Prescribing cannabinoids for pain is a challenge

Hillel M. Finestone is a Physiatrist at the Elisabeth Bruyere Hospital and Professor, Division of Physical Medicine and Rehabilitation, University of Ottawa.

 

My 52-year-old patient took his BP at a pharmacy on 6 separate occasions.  Systolic BP values were high, ranging from 150-177. When I take his BP in the office it’s 168/98.  Yup, he has high BP.  He’s 10 pounds overweight, doesn’t have diabetes, doesn’t smoke and thinks that he was told that his BP was “probably high” 5 years ago, but he didn’t feel that medications would make a difference.

We talk about weight loss, healthy eating and reducing high sodium foods, that we don’t know why BP elevates but that medications really work and help stop strokes and heart attacks from occurring.  He agrees to my prescription of one medication and we discuss its side effects.  A drug information sheet is provided.

Clean.  Fairly precise.  Not very controversial, although my hockey playing medical colleague of the Kermit Hockey League always tells me that antihypertensives are crazily overprescribed.

I ask myself, “Is prescribing an anti-hypertensive the same as prescribing ‘medical’ cannabinoids?”  Some would have us believe so.  However, there are differences.

In my world medical cannabinoids prescribing runs like this:

A 32-year-old has a long history of intermittent neck and back pain which she manages with yoga classes, Pilates, massage therapy, physiotherapy sessions, and occasionally acetaminophen, ibuprofen and naproxen purchased over the counter. But 3 months ago she was involved in a car accident. Her neck and back pain quickly escalated and sitting became problematic, which affects her ability to work. As her family doc is on maternity leave it’s been hard for her to receive regular primary medical care. Physiotherapy and massage therapy, arranged through her insurance company, provide temporary relief. She asks for psychological counselling for her poor sleep, panic attacks, and fear of driving; she is scheduled to see a psychologist in a month, who will then likely need to write out a treatment plan to justify future counselling sessions.  Months more to wait.

It’s now 4 months past her accident. She’s tearful, suffering in pain and doesn’t see much hope in sight. I’m the 4th physician she’s seen and she tells me that she’s been smoking her friend’s marijuana on a nightly basis and feels that “it helps”.  She thinks her sleep is somewhat better and that she’s less anxious. The effect of the ½ - ¾ a toke is not enough however to change her overall function.  She’s still working only sporadically and seldom drives as she is too afraid.

She asks for a marijuana prescription. So many of her friends have one.  They usually have been referred by their doctors to a “Cannabis Doctor” who has written the prescriptions while talking on Facetime.

I ask myself, “Do I just treat this type of case like high blood pressure?” My patient has pain; marijuana is supposed to treat pain (I’ve seen that in the newspaper so many times); she’s suffering…Why not?

The problem is that pain is not exactly a diagnosis. It’s a symptom.  It’s much more difficult to measure than BP.  It’s subjective. My patient is clearly in a lot of pain.

The evidence suggests that cannabinoids are effective in the treatment of chronic neuropathic pain but there is insufficient evidence to support their use for chronic musculoskeletal pain. Recent Canadian guidance for primary care practitioners supports this. Suggested treatments for pain are initially non-pharmacological, e.g. physiotherapy, yoga, exercise.  Cannabinoids are way down the treatment list, after over the counter analgesia and other agents.

But in a medical system where a patient in pain cannot receive optimal stepped, multidisciplinary pain care cannabinoids become a “fallback” position. Cannabis is available, and now legal in Canada for recreational purposes, and people are desperate for relief.

What’s more physicians report not receiving adequate training and guidance on prescribing cannabinoids. But cannabinoid companies are doing an excellent job in targeting potential users directly by producing numerous gorgeous-looking brochures, manuals, and “guidelines for use”. And then there are the “Cannabinoids doctors” who sit in an office somewhere and don’t do anything but prescribe the stuff over Skype or FaceTime. I joke that I am going to start up an “Aspirin Clinic”. You get the drift.

The prescription of cannabinoids for pain needs to be more extensively covered in our medical and continuing education. Physician engagement should match that of major cannabinoid producers. Prescribing cannabinoids is NOT like prescribing an antihypertensive, and treating painful conditions needs greater commitment from provincial health ministries in the form of effective multi-disciplinary care. Let’s get real.

Note: The patients depicted in this story are fictional.

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