Case Presentation
Cannabis in the Management of Complex Regional Pain Syndrome
"May I never see in the patient anything but a fellow creature in pain."
Introduction
This case report describes the examination, treatment and management options, and outcomes for a 31 year old female patient diagnosed with Complex Regional Pain Syndrome I (CRPS I). The hypothetical case focuses on the role of medical cannabis in her management . The case presentation builds on a “debate” in the New England Journal of Medicine about recommending Medical Cannabis to a patient suffering with chronic pain. The goal of this presentation is to offer information, and a framework to provide an approach to ethically sound patient-centered pain management recognizing the lack of well-established “evidence-based” decision making. The case includes an overview of Complex Regional Pain Syndrome I (CRPS I), current treatment approach, medical cannabis and practical patient and physician tools to achieve optimal patient centered outcomes. The article will focus on the mechanism of action of cannabis as they relate to current understanding of the pathophysiology of CRPS I.
Additionally, we suggest strategies to build a knowledge base to inform patients and clinicians as to whether and how best (cost, efficacy and safety) to utilize Cannabis in the management of chronic pain in general and patients diagnosed with CRPS I more specifically.
Ms. Rothstein initial interview
Chief Complaint:
Ms. Rothstein is a 31-year-old woman who comes to your office to consult with you regarding a long-standing history of complex regional pain syndrome in her right leg and foot.
History of the Present Condition
Ms. Rothstein is a 31-year-old woman with a long-standing history of complex regional pain syndrome in her right leg and foot. She describes spontaneous, excruciating pain — mainly burning and deep aching — in her right lower leg, as well as allodynia and hyperalgesia. She is currently receiving gabapentin, at a dose of 600 mg orally three times a day, and oxycodone, at a daily dose of 20 mg orally, but has had little alleviation of her pain. She is frustrated by the drowsiness, fatigue, and constipation associated with use of the medications. She reports that her pain has made it difficult to concentrate. She notes her pain is at 8-10 out of 10 most days. She has had to limit her activities. She has avoided social interactions and has had more difficulty in her work.
She is motivated to find alternative treatment regimens. She is also concerned about the risk of opioid dependence. She inquires about a prescription for medical marijuana for her chronic pain.
Introduction and Overview
The Pain Module: The Challenge of Chronic Pain
About Complex Regional Pain Syndrome
Past Medical History
Ms. Rothstein sustained a hairline fracture in the right fibula and became disabled 7 years prior to her current visit. Since several weeks after her injury, she has had intractable pain in her foreleg and foot even though the fracture has healed. Her diagnostic work up included a three-phase bone scintigraphy had shown findings associated with complex regional pain syndrome type 1.
Past Treatment
She has tried a number of treatments for pain relief, including several opioids, regional and sympathetic nerve blocks, transcutaneous nerve stimulation, lidocaine and compounded salves, behavior modification, and acupuncture, as well as alendronate infusions. All these treatments have had an insufficient effect.
Social & Family History
Ms. R. is a graduate student and former varsity soccer player. She currently is employed in a not for profit organization. Denies nicotine, ETOH, or illegal drug use, other than occasional inhaled cannabis of unknown chemovar. She drinks one cup of coffee daily.
Family History: She has no knowledge of history of major psychiatric illness or substance use disorders in biological family members.
Data
Review of Systems
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Psychological: Frustrated with periods of dysphoria.
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Neuro Exam:
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Sleep:
Physical Exam
Imaging
2012 Three-phase bone scintigraphy: findings associated with complex regional pain syndrome type 1.
Evaluation of Pain Complaints
Medical Professional Checklist
Evaluation of Pain Complaints
I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of over-treatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
Hippocratic Oath
Medical Professional Checklist
Although the symptoms, course and diagnostic findings are highly suggestive of CRPS, it has been pointed out that the risk of over diagnosing CRPS must be taken into account. In this case, the detailed history, physical examination, as well as the testing, are necessary to differentiate CRPS from other neuropathic and pain syndromes. The chronicity of the symptoms, make neuropathy (eg, diabetic polyneuropathy) which may present with spontaneous pain, skin color changes, and motor deficits that are distinguished from CRPS and their symmetrical distribution. Furthermore, all kinds of inflammatory, rheumatological, and infectious conditions might induce intense unilateral skin warming. Unilateral arterial or venous occlusive diseases can cause unilateral pain and vascular abnormalities, and therefore must be excluded when diagnosing CRPS. The repetitive artificial occlusion of blood supply to one limb can be seen in psychiatric, factitious disorders when individuals induce secondary structural changes in the blood vessels and cause abnormalities in perfusion that mimic the symptoms and signs of CRPS.
Differential Diagnosis
Complex Regional Pain Syndrome I (CRPS I) Criteria
Post-traumatic Neuralgia
Somatization Disorder
Impression and Problem List
Ms. Rothstein is a 31-year-old woman with a long-standing history of complex regional pain syndrome 1 in her right leg and foot. Additionally she is experiencing drowsiness, fatigue, cognitive challenges and constipation. Her social and professional function is severely impacted by her symptoms. Ms. Rothstein has tried multiple (but not all) therapies that would be considered to be evidence-based for her chronic, disabling pain but has not had improvement and has had substantial side effects.
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Chronic Pain: Manifested with spontaneous, excruciating pain — mainly burning and deep aching — in her right lower leg, as well as allodynia and hyperalgesia.
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Peripheral Neuropathy: Secondary to complex regional pain syndrome 1
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Drowsiness, fatigue: likely associated with use of the medications.
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Cognitive: She reports that her pain has made it difficult to concentrate.
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Constipation:
Decision Making: Multimodal approach
Complications of Cannabis Use
Patient Support and Advocacy Groups:
Reflex Sympathetic Dystrophy Syndrome Association (RSDSA)
Treatment Plan
A patient-centered, multimodal approach to pain management consists of using more than one treatment modality from one or more medical disciplines to be incorporated into a pain treatment plan. The model builds on the patient’s interest and leveraging self care. The model uses concurrent treatment by a team specializing in psychological therapies, rehabilitation, and pain specialty care.
Such modalities allow for different approaches to address the pain condition (acute and chronic) from a variety of mechanisms, often allowing for a synergistic approach that addresses the different aspects of the pain condition, including addressing improved symptoms and functionality. Multidisciplinary approaches incorporate various disciplines to address different components of chronic, often complex pain conditions including biopsychosocial effects of the medical condition on the patient. The efficacy of such a coordinated, integrated approach has been documented in the scientific literature to reduce pain severity, improve mood and overall QoL, and increase function.
In Ms. Rothstein’s case, cannabis is an appealing option and should be discussed as part of the overall approach to her pain management. ( A more extensive discussion of cannabis in chronic pain see below) To address the frustration she has expressed with the inefficacy, side effects, and addictive nature of opioids. The efficacy of cannabis, particularly when it is used as a component of a treatment plan for chronic pain and allodynia, makes it a strong choice for Ms. Rothstein. Its potential as a replacement for opioids is especially appealing.
Treatment Plan : Multimodal Approach
Discussion of Options
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Life Style: SEEDS for well being
Role of cannabis in the treatment of pain in general
Complications of Cannabis Use
Monitoring the use for efficacy and side effects
Once Medical Cannabis is utilized by Ms. Rothstein, monitoring for efficacy and side effects should be a focus of care. She may utilize logs to track the particular cannabis product and measure the symptoms she is experiencing.
Physical Functions
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Chronic Pain: Manifested with spontaneous, excruciating pain — mainly burning and deep aching — in her right lower leg, as well as allodynia and hyperalgesia.
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Peripheral Neuropathy: Secondary to complex regional pain syndrome 1
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Drowsiness, fatigue: likely associated with use of the medications.
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Cognitive: She reports that her pain has made it difficult to concentrate.
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Constipation:
Social and professional function
Her social and professional function is severely impacted by her symptoms.
My Tool Box fo Well Being
My Life Style
Monitoring, Journalling and Logging my Experience
Monitoring Pain and its Treatment
Summary and Conclusion
Ms. Rothstein has a chronic pain condition that is unlikely to resolve. Instead of the serial and uncoordinated approach to pain control such as that described in the vignette, the role of cannabis as part of a multidisciplinary program should be tried; this patient centered approach is most likely to be beneficial for Ms. R. in parameters that are important to her. Although there is concern that in the long term utilizing medical marijuana, which is an unproven treatment with poorly defined toxic effects, safety, and efficacy, may be ineffective, it appears to provide an excellent option at this point. There is need to educate Ms. Rothstein and other members of her medical team as he the safe use of medical cannabis that will achieve the best outcome for her.
In addition, like with all treatments and interventions, use of medical cannabis must be closely monitored for any side effects of medical marijuana and to seek to minimize or reverse them.