Overview of Interventional Procedures and Medical …Overview of Interventional Procedures and...
Transcript of Overview of Interventional Procedures and Medical …Overview of Interventional Procedures and...
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Overview of Interventional Procedures and Medical
CannabisChristina Gonzaga, DO
Medical Director
Park Nicollet Pain Management Clinic
St. Louis Park, Minnesota
April 27, 2018
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AgendaAbout Me
Disclosures
Objectives
Overview of Pain
Specialized Tests
Case 1
Intervention
Case 2
Medical Cannabis
References
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Introduction
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Abbreviated Curriculum Vitae
• Medical Director
• Pain and PM&R Boarded
• BA in history from Loyola University Chicago
• DO from Western University of Health Sciences Pomona, CA
• Residency: St. Vincent’s Manhattan, NS-LIJ
• Fellowship: Anesthesia pain, Thomas Jefferson University, Philadelphia
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I have nothing to disclose
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Learning objectives
• The state of pain care today• Review of the pain history and physical
examination• Brief review of interventional pain procedures • Review of medical cannabis: risks, benefits and
the future
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Current State of Pain Care
Patients with Pain
Rehab Services
External Pain Clinics
Primary Care
Chiro
Mental Health
Emergency Center
Urgent Care
PMR
Addiction Medicine
Surgical Services
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Why do we need to design a better way?
• Increases in opioid related deaths• CDC guidelines
“Unless the nation develops an increased tolerance to chronic pain, reduction in opioid leaves a vacuum that will be filled with other therapies.”12
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Interdisciplinary Care Model
Patients with Pain
Pain-boarded
Physician
MTM Pharmacy
Rehab
Services (OT/PT)
Pain Psychology
Nursing Care Coordination
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Role of the Pain Physician
• Team player: Collaborate with all members of the interdisciplinary team
• Trouble shoot medical aspects of the patient • Medication management and interventional management • Goals: Keep in mind the CDC guidelines. Decrease to
lowest effective dose, work with the individual needs of patients, work along side team to educate, guide, and help patients develop multiple tools to help them manage pain.
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Interventional Procedures
•Back to the basics: history and physical
•Do not treat the diagnostic exam, treat the person in front of you
•Talk and LISTEN to your patient
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History Location
Character
Severity
Timing
Onset
Duration
Frequency
Alleviating and aggravating factors
Associated signs and symptoms
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Back Pain RED FLAGS Back pain in childrenConstant progressive pain at nightHistory of cancer/Marked weight loss Use of systemic steroidsIntense pain with minimal motion/structural deformityDrug abuse or HIV infectionSystemic illnessDifficulty with urination
Loss of anal sphincter tone or fecal incontinence, saddle anesthesiaWidespread progressive motor weakness or gait disturbance Inflammatory disorders (ankylosing spondylitis) Marked morning stiffnessPeripheral joint involvementPersisting severe restriction of motion
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Physical Examination
• Observation:• Skin, muscle mass, bony structures,
as well as observation of overall posture
• Position of lumbar spine (Scoliosis)• Gait
• Palpation:• Bones• Facet joints• Ligaments and inter-discal spaces• Muscles
Active range of motion Forward flexion (Discogenic?)
Extension (Facet joints?)
Side bending (Facet joints?)
Rotation (Facet joints?)
Neurologic Examination Manual muscle testing
Pinprick and light touch sensation
Reflexes
Balance
Babinski
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Sensation and Sensory ExaminationMechanical Nociceptors:
• Pin prick and pinch
Heat Nociceptors:• Temperature greater than 45 degrees Celsius
Polymodal Nociceptors:• Respond equally to mechanical, heat , and chemically noxious stimuli
Fast Pain:• Transmitted by well-localized myelinated A-fibers and is characterized by sharp, shooting pain
Slow Pain:• Transmitted by unmyelinated C fibers and is characterized as dull, poorly localized burning pain
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Motor Examination: Muscle Grading
• 5 Normal: Complete range of motion against gravity with full resistance
• 4 Good: Complete range of motion against gravity with some resistance
• 3 Fair: Complete range of motion against gravity
• 2 Poor: Complete range of motion with gravity eliminated
• 1 Trace: Evidence of slight contractility; No joint motion
• Zero: No evidence of contractility
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Muscle Stretch Reflexes/DTRs
Grading:
0 = No response
1+ = Reduced (less than expected)
2+ = Normal
3+ = Moderately hyperactive (greater than expected)
4+ = Hyperactive with clonus (upper motor neuron sign)
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Commonly Test Nerve Root Levels
C5-C6 Biceps reflex
C7-C8 Triceps reflex
L3-L4 Patellar reflex
S1-S2 Achilles reflex
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What’s the root cause?Root Dermatome Muscle Weakness
C4 Shoulder Levator Scapulae (Shoulder shrug)
C5 Lateral arm Deltoid
C6 Lateral forearm, first and second finger
Biceps, Extensor carpi radialis (weakness in wrist extension)
C7 Middle finger Triceps (weakness in elbow extension)
C8 Fourth, fifth finger; medial forearm
FDP; Finger flexion of middlefinger
T1 Medial arm Dorsal inter-ossei; Difficulty in keeping fingers abducted against resistance
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Root Dermatome Muscle Weakness
L1 Back, over the greater trochanter and groin
None
L2 Back, front of thigh to knee Psoas, hip abductors
L3 Back, upper buttock, front of thigh and knee, medial lower leg
Psoas, quadriceps
L4 Inner buttock, outer thigh, inside of leg, dorsum of foot
Tibialis anterior, extensor hallucis; quadriceps
L5 Buttock, back and side of thigh; lateral aspect of leg; dorsum of foot; inner half of sole and first, second, and third toes
Extensor hallucis, peroneals, gluteus medius, ankle dorsiflexors,hamstrings, calf wasting
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Physical Examination
Root Dermatome Muscle Weakness
S1 Buttock, back of thigh, and lower leg
Calf and hamstrings; wasting of gluteus, plantar flexors
S2 Buttock, back of thigh, and lower leg
Calf and hamstrings; wasting of gluteus, plantar flexors
S3 Groin , inner thigh None
S4 Perineum, genitals, lower sacrum
Bladder, rectum
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Dermatomes
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Upper Extremity Dermatomes
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Lower Extremity Dermatomes
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Physical Examination
Abdominal muscle strength Pelvis stabilizer strength i.e. gluteus medius and
gluteus maximusTightness or stiffness of hamstringsTightness or stiffness or hip flexorsTightness or stiffness of hip rotatorsOther specialized musculoskeletal examinations
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Spurling’s Test: Cervical radiculopathy
• Extension and side-bending impinges the neural foramen and causes shootingpain down that arm
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Drop Arm Test
• May be sign of rotator cuff tear
• Careful to differentiate possible weakness of deltoid versus a cervical root problem
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Yergason’s Test
• Palpate the bicipital groove• Examiner provides resistance• Patient actively tries to pronate while examiner supinates/external rotates arm• Pain in groove may be sign of bicep tendinitis
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Patrick’s Test
• Stresses the hip and sacroiliac joints• Same side hip pain = degenerative disease of hip• Opposite side pain may be due to SI joint dysfunction• AKA: FABER
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Tinel’s sign for CTS
• Test for carpal tunnel syndrome• Tap over carpal tunnel, testing median nerve• Pain shooting down first three digits is a positive test
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Phalen’s test for CTS
• Hold for 1 minute• Tests the median nerve• Pain shoots down first three digits
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Straight Leg Raise
• Stretches the sciatic nerve• Positive from about 30-70 degrees• Anything greater than 70 may be due to hamstring tightness
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Gaenslen’s Test
• Testing for SI joint pain• If pain is reproduced, then it is positive• Note, the symptomatic leg is off the table
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Slump Test
Patient at edge of table with legs hanging down
Patient actively flexes through cervical, thoracic and lumbar spine
Examiner performs a straight leg raise
Once symptoms are elicited, the examiner asks the patient is asked to extend the cervical spine
Positive if cervical extension alleviates the symptoms
May show impaired neural tissue mobility
Sensitize with ankle dorsiflexion
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Slump Test
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Iliac Compression Test
• Compress directly over iliac crest• Pain on same side may be SI joint pain• Pain on opposite side may be caused by greatertrochanteric bursitis (make sure to check)
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McMurray Test: Lateral Meniscal Tear
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McMurray Test: Medial Meniscal Tear
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Case Study
• A 65 year old female presents to your office with a 1 year history of chronic low back pain. PMHx: HTN. PSHx: None. Denies loss of bowel or bladder. MRI review shows some degenerative changes, mild neuro foraminal stenosis, moderate central canal stenosis. No signs of radicular leg pain are exhibited. Gait is intact and non antalgic. No assistive device noted. Transfers independently. Normal muscular examination and neurological examination. Denies back pain waking her up at night. No acute loss of weight. She notes when she extends her back pain is exacerbated. No buttock pain noted. You decide that there are no immediate dangers, so you send her to PT. She asks for medications. Given she has no kidney issues, liver issues, or GI bleeds, you advise her to intermittent use either Tylenol or ibuprofen and send her out. You’ll see her after PT.
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Interventional Pain ProceduresINTERVENTIONAL PROCEDURE TYPES REASONS TO DO THEM
Epidurals: transforaminals and interlaminars, selective nerve root blocks, caudal
Stenosis, spondylopathy with radicular symptoms
Intercostal nerve blocks Intercostal neuritis, rib pain, post herpetic neuralgia
Peripheral joint injections (hip, knee, shoulder), piriformis injections
Hip arthritis, subacromial bursitis, shoulder arthritis, knee osteoarthritis, greater trochanteric bursitis, piriformis syndrome, iliopsoas bursitis
Sacroiliac joint injection Buttock pain
Lumbar, thoracic, and cervical rhizotomies, sacroiliac rhizotomy, facet injections
Axial pain, facet arthropathy, sacro- iliac joint pain.(No radicular symptoms)
Coccyx injection Coccydynia
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Interventional ProceduresINTERVENTIONAL PROCEDURE TYPES REASONS TO DO THEM
Peripheral joint rhizotomies (Genicularnerves, femoral articular branch and obturator nerve)
Knee pain post total knee, hip pain post total hip replacement, hip labral tear, AVN, hip osteoarthritis
Lumbar sympathetic blocks, stellate ganglion block
Sympathetic mediated pain, upper and lower extremity CRPS, often precedes stimulator trials/implants
Vertebroplasty, Kyphoplasty (use of balloon) Non-traumatic osteoporotic compression fracture
Intrathecal pain pumps Cancer pain, chronic pain ?
Spinal cord stimulators Failed back syndrome, CRPS, peripheral chronic nerve pain
Ganglion Impar Block Blocks relieve perineal pain from cancer of the cervix, endometrium, bladder, rectum.
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How about that case?The patient comes back to you with continued low back pain. Minimal improvement after 6 weeks of PT. She is looking for
further input and your professional opinion on this pain.
What will you offer her next?
1. Live with the pain
2. Facet joint injection
3. Lumbar frequency ablation
4. Spinal cord stimulator trial
5. Early retirement
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Facet joint injections, medial branch blocks, and radiofrequency ablations
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Radiofrequency Ablation
• Etiology: Axial Pain w/o radicular symptoms
• 2 Medial Branch blocks vs. intraarticular injections
• Burn twice between 70-80 degrees Celsius
• Typically lasts 4-12 months; large variability
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Conclusions• Level II evidence for long-term effectiveness of radiofrequency
ablation in lumbar and cervical spines, for facet joint medial branch blocks in cervical, thoracic, and lumbar spine
• Level III evidence for thoracic radiofrequency ablation, lumbar and cervical intraarticular joint injections
• Cohen, et al suggest (case control study) suggest medial branch blocks over facet joints lead to better outcomes than intra-articular joint injections 15
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Lumbar Radiculopathy
• Epidemiology
• Occurs in approximately 3-5% of the population
• Men and women are affected equally
• Men are most commonly affected in their 40s
• Women are most commonly affected between ages 50-60
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Epidurals • Widely accepted• Safety and effectiveness accepted• Literature shows most effectiveness in the first couple of weeks• Some literature shows longer than one year• Randomized controlled trials are rare• Trial designs often have low enrollees• Possible that anesthetic alone may be as effective as using
steroid and anesthetics• Suggestion that epidurals may help to decrease opioid intake in
certain groups2,3,4
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Spinal Cord Stimulators
• Failed Back Surgical Syndrome (FBS) • Radicular pain syndrome or radiculopathies
resulting in pain secondary to FBS or herniated disk• Post-laminectomy pain• Multiple back operations• Unsuccessful disk surgery• Degenerative Disk Disease (DDD)/herniated disk
pain refractory to conservative and surgical interventions
• Epidural fibrosis• Arachnoiditis or lumbar adhesive arachnoiditis• Complex Regional Pain Syndrome (CRPS)• Peripheral nerve pain ?About Me Disclosures Objectives Overview Tests Case 1 Intervention Case 2 Cannabis References
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Spinal Cord Stimulation
• Should be a last resort
• Requires a trial prior to implantation
• Psychological work up needed
• Ability to operate the programming is important
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Spinal Cord Stimulators: Possible Benefits
• Long-term pain relief
• Improved quality of life
• Successful pain disability reduction
• May be less expensive and more clinically effective that re-operation for failed back surgical syndrome
• Decreased opioid usage
• Decreased reported subjective pain scores
7 ,8, 9
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We’ve come a long way…
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Case Study• A 39 year old male construction worker presents to your office.
PMHx and PSHx unremarkable. He is used to some amount of low back pain but now has developed pain down the right leg. States that it has been going on for 8 weeks. No loss of bowel or bladder. Started gradually and has worsened. He feels subjectively weak in the right lower extremity. Burning pain. History reveals no red flags. He has slight weakness in right quadriceps. No atrophy noted. Antalgic gait, off-loading the right leg. No assistive device needed. You sent him to PT for a few weeks (traction and therapeutic exercises) with no improvement in pain. MRI without contrast ordered.
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Lumbar MRI findings
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Physical examination
• 4/5 in right knee extension
• No wasting noted
• Decreased right patellar reflex
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Question #1
What nerve root is affected?
a. L2b. L3c. L4d. L5e. S1
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What do you do next?
• Right L4 epidural• Consideration of multiple
(2-3)• Have him complete PT• If all fails, referral to for
surgery consultation
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Medical Cannabis
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Medical Cannabis
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Cannabinoids: Subgroups
1. Endogenous endocannabinoids
2. Botanicals (phytocannabinoids): 60 identified
3. Synthetic Derivatives
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Dr. Raphael Mechoulam discovers the first cannabinoid Δ-tetrahydrocannabinol (THC) in 1964
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Endocannabinoid System
• ECS modulates the sensitivity to neurotransmitters like NE and serotonin
• Human experience of pain and response to stress involves interaction of endocannabinoids through endorphins and cortisol release
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Important Receptors: Research for the FutureCB1:
• Accounts for psychotropic action of THC and its analgesic effects.
• Pre-synaptic activation of CB1 inhibits GABA (“Stop”) or Glutamate (“Go”) pathways.
• Present in areas of the brain and play a role in memory, mood, sleep, appetite and pain sensation.
CB2:
• Theorized to modulate persistent inflammatory and neuropathic pain conditions.
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FDA Approved Synthetic Cannabis Pharmaceuticals Dronabinol (Marinol): 1986
• Synthetic Delta-9 THC
• FDA approved for treatment of nausea and vomiting for patients in cancer treatment, appetite stimulant for AIDS patients, analgesics to ease neuropathic pain in multiple sclerosis patients
Nabilone (Cesamet):
• Synthetic cannabinoid similar to THC
• FDA approved for treatment of nausea and vomiting in patients undergoing cancer treatment
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Pharmacology and Pharmacokinetics of THC13
• Major psychoactive delta-9 tetrahydrocannabinol (THC)
• Oral: Low bioavailability (6-20%). Peak plasma concentrations after 1-6 hours and half life of 20-30 hours.
• Inhalation: Peak concentration of THC occurs in 2-10 min and rapid decline for 30 minutes.
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Minnesota: Approved Conditions for Medical Cannabis
• Cancer associated with severe/chronic pain, nausea or severe vomiting, or severe wasting
• Glaucoma• HIV/AIDS• Tourette’s Syndrome• Amyotrophic Lateral Sclerosis (ALS)• Seizures including those including those characteristic of epilepsy• Severe muscle spasms including those characteristic of multiple sclerosis• Crohn’s Disease• Terminal illness, with a life expectancy of less than one year, if the illness or treatment
produces severe/chronic pain, nausea or severe vomiting, cachexia or severe wasting• Intractable Pain• Post-Traumatic Stress Disorder (PTSD)
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Arizona: Approved Conditions• Acquired immune deficiency syndrome (AIDS) • Amyotrophic lateral sclerosis (ALS)• Crohn's disease • Human immunodeficiency virus (HIV) • Agitation of Alzheimer's disease • Cancer• Glaucoma• Hepatitis C• Post-Traumatic Stress Disorder (PTSD) • IF A CHRONIC OR DEBILITATING DISEASE OR MEDICAL CONDITION OR THE
TREATMENT FOR A CHRONIC OR DEBILITATING DISEASE OR MEDICAL CONDITION CAUSES: Cachexia or wasting syndrome, severe and chronic pain, severe nausea, seizures, including epilepsy characteristics, severe or persistent muscle spasms, including those characteristic of multiple sclerosis
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Medical Cannabis
• Inhaled as smoke or vapor
• Liquid or oral extracts
• Topicals/Balms: CBD only (federally legal)
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Smoked or Vaporized Cannabis11
• Rapid onset, short duration of action
• RCT are limited to short time frames and small patient populations
• One study showed smoked cannabis increased pain tolerance
• Another study showed no therapeutic effect against a pain stimuli at 2% THC but increased pain experience at 8%. Suggestion of a therapeutic window
• Multiple studies looking at HIV neuropathy or neuropathic pain are promising for decrease in VAS pain rating
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Oral and Oral-Mucosal Cannabis11
• Longer onset, longer duration of action
• Variable duration effects
• Effects vary among different populations
• Study: Women with higher estrogen responded with better pain relief
• Study: Men appeared to have better pain relief response
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THC: CBD11 Ratios
• Cannador® cannabis extract (various THC: CBD). Phase III RCT of 2THC: 1: CBD n=630. Decrease in pain related to spasms.
• Nabixamols (Sativex®) THC: CBD Multiple studies demonstrate pain relief in chronic pain. Suggestion that combination is more effective than THC alone.
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Dosing
• Complex question
• There is no standardized dosing
• Variable as each person is different (genetics of endocannabinoid system, metabolism, tolerance, past exposure)
• Conversion from smoked to oral dosing unknown
• Titrate slowly
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Short Comings
• Products also are not standardized
• Ratios of THC: CBD not well understood in terms of most appropriate dosing• The most popular theory is that the more neuropathic and inflammatory pain issues
do better with higher THC while the most chronic, intractable wide musculoskeletal pain does better with higher CBD.
• Drug-Drug interactions can occur
• Side Effects
• Long term effects are unknown
• Cost prohibitive
• Legal issues: Federal Vs. State
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Drug-Drug Interactions13
• Potentiate CNS depressant effects with benzodiazepines, alcohol, opioids
• Possible mania induced when combined with SSRIs
• Increased tachycardia and delirium with TCAs and sympathomimetics
• Increase risk of immunosuppression with corticosteroids
• May decrease effectiveness of anti-psychotics
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Side Effects and Risks
• Impairment of memory (cognitive change), decrease motor coordination, altered judgement
• High dosing of THC may cause psychosis
• Increased heart rate
• Nausea and vomiting (“cannabinoid hyperemesis syndrome”)
• Dry mouth
• Dizziness and headache
• Sedation
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Side Effects and Risks• Dependence and addiction
• Increased risk of pulmonary issues (similar to smoking)
• Increased risk of lower birth weights, possible affect on neurodevelopment
• Possible increased risk of cancer
• Increased risks of traffic accidents
• May cause liver fibrosis in HCV patients
• May cause acute pancreatitis
• Withdrawal symptoms10, 11, 13
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The Final Question
A 35 year old male comes to your clinic with complaints of global wide spread pain. He is a poor historian but further digging into his chart, discussion with former clinicians, and further probing of the patient the true details of his history come to light. He has a history of chronic low back pain, global wide spread pain, history of substance abuse, and schizophrenia. He has a long history of non compliance with treatment plans, well-documented acute psychotic episodes, and the current use of Zyprexa, a second generation anti-psychotic.
Is this a good candidate for medical cannabis?
1. Yes.
2. No.
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The future of cannabis
• With the liberalization of use, it is important well-done, double blinded RCT are done and that their length of study is substantial
• Possible that using specific cannabinoids for specific conditions may prove beneficial14
• Goal: Decrease pain. Do not exchange one epidemic for another
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Medical Cannabis: Summary • Every patient deserves care that is safe and based on medical evidence
• Limited moderate-level evidence reveals some promising use in pain13
• Conflicting literature13
• Observational studies find a decrease in opioid addiction and overdoses in states that legalize12
• May act synergistically with opioids11
• Lack of high quality, long term clinical trials12
• Considered an experimental drug
• Death has not be associated with use of medical cannabis
• There are risks
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The End
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Thank you for your time!
•Contact information: [email protected]
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References1. Taruli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clinic 25 (2): 387-405.
2. Bayer, F et al. Non-operative treatment of lumbar spinal stenosis. (2016). Technology and Health Care, 551-557
3. Manchiakanti, L et al. Transforaminal epidural injections in chronic lumbar disc hernation: A randomized, double-blind, active-control trial. (2014). Pain Physician, 17: E489-E501.
4. Zhai, J et al. Epidural Injection with and without steroid in managing chronic low-back pain: A Metanalysis of 10 randomized controlled trials. (2017). American Journal of Therapeutics 24, e259-e269.
5. Manchiakanti, L et al. A Systemic Review and Best Evidence Synthesis of Effectiveness of Therapeutic Facet Joint Interventions in Managing Chronic Spinal Pain. (2015). Pain Physician, 18: E535-582.
6. Kumar, K et. al. The effects of spinal cord stimulation in neuropathic pain are sustained: a 24 hour follow-up of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation.( 2008) . Neurosurgery. 63(4):762-770.
7. Harke, H et .al. Spinal cord stimulation in sympathetically maintained complex regional pain syndrome type I with severe disability. A prospective clinical study. Eur J Pain. (2005). 9(4);363-373.
8. North RB, Kidd D, Shipley J, Taylor RS. Spinal cord stimulation versus reoperation for failed back surgery syndrome: a cost effectiveness and cost utility analysis based on a randomized, controlled trial. Neurosurgery. 2007;61(2):361-369
9. Sanders, R et. al Patient Outcomes and Spinal Cord Stimulation: A Retrospective Case Series Evaluating Patient Satisfaction, Pain Scores, and Opioid Requirements. Pain Practice (2016). Volume 16, Issue 7, 899-904.
10. Kim, P and Fishman, M. Cannabis for Pain and Headaches: Primer. Curr Pain Headache Rep. (2017). 21:19 3-11.
11. Andrade, C. Cannabis and Neuropsychiatry, 1: Benefits and Risks. J Clin Psychiatry. (2016). 77: 5 e551-554.
12. Choo, E. Opioids Out, Cannabis In: Negotiating the Unknowns in Patient Care for Chronic Pain. JAMA. (2016). Volume 316, November 17: 1763-1764.
13. Parmar, J. et al. Medical Cannabis patient counseling points for health care professionals based on trends in the medical uses, efficacy, and adverse effects of cannabis-based pharmaceutical drug. Research in Social and Administrative Pharmacy 12. (2016). 638-654.
14. Goldenberg, M. Et. Al. The impact of cannabis and cannabinoids for medical conditions on health related quality of life: a systemic review and meta-analysis. Drug and Alcohol Dependence. 174 (2017). 80-90.
15. Cohen, S. et. Al. Medial Branch Blocks or Intraarticular Injections as a Prognostic Tool Before Lumbar Facet Radiofrequency Denervation. Regional Anesthesia and Pain Medicine. (2015). Volume 4, Number 4: 376-382,.
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