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:
- 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
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
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