As evidence, he tells me about studies that have used a common laboratory test of pain. You expose volunteers’ skin to a piece of metal heated to a temperature most of us would agree is uncomfortable (about 113 degrees Fahrenheit). That’s their “pain threshold.” Then you see whether a drug lets them tolerate a higher temperature without squirming. Wilsey says that marijuana doesn’t seem to increase pain thresholds as much as some other drugs, such as morphine.
Wilsey says we don’t know much about the effect of cannabinoids in regular nociceptive pain because there just haven’t been many studies. Most of the research has been on neuropathic pain because that kind of pain can be very difficult to treat. Rachel had visited multiple specialists and received countless drugs. Those drugs didn’t work, or caused unacceptable side effects, or both, so she was ready to try anything.
On the other hand, patients with more common nociceptive pain have numerous treatment options. There’s acetaminophen (Tylenol), which has been around for decades because it works, as well as non-steroidals like ibuprofen (Motrin) and opioids like morphine. They all work well, so there’s little pressure to come up with another drug to treat nociceptive pain.
As Wilsey says goodbye, I’m thinking that maybe Rachel was onto something. There’s research evidence that what she was doing works, and there’s even growing evidence about how it works. That’s as much as we can say about most drugs, and more than we can say about many.
Less Pain And Less Morphine?
There’s one more element of Rachel’s story that I’m curious about. She wasn’t using marijuana only because it helped her. She also wanted to avoid the side effects of opioids like morphine.
Many of my patients would prefer to replace their opioids with something else if they could. Opioids can cause nausea and dizziness, especially at first. They cause constipation, too, often requiring the use of laxatives every day. And they can make you sleepy, forgetful and sometimes confused.
Could marijuana help someone to reduce the dose of opioids, or stop them altogether?
To answer that question, I seek out Jonathan Gavrin, a physician who has given more opioids to patients in a day than most doctors give in a year. Like Wilsey, he’s an anesthesiologist. But he’s also a palliative care physician who knows a lot about pain management. Gavrin is wiry and compact, with short hair and narrow rectangular glasses. He looks a little like a younger, fitter Kevin Spacey.
When I tell him about Rachel and her desire to avoid opioids, he nods energetically: “Oh, sure. I know that’s true.” Gavrin proceeds to tell me about his bad experiences with opioids and other drugs after he underwent a knee replacement a couple of years ago.
“They made me sick. Really sick. Hated it.” He pauses. “No euphoria, though. They didn’t make me feel good. Just crappy.” He laughs, “I got ripped off.”
So if marijuana could reduce the need for opioids? “That would be great. We don’t want our patients drowning in a pharmacological soup,” Gavrin says.
Yet we do inflict this on patients, all the time. We add drugs on top of drugs, and Rachel was by no means the only victim of a doctor’s prescription pad. I tell Gavrin this.
He laughs again. “Well, of course. We desperately want to make people feel better. So we do everything we can to help. That’s why we’ve developed such a drug culture. It’s hard to see people suffer, so we reach for a prescription pad. Maybe we get lucky with the first drug, but sometimes not, and we add, and add.”