Patients

A sample of 500 adult orthopaedic patients (m = 249, f = 247; 4 = undisclosed, 54 ± 16 years, 18-86 years) were recruited from a single hospital system performing both outpatient and inpatient surgeries in a major metropolitan area. All patients were recruited before surgery within all orthopaedic subspecialties, which included sports medicine; total joint arthroplasty; hand, foot, and ankle; spine; and general orthopaedics. Patients who met inclusion criteria were screened before surgery by the research team and recruited through REDCap e-consent and survey. Because of the supplement/drug-related nature of the study, completion of the surveys was anonymous through instruction of the institutional review board. Inclusion criteria included patients undergoing orthopaedic surgery above the age of 18 years. Patient demographics and procedure distributions are presented in Table I.

Study Protocol

All orthopaedic patients were sent an email with a REDCap link for an anonymous survey. The survey included questions about the following: demographic information, reason for seeking orthopaedic treatment (subspecialty), pain level on the day of survey completion as well as over the past week and month prior to survey completion (Visual Analog Scale [VAS] 0-100), previous knowledge of and/or use of CBD, and indication of whether the patient is supportive of CBD use for perioperative pain management. Those in support of CBD use were also asked about their reasoning for support of CBD use and their openness to the use of CBD for pain management. Those not in support of CBD use were asked about their reasoning for being apprehensive of CBD use for pain management. A copy of the survey can be found in the data supplement (see Appendix).

Statistical Analysis

All statistical analyses were performed using SPSS Statistics Software (v.26; IMB). Independent sample t-tests and an ANOVA followed by a Bonferroni post hoc test for individual pairwise comparisons were used to compare continuous/parametric survey data among sex (male vs female) and age (18-40 years, 41-60 years, 61+ years) for all patients. The same test was used to compare survey responses between patients seeking treatment for acute vs. chronic conditions. Next, among all included procedure types, a one-sample t-test was used to determine perceptions of “efficacy” and “openness to use” (quantified using a VAS scale of 0 [no favorability] to 100 [max favorability]) with scores significantly above 50 considered to be “more favorable” and those below 50 to be “less favorable”. Next, chi-square analysis was used for frequency-based data comparisons between subcategories of respondents. Type-I error was set at α = 0.05 for all analyses.

Last, descriptive statistics for the frequency of the following was recorded: perceptions of what CBD is commonly used for, rational for use by those who reported previously using CBD, reason for first being interested in using CBD among those who reported previous use, reason for not using CBD among patients who reported no previous use, and factors required for patients to consider using CBD among patients who reported no previous use.

Familiarity and Prevalence of Use

The frequency of previous use and those who have heard of CBD among each surgery type is presented in Table II, with over 80% of patients having previously heard of CBD. Of all patients surveyed, 41.8% indicated they have used CBD before (range: 19%-63%) with the highest frequency of use reported among hip arthroscopy patients (62.96%).

Among patients reporting previous use of CBD, rationale frequencies for use are presented in Figure 1. Among those who reported previously using CBD, the majority reported primarily using CBD for pain management (79.43%) (Fig. 1-A). In addition, 17.22% reporting using CBD for management of anxiety/depression, 30.14% for stress, 20.10% for recreational purposes, 7.18% as a sleep aid, and 1.91% have used CBD during cancer treatment. Among the patients who have used CBD, 58.81% stated they were first interested in CBD because they were seeking an alternative treatment (Fig. 1-B). In addition, 49.76% were interested because they were not experiencing relief on current treatment regimens and 44.02% were interested because it was recommended by others (Fig. 1-B).

Among patients reporting no previous use of CBD, rationale frequencies for no previous use are presented in Figure 2. The most common reasons for subjects to have not used CBD before included being unsure of how to obtain CBD (42.76%) or a lack of familiarity with CBD (37.24%) (Fig. 2-A). Most patients who have not used CBD did endorse they would consider using it if a prescription CBD was available (61.22%), there was more available evidence on its safety and efficacy (44.90), or if there were better regulations on its use (28.16%) (Fig. 2-B).

Over 80% of the patients interviewed undergoing each procedure type agreed with the statement that CBD may be effective for controlling pain and that they would be open to using CBD to manage pain (Fig. 3-A). All procedure types except for fracture repair had a statistically significant percentage of subjects who agreed CBD may be effective for controlling pain. All procedure types had a statistically significant percentage of subjects who would be open to using CBD for pain management (Fig. 3-B). When comparing patient-reported pain scores across the past week and month, those who reported prior use of CBD were observed to have higher pain scores across the past month before taking the survey (Fig. 4, p = 0.023).

Last, no effect of sex or age was observed with regard to frequency of CBD use or patient perceptions of CBD (usage or apprehension towards usage).

Prevalence of Use Among Orthopaedic Patient Populations

As of 2019, the Substance Abuse and Mental Health Services Administration reported that approximately 14% of the population aged older than 18 years has used or is currently using CBD²⁴. Subsequently, this frequency rose to nearly 1 in 3 adults in 2020 despite mixed evidence regarding efficacy and a lack of FDA-approved sources designated for the treatment of pain²⁴. In the orthopaedic population surveyed here with over 500 patients among several subspecialties, 41.8% of patients reported having used CBD. This result is somewhat expected considering the primary reason for reported use was pain management, and pain is a common component of why patients seek orthopaedic treatment to begin with. Cumulatively, these findings indicate that even amidst a growing frequency of use among general population adults, use of CBD in the form of nonprescription grade over the counter is even further elevated among orthopaedic patients, regardless of age.

Compared with those who have not used CBD, the pain population that has used or is using CBD was the population that had higher pain levels over longer periods of time (>1 month). Furthermore, arthroscopic procedures of the hip, knee, and shoulder as well as total joint arthroplasty were observed to be among the most frequent users when examining across subspecialty (Table II). However, further study will be required to determine if orthopaedic populations suffering from more chronic conditions may be more likely to seek out alternative pain management strategies before being surgically treated (compared with those with more acute trauma).

Rational for or Against CBD Use Among Orthopaedic Patients

As previously mentioned, pain was the primary factor for patient-reported CBD use. Other reasons for use included treatment of stress and anxiety, or for recreational purposes. This is consistent with data from a survey of individuals who used CBD for medicinal purposes, in which chronic pain was the most common reason for reported use, followed by arthritis or joint pain, then anxiety²⁵. Briefly, the mechanisms of the often reported analgesic effect of CBD includes inhibition of the release of neurotransmitters and neuropeptides from presynaptic nerve endings, modulation of postsynaptic neuron excitability, activation of descending inhibitory pain pathways, and reduction of neural inflammation¹². However, data from human clinical trials remains lacking with previous studies involving only short durations, low sample sizes, blends of different nonpure CBD sources, and a wide range of dosing strategies¹². Therefore, substantial need remains for further evidence on efficacy, dosing, and long-term clinical outcomes.

Despite the current lack of evidence, use of CBD for pain management in the general population continues to rise. Multiple survey-based outcome studies have reported that chronic use of CBD by various clinical populations resulted in a marked reduction in the use of other pain medications. For instance, one study that surveyed chronic pain patients, Schilling et al.²⁶ reported that 59% of patients indicated that CBD helped alleviate their pain, with as many as 67.6% decreasing their pain medication use after initiation of CBD. Another study demonstrated similar findings in patients with fibromyalgia, where patients surveyed endorsed a decreased reliance on pain medication when using CBD²⁷. These reports paired with the findings presented here add further support to warrant large-scale randomized controlled trials and improved availability of pharmaceutical-grade CBD for therapeutic use.

Regarding our orthopaedic patients who had not previously used CBD, the most common reasons for hesitancy of use were lack of access to prescription grade CBD (61%), limited evidence on efficacy (45%), and a lack of regulations on CBD products (28%) (Fig. 2). This further illuminates a need for investigation into the efficacy and safety profile of CBD for treatment of specific medical conditions outside of its current list of FDA-approved conditions. Notably, these reasons were provided in markedly higher frequency compared with the commonly reported stigma of CBD in association with marijuana use²⁸.

Clinical Considerations

Based on a systematic review of multiple randomized controlled trials, CBD is generally well tolerated²⁹. However, its most common side effects include dry mouth, euphoria, hunger, red eyes, and sedation or fatigue. Diarrhea has been reported as an additional side effect. Furthermore, it may interact with the hepatic metabolism of certain medications. Therefore, it is reasonable to conclude that CBD is generally well tolerated and can be safely prescribed as long as a proper review of potential medication interactions is conducted²⁹. Nevertheless, lack of pharmaceutical-grade CBD for therapeutic or recreational use remains a substantial concern and barrier for care providers seeking alternative methods for multimodal pain management. Therefore, providing physicians with data for both efficacy and the ability to safely prescribe CBD holds important clinical value. Furthermore, to our knowledge, no current publications exist that have compared CBD with opioids for postoperative pain management. As previously mentioned, biochemical and subjective evidence exists to support the exploration of CBD as a potential modality for pain management. Obtaining robust evidence for the use of CBD to control pain may help to initiate more widespread use of CBD in the medical field, consequently decreasing the number of written opioid prescriptions.

Limitations and Considerations

As is particularly the case with any survey-based investigation, this study is not without limitations. As with any study surveying perception among patients, there is a risk of bias affecting results. Both recall and response bias can play a factor in the responses received in the study, though the use of electronic surveys may decrease the effect of response by delivering the study resources to the patients in a convenient manner. Furthermore, the survey was completed in a home setting using electronic survey software and not in the clinic which likely influenced the low response rate and may have resulted in selection biases. In addition, since this study took place in a state that has not legalized recreational marijuana, we cannot discount that this may affect the generalizable nature of the present findings³⁰. Expanding this survey across multiple states and comparing perceptions between nonlegalized and legalized states could be a useful next step to better evaluate patient perceptions of CBD. Next, although this survey involved a relatively large sample size of 500 patients, sample size was not matched across subspecialties or age ranges, thus limiting some of the potential comparisons across subspecialty that may have been of interest.