For Pain Relief, the ‘a’ in CBDa Makes All the Difference
By Chris Carmichael,
Founder and Head Coach of CTS
Nearly 50 years of riding (and crashing) bikes have taken their toll on my body. Nonetheless, I count myself as fortunate; injuries haven’t taken me away from the activities I enjoy or left me otherwise debilitated. But this year, as I near my 60th birthday, I’ve realized I’m more sore more often than I used to be. For reasons I’ll explain shortly, I knew I didn’t want to take over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) frequently or for extended periods of time, and my acute level of pain hasn’t warranted the use (and potential for addiction) of opioid pain killers. I’ve used cannabidiol (CBD) to reduce pain and improve sleep quality before, and more recently discovered that – for me – CBDa does an even better job on pain management.
This summer has been tougher than most. With most events and large-scale training camps cancelled for 2020 due to COVID, I have been working a lot of one-on-one and small-group cycling camps (abiding by local regulations and CDC guidelines). Don’t get me wrong, I love my job, but this summer I’ve ridden up Pikes Peak three times, climbed Cheyenne Canõn in Colorado Springs dozens of times, mountain biked and hike-a-biked all over the Rockies, and competed in the 4-day Pikes Peak Apex mountain bike race. Grinding up climbs that last 2-3 hours is particularly tough on my left leg, the one that’s an inch shorter due to a broken femur in 1986. The break split the femoral condyles at the knee, and while I am fortunate the knee is in pretty good shape for my age, it is prone to soreness. This summer, the pain was starting to reduce the quality of my sleep, and hence my recovery from training. And persistent pain was making some longer rides and longer climbs uncomfortable.
To understand why I’ve chosen CBDa for pain relief, and why I recommend it for endurance athletes, we have to start with the problematic nature of NSAIDs and opioids. If you already know this part, scroll down to the part about CBDa.
NSAIDs are dangerous for athletes
For years, probably decades, over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) were the go-to day-to-day solution for pain. This classification of drugs includes ibuprofen (Advil) and naproxen (Aleve). They were aggressively marketed for post-activity relief of pain and inflammation, whether that activity was dancing, gardening, moving furniture, or exercising. And the ads worked. Athletes seemingly ate NSAIDs like candy for delayed onset muscle soreness (DOMS), pain from minor injuries, and even pain during workouts and events. That last one is where people got into the most trouble.
The effects of NSAID use by athletes has been extensively studied, and the research overwhelmingly finds them more dangerous than they are helpful. Here is a summary of the relevant research findings and sentiments. The extensive list of references supporting this list can be found at the end of this article:
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- The use of NSAIDs increases the risk of hyponatremia (low blood sodium) in endurance athletes.
- The use of NSAIDs increases the risk of acute kidney injury in endurance athletes.
- NSAID use is prevalent amongst participants triathlon, cycling, running, and ultrarunning events.
- Athletes generally do not know the risks of NSAID use.
- NSAIDs have not been shown to improve performance.
- There is very little evidence that demonstrates NSAIDs improve injury outcomes.
- NSAIDs can perpetuate existing musculoskeletal injuries, primarily through masking pain but also by affecting the biochemistry of the healing process.
Nevertheless, medical directors at several ultradistance races devote time during pre-race medical briefings to implore athletes to not consume NSAIDs during or after the event. The one I heard most often was from Dr. John Hill, Medical Director for the Leadville 100 Race Series. You can watch it on this video, starting at 9:56. The point is, the risks associated with NSAID use may be pretty low for someone in the general population using it for occasional pain relief and fever reduction. For athletes, and anyone taking them frequently and over a long period of time, the health risks are significant.
Opioids killed more than 72,000 Americans in 2019
The emergence of prescription opioid painkillers like codeine, oxycodone, hydrocodone, and fentanyl provided physicians with highly effective medications for both acute and chronic pain management. People who suffered from debilitating pain for years experienced massive improvements in quality of life. They were able to complete activities of daily living with less pain or pain free. They were able to return to work, which was both fulfilling and lessened economic hardships. And they were able to move more and be more active.
Unfortunately, the addiction and overdose risks of opioids are significant and, according to the US Centers for Disease Control and Prevention (CDC), use and abuse of opioids contributed to the deaths of 72,000 Americans in 2019 alone. Although there are significant risks associated with opioids, these medications are undoubtedly effective for pain management, most physicians prescribe them responsibly, and most patients take them as prescribed and stop taking them within a short period of time. And there are also many doctors and patients using very powerful painkillers responsibly for long-term chronic pain, too. Opioids have their place in pain management, and I was happy to have them in the days after I broke my collarbone, but they need to be reserved for situations that truly call for such a potent pain reliever.
CBDa: What it is and how it may be a better solution for pain
OK, so how do we manage pain without NSAIDs or opioids? Actually, exercise can be part of the solution, as I wrote about a few years ago, and is likely one of the reasons my pain level still classifies as minor, even after all these years. Adding CBDa has helped me, too, and research shows it could potentially provide similar pain relief and anti-inflammatory benefits to NSAIDs with reduced risk for stomach or kidney problems.
NSAIDs work by inhibiting COX-1 and COX-2 enzymes. Of the two, COX-2 enzymes are the bigger player in your body’s response to injury, infection, and inflammation. COX-1 enzymes play a role in protecting the lining of your stomach and intestines, which is why inhibiting them may increase the risk for gastrointestinal bleeding. In a study by Takeda et al, CBDa was shown to selectively inhibit COX-2 enzymes to a far greater extent (9 times greater) than COX-1.
CBDa, or cannabidiolic acid, is found naturally in hemp plants and is the precursor to CBD (cannabidiol). The heat and chemicals used in traditional extraction methods causes CBDa to be converted to CBD. Unfortunately, the same study from Takeda et al showed that once converted to CBD, the selective inhibition of COX-2 enzymes disappeared. A different study by Rock et al showed (albeit in a rodent model) that CBDa was a more effective anti-inflammatory than CBD or THC–the psychoactive compound found in cannabis indica (marijuana) and to a far lesser extent in cannabis sativa (hemp).
CBDa can be thought of as the ‘raw’ form of CBD, before it got processed by heat and chemicals used to extract it from the hemp plant. It seems that as with the nutritional quality of fruits, vegetables, and grains, less processing is a good thing. Planetarie, a company in Denver, Colorado, developed a patent-pending Water Extraction Technology that is less destructive, uses only water and no heat, and yields CBDa that can be integrated into products like the drops and softgels that have helped me get through high volume training this summer. I like it so much I announced a partnership between Planetarie and CTS in September, and I encourage you to try their products and use Code: CTS at checkout to receive a discount on your order.
I, for one, have been really happy with how effectively CBDa helps manage my aches and pains, particularly in my left knee, and I believe it has been key to keeping me in the game and on the bike
References
Rock, Erin M., et al. “Effect of Cannabidiolic Acid and ∆9-Tetrahydrocannabinol on Carrageenan-Induced Hyperalgesia and Edema in a Rodent Model of Inflammatory Pain.” Psychopharmacology, vol. 235, no. 11, 2018, pp. 3259–3271., doi:10.1007/s00213-018-5034-1.
Takeda, Shuso, et al. “Cannabidiolic Acid as a Selective Cyclooxygenase-2 Inhibitory Component in Cannabis.” Drug Metabolism and Disposition, vol. 36, no. 9, 2008, pp. 1917–1921., doi:10.1124/dmd.108.020909.
References for NSAID research
Aguilera, D. (2017). Ultrarunners May Want to Skip the Advil. Retrieved from https://medium.com/stanford-magazine/ultrarunners-may-want-to-skip-the-advil-5f03fed055da
Chabbey, E., & Martin, P. Y. (2019). [Renal risks of NSAIDs in endurance sports]. Rev Med Suisse, 15(639), 444-447. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/30785678
Gorski, T., Cadore, E. L., Pinto, S. S., da Silva, E. M., Correa, C. S., Beltrami, F. G., & Kruel, L. F. (2011). Use of NSAIDs in triathletes: prevalence, level of awareness and reasons for use. Br J Sports Med, 45(2), 85-90. doi:10.1136/bjsm.2009.062166
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Kuster, M., Renner, B., Oppel, P., Niederweis, U., & Brune, K. (2013). Consumption of analgesics before a marathon and the incidence of cardiovascular, gastrointestinal and renal problems: a cohort study. BMJ Open, 3(4), e002090. doi:10.1136/bmjopen-2012-002090
Laird, R. H., & Johnson, D. (2012). The medical perspective of the Kona Ironman Triathlon. Sports Med Arthrosc Rev, 20(4), 239. doi:10.1097/JSA.0b013e3182736e8e
Lee, C., Straus, W. L., Balshaw, R., Barlas, S., Vogel, S., & Schnitzer, T. J. (2004). A comparison of the efficacy and safety of nonsteroidal antiinflammatory agents versus acetaminophen in the treatment of osteoarthritis: a meta-analysis. Arthritis Rheum, 51(5), 746-754. doi:10.1002/art.20698
Loudin, A. (2017). Does taking ibuprofen for pain do more harm than good? Retrieved from http://www.espn.com/espnw/life-style/article/20105680/does-taking-ibuprofen-pain-do-more-harm-good
Martínez, S., Aguiló, A., Moreno, C., Lozano, L., & Tauler, P. (2017). Use of Non-Steroidal Anti-Inflammatory Drugs among Participants in a Mountain Ultramarathon Event. Sports (Basel, Switzerland), 5(1), 11. doi:10.3390/sports5010011
McDermott, B. P., Smith, C. R., Butts, C. L., Caldwell, A. R., Lee, E. C., Vingren, J. L., . . . Armstrong, L. E. (2018). Renal stress and kidney injury biomarkers in response to endurance cycling in the heat with and without ibuprofen. J Sci Med Sport, 21(12), 1180-1184. doi:10.1016/j.jsams.2018.05.003
Medical and Other Risks. Retrieved from https://www.wser.org/medical-and-other-risks/
‘Ohana’ theme throughout 2019 IRONMAN and IRONMAN 70.3 events. (2019). Retrieved from https://www.endurancebusiness.com/2019/industry-news/ohana-theme-throughout-2019-ironman-and-ironman-70-3-events/
Paoloni, J. A., Milne, C., Orchard, J., & Hamilton, B. (2009). Non-steroidal anti-inflammatory drugs in sports medicine: guidelines for practical but sensible use. Br J Sports Med, 43(11), 863-865. doi:10.1136/bjsm.2009.059980
Reynolds, G. Retrieved from https://www.nytimes.com/2017/07/05/well/move/bring-on-the-exercise-hold-the-painkillers.html
Ungprasert, P., Cheungpasitporn, W., Crowson, C. S., & Matteson, E. L. (2015). Individual non-steroidal anti-inflammatory drugs and risk of acute kidney injury: A systematic review and meta-analysis of observational studies. Eur J Intern Med, 26(4), 285-291. doi:10.1016/j.ejim.2015.03.008
Ungprasert, P., Kittanamongkolchai, W., Price, C., Ratanapo, S., Leeaphorn, N., Chongnarungsin, D., & Cheungpasitporn, W. (2012). What Is The “Safest” Non-Steroidal Anti-Inflammatory Drugs? American Medical Journal, 3, 115-123. doi:10.3844/amjsp.2012.115.123
Warden, S. J. (2010). Prophylactic use of NSAIDs by athletes: a risk/benefit assessment. Phys Sportsmed, 38(1), 132-138. doi:10.3810/psm.2010.04.1770
Wharam, P. C., Speedy, D. B., Noakes, T. D., Thompson, J. M., Reid, S. A., & Holtzhausen, L. M. (2006). NSAID use increases the risk of developing hyponatremia during an Ironman triathlon. Med Sci Sports Exerc, 38(4), 618-622. doi:10.1249/01.mss.0000210209.40694.09
Whatmough, S., Mears, S., & Kipps, C. (2017). THE USE OF NON-STEROIDAL ANTI-INFLAMMATORIES (NSAIDS) AT THE 2016 LONDON MARATHON. British Journal of Sports Medicine, 51(4), 409-409. doi:10.1136/bjsports-2016-097372.317
Whatmough, S., Mears, S., & Kipps, C. (2018). Serum sodium changes in marathon participants who use NSAIDs. BMJ open sport & exercise medicine, 4(1), e000364-e000364. doi:10.1136/bmjsem-2018-000364
White, T. (2017). Pain reliever linked to kidney injury in endurance runners. Retrieved from https://med.stanford.edu/news/all-news/2017/07/pain-reliever-linked-to-kidney-injury-in-endurance-runners.html
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Comments 24
CBD oil is very good for pain relief. Even if you are having severe pain, CBD oil or medical marijuana is best for any pain. Many people use it to get relief from pain or depression. Even I use this for pain.julimia2234@gmail.com
Hi.. Check out Juicetiva.com. Been drinking this CBDa juice powder for about 4 weeks. Water-soluble. It actually dissolves in the water unlike other green drinks. The owner Chris is full of information. Don’t be shy to call to ask questions.
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Hello, thanks for sharing with us! I managed to learn so many interesting things from your article. I knew before that CBD oil is very beneficial, but I never realized that it could be used for such a wide range of medical purposes. I like it. It’s like a versatile pill. Of course, this does not mean that it is worth using everywhere, but its benefits are worth recognizing.
I usually have some pain in my back after doing some sport want to get rid of it as soon as I wiil know how!
Temporarily adding CBD to the diet to relieve pain and inflammation really does have a positive effect, and I don’t feel any stomach or kidney problems after taking it.
Is CBDa legal for cyclists? Any problems traveling with it?
Hey Donna. Hi.. Check out Juicetiva.com. Been drinking this CBDa juice powder for about 4 weeks. Water-soluble. It actually dissolves in the water unlike other green drinks. Spoke to the owner, Chris, he is happy to share any information you want. Don’t be shy to call, he’ll answer them all. Grown in California. ✌
Thank you for talking about these issues. To be honest, this is the first time I heard about this drug. Before that, I had always and everywhere heard only about CBD, and now you just opened my eyes to another drug from this plant. Although I always thought that this plant is no longer able to surprise me. But it seems to me that cannabis is just the main discovery of our century. As it turned out, we could avoid many problems and relieve pain for so many years, but we stubbornly did not want to notice it. But it’s good that we were able to notice these important properties and use them for the benefit of people. I hope this will become more affordable over time.
Chris is (was) a trusted source. So, after reading this article I decided to try the CBDa infusion drops from Planetarie. I took a full dose Friday night. Here is my experience:
* My sleep quality was much worse than usual. I had vivid dreams, and woke up with extreme groggy-ness. So groggy it took me an hour to get up. I had bags under my eyes from poor sleep quality.
* Then I spent the next several hours attempting to finish waking up. I was spacey and fuzzy-headed throughout the day, making several odd mistakes like leaving my car in Drive and wondering why the key wouldn’t move. This is not normal for me at all.
* Despite this I finally woke up completely around 3:00 PM. I had a good riding workout.
Saturday night I decided to try a half-dose instead.
* Again I had very poor sleep quality and vivid dreams.
* This time the groggy-ness was even worse. I spent the entire day Sunday trying to recover. I pretty much lost the whole day.
* I experienced the expected amount of soreness from the ride the day before, no reduction in DOMS.
* I generally felt bad all day, fuzzy-headed, very tired, some nausea, and just bad all around.
Summary: I recognize CBD/CBDa may work for some people, but be aware of the risks. For me this stuff was expensive, and highly detrimental. I wouldn’t recommend that anyone try it. Chris is a World-class performance coach, but I’ll think twice before considering him a trusted source of knowledge for any supplements in the future.
My advice is, save your (considerable amount of) money, and go to bed 30 minutes earlier instead. You’ll probably enhance your recovery without the side effects.
After reading your article I purchase a bottle of the soft gels from Planetaire. Other than the instructions to “take one capsule as needed” there doesn’t seeem to be any other directions as to how often to take them. Do you have any more details directions as to how best to use this product?
Hi Chris
Sorry, this does not relate to the bulk of the article, but how have you made accommodations for your leg length discrepancy? (I have had the same issue for 42 years, and biked with it for the last 15.)
I hope to bike well into my even goldener years, but was unsure if little by little I was causing issues that may curtail my activities.
Thanks
Lynn: My right leg is one inch shorter after breaking my femur badly back in 1986. Rocket 7 makes my cycling shoes and the right shoe (the sole) has been built up to about 1/2 inch more than the left shoe. The normal thinking on this, traumatic injuries require making up about 1/2 the leg lenght difference vs. being born with a leg lenght difference then you make up for the entire leg lenght discrepancy. I hope this helps. Chris
Thanks Chris, it’s nice to hear personal experiences from someone who has way more athletic / fitness lifestyle (& career) experience than most. Bottom line for me and many others, (who do even a small amount of research of pharma drugs), is plant-based, centuries old & tested, (some with double-blind, controlled studies), are more effective in the long term, with Tons less, (if any) side effects, (dumb-downed emotions, liver damage, stomach damage, even brain damage in kids, etc.).
Hemp & Cannabis have been used over millenniums, and there have literally thousands of studies of their positive, plenty from reputable universities, (yes, even the big drug funded ones, ha), medical institutions, and independent labs.
It is great that you have success with CBDa. I think I’ll try it! A phase 3 double blinded study comparing it to NSAIDs is the optimal way to compare the 2, otherwise our bias and testimonials will be our “proof” that CBDa is more effective for general use than NSAIDs.
Your description of acetaminophen as an NSAID in incorrect. Acetaminophen is an effective and safe, short acting pain reliever, when used as directed. This is relative since there is no medicine which is safe for every person.
It is also worth remembering that there are studies showing many subjects have improvement of pain using placebo.
Author
Dr. Griffeth,
Thank you for pointing out the error of including acetaminophen in the list of NSAIDs. We have updated the article accordingly. As far as we know, there hasn’t been a randomized double blind placebo controlled study that compared the effects of NSAIDs and CBDa, but we’ll keep looking. – Jim Rutberg, CTS Coach & Editorial Director
Hey J. Griffeth, M.D.
Check out Juicetiva.com. Been drinking this CBDa juice powder for about 4 weeks. Water-soluble. It actually dissolves in the water unlike other green drinks. The owner Chris is full of information. Don’t be shy to call to ask questions.
Sounds great for the aches and pains of being an aging, injured athlete. What about the effect on renal function. That is still mediated by the COX-1 and COX-2 enzymes. Many NSAID users read the bottle and take the doses recommended. Many take the maximum dose of 800mg every 8 hours. That dose leads to a high blood level (well above the therapeutic threshold, but allowing for less frequent dosing) that lasts for that 8 hour period of time. Taking 200 mg every two hours leads to the therapeutic blood level more slowly, but avoids the unnecessarily high blood level that occurs with the 800 mg Q 8 hours. The kidneys do not need to see those high blood levels for any reason. A little tip based on uptake, distribution and other pharmacokinetic principles.
Thank you, it’s really better to take 200mg at a time.
Nice advertisement for your product. Problem is just because something inhibits an enzymatic pathway in vitro doesn’t mean that translates to a clinical response. There are a lot of steps between bench and bed as we say in medicine. Additionally, Tylenol, acetaminophen, is NOT an NSAID. It is purely an analgesic, not an anti-inflammatory. You really should stick to talking about stuff you know about.
Author
Dr. Cyclist,
Thank you for pointing out the error of including acetaminophen in the list of NSAIDs. We have updated the article accordingly. And for advising about the many steps between bench and bed. The same holds true in exercise physiology. For instance, the hypoxic stimulus from sleeping in an altitude tent doesn’t always result in the cascade of effects that leads to improved endurance performance. At the end of the day, human performance is our wheelhouse, and I think you’ll find that over the past 20 years we have been careful to avoid overstating claims. – Chris Carmichael, Founder and Head Coach
Hey Chris: I wasn’t going to open this article, however, I did and I’m pleased to see information presented on other forms of paint relief in “chronic” situations for athletes. I have lived with extreme knee pain for 30+ years and finally did a total knee replacement thinking it would relieve all the pain I had been experiencing. My body tends to make excess scar tissue, so, recently I went back in to do arthroscopic surgery to get it out. I’m eight weeks out and not at the comfort level (pain free) that I’d like to be. Even though the scientific articles are very early on in the experimental stages of CBDa efficacy/safety, it is nice to see another potential option. I’m glad it has helped you! I’ll take a look into it. Thanks Chris!
Thanks Chris for adding what evidence is available, albeit limited, to this testimonial advertisement about CBDa and Planetaria. It helps to see beyond the testimonial to know if it is worth trying for all of us aging athletes.