Originally written: September 11, 2014

About 46% of MS patients smoke marijuana for pain, tremor, insomnia, bladder symptoms, spasticity. Oral sprays probably have fewer risks.

Nabiximols may soon receive FDA approval. They are a liquid extract of 2 strains of cannabis formulated as an oral mucosal spray containing tetrahydrocannabinol (THC) and cannabidiol (CBD) in a 1-to-1 ratio. THC is psychoactive and CBD counteracts that effect. Several trials have shown that the drug is effective for pain within 4 weeks. There was no tolerance or withdrawal when stopping. About 30% had dizziness. Less than 1% of patients had a cannabis high. The drug is approved for MS-related spasticity and pain in the UK, Canada, New Zealand, and 8 European countries.

In contrast, smoked cannabis, though reducing pain by about 30%, causes significant cognitive symptoms in at least a third of patients and drug dependence and withdrawal in about 1 in 10.

Oral cannabis is least popular among patients because of low bioavailability in that it is metabolized in the liver. Dronabinol is a synthetic THC that is available in the US and has an analgesic effect similar to codeine. It is approved for chemotherapy related and AIDS-related nausea, vomiting and weight loss.

A study performed in 2012 sponsored by the Consortium of Multiple Sclerosis Centers of 493 British patients concluded that THC does not slow the progression of primary or secondary progressive MS. The medication was given in an oral capsule, based on weight. About 60% of patients had dizziness and about half had thought or perception changes but fewer patients seemed to develop pain or urinary tract infections.

The American Academy of Neurology issued a practice parameter in 2014 and concluded that Nabiximols and THC are “probably effective” for spasticity, central pain or painful spasms, overactive bladder symptoms, and are probably ineffective for tremor.

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