Pain Management and Medical Cannabis: An Integrative Therapeutic Approach

Almost everyone, at some point in their lives, experiences an extended painful episode, either from traumatic or degenerative musculoskeletal or neurological problems. The negative complicating effects of chronic pain include decreased sleep, mood, and function (mobility, self-care, vocation, and avocation) and increased anxiety and cost of health care. Many conventional pain treatments have unpleasant (or worse) physical and/ or cognitive side effects; cost a lot; need to be sometimes inconveniently administered by ancillary healthcare practitioners, or don’t work very well.

Dedicated and compassionate clinicians, with thorough history procurement and physical, laboratory, and/ or radiographic examinations, endeavor to accurately diagnose the source(s) of pain in order to devise and implement practical and cost-effective treatment plans that would provide optimal clinical outcomes. First-line treatments include: eliminating provocative factors; managing stress; optimizing sleep, exercise, nutrition, and social connection; optimizing mobility seating and sleeping positioning with supports, footwear, pillows, and braces; and prescribing additional professional services from physical or occupational therapists, chiropractors, acupuncturists, Yoga/Tai Chi/Qi Gong instructors, massage therapists, and the rest of the spectrum of care from complementary and alternative practitioners.
Second-line treatments include prescription medication, surgical intervention, and, since the spring of 2018, medical cannabis. Pain physicians have many therapeutic medication options that traditionally have started with non-steroidal anti-inflammatory agents and move to opioid analgesics and adjuvant analgesics (which include: anti-seizure, anti-depressant, antispasmodic agents).

As it turns out, medical cannabis has become quite a popular and effective adjunctive tool that has been shown to have analgesic properties for those suffering from nerve-related pain. It can be seen as fairly safe when administered carefully and thoughtfully. There has never been even one reported case of overdose death by cannabis. Indeed, intoxicated individuals can accidentally physically harm themselves
and others with poor choices made while under the influence.
Medical cannabis is available in 33 of the 50 states and the District of Columbia. In Pennsylvania, the Medical Marijuana Program oversees growers, producers, dispensaries, clinicians, users, and caretakers within a highly- regulated system. Medical cannabis is produced into various formulations that include: vaporizers, sublingual tinctures, transdermal creams/lotions/ ointments/patches, and oral capsules. The list of approved therapeutic indications is growing but includes chronic moderate/severe pain, traumatic and degenerative neurological conditions, cancer, severe bowel disease, glaucoma, PTSD, terminal illness, and most recently, anxiety. Scientific studies, mostly performed in Canada and Israel, have proven therapeutic effect in treating nausea, fatigue, anorexia, insomnia, anxiety, and many other symptoms
and conditions.
Most users have shared that they do not like being intoxicated and out of control during waking hours – there are formulations available with lower concentrations of THC (delta-9 tetrahydrocannabinol), the euphoria-inducing cannabinoid. At night, when sleep and calm are desired, higher concentrations of THC may be dosed to create a controlled and therapeutic intoxication. While many other cannabinoids (cannabidiol, cannabichromene, cannabinol, and terpenes like linalool, humulene, and beta-myrcene) have been isolated, their exact clinical
effects have not been well researched, due to federal rules (Schedule 1 drugs (marijuana is one) are presumed devoid of therapeutic value with purportedly highly addictive potential) prohibiting rigorous scientific study. The “entourage effect” of exposure to the spectrum of
cannabinoids is considered beneficial but has not been adequately elucidated.
The process that a prospective user must follow starts with online registration with the PA Department of Health’s Medical Marijuana Program, physician certification (performed once a preponderance of conventional therapeutic options has been trialed and failed to produce adequate results), and then procurement of the user’s or caretaker’s identification card. Certification requires physicians to review risks and benefits of treatment, travel restrictions, goals of treatment, strategies for therapeutic trials, and other logistical/practical information. There are many dispensaries from which to choose which keeps prices relatively competitive.
While there are myriad approaches to treating pain and reducing the burden of associated symptoms, in order to optimize function and quality of life, medical cannabis is playing an increasingly important role as a tool in the physician’s medical bag. Early evidence has shown that where medical cannabis is offered, prescriptions for opioids have declined, or at least the dosing of opioids is reduced. It remains to be conclusively determined if this translates into reduced opioid overdoses and deaths. However, anecdotal reports have been encouraging.

L. Matthew Schwartz, MD, is board-certified in physical medicine, pain medicine, and integrative holistic medicine. He diagnoses serious medical conditions that qualify for medical cannabis certification. He also provides certification for eligible adults. He can be reached at MyHealth360, 1108 East Willow Grove Avenue, Wyndmoor, PA, 19038. Originally published on myhealth360.org. Reprinted by permission.