Chronic Pain as Seen by a Clinic Dedicated to Medical Cannabis – Part 1

Pain is part of life, but for some people there is simply no respite from pain. When pain becomes chronic, it’s difficult to make it go away completely. Therefore, it’s no surprise that chronic pain is an enormous global public health problem. About one in four Canadians aged 15 or older (or an estimated 7.63 million people) live with chronic pain, and it is about one in five people in the United States. [1, 2] It is the leading cause of disability in working-age adults, impacting activities of daily living and quality of life. [3]

We know how chronic pain can be difficult to manage, as most of our patients have chronic pain, or pain as part of a chronic condition.

REAL-WORLD DATA FROM SANTÉ CANNABIS’ OBSERVATIONAL STUDY

Chronic pain conditions are frequent in patients seen at Santé Cannabis’ clinics: pain-related diagnoses make over 50% of all diagnoses (figure 1) and pain symptoms affect 80% of the 1275 patients assessed between July 2020 and March 2021.

Figure 1: Primary diagnoses proportions from 1275 patients followed at Santé Cannabis (July 14, 2020—March 31, 2021)

Furthermore, chronic pain is frequently associated with a myriad of other frequent symptoms that are directly impacted by pain, such as sleep disturbances, [4, 5] anxiety and depression, [6, 7] fatigue, nausea, etc. The following graphic (figure 2) shows the most common secondary symptoms reported by patients living with pain at our clinics.

Figure 2: Secondary symptoms in 1019 patients living with pain and followed at Santé Cannabis (July 14, 2020—March 31, 2021).

CHRONIC PAIN IS NOT A MONOLITH

Chronic pain is pain that persists or recurs for more than three months.[8] It is a convenient umbrella term, regrouping widely different pain types.

Chronic pain is classified according to its cause, cancer and non-cancer origin, and by the way the pain is produced (its mechanism) in neuropathic pain, nociceptive pain, and mixed pain (including both neuropathic and nociceptive pain).

Figure 3: Classification of pain

We see a wide array of chronic pain conditions at our Santé Cannabis clinics, from neuropathic pain in multiple sclerosis to cancer pain, fibromyalgia and chronic low-back pain. It is common that patients consider our clinic as a last option to manage their chronic pain – and it makes sense, since there are several conventional treatments for chronic pain supported by better evidence than cannabinoid-based medicines currently are.

MANAGEMENT OF CHRONIC PAIN

The modern pharmacopeia possesses more than a few options for pain management. Cannabinoid-based medicines have their use in pain management as a third- or fourth-line treatment, [9] and generally recommended as adjunctive treatment. [10, 11] There are both pharmacological and non-pharmacological treatment options that can work in combination to relieve and cope with pain.

Non-pharmacological therapies include (but are not limited to) physiotherapy, exercise, cognitive behavioural therapy (CBT), occupational therapy, acceptance and commitment therapy (ACT), mindfulness, massage, osteopathic manipulation, etc. [12-15]

As for pharmacological treatments, the following analgesic ladder shows a simple strategy (figure 4); it is adapted from the World Health Organization analgesic ladder, initially intended for cancer pain, but now also applied to chronic non-cancer pain. [12, 16]

NSAIDS: nonsteroidal anti-inflammatory drugs; TCAs: tricyclic antidepressants; SNRIs: serotonin-norepinephrine reuptake inhibitors

Figure 4: Analgesic ladder (adapted from [12, 16])

When considering cannabinoid-based medicines, it is important that a discussion takes place between the healthcare provider and the patient in a shared decision-making process. [9] Indeed, cannabinoids efficacy, potential adverse effects, cost, and related stigma should be addressed so that patients are adequately informed.

MULTIMODAL TREATMENT

Chronic pain treatment includes more than pharmaceuticals, as these are often not as effective when used alone. Behavioural and other psychology-based therapies play an important role in chronic pain management to help patients cope with the emotions that accompany pain, such as anxiety, depression, frustration, etc.

Furthermore, our medical team observes that chronic pain often occurs in individuals who underwent emotional trauma (resulting from violence, abuse, neglect, etc.)—highlighting the need for a multimodal therapy to help improve the combination of emotional and physical pain.

We also believe that chronic pain patients benefit more from a holistic approach incorporating lifestyle changes, as pain and anxiety/stress act one upon another in a vicious circle. Indeed, patients living with unrelieved chronic pain often are trapped in a pain-centered pattern, where anxiety—and decreased activity, deconditioning and fatigue—contributes to worsening pain and reduce their quality of life (see figure 5).

Chronic pain is generally recognized to impact sleep and contribute to depression, but it may not be common knowledge that persistent pain is also associated with memory decline. [17, 18]

Figure 5: Pain-centered life

At Santé Cannabis, the role of our medical team is to help patients help themselves. In our experience, patients who undertake a multimodal treatment obtain better therapeutic results. Promoting the practice of physical activities, providing strategies to manage stress, and improving sleep can prove extremely helpful to guide patients out of their pain-centred life (see figure 6).

Some of our patients reported better coping with the practice of mindfulness—an example of simple, inexpensive, and empowering therapy for which we provide information and support through virtual talks and support groups meeting. Patients often do not realize how they can be empowered in their own healthcare and get control over their pain, rather than being victimized by it.

“When their functionality improves, my patients say that they feel like they can control their pain instead of the pain controlling them.

Some tell me they feel as if they had regained their lives.” Dr Michael Dworkind

Figure 6: Function-centered life

On a last note, the environment in which patients live also impacts pain levels directly or indirectly (e.g., through work-related stress levels). Evaluating the context and situation of a patient helps to better assess pain and pain-related symptoms, since they fluctuate according to what happens to the body and the mind. For example, if context has changed, it will likely affect the patient’s condition and, therefore, their response to treatment.

PAIN AND STIGMA

Chronic pain is incredibly hard to treat, and it is difficult for patients to find a treatment that will help them manage or overcome their pain. Many healthcare professionals do not receive extensive enough training on chronic pain; this affects their ability to provide adequate recommendations on pain management and in turn poses a serious threat to patients’ safety. [19, 20]

Chronic pain patients need access to multimodal treatments, and they need to be able to have an honest discussion about their treatment expectations and outcomes with their healthcare provider. Due to the challenges and lengthy commitment needed with treating pain, stigma may affect perceptions about pain conditions and the patients who suffer from them.

One example of stigma is when some healthcare professionals are dismissive about fibromyalgia, as the condition is hard to manage with success, and there has been an influencing notion passed around that it is a condition mainly caused by a patient’s mental state.

If there is no measure to diagnose fibromyalgia, does it exist?

Often, fibromyalgia patients must be very persistent in seeking treatment as well as in getting recognition for their condition. While remaining a diagnosis of exclusion—which means patients spend a long time with their physician and specialist(s) trying to determine the cause of their pain and other symptoms—more and more scientific evidence supports the validity of fibromyalgia as a pain disorder and its treatment.

There is also persistent stigma associated with pain expression, in particular with those that are vocal about their pain (emotional outburst, cries) being often perceived as exaggerating. It is vital to acknowledge the cultural and gender-related differences in pain communication. If a patient is reporting pain, we as a medical clinic believe that healthcare professionals should remain sensitive and respectful, and provide a proper, objective and attentive assessment of the reported pain and symptoms. Ignoring or downplaying reported pain and symptoms is counterproductive and does not help patients get better.

At Santé Cannabis, we know what stigma is – just read our name-, and we mean to push forward and fight stigmatization. We wish our patients to be heard, so we advocate for their rights; we want cannabinoid-based treatments to be prescribed and dispensed like other medications, so we advocate for improved access. We want more research on medical cannabis, so we contribute to the growing body of evidence on cannabinoid-based medicines with our ongoing observational study. To all the patients who accept to be part of this study, we thank you for your contribution to Science. We hope that our collective effort will help to improve patient care.

Stay tuned for Part 2 of this blogpost, where we’ll go over the current evidence supporting cannabinoid-based medicines for pain management and much more!

Author: Charlotte Bastin

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