Endocannabinoids in Orthopedic Surgery and Musculoskeletal Medicine: Is it Time for a Green Standard



Abstract Keywords: Endocannabinoids; Orthopedic Surgery; Musculoskeletal Medicine; Cannabis Cannabis and endocannabinoid agonists have been safely used for decades by a large segment of the United States population for both recreational and medicinal purposes [1]. The medical use of cannabis products has been legislatively restricted for decades in the United States [2]. Due to widespread enthusiasm for cannabis in American Society, no authority can deny the wide margin of safety that exists, even for chronic use [3,4]. Newly enacted legislation over the last several years has decriminalized cannabis consumption and even legalized its use in some states for both recreation and medicinal purposes [5]. Most recently, clinicians’ guides to cannabidiol (CBD) and hemp oils have moved to the front seat of many prestigious clinical publications [6]. The translation of cannabinoids from herbal preparations into highly regulated prescription drugs is progressing very rapidly and healthcare practitioners must become familiar with its mechanisms and possible clinical applications [7]. These drugs and supplements may provide an unmet need in the management of patients with osteoarthritis and other musculoskeletal ailments. It may be time for a new gold standard in our approach to the clinical condition of arthritis where these pharmaceuticals play an important role.

Cannabis preparations are available in legal and illegal formats and may or may not include the active agent, delta-9-tetrahydrocannabinol (delta-9-THC) found in traditional cannabis sought out by the counter-culture [8]. Availability of the legal pharmaceutical and the legal and illicit formats of the drug/supplement in the United States varies widely and is largely dependent upon constantly changing state and federal laws [9]. This constantly changing climate has left many orthopedic surgeons and other healthcare providers to speculate on the appropriate way to answer questions patients present regarding endocannabinoid agonists [10].

This article seeks to familiarize the orthopedic surgeon and other musculoskeletal healthcare providers with the information they need to be able to counsel patients appropriately about the potential risks, benefits, alternatives and complications associated with endocannabinoid management and dosing. While endocannabinoids are well tolerated, they are not benign, with the two most common side effects being anxiety and mood alterations and more serious complications have been reported [11]. These complications are likely to be patient specific and may be difficult to predict due to cognitive variability in the general population and to uncertain dosing in unregulated preparations. Some authors have suggested a maintenance dose of 10 - 20 mg/kg CBD administered daily in divided dosing based on clinical response, while others have recommended adhering to the same “start slow and go slow approach guidelines” published for cannabis by the state of California [12]. We agree with the concept of starting low and proceeding in a slow and deliberate fashion with treatment. We believe that an understanding of the generally tolerated dose response curves suggested in the current literature may represent a good ‘starting point’ for that approach.

While the sativa plant contains at least 113 phytocannabinoids, for the purposes of this discussion, the two primary molecules that have been recently exploited for their medical uses in the United States and elsewhere are delta-9-THC and CBD. The psychotropic effects of endocannabinoids are distinct from the anti-inflammatory and immunomodulatory effects. CBD exceedingly antagonizes psychotropic effects from the D9THC molecule through competitive inhibition for the same receptor. This is an important point for understanding accurate endocannabinoid dosing of different preparations and potential indications for management with different preparations and how CBD functions in biological systems.


To Continue Reading https://www.ecronicon.com/ecor/pdf/ECOR-11-00592.pdf

S. Austin Yeargan III, MD Orthopedic Surgeon Molecular Immunobiologist

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