Interactive Case Study: Use of Cannabis Extract for Local Treatment of Neuropathic Pain
We have been using cannabis for pain treatment for several years. We also have good experiences with it in difficult-to-control symptoms of neuropathic pain, as illustrated in the following case study. Until recently, our patients only used cannabis orally or via vaporization. With the availability of cannabis extracts, a new option has emerged – local therapy.
A 78-year-old patient underwent surgery on her right knee – TEP – 5 years ago. The procedure went smoothly, and the subsequent hospitalization was unremarkable. Shortly after discharge, however, she began to feel an unpleasant pull in the knee area and on the calf of the right lower limb. The intensity of the issues increased to a pressure pain. Various analgesics, most often non-steroidal anti-inflammatory drugs (NSAIDs), were tried during follow-ups at the orthopedic clinic, but without significant effect. The pain persisted.
Because the patient's condition did not improve in the following months, 3 years after the knee TEP, in agreement with treating orthopedists and neurosurgeons, a denervation operation of the n. saphenus was proposed (preceded by a successful nerve blockade with a local anesthetic providing a week’s relief).
Several weeks after the operation, the pain in the right lower limb reappeared. It became even more intense, and she felt it over a larger area of the calf. It also changed from a pressure pain to a burning pain. Since this state persisted, 4 years after the joint replacement and more than a year after the neuro-ablation procedure, she was eventually referred to a pain clinic.
During the initial examination, we found that the surgical wounds had healed per primam. The scar from the denervation procedure was still painful. We noted hypesthesia on the skin in the innervation area of n. saphenus and allodynia on the inner side of the knee. She felt spontaneous burning pain in the upper half of the calf. She reported the intensity as very strong. She had a sensation of fluid running down her leg. The patient was very tired of all this, skeptical about any interventional methods. She was troubled by the fact that many years of using analgesics had solved nothing, and she did not want to take so many drugs anymore.
Considering all the information, we leaned towards local treatment combined with reduced oral treatment. We scheduled the patient for the application of a capsaicin patch, to take pregabalin 75 mg at night, and a combination of tramadol/paracetamol 37.5/325 mg 1 tablet for pain.
After applying the capsaicin patch, the intensity of the pain decreased by 60%. For home local treatment, we prescribed a cream with 5% lidocaine for application to the painful areas of the right lower limb. On the combined therapy, the patient had no significant problems.
About six months later, the effect of capsaicin waned. Higher doses of pregabalin or increasing the dose of the combined analgesic containing tramadol/paracetamol were not tolerated by the patient. This led to the rotation of the analgesic to sustained-release tapentadol, gradually increased to 2 x 100 g. Pain control improved.
Re-application of the capsaicin patch was indicated. However, its second application was more painful for the patient, and it had a good effect for only a few days. Therefore, we prescribed a combined antineuropathic cream (5% lidocaine, 2% AMT, 0.2% clonidine). It was more effective than the lidocaine preparation alone, providing pain relief for several hours. Over the next year, periods of worsened condition, with complaints of burning in the right leg up to the groin, alternated with periods when the pain was under control.
Two years after the start of our treatment, when the issues slightly worsened again, the patient contacted us once more. The effect of the antineuropathic cream had diminished – complete relief lasted only an hour, then the burning pain gradually worsened. She wanted something different.
We prescribed a cream with a full-spectrum cannabis extract containing 10% THC and 2% CBD. We used Pentravan as the vehicle. This base allows the preparation of a cream with higher concentrations of active ingredients and more than one medicinal component. The effect was excellent. It provided the best relief of all the creams tried. Relief from one application lasted nearly the entire day. She now uses it along with sustained-release tapentadol 2 x 100 mg and pregabalin 2 x 75 mg and is satisfied.
We use the cannabis cream in our clinic with very good effect, especially where hypersensitivity of the skin is detected. It has also proven effective for joint or muscle pain.
MUDr. Lenka Kocmichová
chronic pain clinic, České Budějovice Hospital
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