Patient Case Study: Chronic Pain

by Jan 28, 2021Case Study, Education

Introduction

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

DOH certification
Severe chronic or intractable pain of neuropathic origin or severe chronic or intractable pain

Case Presentation

Medical history and allergies

  • History of hypertension, hyperlipidemia, asthma, insomnia, chronic pain
  • Chronic pain due to fall in 2005, neuropathic in origin – constant
  • Allergy: penicillin, cephalosporin

Medication
Rosuvastatin, Estradiol, Allegra, Asmanex, Flonase, Lidocaine, Triamterene/HCTZ, Tizanidine, Gabapentin, Carbatrol ER, Oxycodone, Acetaminophen

Illicit substances or ETOH
Alcohol used once weekly. No illicit substance.

History of Cannabis use
Naïve – no prior cannabis use

Chief complaint(s)
Pain all over but primarily in her back and affects her ability to complete daily activities, along with insomnia due to pain

Restrictions of use (personal and DOH)
Patient has asthma, so does not want to vaporize her medication, prefers to use oral forms or topicals

Management

Formulation(s)

  1. Ilera Hope #1 1:1 tincture (THC ≈ 5 mg/ml, CBD ≈ 5 mg/ml)
  2. Ilera Hope 2 5:1 Tincture (THC: 8 mg/ml, CBD 1.6 mg/ml)
  3. Ilera Dream 8:1 tincture (THC≈ 4.67mg/ml, CBD≈ 0.5mg/ml)
  4. Ilera Soothe cream (THC: 140 mg, CBD 21 mg per jar)
  5. Substitute for Dream- Ilera THC+ tincture (THC ≈ 10mg/ml)
  6. Substitute for Hope #1 – Liberty 1:1 CBD tincture (THC≈ 8.2mg/ml, CBD≈ 8.1 mg/ml)

Dosage

  1. Hope #1 tincture: Start with 0.25ml once daily for daytime pain can increase by 0.25ml increments every 3 days if needed if tolerated
  2. Dream tincture: Start with 0.25ml at bedtime for insomnia increasing by 0.25ml every 3 nights if needed if tolerated.
  3. Soothe cream: Apply to affected area(s) up to four times a day.

Frequency

  1. Hope #1 tincture: Start with once daily and once patient can feel onset and duration can move to twice daily
  2. Dream tincture: 30min – 1 hour before bedtime
  3. Topical: As needed

Other Comments
6/18 – Initial visit. Counseled to separate opiate and alcohol use from cannabis use by 4 hours to avoid sedation and cognitive impairment. Patient states she uses her Oxycodone sparingly as needed.

7/3 – Patient has titrated up to 1ml of Hope #1 tincture and she states it is working well for her pain. Her onset is anywhere from 30min – 1hour and duration is about 7-8 hours. She takes at 8:30am and has relief until 4:30pm. Patient is taking 1ml of Dream tincture at 11pm and waking up at 4:30am in extreme pain. Discussed continue increasing dose of DREAM tincture and taking HOPE #1 tincture twice a day.

7/20 – Hope #1 tincture dosed at 1ml at 6am and 2pm. Patient is getting pain relief. She no longer needs to take her acetaminophen. Patient is taking 1.25ml of Dream tincture and able to sleep until 6am which is a major accomplishment for her. We decided to try Liberty 1:1 tincture for cost savings. Liberty is more concentrated so patient will start at 0.5ml twice a day.

8/6 – Patient states the Liberty 1:1 tincture duration is not as long acting as compared to the Hope #1 tincture and she needs to take the Liberty tincture at 0.75ml three times a day, negating the cost savings. Patient will switch back to Hope #1 tincture after finishing her current bottle of Liberty tincture. Dream tincture is no longer available, patient will switch to 0.5ml of THC+ tincture at bedtime.

8/13 – Patient states that 0.5ml of THC+ tincture worked great for sleep, even better than the Dream tincture. Patient has her good nights and bad nights. Encouraged patient to dose increase if she knows it’s going to be a bad night. Patient is stable on 1ml Hope #1 tincture twice a day. Patient is using the Soothe cream when she is in the car for long periods of time.

Outcome

Patient is now stable on her daytime and nighttime regimens. She takes HOPE #1 tincture at 1ml twice a day and THC+ tincture at 0.5-0.75ml at bedtime. The Soothe cream is used as needed for long car rides. She still has good days and bad days, but her marijuana regimen helps her have more good days. She is not completely pain free but able to complete her daily tasks. Patient has been able to stop taking acetaminophen, which she is very happy about because she was concerned about her high dose and liver damage.

Discussion
Starting low and slowly increasing is a good way to find therapeutic dose without unwanted side effects. Not all tinctures are created equal. Even though she was converted to an equivalent dose the tincture did not last as long for her negating the cost savings. In her own words, “medical marijuana has been a Godsend and she is so grateful to be able to have access to medical marijuana”.

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