Medical Cannabis Used as an Alternative Treatment for Chronic Pain Demonstrates Reduction in Chronic Opioid Use - A Prospective Study.

BACKGROUND: Chronic opioid therapy (COT) has been used to treat many chronic pain conditions even with poor evidence for its long-term effectiveness. Medical cannabis has emerged with certain pain-relieving properties, which has led to questions as to its' potential application, especially in relation to its effect on opioid use. OBJECTIVES: This study investigates a proposed clinical context in offering medical cannabis as a treatment for chronic pain for those already using chronic opioid therapy. It then details patients' daily morphine milligram equivalent (MME) usage. STUDY DESIGN: This single-center prospective study follows a group of patients trialing medical cannabis treatment for chronic pain that is already using COT in order to determine individual efficacy. Continued medical cannabis treatment was a decision made by the patient, after trialing medical cannabis, to either continue medical cannabis along with COT at a reduced daily MME, or to revert back to their previous COT regimen. SETTING: This study was performed at the Allegheny Health Network Institute for Pain Medicine in Pittsburgh, Pennsylvania. The state of Pennsylvania legalized medical cannabis in April of 2016, and it became available to patients in February of 2018 through medical dispensaries. METHODS: One hundred and fifteen patients met the inclusion criteria, with the majority of those excluded due to not being treated with COT. Of the 115 who chose to undergo a medical cannabis trial in addition to their COT, 75 chose to remain certified for medical cannabis as they had significant pain relief and subsequently weaned down on opioids. Additionally, of the 115 choosing to undergo a medical cannabis trial, 30 chose to be decertified due to ineffectiveness or side effects, and those were placed back on their COT regimen. The other 10 were not included for other denoted reasons. Compliance was monitored through urine drug screens (UDS). RESULTS: There was a 67.1% average decrease in daily MME/patient from 49.9 to 16.4 MME at the first follow-up. There was a 73.3% decrease in MME at second follow-up from 49.9 to 13.3 MME with an ANOVA analysis denoting a significant difference of P < 0.0001. LIMITATIONS: The period of follow-up presented at this point includes their first 6 months of treatment with medical cannabis and COT concomitantly. CONCLUSIONS: Presenting medical cannabis to chronic pain patients on COT should be done in the context of a patient choice between medical cannabis WITH decrement of COT or continued current dose of COT in order to maximize effectiveness in opioid reduction as well as to limit polypharmacy concerns regarding medical cannabis. Allowing for a temporary short-term period where patients may trial medical cannabis, while concomitantly gradually weaning their COT, is also essential in determining medical cannabis' individual effectiveness for that patient's specific type of chronic pain, which should serve to maximize long-term opioid reduction results and hence decrease opioid-related overdose deaths.

The Social and Functional Implications of High- Versus Low-Dose Opioids on Chronic Non-Cancer Pain.

BACKGROUND: Chronic non-cancer pain (CNCP) is a major health concern. Opioids may be a useful treatment option, but their use still remains controversial given the significant risks and epidemic of opioid addiction and abuse. There is limited data on whether opioid therapy is an effective treatment option for chronic non-cancer pain. OBJECTIVE: To assess both physical and emotional dimensions of health for patients on opioid therapy for CNCP by reviewing the 36-Item Short Form Health Survey (SF-36) . STUDY DESIGN: This study was a retrospective cohort review. SETTING: Outpatient pain clinic. METHODS: We recruited 182 patients at the West Penn Pain Institute outpatient pain clinic: 94 patients were recruited for the low-dose opioid group (5-30 morphine milligram equivalents [MME]) while 88 patients were recruited for the high-dose opioid group (> 90 MME). Each patient filled out the SF-36 survey used to assess both the physical and emotional dimensions of their health. We also analyzed patients' employment status, reasons for unemployment, pain diagnosis, side effects, and compliance issues through the electronic medical record (EMR). RESULTS: Mean scores on General Health Perceptions for the low-dose and high-dose opioid groups were 50.3 ± 21.6 and 44.4 ± 21.9, respectively (P = .07). Though not reaching statistical significance, high-dose patients had lower item scores, indicating a perception of poorer health. There were no significant differences between the low-dose and high-dose opioid treatment groups on any of the mean scores from the 8 domains of the SF-36. There was a statistically significant association between opioid treatment group and working status, noncompliance, and the self-reported number of side effects. Patients treated with high-dose opioids had significantly higher rates of unemployment (85%) than did low-dose opioid patients (66%) (x-squared[1] = 8.48, P =.004; odds ratio [OR] = 2.89 [95% confidence interval (CI), 1.39-6.01]). Unemployed patients in the high-dose treatment group were more likely to list disability as unemployment while retirement was the most common response in the low-dose treatment group. Patients treated with high-dose opioids had significantly higher rates of self-reported side effects (46%) than did low-dose opioid patients (21%) (x-squared[1] = 12.02, P =.001; OR = 3.08 [95% CI, 1.61-5.89]). Patients treated with high-dose opioids had significantly higher rates of noncompliance (49%) than did low-dose opioid patients (33%) (x-squared[1] = 4.75, P =.029; OR = 1.94 [95% CI, 1.07-3.54]). Thus, the odds of a high-dose opioid patient being unemployed were 2.89 times greater than the odds for a low-dose opioid patient; the odds of a high-dose opioid patient self-reporting side-effects were 3.08 times greater than the odds for a low-dose opioid patient; and the odds of a high-dose opioid patient being noncompliant with their medications were 1.94 times greater than the odds for a low-dose opioid patient. LIMITATIONS: The observation al design prohibits drawing causal relationships, and entry criteria was restricted. CONCLUSIONS: These data suggest that patients receiving low-dose and high-dose opioid treatment do not have significantly different quality-of-life outcomes. Future studies that incorporate longitudinal data are necessary to examine the temporal relationship between quality of life and opioid therapy. KEY WORDS: Chronic pain, chronic non-cancer pain, opioids, pain, quality of life, side effects, noncompliance, unemployment.

Utility of oral fluid in compliance monitoring of opioid medications.

BACKGROUND: Prescription drug abuse is the fastest growing drug problem in the United States, and the increase in unintentional drug overdose deaths has been driven by the increase in opioid analgesic use. Given the epidemic of non-medical prescription pain reliever use and the current medico-legal climate, it is increasingly important for the prescriber to monitor for medication compliance. OBJECTIVES: The purpose of this IRB approved study is to compare the results of oral fluid (OF) and routine urinalysis for monitoring compliance in a single academic pain management program in an urban setting in order to evaluate the utility of OF analysis in compliance monitoring when prescribing opioid medications. STUDY DESIGN: Outcomes analysis of prospective, consecutive, paired comparison study with clinical implications. SETTING: Single academic interventional pain management center in the United States. METHODS: Paired OF and urine specimens were collected for each patient with signed informed consent, at the Institute for Pain Medicine, Western Pennsylvania Hospital, from patients who routinely donated urine on a random basis for compliance testing. A total of 153 paired specimens were analyzed. Demographic and prescription data were made available. Specimens were screened using immunoassay and presumptive positive findings were confirmed with liquid-chromatography and mass spectrometry. Although both matrices were tested for a wider range of medications, the data presented here are representative of analgesic opioids and benzodiazepine drug classes only. RESULTS: Following exclusion criteria, of the 132 remaining specimen pairs that were positive for opioids or benzodiazepines in at least one matrix, 101 pairs showed exact drug class matches (76.5%). In an additional 21 pairs, at least one drug class was positive in both matrices (15.9%), giving an overall agreement of 92.4%. Overall, 191 positive results were found in urine averaging 1.4 drugs per specimen; 176 positives were detected using OF for an average of 1.3 drugs per specimen. CONCLUSIONS: In the setting of stable dosing of prescription opioids and/or concomitant illicit drug use, given comparable detection rates between urine and OF matrix qualitative results, the OF matrix for drug testing for compliance monitoring may serve as a useful and valid testing tool. The authors conclude that overall OF analysis produces comparable results to urine sample analysis with detection rates differing primarily due to differences in windows of detection for different drug classes. LIMITATIONS: The limitations include the study was performed in a single academic center in an urban community. Also, there is a paucity of literature regarding windows of detection for OF analysis compared to urine. IRB: APPROVED - Allegheny-Singer Research Institute West Penn Allegheny Heath System (ASRI-WPAHS) - IRB Study #FWA00015120.

Spinal cord stimulation for treatment of pain in a patient with post thoracotomy pain syndrome.

Post Thoracotomy Pain Syndrome (PTPS) is defined as pain that occurs or persists in the area of the thoracotomy incision for at least 2 months following the initial procedure.  The true incidence of PTPS is hard to define as literature reports a wide range of occurrence from 5% to 90%.  Thoracotomy is associated with a high risk of severe chronic postoperative pain.  Presenting symptoms include both neuropathic pain in the area of the incision, as well as myofascial pain commonly in the ipsilateral scapula and shoulder.  Pain management can be challenging in these patients.  Multiple treatments have been described including conservative treatments with oral nonsteroidal anti-inflammatory drugs (NSAIDs); topically applied, peripherally acting drugs; neuromodulating agents; physical therapy; transcutaneous electrical nerve stimulation as well as more invasive treatments including intercostal nerve blocks, trigger point steroid injections, epidural steroid injections, radiofrequency nerve ablation, cryoablation, and one case report of spinal cord stimulation.  Unfortunately, a portion of these patients will have persistent pain in spite of multiple treatment modalities, and in some cases will experience worsening of pain. This case report describes the novel utility and complete resolution of symptoms with spinal cord stimulation (SCS) in treatment of a patient with persistent PTPS. In the operating room, a percutaneous octet electrode lead was placed using sterile technique under fluoroscopic guidance and loss-of-resistance technique.  The octet electrode lead was subsequently advanced with the aid of fluoroscopy to the level of the T3 superior endplate just right of midline.  The patient's pain distribution was captured optimally with stimulation at this level.  With the assistance of a neurosurgeon, the lead was anchored, tunneled, and connected to a generator, which was implanted over the right iliac crest.  The patient tolerated the procedure well with no complications. We report the successful use of SCS as well as complete resolution of symptoms at 4 months follow-up, in a patient with persistent PTPS, which was resistant to other modalities. In conclusion, studies designed to evaluate the effectiveness of SCS for PTPS may be warranted.

Sternoclavicular steroid injection for treatment of pain in a patient with Osteitis condensans of the clavicle.

Osteitis condensans of the sternoclavicular joint was first described by Brower et al in 1974. It is a rare benign disorder primarily affecting women of child-bearing age. Persistent pain and swelling in the medial part of the clavicle are the most common presenting symptoms and may represent an inflammatory process in the joint among other proposed etiologies. Radiological findings include sclerosis of the medial part of the clavicle and a normal sternoclavicular joint. Diagnosis is usually confirmed by biopsy. Pain management can be challenging in these patients. Multiple treatments have been described in the past including oral NSAIDS, physical therapy, radiation, surgical resection, and oral corticosteroids but have met with limited success. This case report describes the novel utility of sternoclavicular joint steroid injections in treating a patient with Osteitis condensans of the clavicle after failed medical therapy. Based on our clinical experience, and given the limited clinical success of other reported conservative treatment measures, a sternoclavicular joint injection under fluoroscopic guidance using a local anesthetic-corticosteroid injectate should be considered as a viable treatment option for pain associated with Osteitis condensans of the clavicle.