular muscle pain. 60 patients were included, who received intraoral formulations of 5% or 10% CBD or placebo for several weeks. The double-blind study found that CBD administration reduced mandibular pain, muscle tension, and the frequency of bruxism episodes during sleep, compared to placebo. Treated patients reported improvement in mandibular mobility and less pain when chewing, indicating a potential use of CBD in the management of musculoskeletal pain associated with spasms or tension (such as those from bruxism). This is a novel field where few therapies offer effective relief, and CBD could represent a non-invasive alternative to improve symptoms and quality of life.

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Inflammatory and Musculoskeletal Pain (Arthritis and Osteoarthritis)

Pain of inflammatory or degenerative musculoskeletal origin (such as osteoarthritis, rheumatoid arthritis, or chronic joint pain) has been the subject of numerous studies with CBD, given its known anti-inflammatory activity.

• In a randomized 2022 study, a topical CBD treatment was tested in patients with thumb base arthritis (rhizarthrosis), a form of hand osteoarthritis. 18 patients with trapeziometacarpal osteoarthritis participated, applying a CBD ointment (6.2 mg/mL) to the affected joint or a placebo ointment for 2 weeks. The results showed significant improvements in pain and hand functionality in the CBD-treated group compared to placebo. Pain scales on movement significantly decreased, and manual dexterity increased, with no major adverse events. This suggests that topical CBD can relieve joint pain and local inflammation in osteoarthritis, constituting a practical option given that it acts locally and minimizes systemic exposure.

• Similarly, an open-label study in 2024 evaluated a transdermal CBD gel (4% w/w) applied three times a day for 4 weeks in 15 patients with hand osteoarthritis. Although this study did not have a placebo group, patients showed reduced pain and improved grip strength after treatment, according to subjective and objective measures, with no serious adverse effects. The authors conclude that topical/transdermal CBD could be beneficial in hand osteoarthritis or other superficial joints, although they recommend larger controlled studies. The topical route appears advantageous for this type of localized pain, leveraging CBD's high skin permeability (which is ~10 times greater than that of THC).

• In animal models and veterinary practice, CBD has also been investigated for inflammatory joint pain. Two clinical trials in dogs with osteoarthritis demonstrated positive results. In one of them, CBD oil was administered at a dose of 2 mg/kg twice daily to dogs with osteoarthritis; after several weeks, an improvement in the comfort and activity of the dogs was observed, measured by veterinary pain and mobility scales (such as the Canine Brief Pain Inventory), with no significant adverse effects. In another study (2020), encapsulated CBD (20 mg/day) vs. non-encapsulated (50 mg/day) was compared in dogs with arthritis, finding both regimens effective in reducing pain and with evidence of objective anti-inflammatory effect (reduction of inflammatory markers). These animal findings support the idea that CBD relieves joint inflammation and suggest that it may have applications in veterinary species (e.g., improving mobility in geriatric pets with osteoarthritis), in addition to being a translational model for joint pain in humans.

• Regarding systemic inflammatory conditions like rheumatoid arthritis, direct clinical evidence with CBD is still limited. However, preclinical studies have been encouraging: in rats with induced arthritis, CBD administration reduces the release of pro-inflammatory cytokines (such as TNF-α, IL-1β) in the joint and attenuates joint damage. Clinically, there is interest in evaluating CBD as an adjuvant in rheumatoid arthritis or other rheumatic diseases; in fact, rheumatology experts express "cautious hope" for CBD in this field, emphasizing its good safety profile but acknowledging the need for more rigorous trials. For now, the use of CBD in chronic inflammatory pain is limited to individual cases or small series, where some patients report relief from pain and stiffness, but large controlled trials are lacking. In countries where medicinal cannabis is permitted, combined THC-CBD products (e.g., nabiximols) are used off-label for refractory inflammatory pain, but it is difficult to attribute effects solely to CBD in these cases.

Neuropathic Pain

Neuropathic pain (originating from nerve damage or dysfunction) is notoriously difficult to treat with current drugs, and less than 50% of patients achieve adequate relief with standard therapies. CBD has emerged as a potential alternative for this type of pain, supported by robust preclinical results: in animal models of neuropathy, CBD reduces allodynia and hyperalgesia and protects neurons against hyperexcitability induced by chemotherapeutics. Regarding clinical evidence in humans:

• A small controlled trial in 2019 explored a topical CBD oil in patients with peripheral neuropathy of the lower extremities (caused by diabetes or other etiologies). 29 patients participated, applying CBD (250 mg total CBD in the bottle) or placebo to their feet for 4 weeks. The results showed that topical CBD significantly improved neuropathic pain, reduced itching sensation, and painful coldness, compared to placebo. Treated patients reported less numbness and improvements in sleep-related quality of life. Given that options for peripheral neuropathy are limited and have side effects (e.g., antidepressants, gabapentinoids), this study suggests that a CBD cream could be a safe and effective option for relieving localized neuropathic symptoms, without causing notable systemic effects.

• Another area of neuropathic pain studied is chemotherapy-induced neuropathies. Although no conclusive clinical trials have been published, case reports and small series indicate that patients with chemotherapy-induced neuropathy (such as that caused by paclitaxel) have obtained partial relief using sublingual CBD oil, improving their functionality. These findings align with studies in mice, where CBD prevented the development of mechanical allodynia and cold allodynia after paclitaxel treatment. The possible mechanism is the protection of sensory nerve fibers against inflammation and oxidative stress induced by the chemotherapeutic agent. While formal clinical evidence is needed, there is therapeutic potential for CBD for peripheral neuropathy of various causes, including diabetes, chemotherapy, or compressive neuropathies.

• An important aspect to note is that current guidelines are cautious regarding CBD/cannabis in neuropathic pain. For example, European and Canadian guidelines place cannabinoids as a third or fourth-line treatment for refractory neuropathic pain. This implies that they are only considered after trying conventional medications (anticonvulsants, tricyclic antidepressants, etc.), and usually referring to THC+CBD combinations. The National Institute for Health and Care Excellence (NICE) in the UK recommended in 2020 not to initiate cannabinoid treatment for neuropathic pain due to a lack of conclusive evidence. However, in individual cases of severe neuropathy where other therapies fail, some specialists might consider a trial with CBD, especially given its safety profile. Still, the efficacy of pure CBD in chronic neuropathic pain remains under debate, with systematic reviews indicating that clinical evidence is of low quality and with inconsistent results. In conclusion, although preclinical CBD appears promising for neuropathy, clinically more controlled trials are needed to establish its true role and appropriate dosage in these conditions.

Cancer Pain and Other Applications

Cancer-related pain (oncological pain) is another area of interest. Historically, studies from the 1970s suggest that cannabinoids may have analgesic effects on tumor pain. Proposed mechanisms include inhibition of neurotransmitter release, activation of descending inhibitory pathways, and reduction of neuroinflammation caused by cancer. However, specific clinical evidence on isolated CBD for oncological pain is very limited. Most trials in cancer patients have used combinations of THC and CBD (e.g., nabiximols/Sativex) finding some modest pain improvement compared to placebo, but it is difficult to discern the contribution of CBD in particular. To date, there are no large published trials of pure CBD for cancer pain, and meta-analyses point to insufficient evidence to routinely recommend cannabinoids for oncological pain. Despite this, some patients with advanced cancer use CBD oil as an adjuvant to manage pain and other symptoms (anxiety, insomnia), reporting subjective benefits. This area remains controversial and controlled studies are needed, especially given that oncological pain management often requires opioids and comprehensive therapies.

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Other investigated applications include visceral pain (for example, in irritable bowel syndrome, IBS). A 2022 exploratory crossover study administered chewing gum with 50 mg of CBD to patients with IBS to evaluate its effect on abdominal pain. The results showed no significant reductions in pain with CBD compared to placebo. The authors suggested that the dose and formulation (chewable) might have influenced the outcome, as some participants had difficulties with administration (chewing for a prolonged time) without achieving sufficient CBD levels. This result indicates that, in IBS-type visceral pain, CBD was not clearly effective in that trial, although questions remain about the bioavailability achieved.

Finally, CBD has been proposed to improve post-exercise muscle pain or pain related to sports injuries. A study in untrained volunteers (2021) tested 150 mg of CBD after intense physical exertion, measuring delayed onset muscle soreness. No benefits were observed in reducing this muscle pain with CBD compared to placebo. It is possible that in this acute-inflammatory context (muscle microtears), the dose used was not sufficient or the treatment time (48h) too short for CBD to show effects. Again, this highlights that the effectiveness of CBD may depend on the type of pain, the dose, and the route of administration, being more evident in established chronic/inflammatory pain than in transient acute models.

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