Overview of Interventional Procedures and Medical Cannabis
Christina Gonzaga, DO Medical Director Park Nicollet Pain Management Clinic St. Louis Park, Minnesota April 27, 2018 Agenda About Me Disclosures Objectives Overview of Pain Tests Case 1 Intervention Case 2 Medical Cannabis References About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References About Me
• Medical Director • Pain and PM&R • BA in history from Loyola University Chicago • DO from Western University of Health Sciences Pomona, CA • Residency: St. Vincent’s Manhattan, NS-LIJ • Fellowship: Anesthesia pain, Thomas Jefferson University, Philadelphia
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References I have nothing to disclose
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Learning objectives
• The state of pain care today • Review of the pain history and physical examination • Brief review of interventional pain procedures • Review of medical cannabis: risks, benefits and the future
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Current State of Pain Care
Rehab Services Surgical External Services pain clinics
Addiction Primary Medicine Patients Care with Pain PMR Chiro
Urgent Mental Care Health Emergency Center
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Why do we need to design a better way?
• Increases in opioid related deaths • CDC guidelines
“Unless the nation develops an increased tolerance to chronic pain, reduction in opioid leaves a vacuum that will be filled with other therapies.”12
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Interdisciplinary Care Model
Pain- boarded Physician
MTM Nursing Care Coordination Pharmac y Patients with Pain
Pain Rehab Psycholog Services y (OT/PT)
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Role of the Pain Physician • Team player • Work in collaboration with all members of the interdisciplinary team • Trouble shoot medical aspects of the patient • Medication management and interventional management • Goals: Keep in mind the CDC guidelines. Decrease to lowest effective dose, work with the individual needs of patients, work along side team to educate, guide, and help patients develop multiple tools to help them manage pain.
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Interventional Procedures: How do you choose? •Back to the basics: history and the physical •Do not treat the diagnostic exam, treat the person in front of you •Talk to and LISTEN to your patient
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References History Location Character Severity Timing Onset Duration Frequency Alleviating and aggravating factors Associated signs and symptoms
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Back Pain RED FLAGS
Back pain in children Loss of anal sphincter tone Constant progressive pain or fecal incontinence, at night saddle anesthesia Widespread progressive History of cancer/Marked motor weakness or gait weight loss disturbance Use of systemic steroids Inflammatory disorders Intense pain with minimal (ankylosing spondylitis) motion/structural deformity Marked morning stiffness Peripheral joint Drug abuse or HIV infection involvement Systemic illness Persisting severe restriction Difficulty with urination of motion
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Physical Examination
Active range of motion • Observation: Forward flexion (Discogenic?) • Skin, muscle mass, bony structures, Extension (Facet joints?) as well as observation of overall posture Side bending (Facet joints?) • Position of lumbar spine (Scoliosis) Rotation (Facet joints?) • Gait Tendinopathy? Tear? Neurologic Examination • Palpation: Manual muscle testing • Bones Pinprick and light touch sensation, • Facet joints Reflexes • Ligaments and intradiscal spaces Balance Muscles • Babinski
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Sensation and Sensory Examination
Mechanical Nociceptors: • Pin Prick and pinch Heat Nociceptors: • Temperature greater than 45 degrees Celsius Polymodal Nociceptors: • Respond equally to mechanical, heat , and chemically noxious stimuli Fast Pain: • Transmitted by well-localized myelinated A-fibers and is characterized by sharp, shooting pain Slow Pain: • Transmitted by unmyelinated C fibers and is characterized as dull, poorly localized burning pain
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Motor Examination: Muscle Grading
• 5 Normal=Complete range of motion against gravity with full resistance • 4 Good=Complete range of motion against gravity with some resistance • 3 Fair=Complete range of motion against gravity • 2 Poor=Complete range of motion with gravity eliminated • 1 Trace=Evidence of slight contractility; No joint motion • Zero=No evidence of contractility
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Muscle Stretch Reflexes/DTRs
Grading 0 =No response 1+ = Reduced, less than expected 2+ = Normal 3+ =Greater than expected, moderately hyperactive 4+ =Hyperactive with clonus (upper motor neuron sign)
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Commonly Test Nerve Root Levels
C5-C6 Biceps reflex C7-C8 Triceps reflex L3-L4 Patellar reflex S1-S2 Achilles reflex
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References What’s the root cause? Root Dermatome Muscle Weakness C4 Shoulder Levator Scapulae (Shoulder shrug) C5 Lateral arm Biceps
C6 Lateral forearm, first and Extensor carpi radialis second finger (weakness in wrist extension)
C7 Middle finger Triceps (weakness in elbow extension)
C8 Fourth, fifth finger; medial FDP; Finger flexion of middle forearm finger
T1 Medial arm Dorsal interossei; Difficulty in keeping fingers abducted against resistance
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Root Dermatome Muscle Weakness L1 Back, over the greater None trochanter and groin L2 Back, front of thigh to knee Psoas, hip abductors
L3 Back, upper buttock, front Psoas, quadriceps of thigh and knee, medial lower leg L4 Inner buttock, outer thigh, Tibialis anterior, extensor inside of leg, dorsum of hallucis; quadriceps foot L5 Buttock, back and side of Extensor hallucis, thigh; lateral aspect of leg; peroneals, gluteus medius, dorsum of foot; inner half ankle dorsiflexors, of sole and first, second, hamstrings, calf wasting and third toes
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Physical Examination
Root Dermatome Muscle Weakness S1 Buttock, back of Calf and hamstrings; thigh, and lower leg wasting of gluteus, plantar flexors S2 Buttock, back of Calf and hamstrings; thigh, and lower leg wasting of gluteus, plantar flexors S3 Groin , inner thigh None S4 Perineum, genitals, Bladder, rectum lower sacrum
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Dermatomes
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Upper Extremity Dermatomes
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Lower Extremity Dermatomes
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Physical Examination
Abdominal muscle strength Pelvis stabilizer strength, i.e. gluteus medius, maximus Tightness or stiffness of hamstrings Tightness or stiffness or hip flexors Tightness or stiffness of hip rotators Other specialized musculoskeletal examinations
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Spurling’s Test: Cervical radiculopathy
•Extension and sidebending impinges the neural foramen and causes shooting pain down that arm
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Drop Arm Test
•May be sign of rotator cuff tear
•Careful to differentiate possible weakness of deltoid (could be a root problem)
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References YergasonTest
•Palpate the bicipital groove •Examiner provides resistance •Patient actively tries to pronate while examiner upinates/external rotates arm •Pain in groove may be sign of bicep tendinitis
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Patrick’s Test Illustrated
•Stresses the hip and sacroiliac joints •Same side hip pain = degenerative disease of hip •Opposite side pain may be due to SI joint dysfunction •AKA: FABER
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Tinel’s sign for CTS
•Test for carpal tunnel syndrome •Tap over carpal tunnel, testing median nerve •Pain shooting down first three digits is a positive test
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Phalen’s test for CTS
•Hold for 1 minute •Tests the median nerve •Pain shoots down first three digits
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Straight Leg Raise
•Stretches the sciatic nerve •Positive from about 30-70 degrees •Anything greater than 70 may be due to Hamstring tightness
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Gaenslen Test
•Testing for SI joint pain •If pain is reproduced, then it is positive •Note, the symptomatic leg is off the table
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Slump Test
Patient at edge of table with legs hanging down Examiner positioned in front of the patient Patient actively flexes through cervical, thoracic and lumbar spine Examiner performs a straight leg raise Once symptoms are elicited, the examiner asks the patient is asked to extend the cervical spine Positive if cervical extension alleviates the symptoms May show impaired neural tissue mobility Sensitize with ankle dorsiflexion
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Slump Test
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Iliac Compression Test
•Compress directly over iliac crest •Pain on same side may be SI joint pain •Pain on opposite side may be caused by greater trochanteric bursitis (make sure to check)
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Iliac Compression Test
•Compress directly over iliac crest •Pain on same side may be SI joint pain •Pain on opposite side may be caused by greater trochanteric bursitis (make sure to check)
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References McMurray Test: Lateral Meniscal Tear
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References McMurray Test: Medial Meniscal Tear
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Case Study
• A 65 year old female presents to your office with a 1 year history of chronic low back pain. PMHx: HTN. PSHx: None. Denies loss of bowel or bladder. MRI is reviewed and shows some degenerative changes, mild neuro foraminal stenosis, moderate central canal stenosis. No signs of radicular leg pain are exhibited. Gait is intact and non antalgic. No assistive device noted. Transfers independently. Normal muscular examination and neurological examination. Denies back pain waking her up at night. No acute loss of weight. She notes when she extends her back pain is exacerbated. No buttock pain noted. You decide that there are no immediate dangers, so you send her to PT. She asks for medications. Given she has no kidney issues, liver issues, or GI bleeds, you advise her to intermittent use either Tylenol or ibuprofen and send her out. You’ll see her after PT.
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Interventional Pain Procedures INTERVENTIONAL PROCEDURE TYPES REASONSTO DO THEM
Epidurals: transforaminals and interlaminars, Stenosis, spondylopathy with radicular selective nerve root blocks, caudal symptoms Intercostal nerve blocks Intercostal neuritis, rib pain
Peripheral joint injections (hips, knees, sub- Hip arthritis, shoulder bursitis, shoulder acromial bursitis, shoulder), piriformis arthritis, knee osteoarthritis, greater injections trochanteric bursitis, piriformis syndrome Sacroiliac joint injection Buttock pain
Lumbar, thoracic, and cervical rhizotomies, Axial pain, facet arthropathy, sacro- iliac joint sacroiliac rhizotomy, facet injections pain No radicular symptoms Coccyx injection Coccydynia
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Interventional Procedures INTERVENTIONAL PROCEDURE TYPES REASONSTO DO THEM
Peripheral joint rhizotomies (Genicular nerve Knee pain post total knee, hip pain post total RFA, Femoral articular branch and obturator hip replacement, hip labral tear, AVN, hip nerve) osteoarthritis Lumbar sympathetic blocks, stellate ganglion Sympathetic mediated pain, Upper and block lower extremity CRPS, often precede stimulator trials/implants Vertebroplasty, Kyphoplasty (use of balloon) Non traumatic osteoporotic compression fracture Intrathecal pain pumps Cancer pain, chronic pain ?
Spinal cord stimulators Failed back syndrome, CRPS, peripheral chronic nerve pain Ganglion Impar Block Blocks relieve perineal pain from cancer of the cervix, endometrium, bladder, and About Me Disclosures Objectives Overview Tests Caserectum. 1 Intervention Case 2 Cannabis References How about that case? That patient comes back to you with continued low back pain. Minimal improvement after 6 weeks of PT. She is looking for further input and your professional opinion on this pain. What will you offer her next? 1. Live with the pain 2. Facet joint injection 3. Lumbar frequency ablation 4. Spinal cord stimulator trial 5. Early retirement
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Facet Joint Injections, medial branch blocks, and radiofrequency ablations
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Radiofrequency Ablation
• Etiology: Axial Pain w/o radicular symptoms • 2 Medial Branch blocks vs. intraarticular injections • Burn twice between 70- 80 degrees Celsius • Typically lasts 4-12 months; large variability
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Conclusions • Level II evidence for long-term effectiveness of radiofrequency ablation in lumbar and cervical spines, for facet joint medial branch blocks in cervical, thoracic, and lumbar spine • Level III evidence for thoracic radiofrequency ablation, lumbar and cervical intraarticular joint injections • Cohen, et al suggest (case control study) suggest medial branch blocks over facet joints lead to better outcomes that intraarticular joint injections
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Lumbar radiculopathy
•Epidemiology •Occurs in approximately 3-5% of the population •Men and women are affected equally •Men are most commonly affected in their 40 •Women are most commonly affected between ages 50-60. 1
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Epidurals • Widely accepted • Safety and effectiveness accepted • Literature shows most effectiveness in the first couple of weeks • Some literature shows longer than one year • Randomized controlled trials are rare • Trial designs often have low enrollees • Possible that anesthetic alone may be as effective as using steroid and anesthetics • Suggestion that epidurals may help to decrease opioid intake in certain groups 2,3,4
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Spinal Cord Stimulators
• Failed Back Surgical Syndrome (FBS) • Radicular pain syndrome or radiculopathies resulting in pain secondary to FBS or herniated disk • Post-laminectomy pain • Multiple back operations • Unsuccessful disk surgery • Degenerative Disk Disease (DDD)/herniated disk pain refractory to conservative and surgical interventions • Epidural fibrosis • Arachnoiditis or lumbar adhesive arachnoiditis • Complex Regional Pain Syndrome (CRPS) • Peripheral nerve pain ?
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Spinal cord stimulation
•Typically last resort •Requires a trial prior to implantation •Psychological work up needed •Ability to operate the programming is important
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Spinal Cord Stimulators: Possible Benefits
• Long-term pain relief • Improved quality of life • Successful pain disability reduction • May be less expensive and more clinically effective that re-operation for failed back surgical syndrome • Decreased opioid usage • Decreased reported subjective pain scores
7 ,8, 9
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References We’ve come a long way.
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Case Study
• A 39 year old male construction work. PMHx and PShx unremarkable. He is used to some amount of low back pain but now has developed pain down the right leg. States that it has been going on for 8 weeks. No loss of bowel or bladder. Started gradually and has worsened. He feels subjectively weak in the right lower extremity. Burning pain. History reveals no red flags. He has slight weakness in right quadriceps. Antalgic gait, off- loading the right leg. Sent to PT for a few weeks (traction) with no results. MRI ordered.
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Lumbar MRI findings
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Physical examination
• 4/5 in right knee extension • No wasting noted • Decreased right patellar reflex
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Question #1
What nerve root is affected? a. L2 b. L3 c. L4 d. L5 e. S1
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References What do you do next?
• Right L4 epidural • Consideration of multiple (2-3) • Complete PT • If all fails, referral to for surgery consultation
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Medical Cannabis
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Cannabinoid Sub-groups
Types: 1.Endogenous system 2.Phytocannabinoids : 60 discovered thus far 3.Synthetics –FDA approved
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Medical Cannabis
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Cannabinoids: Subgroups
I. Endogenous endocannabinoids II.Botanicals (phytocannabinoids): 60 identified III.Synthetic Derivatives
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Endocannabinoid System • Dr. Raphael Mechoulam discovers the first cannabinoid Δ-tetrahyrocannabinol (THC) in 1964 • ECS modulates the sensitivity to neurotransmitters like NE and serotonin • Human experience of pain and response to stress involves interaction of endocannabinoids through endorphins and cortisol release
10 About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Important Receptors: Research for the Future
CB1: • Accounts for psychotropic action of THC and its analgesic effects • Pre-synaptic activation of CB1 inhibits GABA (“Stop”) or Glutamate (“Go”). • Present in areas of the brain and play a role in memory, mood, sleep, appetite and pain sensation. CB2: • Theorized to modulate persistent inflammatory and neuropathic pain conditions
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References FDA Approved Synthetic Cannabis Pharmaceuticals
Dronabinol (Marinol): 1986 • Synthetic Delta-9 THC • FDA approved for treatment of nausea and vomiting for patients in cancer treatment, appetite stimulant for AIDS patients, analgesics to ease neuropathic pain in multiple sclerosis patients Nabilone (Cesamet): • Synthetic cannabinoid similar to THC • FDA approved for treatment of nausea and vomiting in patients undergoing cancer treatment
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Pharmacology and Pharmacokinetics of THC13 • Major psychoactive delta-9 tetrahydrocannabinol (THC) • Oral: Low bioavailability (6-20%). Peak plasma concentrations after 1-6 hours and half life at 20-30 hours. • Inhalation: Peak concentration of THC occurs in 2-10 min and rapid decline for 30 minutes.
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Minnesota: Approved Conditions for Medical Cannabis
• Cancer associated with severe/chronic pain, nausea or severe vomiting, or severe wasting • Glaucoma • HIV/AIDS • Tourette’s Syndrome • Amyotrophic Lateral Sclerosis (ALS) • Seizures including those including those characteristic of epilepsy • Severe muscle spasms including those characteristic of multiple sclerosis • Crohn’s Disease • Terminal illness, with a life expectancy of less than one year, if the illness or treatment produces severe/chronic pain, nausea or severe vomiting, cachexia or severe wasting • Intractable Pain • Post-Traumatic Stress Disorder (PTSD)
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Arizona: Approved Conditions • Acquired immune deficiency syndrome (AIDS) • Amyotrophic lateral sclerosis (ALS) • Crohn's disease • Human immunodeficiency virus (HIV) • Agitation of Alzheimer's disease • Cancer • Glaucoma • Hepatitis C • Post-Traumatic Stress Disorder (PTSD) • IF A CHRONIC OR DEBILITATING DISEASE OR MEDICAL CONDITION OR THE TREATMENT FOR A CHRONIC OR DEBILITATING DISEASE OR MEDICAL CONDITION CAUSES: Cachexia or wasting syndrome, severe and chronic pain, severe nausea, seizures, including epilepsy characteristics, severe or persistent muscle spasms, including those characteristic of multiple sclerosis
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Medical Cannabis
• Inhaled as smoke or vapor • Liquid or oral extracts • Topicals/Balms: CBD only (federally legal)
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Smoked or Vaporized Cannabis11 • Rapid onset, short duration of action • RCT are limited to short time frames of the study and small patient populations • One study showed smoked cannabis increased pain tolerance • Another study showed no therapeutic effect against a pain stimuli at 2% THC but increased pain experience at 8%. Suggestion of a therapeutic window. • Multiple studies looking at HIV neuropathy or neuropathic pain are promising for decrease in VAS pain rating
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Oral and Oral-Mucosal Cannabis11
• Longer onset, longer duration of action • Variable duration effects • Effects vary among different populations • Study: Women with higher estrogen responded with better pain relief • Study: Men appeared to have better pain relief response
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References THC: CBD11 Ratios
• Cannador® cannabis extract (various THC: CBD). Phase III RCT of 2THC: 1: CBD n=630. Decrease in pain related to spasms. • Nabixamols (Sativex®) THC: CBD Multiple studies demonstrate pain relief in chronic pain. Suggestion that combination is more effective than THC alone.
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Dosing
• Complex Question • There is no standardized dosing • Variable as each person is different (genetics of endocannabinoid system, metabolism, tolerance, past exposure) • Conversion from smoked to oral dosing unknown • Titrate slowly
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Short Comings
• Products are not standardized • Ratios of THC: CBD not well understood in terms of most appropriate dosing. • The most popular theory is that the more neuropathic pain issues do better with higher THC while the most chronic, intractable while spread pain/inflammatory pain does better with higher CBD. • Drug-Drug interactions can occur • Side Effects • Long term effects are unknown • Cost prohibitive • Legal issues: Federal Vs. State
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Drug-Drug Interactions13
• Potentiate CNS depressant effects with benzodiazepines, alcohol, opioids • Possible mania induced when combined with SSRIs • Increased tachycardia and delirium with TCAs and sympathomimetic • Increase risk of immunosuppression with corticosteroids • May decrease effectiveness of anti-psychotics
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References The future of cannabis
•With the liberalization of use, it is important well- done, double blinded RCT are done and that their length of study is substantial •Possible that using specific cannabinoids for specific conditions may prove beneficial14 •Goal: Do not exchange one epidemic for another
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Side Effects • Impairments of memory (cognitive change), decrease motor coordination, altered judgement • High dosing my cause psychosis • Increased heart rate • Nausea and vomiting (“cannabinoid hyperemesis syndrome”) • Dry mouth • Dizziness and headache • Sedation
10, 11, 13 About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Side Effects • Dependence and addiction • Increased risk of pulmonary issues (similar to smoking) • Increased risk of lower birth weights, possible affect on neurodevelopment • Possible increased risk of cancer • Increased risks of traffic accidents • May cause liver fibrosis in HCV patients • May cause acute pancreatitis • Withdrawal symptoms 10, 11, 13 About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References The Final Question
A 35 year old male comes to your clinic with complaints of global wide spread pain. He is a poor historian but further digging into his chart, former clinicians, and with patient, details a history of chronic low back pain, global wide spread pain, history of substance abuse, and schizophrenia. His chart reveals a long history of non compliance with treatment plans, well- documented acute psychotic episodes, and the current use of Zyprexa, a second generation anti-psychotic.
Is this a good candidate for medical cannabis? 1. Yes. 2. No.
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Medical Cannabis: Summary
• Every patient deserves care that is safe and based on medical evidence • Limited moderate-level evidence reveals some promising use in pain13 • Conflicting literature13 • Observational studies find a decrease in opioid addiction and overdoses in states that legalize12 • May act synergistically with opioids11 • Lack of high quality, long term clinical trials12 • Considered an experimental drug • Death has not be associated with use of medical cannabis • There are risks
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References The End
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References Thank you for your time
•Contact information: [email protected]
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References References
1. Taruli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clinic 25 (2): 387-405. 2. Bayer, F et al. Non-operative treatment of lumbar spinal stenosis. (2016). Technology and Health Care, 551-557 3. Manchiakanti, L et al. Transforaminal epidural injections in chronic lumbar disc hernation: A randomized, double-blind, active-control trial. (2014). Pain Physician, 17: E489-E501. 4. Zhai, J et al. Epidural Injection with and without steroid in managing chronic low-back pain: A Metanalysis of 10 randomized controlled trials. (2017). American Journal of Therapeutics 24, e259-e269. 5. Manchiakanti, L et al. A Systemic Review and Best Evidence Synthesis of Effectiveness of Therapeutic Facet Joint Interventions in Managing Chronic Spinal Pain. (2015). Pain Physician, 18: E535-582. 6. Kumar, K et. al. The effects of spinal cord stimulation in neuropathic pain are sustained: a 24 hour follow-up of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation.( 2008) . Neurosurgery. 63(4):762-770. 7. Harke, H et .al. Spinal cord stimulation in sympathetically maintained complex regional pain syndrome type I with severe disability. A prospective clinical study. Eur J Pain. (2005). 9(4);363-373. 8. North RB, Kidd D, Shipley J, Taylor RS. Spinal cord stimulation versus reoperation for failed back surgery syndrome: a cost effectiveness and cost utility analysis based on a randomized, controlled trial. Neurosurgery. 2007;61(2):361-369 9. Sanders, R et. al Patient Outcomes and Spinal Cord Stimulation: A Retrospective Case Series Evaluating Patient Satisfaction, Pain Scores, and Opioid Requirements. Pain Practice (2016). Volume 16, Issue 7, 899-904. 10. Kim, P and Fishman, M. Cannabis for Pain and Headaches: Primer. Curr Pain Headache Rep. (2017). 21:19 3-11. 11. Andrade, C. Cannabis and Neuropsychiatry, 1: Benefits and Risks. J Clin Psychiatry. (2016). 77: 5 e551-554. 12. Choo, E. Opioids Out, Cannabis In: Negotiating the Unknowns in Patient Care for Chronic Pain. JAMA. (2016). Volume 316, November 17: 1763-1764. 13. Parmar, J. et al. Medical Cannabis patient counseling points for health care professionals based on trends in the medical uses, efficacy, and adverse effects of cannabis-based pharmaceutical drug. Research in Social and Administrative Pharmacy 12. (2016). 638-654. 14. Goldenberg, M. Et. Al. The impact of cannabis and cannabinoids for medical conditions on health related quality of life: a systemic review and meta- analysis. Drug and Alcohol Dependence. 174 (2017). 80-90.
About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References