James, a 25-year-old man with active multiple myeloma was referred to our clinic for chronic back pain. At the time of his initial evaluation, he was still suffering from Multiple Myeloma, a cancer of the bone that is frequently associated with severe bone pain and sometimes fractures. James had bone lesions throughout his spine, which led to multiple compression fractures, most severe in the upper back and neck area. At the time of his initial evaluation, his pain score ranged (on a scale from 1-10) between 4 on a good day, and 10 on a bad day.
He was concurrently undergoing chemotherapy with plans for an autologous stem cell transplant, often a curative treatment for patients with Multiple Myeloma, which he received in January of 2016. Fortunately, he has done quite well and has been cured of his cancer. Unfortunately, by the time treatment was successful, his dosage of opiate medications was significant. He was taking large quantities of Methadone and Oxycodone, as well as gabapentin. Like many overwhelmed young patients suffering from a devastating and debilitating disease, our patient had developed a significant physical and psychological dependence on his Oxycodone, the medication that he was supposed to take “as needed” for breakthrough pain. He was taking the Oxycodone every four hours throughout the day for multiple reasons and not as was prescribed. Although the journey was going to be difficult, the decision was made to try to taper James off of his opioid-based medication regimen.
During the course of his disease and treatments, it was clear that he had developed depression. He agreed to start formal psychiatric counseling. He was also started on Escitalopram (Lexapro), which was later changed to Bupropion (Wellbutrin). While maintaining his Methadone intake for baseline pain control, his Oxycodone was tapered down. His gabapentin was eventually changed to Pregabalin after the cessation of Oxycodone, which he responded better to. It was at this time that medical marijuana was added for pain control and to help continue to titrate down his opioid-based regimen.
He was prescribed a sublingual preparation of medical marijuana, a 1:1 THC to CBD formulation (~5 mg THC and ~5 mg CBD per mL), with the intent to take 0.2 mL up to every six hours as needed for pain. The process to completely discontinue his Oxycodone took over a year but was eventually successful with the help of medical marijuana. After discontinuing Oxycodone, he began to taper down his methadone intake. He is currently on less than 1/10th of his initial opioid regimen, and we are hopeful that he will soon be off of opioid medications entirely. On last evaluation, his pain score ranged from 4-7, which has been acceptable.
Take Home Messages:
This case demonstrates how medical marijuana can be used simultaneously with multiple types of opioid and non-opioid pain medications to address complex pain. When used properly, medical marijuana can provide significant pain-relief and can be a useful replacement for potentially more dangerous opioid medications. Furthermore, for those who wish to stop taking opioids but are having a difficult time decreasing or stopping doses, medical marijuana can potentially be used as a replacement to aid in the down-titration of the other, less desirable medications.
The names on this reported case have been changed in order to protect patient confidentiality.
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