Topical CBD absorption and augmenting patient pain management

New studies make the case for topical cannabinoids with creams that have proper topical CBD absorption

The global pain management market, estimated at $80 billion^[1] in 2021, is expected to grow at an annual rate of 7.4% per year through 2027. Topical analgesics targeting mild to moderate pain are a $7.2 billion market. Agents with proper topical CBD absorption, although generally ineffective against deep tissue pain, allow precise targeting^[2] of localized pain while providing systemic safety, rapid onset and low risk of tolerance or abuse.

Many topical pain agents were originally developed as oral or injected drugs and later reformulated in a dosage more suited to topical administration (e.g., creams, gels, ointments). These include salicylates, nonsteroidal anti-inflammatory drugs (NSAIDs), capsaicinoids, corticosteroids and opioids. Physicians currently recommend these medicines to treat localized eczema, contact dermatitis, psoriasis, abrasions, muscle aches, etc.

Given their established therapeutic efficacy, the major benefit of topical pain agents is the ability to treat localized pain while minimizing systemic dosing, adverse events and drug interactions: For example, with clobetasol, a prescription-only corticosteroid used to treat swelling and itching, side effects occur in one-third of patients receiving the drug orally, but are absent^[3] when the drug is applied to the skin.

The case for topical cannabinoids

Patients and physicians often turn to “natural,” non-pharmaceutical approaches for the relief of mild to moderate pain. Examples include both oral (e.g., turmeric, pycnogenol, ginger) and topical (capsaicin, willow bark) agents. Some, like capsaicin patches,^[4] have been approved by the U.S. Food and Drug Administration for treating nerve pain.

Cannabinoids are an emerging group of compounds with the potential for both oral and topical administration for pain relief. Found mainly in cannabis products, cannabinoids act on one or both cannabinoid receptors:^[5] CB1 receptors, which arise mostly in the brain, limbic system and the eye, and CB2 receptors, which are located in immune cells.

Of the more than 80 cannabinoids, non-psychotropic cannabidiol (CBD) acts as a complex agonist and antagonist on more than 70 distinct molecular targets,^[6] including enzymes, ion channels, G-protein coupled receptors, transporter proteins, and nuclear receptors, many of which mediate pain, inflammation and mood.

Randomized, controlled clinical trials on cannabis in pain relief tend to be small and often include full-spectrum cannabinoids rather than CBD alone. The studies thus far undertaken, however, are encouraging.

Topical CBD absorption and study results

A preclinical study on a rat knee osteoarthritis mode^[7] using CBD gels found that treated animals recovered to near-baseline activity. The authors concluded that “topical CBD application has therapeutic potential for relief of arthritis pain-related behaviors and inflammation without evident side-effects.”

One small crossover study^[8] examining the topical application of commercial CBD oil on 29 patients with peripheral neuropathy concluded that “the transdermal application of CBD oil can achieve significant improvement in pain and other disturbing sensations in patients with peripheral neuropathy. The treatment product was well tolerated and may provide a more effective alternative compared to other current therapies in the treatment of peripheral neuropathy.”

Recently a small, randomized, double-blind crossover study in humans examined the effectiveness of topical CBD for treating neuropathic pain.^[9] Investigators found “a statistically significant reduction in intense pain, sharp pain, cold and itchy sensations in the CBD group,” and no adverse events. They concluded that transdermal CBD “may provide a more effective alternative compared to other current therapies in the treatment of peripheral neuropathy.”

Incorporating CBD into your practice

There is no dearth of advice on maximizing the profitability of a chiropractic practice. A path toward expanding business involves increasing the value of your services to patients. Non-pharmaceutical interventions to help patients manage mild to moderate pain represent a significant value-added component to the modern chiropractic practice.

This publication’s 2021 Salary & Expense Survey^[10] of U.S. chiropractors uncovered several key areas that support offering CBD products directly to patients. These categories include nutritional supplements (53% of those surveyed offering them), topical creams (47%), and CBD products (32%). Twenty-eight percent of those surveyed specifically offered topical CBD products.

Given the widespread practice of chiropractors offering non-pharmaceutical alternatives for treating pain, the encouraging clinical results on CBD’s effectiveness (including as a topical treatment), and its acceptance among clinicians, it appears that topical CBD is entering the mainstream.

A 2016 article^[11] suggested that, depending on practice size and characteristics, chiropractors could earn anywhere from $500-$20,000 per month from the sale of supplements. Six years later, those figures are probably on the low side. Regardless, they clearly demonstrate a financial benefit to practices.

Selling CBD products directly to patients, however, involves more than money. Practitioners must first and foremost believe in these products and the value they bring patients. This involves educating yourself on the benefits through the scientific literature, keeping up to date on the latest clinical data and sharing it with patients when appropriate.

Bringing more value to patients

Products with maximum topical CBD absorption have entered the mainstream of chiropractic by virtue of its already wide consumer acceptance,^[12] its well-established safety and limited but encouraging evidence of clinical efficacy.

While a solid financial case can be made for selling CBD creams, ointments and gels, the decision to sell or not boils down to the value these products bring patients. Once chiropractors decide to sell these products, they must continue to educate themselves on the benefits and potential risks and monitor the progress of patients who use these products.

JOSEPH D. SALAMONE, DC, DAAPM, FRCCM, has had a private practice in Fairfield, N.J., for more than 30 years, and writes for Parker Laboratories HELIX (Helix4Pain.com). He founded the American Academy of Hospital Chiropractors, where he was one of four in the country to be on call in the emergency room.

References

^[1]  BCC Research, 2019. The Global Market for Pain Management Drugs and Devices. Accessed here

^[2] Jorge LL, Feres CC, Teles VE. Topical preparations for pain relief: efficacy and patient adherence. J Pain Res. 2010;4:11-24. Published 2010 Dec 20. doi:10.2147/JPR.S9492.

^[3] Kiran MS, Vidya S, Aswal GS, Kumar V, Rai V. Systemic and Topical Steroids in the Management of Oral Mucosal Lesions. J Pharm Bioallied Sci. 2017;9(Suppl 1):S1-S3. doi:10.4103/jpbs.JPBS_91_17.

^[4] Privitera, Rosario; Anand, Praveen Capsaicin 8% patch Qutenza and other current treatments for neuropathic pain in chemotherapy-induced peripheral neuropathy (CIPN), Current Opinion in Supportive and Palliative Care: June 2021 – Volume 15 – Issue 2 – p 125-131

doi: 10.1097/SPC.0000000000000545.

^[5] Cather JC, Cather JC. Cannabidiol primer for healthcare professionals. Proc (Bayl Univ Med Cent). 2020;33(3):376-379. Published 2020 Jul 6. doi:10.1080/08998280.2020.1775437

^[6] Mlost J, Bryk M, Starowicz K. Cannabidiol for Pain Treatment: Focus on Pharmacology and Mechanism of Action. International Journal of Molecular Sciences. 2020; 21(22):8870. https://doi.org/10.3390/ijms21228870

^[7] Hammell DC, Zhang LP, Ma F, Abshire SM, McIlwrath SL, Stinchcomb AL, Westlund KN. Transdermal cannabidiol reduces inflammation and pain-related behaviours in a rat model of arthritis. Eur J Pain. 2016 Jul;20(6):936-48. doi: 10.1002/ejp.818. Epub 2015 Oct 30. PMID: 26517407; PMCID: PMC4851925.

^[8] Xu DH, Cullen BD, Tang M, Fang Y. The Effectiveness of Topical Cannabidiol Oil in Symptomatic Relief of Peripheral Neuropathy of the Lower Extremities. Curr Pharm Biotechnol. 2020;21(5):390-402. doi: 10.2174/1389201020666191202111534. PMID: 31793418

^[9] Xu DH, Cullen BD, Tang M, Fang Y. The Effectiveness of Topical Cannabidiol Oil in Symptomatic Relief of Peripheral Neuropathy of the Lower Extremities. Curr Pharm Biotechnol. 2020;21(5):390-402. doi: 10.2174/1389201020666191202111534. PMID: 31793418.

^[10] Citation not available on site.

^[11] Citation not available on site.

^[12] Grand View Research. Cannabidiol Market Size, Share & Trends Analysis Report By Source Type (Hemp, Marijuana), By Distribution Channel (B2B, B2C), By End-use (Medical, Personal Use), By Region, And Segment Forecasts, 2021 – 2028. February, 2021.