Reader response
Myron Yaster MD
From Dr. Mark Schreiner commenting on cannabinoids in the treatment of chroinic/persistent pain
I’d like to share my second-hand experience with medical marijuana based on my wife Janet’s experiences. I know this is anecdote, the plural of which is not data, and yet in absence of compelling data, what else is there?
Since 2008, Janet has undergone multiple spinal surgeries initiated by herniating three discs in 2005 and failure of medical management. Ever since, this 5-foot tall, 90-pound woman, with rods and screws from L5 to T10, has been in severe to moderate pain. Indeed, her pain journey continues and this past August, she had her hardware removed and another fusion at T7-8.
Before her first surgery, she had a number of nerve blocks, some successful, some not, and was treated with a number of drugs intended to treat neuropathic pain. Pregabalin, gabapentin, amitriptyline, tizanidine, and others. Pregabalin and gabapentin made her so sleepy she couldn’t function and she never was able to tolerate a therapeutic dose. On amitriptyline and tizanidine she became severely depressed bordering on suicidal. Opiates have had their own horrible side effects including, severe constipation, depression, brain-fog, sedation, respiratory depression, etc. And withdrawal is its own special type of hell. Severe respiratory depression in the PACU with lots of hubbub around her bed to treat it after surgery #3 and a period of intra-op awareness triggered severe PTSD which has required lots of therapy.
For the first operation, she was discharged on 32 mg of hydromorphone (Dilaudid) per day and she was still on it in 2011. While on tour with her band in 2011, while still stuck on hydromorphone, her 20-something bandmates suggested she try marijuana. Within 2 weeks she was off opiates. For surgeries 3 – 7 withdrawal symptoms started once she got below 10 mg per day. After surgeries 5 – 6, she had Marinol (THC) in the hospital which allowed her to go home on 16 mg/day of hydromorphone.
However, after her most recent operation which involved a huge incision and removal of lots of hardware, she had a surprising amount of pain and was ultimately discharged on 48 mg/day of hydromorphone. After gaining access to her bong, she was down to 32 mg/day on the first day at home. A pretty substantial reduction. This time it took 8 months to get off of hydromorphone. I have no idea why post-op pain should last this long (6 months – 3 years), but it does.
So Janet has successfully managed her pain primarily with marijuana and NSAIDs since 2011 with way fewer side effects than with opiates or neuropathic pain meds. During the daytime, when not in severe pain she uses a sativa strain; evenings or when her pain is worse, she uses indica. While there are no pure strains of indica or sativa anymore, the strains one can buy are advertised as leaning one way or the other. Indica is more sedating and provides better pain relief; sativa can even be energizing. I cannot tell from her behavior when she has smoked or vaped recently.
Marijuana has the great advantage in that it can be titrated to effect, something anesthesiologists should appreciate when discussing the use of medical marijuana. Finally, I see great emphasis on the side effects of marijuana without equal consideration given to the side effects of the alternatives, some of which can be pretty severe.
From Amy Vinson MD Boston Children’s Hospital on BMTs and post op pain
I am often very surprised by hypothesis’ that people state in articles. It would have NEVER occurred to me that children with infected ears WOULDN’T feel considerably BETTER after the procedure. Chronically infected ears are super painful and disorienting. The procedure literally lances the abscess and relieves all the pressure and lets them hear and orient without pain. The absence of pain is pleasure, right? They should be the happiest kids in the PACU! It’s like an appy - you should feel BETTER after this procedure. Or a displaced fracture - you’re gonna feel loads BETTER. The idea that surgical "procedure = more pain" is often knee-jerk and lacks the perspective of the whole reality. We frequently report post-operative pain scores without reporting pre-operative pain scores. We do it all the time. Anyway….very cool article, but their hypothesis just surprised me. Maybe it’s my pediatric background of having taken care of tons of kiddos with ear infections.
From Dr. Hannah Lonsdale, Assistant Professor of Anesthesiology, Vanderbilt Children’s Hospital, Nashville, TN
Thanks to the PAAD team for this week’s informative articles on cannabinoids for pain management. As cannabis use for both medical and recreational purposes becomes more frequent, PAAD readers may also be interested to learn more about Cannabis Hyperemesis Syndrome (CHS), an increasingly recognized but seemingly paradoxical condition in some adults and children who are chronic users of cannabis. CHS manifests in a similar fashion to cyclical vomiting syndrome, with cycles of severe, persistent nausea and vomiting that last for hours to weeks, followed by a recovery phase which may last for weeks to months. A pragmatic set of diagnostic criteria for use in adolescents is given below. An unusual and potentially pathognomonic feature is compulsive hot water bathing, which is reported to relieve nausea.
The most effective treatment for the acute symptoms of CHS involves IV rehydration and haloperidol, as ondansetron has been found to be relatively ineffective. The only know effective long-term treatment is full cessation of cannabis use. It’s incidence in children is currently unknown- the largest study to date is our single-institution case series of 30 patients aged between 13 and 20 years.
CHS is worth bearing in mind as part of a differential diagnosis in children with intractable vomiting who use cannabis, and I encourage all clinicians to discreetly tackle the question of substance use with our adolescent patients. Cannabis is certainly not a benign addition to a pain management plan.
Major Criteria
Regular cannabis use for three months or more
Onset or worsening of episodic nausea and vomiting resembling Cyclical Vomiting Syndrome after the start of regular cannabis use
Absence of other underlying medical conditions which could explain the symptoms, after all appropriate negative investigations
Supporting Criteria
Symptomatic relief with hot showers or baths
Weight loss
Change in bowel habit
Abdominal pain
References
Lonsdale H, Kimsey KM, Brown JM, Dey A, Peck J, Son S, Wilsey M. Pediatric Cannabinoid hyperemesis: A single institution 10-year case series. Journal of Adolescent Health. 2021 Feb 1;68(2):255-61.
Brown JM, Wilsey MJ, Dhana L, Lonsdale H. Acute Treatment of Adolescent Cannabinoid Hyperemesis Syndrome with Haloperidol, Lorazepam, and/or Capsaicin: A Single Institution Case Series. Accepted for publication, Journal of Psychiatric Practice.
Lonsdale, H., & Wilsey, M. J. Pediatric cannabinoid hyperemesis. Current opinion in Pediatrics 2022, 34(5), 510-515.
Lonsdale H, Brown JM, Wilsey M. Adolescent Cannabis Hyperemesis Syndrome During the COVID-19 Pandemic. Pediatric emergency care. 2022 Jan 1;38(1):e68.