Written by Dustin Lee, PharmD

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Introduction

Patient demographic

83 years old cannabis-naïve female with multiple chronic diseases/medications

DOH certification

Severe chronic or intractable pain of neuropathic origin or severe chronic or intractable pain

Case Presentation

Medical history and allergies

• History of arthritis in both knees, shoulders, and hips. Her hip arthritis prevents her from moving around as it radiates down her side.
• Uses a wheelchair most of the time, and her pain is described as a burning feeling. The patient has been dealing with the pain for years and she is starting to feel hopeless.
• Also has hypertension, GERD, hypothyroidism, anxiety, and hyperlipidemia all controlled with medications.
• No known drug allergies

Medication

Hydrocodone/Acetaminophen, Omeprazole, Simvastatin, Lisinopril, Gabapentin, Levothyroxine, Sertraline

Illicit substances or ETOH

Denies illicit substances or use of alcohol

History of Cannabis use

Naïve to therapy

Chief complaint(s)

Right hip pain traveling down to her knee. The pain is described as a burning pain and subsides when she is rested. It is difficult getting out of bed in the morning and she does not want to continue opioids or steroids and declined surgical intervention.

Restrictions of use (personal and DOH)

No restrictions on Department of Health, patient would like to avoid inhalation

Management

Formulation(s)

• No restrictions on Department of Health, patient would like to avoid inhalation
• Ilera Hope #1 Tincture (5 mg/ml THC; 5 mg /ml CBD), started with 0.25ml (1.25mg THC/1.25 CBD), titrated up to 1ml (5 mg THC/5 CBD). Patient was then changed to a higher concentrated tincture.
• Ilera Hope #2 Tincture (8 mg/ml THC; 1.6 mg/ml CBD), stated with 0.5ml (4mg THC; 0.8 mg CBD), titrated up to 2ml (16 mg THC; 3.2 mg CBD). Patient was then changed to a higher concentrated tincture.
• PurePenn/Moxie Fruit Punch Tincture (26 mg/mL THC), started with 0.5ml (13 mg THC), titrated up to 1ml (26 mg THC). Patient was then changed to a higher concentrated tincture.
• PurePenn/Moxie Earl Grey Tincture (32mg/mL THC), started with 0.75ml (24mg THC), titrated up to 1ml (32mg THC), Patient started using a different tincture due to inventory availability.
• PurePenn/Moxie Root Beer Tincture (33mg/mL THC), started with 0.75ml (24.75mg THC), titrated up to 1ml (33mg THC)

Dosage

• Dose: 0.25mL sublingual (1.25mg THC / 1.25mg CBD)
• Start with 0.25ml (1.25mg THC/ 1.25mg CBD), twice a day. Patient may titrate upwards gradually every 3 days by 0.25ml if needed

Frequency

• Twice a day

Other Comments

Patient was instructed to hold medicine under the tongue for at least one minute. Titration instructions were to increase by 0.25ml every 3 days until effective dose is achieved.  There are possible drug interactions with hydrocodone and Levothyroxine. To lower chances for adverse effects its recommended to space out medical cannabis by at least 4 hours from opioids. The patient has a thyroid level scheduled. She was instructed to continue to monitor her blood pressure and sugar while using cannabis.

Outcome

Patient started to notice an effect when using 1mL of Hope #1 tincture (5mg THC /5mg CBD). She would dose once in the morning and afternoon. Her caregiver reported an improvement in her mood and energy level. The patient continued with the titration schedule as she felt comfortable increasing the dose with no reported side effects. The patient reached a final dose of 32mg of THC in the morning and afternoon. The CBD was removed from the regimen as the patient tolerated cannabis and lack of availability of high THC/CBD tincture concentrations. The patients care giver noticed a decrease in her opioid use and being able to stand in the shower with no assistance.

Discussion

The patient is an 83-year-old female who is new to cannabis with no experience. She has chronic right hip pain which radiates down her side, lowering her quality of life. After exhausting many pain management options, she was referred to medical cannabis as an alternative. Oral forms of cannabis were recommended due to the patients concern with inhalation and she never used any type of inhaled medicine. Step by step instructions were provided to the patient and care giver to slowly increase the dose by 0.25mL increments every 3 days until an effective dose was obtained.

Her caregiver would objectively measure her pain by how much hydrocodone/acetaminophen the patient would need. On average the patient consumed 4 tablets a day.  As the patient’s dose increased to 32mg THC, the patient started using 3 tablets a day and her caregiver noticed she was more willing to get up on her own and was able to shower with minimum assistance.

Since the patient had no experience with cannabis in the past and did not want to be intoxicated, using CBD and slowly increasing the dose every 3 days helps minimize unwanted side effects at the beginning of therapy. Since the patient was started with a 1:1 formulation, the patient was able to get a feel for what cannabis felt like, then as she reported back on how she was doing, dose adjustments were made.  She reached a final dose of 32mg of THC once in the morning and once at night. The patient reports no side effects with this dose and will continue with this regimen. The patient was instructed to reach out to a pharmacist if she or the caregiver had any questions.