SOAP Note Diaries
“ER docs practicing in a cannabis world”
My Body has a Mind of Its Own: Sarah’s Story
As I walk into the room I try to focus completely on Sarah, a young woman who is presenting to the emergency room today for numbness and tingling.
She sits calmly, although I can tell she is nervous. She periodically jitters around in her hospital bed, laughs nervously and apologizes for coming to the emergency department.
“I just didn’t know where else to go. It seems no one can help me and I know something is wrong.”
To be honest, as an EM (emergency medicine) physician I don’t love the vague complaint of numbness and tingling. In my experience the causes are vast and with limited time and resources in the emergency room it seems impossible at times to find a diagnosis. But, I’m going to try my best for Sarah. I know she wouldn’t be here if it were not a last resort.
I ask her what’s been going on and she immediately loses her calm demeanor and bursts into frantic tears. “It’s just been so frustrating, I feel like I am going crazy and I am really scared”. She reveals to me that she has been plagued for months by random numbness and tingling in her arms and legs, and now even has a little bit of weakness in her left arm that comes and goes. Sometimes she feels her vision is going blurry. Other days, she has painful spasms that coarse throughout her back like electricity striking her every 5 minutes. She lowers her voice and sheepishly admits, “On top of all that, I noticed I don’t even have a sexual drive anymore with my husband.”
Many people, including doctors, including ourselves at times, may brush Sarah off. “You’re just stressed. You need more sleep. It’s all in your head.” I can tell she has heard all this before as she quickly assures me again that she “is not crazy.” I stop her. “I don’t think you’re crazy Sarah. Let’s get some further testing and see if we can figure out what is going on.” She smiles timidly, relieved that someone is taking her seriously. She just wants an answer.
Sarah’s MRI ended up showing characteristics concerning for multiple sclerosis. The diagnosis is certainly not always this simple, but we got lucky, if you can call it that.
I went back into the room to discuss this with her. You could sense her internal struggle between relief that something was wrong and she wasn’t “crazy” versus accepting that she now has to live with this new disease process.
Patients who deal with MS have various symptoms and challenges they face on a daily basis and we see them in the ER for many of these. Neuropathic pain, muscle spasms, spasticity, depression, anxiety, and insomnia just to name a few. It is difficult to see them keep coming back to the ER feeling hopeless about their quality of life.
Objective: We reviewed the literature to see how patients like Sarah could improve their quality of life with medical cannabis.
Interestingly, spasticity seen with MS is one of the few diagnoses that has significant evidence-based studies to support the use of cannabis in its treatment. This type of evidence is what the medical community considers a “good” study that they feel comfortable using to guide their practice.
Many of the studies that are done on cannabis are simple observational studies which do not meet this rigorous evidence-based criteria.
It seems cannabis can be used to treat a range of symptoms including spasticity, muscle spasms, issues with mood and cognition, bladder and bowel problems, neuropathy and insomnia.
Cannabis is a known powerful antioxidant and some researchers ask the question if this could help reduce oxidative damage and slow death of neurons. This would translate to slowing the overall process of multiple sclerosis.
Unfortunately, at this time there just isn’t enough research to know if this is possible. However, we find it an interesting area of future research.
Assessment and Plan: Medical cannabis has been shown to help with spasticity in people with MS.
With the correct guidance it could also potentially help with a number of other challenges people face with MS. Since research is limited, it is best to trial medical cannabis in very small doses first to see if there is a benefit to the patient.
It can take a bit of trial and error to achieve the correct combination of cannabis to obtain the desired effect. We suggest having the guidance of a Cannabis trained physician to accomplish your treatment goals.
As always, you should discuss your plan to use medical Cannabis with your neurologist and other specialists to make sure you achieve optimal treatment. We also want to ensure it does not interfere with any other ongoing treatment plans you may have for your MS.
We DO NOT currently recommend using cannabis to try and slow the progression of MS, but this is something to continue to watch going forward as more research is produced.
Sarah walked out of the emergency department that day feeling more empowered than she had in the last few months.
She knows it’s a long road ahead, but she tells me at least she has hope now. And hope is a pretty priceless emotion to keep when you’re battling chronic illness.
As she walked out of the room, I smiled and thought, “You got this Sarah. And we have your back.”
Recommended Reading and resources:
“Cannabis Pharmacy; the practical guide to medical marijuana” 2017 edition. By Michael backs with foreward by Andrew Weil, MD. Jack D McCjue MD medical editor.
“Cannabinoids in multiple sclerosis (CAMS) study: safety and efficacy data for 12 months follow up”
J Zajicek, H Sanders, D Wright, P Vickery, W Ingram, S Reilly, A Nunn, L Teare, P Fox, and A Thompson
J Neurol Neurosurg Psychiatry. 2005 Dec; 76(12): 1664–1669.
“Effect of dronabinol on progression in progressive multiple sclerosis (CUPID): a randomised, placebo-controlled trial.”
Zajicek J1, Ball S2, Wright D2, Vickery J2, Nunn A3, Miller D4, Cano MG2, McManus D4, Mallik S4, Hobart J2; CUPID investigator group.
Lancet Neurol. 2013 Sep;12(9):857-865. doi: 10.1016/S1474-4422(13)70159-5. Epub 2013 Jul 13.