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Pain Management

One thing we can all agree about pain is that it’s painful; literally, figuratively and every way in between. Pain not only causes unwanted and unpleasurable sensations, it also contributes to sleeplessness, psychological disorders, financial stress and emotional stress to name a few. The inability of modern healthcare to find solutions for managing pain has led to an ever changing set of guidelines and recommendations. In fact, pain management has been so poorly mismanaged that it is considered the greatest contributor to the current opioid crisis.

In the early- mid 1990’s, the American Pain Society came up with the idea that pain should be added as the “5th Vital sign” along with temperature, blood pressure etc. The thinking behind this was that since pain was a significant factor in many patients' presentations when seeking care that it should be included as a way of addressing and measuring if the patient is receiving adequate treatment. This is why you’ve often heard a health care provider ask you “what's your pain on a scale of 1-10”?

Although seemingly well intended, a curious phenomenon was happening as this policy began gaining widespread adoption- opioid abuse. As more physicians began to address patients' pain, they increased their prescription of opioids and other narcotic pain relievers. This, coupled with targeted efforts by pharmaceutical companies to increase opioid prescriptions and minimize the awareness of their dangerous potential help create the opioid crisis. In addition, many hospitals and health care providers began to see pain less as a patient care issue but more of a customer relations issue, and they tried to keep the customer satisfied.

But did they keep their customer satisfied? Approximately twenty percent of the adults in the US suffer from chronic pain. Chronic pain is defined as pain lasting longer than the normal course of healing or greater than three months. The source of this pain can be multifactorial: back pain, knee pain or unspecified joint pain, headaches, neuropathic, etc and can range in intensity from mild to severe. Severe pain can be debilitating and places people at risk for other adverse events events like depression, early dementia, suicide and early death. In addition, studies showed that despite seeking treatment, only about ⅓ of the population that suffers from chronic pain reported getting satisfactory pain relief, with a third reporting not getting adequate pain relief at all.

The burden of chronic pain is not shared proportionately throughout the population either. The incidences of chronic pain increase as people age, with those over the age of 60 reporting the highest levels of pain. In addition factors such as race, socio economic status, education and gender increase the likelihood of a person to suffer from chronic pain. With that, the cost of treatment, lost wages and productivity from chronic pain was at one point approximated to be near $600 billion annually.

As evidenced by data, pain is a poorly managed condition. The inability of the medical community to for a consensus on how pain is best treated has led to the development of a multi faceted approach to pain management. This involves “alternatives” to the usual analgesic treatments like opiods, narcotics and Non-steroidals. These include other drugs like gabapentin, off label use of drugs like SSRI’s and antidepressants, and non pharmaceutical options such as physical therapy, acupuncture, massage, yoga, tai-chi, meditation, and psychotherapy.

In addition, many in the medical and scientific community have begun investigating and treating patients with cannabis and/or hemp derived products. Cannabis/ marijuana and it's cousin plant hemp have been used by humans for medicinal purposes for thousands of years. It is known to have been used for relief of pain associated with childbirth, arthritic and rheumatic pain and gout. It was a mainstay of physician directed and self guided treatment until the proliferation of other analgesics like aspirin and its relegation to illegal status.

In 1996 Californa became the first state to legalize cannabis consumption. Through many studies thereafter when asked the primary reason for consuming cannabis- over two thirds of people report using cannabis for pain relief. The most common reported uses were for back pain, arthritis, headaches and post surgical pain. THe most common reported reasons were its effectiveness versus other options and the lower perceived risk of unwanted side effects like constipation and decreased risk of adverse events like addiction and/or overdose.

The major components of the cannabis plant that help with pain relief are a class of compounds called cannabinoids. These substances produced by both the both and the plants perform a number of interwoven tasks in the human body. The major cannabinoids related to analgesia/ pain relief are THC (tetrahydrocannabinol) and CBD (Cannbidiol).

Through a number of mechanisms, the compounds are able to provide analgesia. Predominantly through their interaction with specific receptors in the body called cannabinoid & cannabinoid type receptors which cause secondary actions at the cellular level. They also act directly on the neuroreceptors like mu and delta opioid receptors, inhibit the release of excitatory neurotransmitters like glutamate and can decrease the proliferation of pain associated compounds like substance P. It can also serve as a potent anti inflammatory. What this indicates is that there is some scientific basis to the anecdotal reports that have proliferated about the pain relieving benefits of cannabis.

Despite all the promise, using cannabis or CBD is not without risks. There is for example the risk of development of a poorly understood cyclic vomiting disorder called cannabis hyperemesis syndrome. In addition, there are risks of drug interactions which can cause higher risks of bleeding, increased somnolence and yes, THC use can put one at risk for substance use disorder referred to as cannabis use disorder.

The best advice for incorporating cannabis or CBD as a part of your pain treatment regimen is to first see your physician to have a check up and ensure there are no contraindications. Make sure you are purchasing from reliable/ trust worthy sources. Be aware that one of the major side effects is sleepiness especially if you are using other medications. Make sure you are not operating heavy machinery are engaging in any activities where you may be putting yourself and others at risk. THC is a psychotropic compound. It can decrease your processing, reaction times as well as alter judgment. CBD on the other hand is non psychoactive and does not pose those same risks but may not be beneficial in all instances. Most importantly start with low doses and increase slowly until you find the appropriate level for you.

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