Case Study: Reducing Opioid Use by Back Pain Sufferers

According to a 2019 article in Seminars of Neurology, back pain is a common reason for seeking medical evaluation in the United States and is one of the top five emergency department chief complaints.1 Nearly 90% of patients who present with traumatic back pain ultimately have no clear etiology for their discomfort and experience varying degrees of pain relief within four to six weeks, irrespective of therapy. However, approximately 2% of acute back pain complaints are attributed to life- and/or function-threatening processes.

Etiology of Spinal Instability and Spinal Fusion Surgery
Virtually every category of disease affecting the bones, disks, joints, or ligamentous support structures of the spine can produce spinal instability. These causes can be infection, trauma, degenerative disorders, as well as iatrogenic (postoperative) etiologies.2

Epidemiology
Spinal instability isn’t a single disease but a pathologic consequence of a variety of different spine disorders (eg, traumatic fractures, metastatic tumors, and degenerative conditions), each with its own epidemiology. It’s neither possible nor meaningful to determine the incidence and prevalence of spinal instability in the population. Furthermore, because of the disagreements about the indications for spine fusion (at least for degenerative disease), the incidence of spinal instability doesn’t correlate with the observed frequency of spine fusion surgery.

More than 400,000 spinal fusions are performed in the United States annually. Most of these operations are performed for degenerative disease of the spine. Between 1998 and 2008, the annual number of spinal fusion discharges increased 137%, from 174,223 to 413,171, and the mean age for spinal fusion increased from 48.8 to 54.2 years.3

For these patients, postoperative care often involves the use of aggressive parenteral opiates for the first 12 to 36 hours, after which the patients are converted to oral analgesics, often opiates. The American College of Surgeons reported in their October 2020 Bulletin that “the surgical setting accounts for 9.8% of opioid prescriptions, making it a clear contributor to the opioid crisis in the United States.”4 The Ohio Board of Pharmacy has monitored the use of all outpatient prescribed controlled substances since 2006.5 According to the Prescription Drug Monitoring Program or PDMP, the total number of opioid doses dispensed reached a high of 793 million in 2012. That number had decreased considerably by 2019 to 415 million doses.

Case Presentation

Patient’s Complaint
The patient is a 54-year-old female who visited our dispensary in November 2019. She completed an intake form that asks about the history of her qualifying condition for the Ohio Medical Marijuana program—in this case, “pain that is either chronic and severe or intractable.” She also indicated other comorbid conditions such as anxiety, depression, and insomnia, as well as a diagnosis of asthma.

She explained the etiology of her condition during her conversation with the pharmacist. Having worked at a big-box retailer in 2003, she described job tasks that included unloading pallets from delivery trucks and moving them to various parts of the warehouse. Although she experienced back discomfort after months of working, she didn’t describe it as acute. However, one evening during work she bent down to pick something up and could not straighten her back.

She visited her doctor, who started her on a regimen of opiate pain medications, including Vicodin. The doses of opiates continued to escalate over the coming months due to her pain levels, and to this was added additional antianxiety and antidepressant medications. Eventually, a myelogram revealed compression of both the S1-L5 and L3-L4 spine segments, and surgery was recommended to fuse the spinal areas.

The patient underwent the first surgery on May 4, 2003 and then a second about a week later due to the development of a hematoma. The surgery required six screws and resulted in a successful fusion of L3-L4. A few weeks later, a third surgery was required due to a methicillin-resistant Staphylococcus aureus (MRSA) infection. When the infection cleared, the patient went to the Cleveland Clinic because she could not lift her right leg. The surgeon observed that the patient had bone spurs along her spine and suggested she have a fourth surgery. Prior to the surgery, the surgeon explained his concerns about the risk of leaking spinal fluid. Unfortunately, a fifth surgery in March was necessary to drain the spinal fluid due to a nick of the spinal sac.

The patient’s pain persisted, and more pain medications were prescribed, including morphine sulfate 120 mg sustained release and, ultimately, an intrathecal morphine pump. During the period of surgical procedures, the patient experienced significant weight gain. Prior to the first surgery she weighed approximately 190 lbs. She stated that due to loss of mobility and wheelchair confinement, her weight rose to 294 lbs.

In one particularly horrifying moment while she was using the intrathecal morphine pump, her 11-year-old son found her unresponsive prior to heading to school in the morning. He called 911. Paramedics treated her with multiple doses of Narcan on the trip to the emergency room. The emergency department physicians had trouble stopping the morphine pump and started a Narcan drip to offset the heavy dose of morphine entering her system.

By the time she’d arrived at our dispensary in 2019, she’d regularly been visiting a clinic for her pain management and had been taking a new opiate called Xtampza ER (extended-release oxycodone). Prior to this, she was taking Opana ER (extended-release oxymorphone hydrochloride), but the FDA had requested this drug be removed from the market because “the benefits of this drug no longer outweighed its risks.”6 She went through withdrawal symptoms for two weeks when switching between these drugs.

Her full medication list included the following:

• Xtampza ER 18 mg BID;
• Lyrica 150 mg BID;
• Norco 10/325 QID PRN;
• Wellbutrin SR 200 mg once daily;
• Celexa 40 mg daily;
• levothyroxine 150 mcg daily;
• furosemide 20 mg daily;
• Prilosec 40 mg daily;
• potassium 10 mEq daily;
• Ventolin inhaler PRN; and
• Advair 250/50 PRN.

This patient was a highly motivated individual who was still visiting the pain clinic regularly. She was desperate to stop all her pain medication because her family described her as “spaced out.”

The Plan of Care
We began by discussing her current pain therapy, and I explained how medical cannabis could play a part in her pain treatment. My process is to describe to patients the benefits and risks of this therapy, including how CBD and tetrahydrocannabinol THC in various ratios can help. We typically start patients on a 1:1 ratio of CBD to THC at a dose of approximately 2.5 mg each. She was using an over-the-counter CBD product, so we started her with an all-THC tincture to supplement the over-the-counter CBD. I recommended she start at once per day to help monitor her new treatment effects. She was instructed to watch her side effects such as dizziness and drowsiness in addition to her pain relief.

The patient returned 20 days after the first visit and reported some pain relief but not to her satisfaction. She was still highly motivated to decrease her opiate medications. I recommended she increase her dose to 5 mg and increase the frequency up to three times per day.

She returned the following month and reported better results. She decreased her other pain medications with the assistance of her pain management doctor. Her immediate family started to notice that she was less “spaced out” and she could spend more time with her grandchildren.

The patient continued this dose of the THC tincture and continued to decrease her opiate medications. In August 2020, she reported that she no longer was taking any opiates for pain. She’s lost 100 lbs, she walks 10,000 steps per day, and her family says she is happy, upbeat, and more motivated.

Conclusion
Many patients are motivated to decrease their opiate pain therapies. Unfortunately, clinicians often don’t understand the pharmacology of cannabis and don’t perceive this therapy as an excellent adjunct to opiate medications. Cannabis continues to be lumped into drugs of abuse—tested for and often a reason to discontinue patients from a pain management program. Cannabis, however, can be an ideal therapy to help reduce opiate pain medications for patients given its lack of activity in the brain stem to potentiate respiratory depression. For these patients who want to reduce or eliminate opiate pain therapy, cannabis with proper guidance from a trained clinician can be an excellent path to do so.

— Joe Jeffries, RPh, from St Clairsville, Ohio, graduated from Ohio Northern University with a bachelor of science in pharmacy and received his license to practice pharmacy in 1989. He worked in community pharmacy for 13 years. He was president of the Ohio Pharmacist Association for the 2000–2001 term and served on various committees within the association. He was pharmacy director for Barnesville Hospital from 2002 to 2018 and recently helped start an Ambulatory Detox Center—Addiction Services of Eastern Ohio—at that location in Southeastern Ohio. He was given the Ohio Hospital Association’s Health Care Worker of the Year award in 2018. He’s pharmacy director for FarmaceuticalRx—a multistate, licensed medical marijuana company with the mission to bring health care, science, and innovation to the medical marijuana sector. FRXHealth is a pharmacist-driven dispensary in East Liverpool, Ohio.

References