Nabiximols vs. Cannabis Decoction for MS Spasticity: What a New Formulation Comparison Study Found
| Audience | Patients with MS-related spasticity using or considering nabiximols, clinicians managing cannabinoid therapy for multiple sclerosis, and researchers studying how cannabinoid formulation affects real-world outcomes |
| Primary Topic | A retrospective single-center cohort study comparing nabiximols and compounded cannabis decoction for multiple sclerosis-related spasticity, spasms, and pain in 63 patients, published in Multiple Sclerosis and Related Disorders, August 2026 |
| Source | Read the study on PubMed |
Nabiximols vs. Cannabis Decoction for MS Spasticity: What a New Formulation Comparison Study Found
In a retrospective single-center study of 63 multiple sclerosis patients, both nabiximols and compounded cannabis decoction improved spasticity, spasms, and pain, but nearly two-thirds of patients eventually discontinued nabiximols, and those who switched to decoction saw further improvement with fewer reported adverse effects.
| Study Type | Retrospective, single-center cohort study |
| Population | 63 adults with multiple sclerosis-related spasticity who initiated nabiximols between 2013 and 2024 |
| Comparison | Continued nabiximols versus switching to compounded cannabis decoction after nabiximols discontinuation |
| Outcome Measures | Modified Ashworth Scale (spasticity), Numerical Rating Scale (spasticity and pain), Penn Spasm Frequency Scale (spasm frequency) |
| Analysis Methods | Within-group and mixed-effects model efficacy analyses; Cox regression for discontinuation risk |
| Discontinuation Result | 39 of 63 patients (61.9%) discontinued nabiximols during the study period; 14 switched to cannabis decoction |
| Efficacy Result | Both nabiximols and cannabis decoction were associated with significant improvement in spasticity, spasms, and pain from baseline; among switchers, cannabis decoction produced significant improvement across all outcomes |
| Tolerability Result | Adverse effects reported in 27.0% of nabiximols users versus 14.3% of cannabis decoction users; nabiximols showed a higher, though not statistically significant, discontinuation rate |
| Predictors Identified | Longer disease duration was associated with discontinuation due to inefficacy; tetraspasticity predicted switching to cannabis decoction |
| Journal | Multiple Sclerosis and Related Disorders |
| Published | August 4, 2026 |
| DOI | 10.1016/j.msard.2026.107428 |
| PMID | 42594706 |
Researchers retrospectively reviewed the records of 63 adults with multiple sclerosis-related spasticity who started nabiximols, an oromucosal spray with a fixed 1:1 ratio of THC to CBD, at a single Italian center between 2013 and 2024.
Spasticity, spasm frequency, and pain were tracked using three validated instruments, the Modified Ashworth Scale, Numerical Rating Scales, and the Penn Spasm Frequency Scale, at baseline and follow-up. Discontinuation risk was analyzed with Cox regression.
Patients who remained on nabiximols showed statistically significant improvement in spasticity, spasms, and pain compared with baseline.
Among the 14 patients who switched to a compounded cannabis decoction after stopping nabiximols, cannabis decoction was associated with significant improvement across all three outcome measures.
Nearly two-thirds of the cohort, 39 of 63 patients (61.9%), discontinued nabiximols at some point during the study period, and 14 of those patients switched to cannabis decoction rather than stopping cannabinoid therapy altogether.
Adverse effects were reported in 27.0% of nabiximols users compared with 14.3% of cannabis decoction users, and nabiximols showed a higher, though not statistically significant, discontinuation rate than decoction.
The study authors note that differences in cannabinoid composition and pharmacokinetics between the standardized oromucosal spray and the compounded decoction may explain some of the variation in outcomes and tolerability between the two preparations.
Two clinical predictors emerged: longer disease duration was associated with discontinuing nabiximols due to inefficacy, while having spasticity in all four limbs, tetraspasticity, predicted switching to cannabis decoction rather than stopping cannabinoid therapy entirely.
This was a retrospective, unblinded, non-randomized, single-center study with no placebo comparator. The 14-patient switcher subgroup is small, and these patients were not randomly assigned to decoction, they chose or were guided to it after nabiximols had already proven inadequate or poorly tolerated for them.
The cannabis decoction used in this study was a compounded preparation dispensed under Italian pharmacy regulations, not a standardized commercial product with a fixed cannabinoid ratio, so its dose and composition are not directly comparable to products available elsewhere, including the United States.
CED Clinic has previously covered systematic reviews and meta-analyses of cannabinoids for MS spasticity that focus on randomized-trial efficacy, generally finding modest, patient-reported benefit with THC:CBD extracts and low overall certainty of evidence. This new study asks a different, complementary question: not whether nabiximols works in a trial setting, but how many real-world patients actually stay on it, and what happens to the ones who do not.
Because nabiximols is authorized in the United Kingdom, Canada, and parts of Europe but not FDA-approved in the United States, this specific formulation comparison is most directly relevant to clinicians and patients in those markets. For US cannabis clinicians, the more transferable lesson is the reminder that formulation, dose consistency, and route of administration can meaningfully affect both tolerability and a patient’s willingness to continue any cannabinoid therapy.
What stands out to me most in this study is not the decoction comparison, it is the 61.9% discontinuation rate for nabiximols. That number deserves attention on its own, because it reflects a real-world attrition pattern that shorter randomized trials rarely capture, and it matches what many of us see clinically: patients start a standardized cannabinoid product, and a majority do not stay on it long term for reasons that go beyond simple lack of efficacy.
I would be cautious about reading the decoction findings as proof that a compounded, non-standardized preparation outperforms an approved product. Fourteen patients who had already failed or not tolerated nabiximols is a selected group, not a fair comparison group. What I take from this study is a prompt to have an honest conversation with patients about why a cannabinoid therapy is not working, whether that is efficacy, tolerability, or something about the formulation itself, rather than a signal to switch formulations as a first move.
How to Read a Formulation-Switch Study Without Overclaiming
A retrospective study comparing two cannabinoid formulations can highlight a genuinely important real-world pattern while still being vulnerable to confounding that a randomized trial would control for.
Four checks keep this study’s real contribution, an attrition and tolerability signal, from being mistaken for proof that one formulation beats the other.
A Four-Step Reading Frame
Confirm what was compared
Continued nabiximols versus a self-selected group who had already stopped nabiximols and switched to decoction, not a randomized head-to-head trial.
Note who ended up in each group
Switchers chose or were guided to decoction after nabiximols had already failed them, which biases the comparison.
Separate attrition from efficacy
The 61.9% discontinuation rate for nabiximols is a real, useful finding on its own, independent of what decoction did afterward.
Watch for standardization
The decoction had no fixed dose or ratio, so its reported benefit cannot yet be tied to a reproducible product.
The Same Study Can Mean Different Things Depending on the Question Being Asked
Scientific papers rarely answer a single question. Patients, clinicians, researchers, policymakers, and critics often read the same data differently. The perspectives below explore how this study looks through several evidence-based lenses.
A Real Pattern, Not a Reason to Switch on Your Own
If you are on nabiximols for MS spasticity and it is not working well or is hard to tolerate, this study confirms you are far from alone: most patients in this cohort eventually stopped it.
It does not mean switching to a cannabis decoction will work better for you specifically. The patients who improved after switching were a small, selected group, and any change to your cannabinoid regimen should be made with your treating clinician.
Attrition Deserves as Much Attention as Efficacy
A 61.9% discontinuation rate over an 11-year window is a clinically important finding independent of what came next, and it argues for proactively asking patients about tolerability and adherence rather than assuming a prescribed cannabinoid is being used as intended.
The decoction data can inform a conversation about alternatives when nabiximols fails, but it should not be presented to patients as an evidence-based second-line protocol given the retrospective, confounded comparison.
Fixed Ratio Spray Versus Variable Decoction
Nabiximols delivers a standardized, fixed 1:1 THC:CBD ratio through an oromucosal spray, while a decoction is an aqueous extraction whose cannabinoid content depends on starting plant material, preparation method, and steeping conditions.
The study authors explicitly point to differences in cannabinoid composition and pharmacokinetics between the two preparations as a plausible explanation for the different tolerability and outcome patterns observed.
Confounding by Indication Is the Central Problem
The 14 patients who switched to decoction were not randomly assigned; they switched because nabiximols had already failed them, which makes any improvement after switching difficult to separate from regression to the mean or a fresh-start effect.
A retrospective, unblinded chart review of a 14-person subgroup cannot support a claim that one cannabinoid formulation is more effective than another.
Different Formulations Face Different Regulatory Paths
Nabiximols is authorized as a prescription medicine in the United Kingdom, Canada, and several other countries, while compounded cannabis decoctions are dispensed through Italian pharmacies under national rules that do not have a direct US equivalent.
This regulatory patchwork means the findings translate unevenly across countries, and US clinicians should not assume a decoction obtained through a domestic dispensary matches the compounded preparation studied here.
Standardization Is the Variable Most Likely to Matter
Nabiximols has a fixed, quality-controlled THC:CBD ratio and dose per spray, while the compounded decoction in this study had no reported standardized dose or cannabinoid concentration.
Without knowing the decoction’s actual THC and CBD content, clinicians cannot translate its reported tolerability advantage into a specific, reproducible recommendation for patients.
Framing This Accurately Protects Patient Trust
Describing this study as proof that cannabis decoction beats an approved pharmaceutical spray would overstate a confounded, 14-person retrospective comparison.
Accurately reporting both the meaningful attrition signal and its real limitations helps preserve trust in cannabinoid research as real-world formulation questions get more attention.
A Prompt for a Prospective Trial, Not an Answer
The study’s own authors call for prospective studies to confirm these findings and optimize treatment strategies, which is the clearest signal that this retrospective analysis is a starting point rather than a conclusion.
A properly designed prospective comparison, with standardized decoction dosing and a fair, non-confounded comparator, is the necessary next step this single-center chart review does not provide.
Join the Conversation
Have a question about how this applies to your situation? Ask Dr. Caplan
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When a new paper overlaps with earlier CED Clinic coverage, we preserve the chain instead of hiding the overlap. These links point to older related posts so readers can compare what is new, what is repeated, and how the evidence has moved.
A systematic review of 27 randomized trials found modest patient-reported improvement in MS spasticity with THC:CBD extracts, with low overall certainty of evidence and frequent, mostly mild to moderate adverse events.
A meta-analysis of nabiximols across roughly 2,949 MS patients found significant improvement in bladder function, sleep, spasm quality, and gait, with the authors rating their own evidence certainty low to very low.
CED's most recent MS spasticity coverage summarized emerging evidence supporting cannabis-based therapies as an adjunctive option when conventional treatments are inadequate or poorly tolerated.
Frequently Asked Questions
What did this study look at?
A retrospective, single-center review of 63 adults with multiple sclerosis-related spasticity who started nabiximols between 2013 and 2024, tracking spasticity, spasm frequency, and pain, along with how many patients discontinued nabiximols and what happened to those who switched to a compounded cannabis decoction.
What is nabiximols?
Nabiximols is an oromucosal spray with a fixed 1:1 ratio of THC to CBD, approved as a prescription treatment for MS-related spasticity in the United Kingdom, Canada, and several other countries. It is not FDA-approved in the United States.
What is cannabis decoction?
In this study, cannabis decoction was a compounded cannabis preparation dispensed through Italian pharmacies under a medical prescription. It does not have a standardized cannabinoid dose or ratio the way nabiximols does, and it is not equivalent to any specific product sold elsewhere, including the United States.
How many patients discontinued nabiximols?
Thirty-nine of 63 patients, 61.9%, discontinued nabiximols at some point during the study period, and 14 of those patients switched to cannabis decoction rather than stopping cannabinoid therapy altogether.
Did cannabis decoction work better than nabiximols?
Among the 14 patients who switched, cannabis decoction was associated with significant improvement across all measured outcomes, and adverse effects were reported less often, 14.3% versus 27.0% for nabiximols. However, this was a small, self-selected group who had already found nabiximols inadequate, so this does not establish decoction as a superior treatment in a fair, head-to-head comparison.
Were adverse effects more common with one formulation?
Adverse effects were reported in 27.0% of nabiximols users compared with 14.3% of cannabis decoction users, and nabiximols showed a higher, though not statistically significant, discontinuation rate than decoction.
What predicted whether a patient discontinued nabiximols or switched to decoction?
Longer disease duration was associated with discontinuing nabiximols due to inefficacy, while having spasticity in all four limbs, tetraspasticity, predicted switching to cannabis decoction rather than stopping cannabinoid therapy entirely.
Why might cannabis decoction and nabiximols produce different results?
The study authors point to differences in cannabinoid composition and pharmacokinetics between the standardized oromucosal spray and the compounded decoction as a plausible explanation, though the study was not designed to isolate that mechanism directly.
What are the main limitations of this study?
The study was retrospective, unblinded, non-randomized, and conducted at a single center with no placebo comparator. The 14-patient decoction switcher group was not randomly assigned and had already found nabiximols inadequate, which confounds any comparison between the two formulations. The decoction also lacked a standardized dose or cannabinoid ratio.
Does this mean I should switch from nabiximols to a cannabis decoction?
No. This study does not support switching formulations on your own. It shows that many patients eventually stop nabiximols and that a small subgroup who switched to decoction improved with fewer reported side effects, but any change to cannabinoid therapy for MS spasticity should be discussed with your treating clinician, and nabiximols and the decoction studied here are not available or regulated the same way in every country.
