Case Reports in the use of Medicinal Cannabis. By Dr. Brubaker
Physicians often present cases/patients in the form of case reports in writing and at medical grand rounds at medical centers. I am providing a few interesting patients who are interesting and have success stories.
Cannabis Case Report #1:
Tara H. is a 34-year-old Caucasian woman who I first saw for a cannabis recommendation in January 2014. She wanted to use cannabis legally for pain and her bipolar disorder. The patient provided a list of her medications, which included Robaxin, Dexilant, Atarax, diazepam, Norco, clonidine, NuDexta, calcitonin, Geodon, TriCor, Wellbutrin, Lipitor, calcium and vitamin D3. The patient had been on numerous narcotics including OxyContin in the past. As a result, all of her teeth decayed from the medication causing dry mouth. The patient wanted to get off her medications.
During the course of my history and physical examination, she related that she was diagnosed with complex regional pain syndrome (RSD), Tourette’s syndrome, chronic pain, bipolar, and insomnia. She stated that she had right hip pain that she acquired in the military during boot camp. We had a long discussion regarding her diagnoses and medications.
The following month (February 2014), I started weaning her off of medications, because I found no evidence of complex regional pain syndrome or Tourette’s syndrome. I discovered that these diagnoses were originating from the side effects of her medications. I had an MRI performed on her right hip, which turned out to be negative. In one of her visits, she came in with severe muscle spasm in her right lumbar and gluteal (buttocks) region. After careful examination, I felt the patient had a herniated disc in the lumbar region, along with sciatica. An MRI of the lumbar spine was performed, which showed a disc at L4-5 and L5-S1. This was producing her right hip pain.
Meanwhile, the patient was weaned off of almost every medication except her cholesterol medication. The patient no longer had any tics or tremors, which was misdiagnosed as Tourette’s syndrome. There was no evidence of any complex regional pain syndrome signs or symptoms, especially getting off of all medications.
The patient does have low back pain with sciatica that is controlled with medicinal cannabis. All of her teeth have been pulled and she now has dentures. She is not a surgical candidate for her low back pain and disc pathology. Therefore, the medicinal cannabis can provide enough pain relief to keep her functional. It also allows her to sleep at night. Her anxiety has also been controlled.
Had cannabis been used recreationally, the results would be totally different and less positive.
Cannabis Case Report #2:
Pamella S. is a 60-year-old woman who I first saw in 2014 for musculoskeletal pain related to fibromyalgia. At the time she came to see me for medicinal cannabis, she was taking eight 10/325 mg Norco’s a day and 3 Xanax 1 mg a day. She also had been on medications approved for fibromyalgia in which she had side effects. The patient had 18/18 tender points that were extremely painful. She had mental fog, along with anxiety and depression. She was unable to sleep at night. She wanted an alternative to her narcotics and benzodiazepines. I provided guidance for her to wean off the medications and replace them with cannabis.
I saw the patient in April 2016 for her third annular renewal. She stated that she was off all medications and that the cannabis was controlling and reducing her pain by 80%. She no longer had anxiety, depression, or insomnia. With examination, the patient remains with 18/18 tender points; however, palpation of these tender points did not produce the amount of pain that she had initially with my examination. Her pain with palpating the tender points was approximately 1-2/10 on a pain scale of 0-10 with 10 being the worst possible pain. The patient was very happy with her results, and stated that “I saved her life!”
Had cannabis been used recreationally, the results would be totally different and less positive. When used recreationally, the patient is not as “open to solutions or treatment options”. It is often viewed as recreational and not medicinal.
Cannabis Case Report #3:
James F. is a 77-year-old man who has a long history of deep venous thrombosis in his legs. It has plagued him ever since he was a young man and it has only gotten worse as he aged. He had major surgery in both legs by a vascular surgeon to prevent amputation. Sometime in the 1990s, his vascular doctor discovered that he had factor V Leiden, which is a congenital clotting problems that causes thrombosis (clotting), especially in veins of the lower extremities. As a result of his condition and multiple surgeries, he developed severe neuropathic pain. He was placed on narcotics by his doctors and when he could not obtain enough from the doctors he purchased narcotics on the street. I related to the patient that narcotics can actually produce pain, which is called opioid hyperalgesic syndrome (Note*). The patient then started using cannabis and came to see me a few years ago for a legal recommendation. We weaned him off of the narcotics, and now his neuropathic pain is controlled, averaging 2/10. This is considered mild pain on a scale of 0-10, with 10 being the worst possible pain. He experienced a 10/10 while taking narcotics.
Cannabis Case Report #4:
J.D. is a 55-year-old woman who I saw for obesity, fatigue, and joint pain. She developed painful red/purple lesions/nodules on her lower extremity. She had no history of hepatitis B and the laboratory results confirmed she was never exposed to hepatitis. She denied any history of methamphetamine use. She also was not on medications that could cause his condition.
My preliminary diagnosis was polyarteritis nodosa. To prove that she had this condition, one of the nodules was biopsied and sent to laboratory for diagnosis. The picture shows histologically under the microscope that there is fibrinoid necrosis (pink globules in the center of the picture) along with chronic inflammatory cells, lymphocytes (the black dots throughout the picture). There is a resemblance of the vessel with the circular configuration in the center of the picture.
The next step was to place the patient on high-dose prednisone, followed by maintenance dose. The patient decided she wanted an alternative method of treatment. She wanted to try a cannabis oil for topical use, along with vapor rising cannabis. She did not want to be referred to a rheumatologist. I agreed to this treatment; however we have an understanding that if the disease progressed to other tissues in her body such as the kidneys, she would need to be referred.
The lesions on her skin dissipated over the 3-4 months of using the topical cannabinoids. She has been seen periodically over the past 6 years and the vascular lesions have not returned on her legs and she has not had any other tissue involvement.
Three of the 4 patients were abusing narcotics. The government, Society, and news media want to blame doctors for prescribing narcotics. I was wrapped-up in that era at the end of the 1900s and in the first decade of this century to prescribe opioids (narcotics) for chronic pain. In California there was a “Patient’s Bill of Rights for Pain”. I would have a pharmaceutical representative in my office every other week telling me that I can escalate the dose of narcotics to reduce their pain until they developed side effects, i.e. constipation. At meetings, and seminars, we were provided the same information. The pharmaceutical companies have created more and more opioids in different forms to provide doctors more medications to prescribe for pain. The FDA needs to also share the blame, because they have been approving all these narcotics. The FDA in the past has also allowed pharmaceutical companies to aggressively market the doctors. Recently, the FDA has curtailed this behavior.
I elected to separate myself from prescribing narcotics by instituting cannabis for chronic pain in 2006. I should have done it sooner, but nevertheless I have learned that narcotics should only be used for acute pain. In fact, my patients who use cannabis with chronic intractable pain have reduced their narcotic intake by 70-80%. In my opinion, there is very little need for chronic opioid use. Obviously, my opinion has become correct in that there are more deaths from opioid use than from car accidents.
Note*: I had received several patients from other physicians around 2005 who were on massive doses of narcotics. These patients had more pain than those on lower doses of opioids. The paradox did not make clinical sense. I could not get these patients off of their narcotics and in fact they wanted more and more and more. I called this opioid hyperalgesia syndrome. In 2006, a paper that was published in the medical Journal noted the same findings and called it opioid-induced hyperalgesia (Angst MS, Clark JD. Opioid-induced hyperalgesia: A qualitative systematic review. Anesthesiology 2006; 104:570587). In retrospect, my observations were accountable and accurate. The reason I called it a syndrome is incorporated into the definition of a predictable, characteristic pattern of behavior, action, etc., that tends to occur under certain circumstances. The patient’s I tried to get off of narcotics damage my property, and produced death threats. Therefore, in my opinion opioid-induced hyperalgesia should also incorporate psychological parameters.