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To the Editor:
Central pain syndromes (CPS) are difficult to treat despite recent advances in pharmacological and surgical management. Therapy commonly requires multiple interventions, continuous monitoring, and adjustment. Cannabis and its derivatives (cannabinoids) have recently received much attention as potential therapeutic agents. The clinical utility of cannabinoids has been suggested on the basis of anecdotal reports and small clinical studies for a wide range of pain syndromes, including cancer pain,1 visceral pain,2 migraine3 and pain associated with spasticity.4 We report a patient with intractable CPS who experienced dramatic relief of pain and dystonia from cannabis.
Case Report
A 42-year-old woman presented to our multidisciplinary pain center with a fifteen-year history of progressive continuous right-sided body and limb pain due to left-sided idiopathic caudate atrophy. Her initial symptom had been numbness of the right hand, suggestive of unilateral carpal tunnel syndrome, for which she underwent unsuccessful carpal tunnel release. Following surgery, she developed right-sided upper and lower limb dystonia with equinovarus foot positioning and abnormal posturing of the right hand. She experienced severe right-sided body and limb pain, characterized by continuous paresthesias and intermittent electric-type pains exacerbated by movement. She was diagnosed with right hemiplegic painful dystonia. She progressively deteriorated, and became wheelchair-bound and unable to write. She complained of continuous debilitating pain. Between 4 and 12 years after the onset of symptoms, three thalamotomies were performed. Each operation was moderately and temporarily successful in reducing pain and dystonia. Numerous additional treatments, including opioids, anticonvulsant agents, tricyclic antidepressants, muscle relaxants, botulinum toxin, physiotherapy and acupuncture, were largely unsuccessful and commonly associated with unacceptable side effects. Thirteen years after the onset of pain, a deep brain stimulator (DBS) was inserted into the left thalamus. Electrical stimulation by internalized battery subjectively reduced her pain by about 50%, and she regained the ability to write. However, she still required continuous treatment with daily low-dose morphine. Subsequent displacement of the DBS required surgical revision, but infection at the stimulator insertion site resulted in removal of the DBS two years after placement. Following removal of the DBS, she was maintained on daily long-acting morphine with breakthrough morphine, at a total daily dose of 250-300mg per day. Additional medications included the antidepressants buproprion (150 mg/day) and amitriptyline (100 mg /day) for depression and migraines, respectively.
One month prior to a recent outpatient visit, the patient self-medicated with herbal cannabis for the first time. She smoked one 'joint' in the morning once a week for three weeks. On each of these occasions, she experienced drowsiness after smoking the cannabis and slept for about two hours. On awakening, she experienced complete pain relief and marked improvement in her dystonia, an effect confirmed by her husband. This resulted in improved ability to write and to take a few steps without support. She also reported complete relief of paresthesia and electric-type pain. She did not require any analgesic medication for the following 48 hours. Her subjective pain score on a 10 cm visual analogue scale (0-none, 10-severe) without medication in previous years was 9. At best, pharmacological and/or surgical intervention reduced her pain level to 4/10. Cannabis therapy resulted in a pain score of zero. No other treatment intervention to date had resulted in such dramatic overall improvement in her condition. Despite the abrupt reduction of chronic high-dose morphine therapy, she also did not report any symptoms of opioid withdrawal.
She has been using cannabis at a dose of one joint daily over the past three months for management of her pain and dystonia, and reports continued benefit. No tolerance to the effects of smoked cannabis has been observed. The dystonia has improved remarkably and the patient now only uses her wheel chair to go outdoors. She has discontinued her opioid treatment completely. Although a neurosurgeon has recommended reimplantation of the DBS, the patient is unwilling to undergo this surgical intervention for as long as her newly-found pain control continues to provide relief.
Source: Elsevier
Central pain syndromes (CPS) are difficult to treat despite recent advances in pharmacological and surgical management. Therapy commonly requires multiple interventions, continuous monitoring, and adjustment. Cannabis and its derivatives (cannabinoids) have recently received much attention as potential therapeutic agents. The clinical utility of cannabinoids has been suggested on the basis of anecdotal reports and small clinical studies for a wide range of pain syndromes, including cancer pain,1 visceral pain,2 migraine3 and pain associated with spasticity.4 We report a patient with intractable CPS who experienced dramatic relief of pain and dystonia from cannabis.
Case Report
A 42-year-old woman presented to our multidisciplinary pain center with a fifteen-year history of progressive continuous right-sided body and limb pain due to left-sided idiopathic caudate atrophy. Her initial symptom had been numbness of the right hand, suggestive of unilateral carpal tunnel syndrome, for which she underwent unsuccessful carpal tunnel release. Following surgery, she developed right-sided upper and lower limb dystonia with equinovarus foot positioning and abnormal posturing of the right hand. She experienced severe right-sided body and limb pain, characterized by continuous paresthesias and intermittent electric-type pains exacerbated by movement. She was diagnosed with right hemiplegic painful dystonia. She progressively deteriorated, and became wheelchair-bound and unable to write. She complained of continuous debilitating pain. Between 4 and 12 years after the onset of symptoms, three thalamotomies were performed. Each operation was moderately and temporarily successful in reducing pain and dystonia. Numerous additional treatments, including opioids, anticonvulsant agents, tricyclic antidepressants, muscle relaxants, botulinum toxin, physiotherapy and acupuncture, were largely unsuccessful and commonly associated with unacceptable side effects. Thirteen years after the onset of pain, a deep brain stimulator (DBS) was inserted into the left thalamus. Electrical stimulation by internalized battery subjectively reduced her pain by about 50%, and she regained the ability to write. However, she still required continuous treatment with daily low-dose morphine. Subsequent displacement of the DBS required surgical revision, but infection at the stimulator insertion site resulted in removal of the DBS two years after placement. Following removal of the DBS, she was maintained on daily long-acting morphine with breakthrough morphine, at a total daily dose of 250-300mg per day. Additional medications included the antidepressants buproprion (150 mg/day) and amitriptyline (100 mg /day) for depression and migraines, respectively.
One month prior to a recent outpatient visit, the patient self-medicated with herbal cannabis for the first time. She smoked one 'joint' in the morning once a week for three weeks. On each of these occasions, she experienced drowsiness after smoking the cannabis and slept for about two hours. On awakening, she experienced complete pain relief and marked improvement in her dystonia, an effect confirmed by her husband. This resulted in improved ability to write and to take a few steps without support. She also reported complete relief of paresthesia and electric-type pain. She did not require any analgesic medication for the following 48 hours. Her subjective pain score on a 10 cm visual analogue scale (0-none, 10-severe) without medication in previous years was 9. At best, pharmacological and/or surgical intervention reduced her pain level to 4/10. Cannabis therapy resulted in a pain score of zero. No other treatment intervention to date had resulted in such dramatic overall improvement in her condition. Despite the abrupt reduction of chronic high-dose morphine therapy, she also did not report any symptoms of opioid withdrawal.
She has been using cannabis at a dose of one joint daily over the past three months for management of her pain and dystonia, and reports continued benefit. No tolerance to the effects of smoked cannabis has been observed. The dystonia has improved remarkably and the patient now only uses her wheel chair to go outdoors. She has discontinued her opioid treatment completely. Although a neurosurgeon has recommended reimplantation of the DBS, the patient is unwilling to undergo this surgical intervention for as long as her newly-found pain control continues to provide relief.
Source: Elsevier
