Pot. Almost 50 percent of the patients in my practice recently used marijuana to reduce their post-op pain. I didn’t prescribe it; the word just seems to be out.
Post-operative pain is part of surgery. We do everything we can to minimize it. The narcotic drugs available are awful. They are addictive, produce constipation, nausea and wooziness.
Narcotics reduce the ability of the patients to participate in rehab exercises, slow their recovery and are part of the cause of muscle atrophy. They are not even good pain relievers; most work by making people feel dissociated from the pain, not really interfering with the pain fibers. To reduce their use, we employ a range of tactics.
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Before surgery, we teach patients about what to expect and how to use ice, compression and elevation to reduce swelling that causes more pain. We start physical therapy before the surgery and book daily physical therapy appointments starting immediately afterward. We educate about how mindfulness, calmness before and after surgery and positive attitudes dramatically affect outcomes.
During surgery, we inject local anesthetics and use regional anesthetic blocks to block the pain fibers from communicating the pain signals to the brain. We then use minimalist surgical approaches trying not to disturb any tissue that does not need to be touched.
The post-operative time is where we all get into trouble. While we prefer to use Tylenol and Toradol (Ketorolac), powerful pain relievers that do not affect the brain the way narcotics do, these drugs are often not enough. Opioids such as Dilaudid, Percocet, OxyContin and Vicodin are often prescribed. The post-operative complications due to these drugs are too many to list.
Today, with the legalization of marijuana in California, many of our patients are self-medicating with various combinations of CBD and THC, the most well-known components of the marijuana plant. Local pot shops sell tinctures, edibles and various other forms in a dizzying combination of THC-to-CBD ratios. The current buzz is that CBD is not psychoactive but reduces inflammation, and the indica version of marijuana plants helps with sleep and relaxation.
The reality of all botanical medications is that there are a wide variety of other active components and most likely they work together, called the entourage effect, to be most potent.
“For the relief of pain … there is no more useful medicine than Cannabis within our reach,” wrote Sir John Russell Reynolds, physician to Queen Victoria, in 1859. Yet, due to government restrictions, we are all at the very early stages of understanding the roles of the two main cannabinoid receptors CB1 and CB2 found in the brain, and CB2 found all over the body, as well as the yet to be found other receptors. Learning how each of these active ingredients work, both independently and together, is a work in progress.
Our patients, however, are not waiting. They report to us a sense of well-being after using pot post-operatively. They use fewer opioids, often returning the bottles to the clinic unopened, and have no side effects from the home remedy. And it is not just acute pain situations in which cannabis is having a major impact. Chronic pain, which we used to treat with buckets full of narcotics, is also being impacted by the cannabis medical revolution.
I don’t yet prescribe cannabis, hewing to the “do no harm” part of my medical oath. But how can I not encourage it?
Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic and chairman of the Stone Research Foundation in San Francisco.