Patient Case Study: Pain & Anxiety

by Nov 30, 2020Case Study, Education

Introduction

Patient demographic
75-year-old cannabis-naïve female with multiple chronic diseases/medications

DOH certification
Chronic pain

Case Presentation

Medical history and allergies

  • History of diabetes mellitus, hypertension, hyperlipidemia, heart murmur, general anxiety disorder, thyroidectomy, chronic lower back pain
  • Completed back surgery 10 years ago for severe lumbar curvature, and there is the possible presence of osteoarthritis (not confirmed with provider). Currently getting steroid injections 3 times yearly
  • Allergies: sulfa, Demerol, Omnicef

Medications
Synthroid, Cardizem CD, Januvia, fluoxetine, ASA 81mg, atorvastatin, Tylenol #3, Tylenol arthritis, acidophilus, Bentyl, Xanax, TheraCran (cranberry supplement), lisinopril, lansoprazole, Invokana, metformin, OTC CBD oil, famotidine, calcium & d3, melatonin

Illicit substances or ETOH
Alcohol used once weekly, if at all. No illicit substances outside of her history with 1:1 topicals (purchased in recreational state) for back pain

History of Cannabis use
No prior cannabis use outside of topical mentioned above

Chief complaint(s)
Lower back pain that ranges from moderate to severe and affects her ability to complete daily activities, along with general anxiety and agitation

Restrictions of use (personal and DOH)
Open to all forms of consumption, although she agrees with the recommendation that primary therapy would preferably be oral due to better dosage control and lack of lung irritation

Management

Formulation(s)

  1. Ilera Soothe 5:1 tincture (THC: 4.23 mg/ml, CBD 0.76 mg/ml)
  2. Ilera Freedom vape cartridge (THC 41.4%, CBD 47.3%)
  3. Terrapin 1:1 topical salve (THC: 94.64 mg, CBD 131.04 mg per jar)

Dosage

  1. Tincture: Start with 0.25ml (to yield approx. 1mg THC), max frequency 4-6x daily. Patient may titrate upwards gradually every 3-5days by 0.25ml if needed
  2. Vape Cartridge: Use for acute pain flares and severe anxiety/panic when tincture relief not sufficient
  3. Topical Salve: Apply a thin layer to lower back for pain, as needed

Frequency

  1. Tincture: Start with 1-2 times daily, but due to 4-6hr duration of action, patient can use every 4-6 hours if needed
  2. Vape Cartridge: As needed
  3. Topical Salve: As needed

Other comments
Tincture and vape cart should be spaced hours from alcoholic drinks, Xanax and Tylenol#3 in the effort to avoid disorientation/cognitive impairment or sedation. Patient’s goal is to discontinue use of these two medications once she is pleased with the results of the medical cannabis regimen. Patient should also watch for palpitations or feelings of a “racing heart” since THC has been shown to alter cardiovascular function, which may be compounded by her current hypertension treatment.

Outcome

Ilera Soothe Tincture alleviates her pain without unwanted sedative/cognitive effects at a dose of 0.5ml. Patient takes one dose in the morning and another in the afternoon; twice daily dosing will suffice. The Terrapin 1:1 salve works well for “spot treatment’ on her lower back; her husband applies it for her as needed, but no more than once daily. The Ilera Freedom vape cart has been discontinued due to patient preference for oral medicine and is not necessary with the patient being stable on 0.5ml tincture dose taken twice daily. The patient is pleased with the relief achieved thus far.

Discussion

We have come to find that patients may achieve all-day relief with minimal dosing frequency. Sublingual tinctures are believed to have a duration of action of up to 6 hours, but our patient here has achieved 24-hour relief using only twice daily. The patient reports less agitation and general anxiety, along with a reduction in lower back pain and increased ease of physical activity.

Adding an immediate-acting inhaled method at the beginning of therapy for “as needed” use for acute flares, break through pain and severe anxiety/panic may not have been necessary. It appears that having a “rescue” medication like vape cartridge would be desirable, but our patient determined that once a stable dose of her long-acting tincture was found, vaping was no longer required. To add, suggesting multiple products in THC-naïve patients could lead to a greater change of overmedication and cognitive impairment, particularly in our elderly population that concurrently use cognition-impairing drugs. This demographic of patients may be better off, for safety purposes, starting with oral products that allow for precise measurement to promote consistent dosing and easier titration.

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