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Open Science Journal of Psychology
2019; 6(1): 1-4
http://www.openscienceonline.com/journal/osjp
Case Studies of Analgesic Cannabinoid Use by
Persons with Chronic Pain from Car Accidents
Zack Zdenek Cernovsky
*
, Larry Craig Litman
Department of Psychiatry, University of Western Ontario, London, Canada
Email address
*
Corresponding author
To cite this article
Zack Zdenek Cernovsky, Larry Craig Litman. Case Studies of Analgesic Cannabinoid Use by Persons with Chronic Pain from Car
Accidents. Open Science Journal of Psychology. Vol. 6, No. 1, 2019, pp. 1-4.
Received: January 5, 2019; Accepted: February 15, 2019; Published: March 6, 2019
Abstract
Reviews recent research on cannabinoids, especially on cannabidiol (CBD) with respect to its neuroprotective properties and
its long term effect on injured tissues and associated chronic pain, and presents case studies of two men (age 52 and 53)
involved in multiple car accidents. They suffered from severe chronic pain, pain related insomnia, the post-concussion
syndrome, and various neurological symptoms such as urinary incontinence. One of them inhaled vaporized cannabis oil of
unknown composition, experienced major pain relief over time, and as a side-effect, unexpectedly and fully recovered from his
terminal pulmonary cancer. The other man suffered from a cardiac arrest after which the cardiologist discontinued his
prescription of hydromorphone of several years: this patient then started to use CBD oil in 1:1 ratio with tetrahydrocannabinol
(THC), and experienced not only substantial pain relief, but also appeared more cognitively alert. Both patients reported that
these cannabinoids provided more adequate relief from pain than their previously prescribed analgesics.
Keywords
Cannabinoids, Cannabidiol, Pain, Addiction, Hydromorphone, Tetrahydrocannabinol
1. Introduction
During psychological assessments over the recent 5 years
of more than 500 patients who were involved in motor
vehicle accidents (MVAs), about 20% of them mentioned
that they routinely use smoked or edible cannabis because
their prescribed or non-prescription analgesic medications
failed to provide an adequate pain relief. Some of these
persons reported that smoking cannabis leads, within about 5
to 15 minutes, to a relaxed state of mind during which the
pain seems more tolerable for several hours, after which time
the pain returns in full force, as before. In contrast, another
large group of our MVA patients said that they avoid
cannabis for fear of the social stigma, or of drug induced
psychosis, or they sought, but have been unable to obtain a
legal prescription for medical cannabis because their
physician is unfamiliar with or reluctant to proceed with
medical use of this herbal substance.
The MVA patients typically suffer from MVA related neck
and back pain due to injuries of mainly cervical or
lumbosacral spine, post-concussion syndrome, PTSD, and
pain related insomnia [1], and are frequently prescribed
various analgesic medications, including also tramadol,
oxycodone, hydromorphone which are notoriously far more
addictive than cannabis. In perhaps only 10% of such patients
treated legally with highly addictive drugs, would their
physician be adequately familiar with medical cannabis, and
above all, with its valuable non-euphoric/non-addictive
extracts such as cannabidiol?
The clinical medical management of pain should be
evidence-based. Unfortunately, less than 5% of medical
schools in North America even teach about endogenous
cannabinoids [2], those produced spontaneously by human
body and which control activities of most of other human
hormones [3] and maintain homeostasis. To teach future
physicians and psychologists about cannabinoids is not a
simple endeavor, because marijuana plants contain circa 500
different chemical substances and there are more than 50
hybrids of marijuana which differ in the relative proportions
of these 500 chemicals. Unfortunately, many of the current
reviews or meta-analytic studies of medical use of
2 Zack Zdenek Cernovsky and Larry Craig Litman: Case Studies of Analgesic Cannabinoid Use by
Persons with Chronic Pain from Car Accidents
“cannabis/cannabinoids” are hopelessly confounded or
produce inconsistent results because they fail to even
differentiate between the various hybrids of cannabis (some
of them containing very high proportions of the psychoactive
tetrahydrocannabinol which is responsible for some cases of
drug induced psychosis), and the non-euphoric/nonaddictive
cannabidiol (CBD) derived from cannabis, and also the
pharmaceutically manufactured analogues of
tetrahydrocannabinol (THC) such as nabilone. Nabilone was
developed to have similarly relaxing effects as smoked
cannabis, but with no or only minimal euphoric impact.
Some of our MVA patients complain that while nabilone
relaxes them, it does not reduce their pain.
Of particular therapeutic interest for management of
chronic pain is CBD because it is a powerful anti-
inflammatory. Well-designed animal studies by Manzanares’
team demonstrated the non-addictive nature of CBD, its
potential for treating behavioral symptoms of PTSD, and also
its potential for alcoholism treatment [4, 5, 6, 7]. Case reports
and statistical studies (e.g., Cernovsky and Elias [8], Elias et
al [9]) also show that some patients with severe pain might
benefit, in the long run, significantly more from the non-
euphoric CBD oils than from usually prescribed
pharmaceutical analgesics, as shown by the extent of pain
reduction and by the propensity of CBD oil to trigger a
gradual (very slow, almost imperceptible over the first
several days) decrease of pain over weeks or months, all
while the dose of CBD may be eventually decreased to
minimal levels such as only a few drops in a month.
Successful clinical applications of CBD include severe
epilepsy such as in the Dravet Syndrome (Perucca [10]),
severe autism (Aran et al. [11]), and even schizophrenia
(Leweke et al. [12]): CBD has neuroprotective effects
(Alvarez et al. [13], Campos [14]).
2. Case Studies
This article presents case studies of two MVA patients who
sustained spinal injuries causing severe pain, post-concussion
syndrome, PTSD, and pain related insomnia.
2.1. Study 1
This first case study involves 53 year old gentleman with a
grade 10 education, a divorced father of 3 children with
whom he has had almost no contact because most of his adult
life was marred by his intense alcohol and drug abuse. Over
the preceding 3 decades, he was involved in 5 vehicular
accidents, sustained repeated injuries to his spine, and was on
a disability pension over the last 8 years. His last MVA was
approximately 11 months prior to our diagnostic interview
and exacerbated his symptoms: the accident left him with
very severe pain, insomnia, PTSD, anxiety, and depression,
and with a loss of bladder control. He had to wear diapers. At
the time of his last MVA, he was also diagnosed via biopsy
with aggressive lung cancer which his oncologist
characterized as terminal. In a last attempt to save or improve
his life, this patient joined alcoholics Anonymous (AA).
Some of his fellow AA members advised him to inhale
vaporized cannabis oil, in order to stop craving for alcohol
and addictive drugs. To his surprise, he was able to stop his
substance abuse without intense withdrawal symptoms.
Furthermore, his lung cancer disappeared within about 3
months of inhaling vaporized cannabis oils on a daily basis
(CBD exerts antitumor activity, see, e.g., Mc. Allister et al.
[15]). He also noticed a considerable decrease of his pain.
Under the influence of AA, he changed his lifestyle to a
more constructive one. For example, he volunteered at a local
horticultural center for medical marijuana in an effort to
provide for others what he started to believe was a life-saving
herb. Instead of wasting time with substance abuse, he spent
some of his free time on internet sites discussing benefits of
medical cannabis. He was undergoing supportive
psychotherapy which helped to reduce his anxiety and
explosive anger. Unfortunately, his nutritional habits were
poor. He was very emaciated and died from a cardiac failure
about a year after our diagnostic interview.
2.2. Study 2
The second case involves a 52 year old gentleman,
formerly a skilled blue collar employee of a college, who was
in 2 car accidents over the preceding 8 years, which resulted
in a moderate post-concussion syndrome and in injuries to
his cervical, thoracic, and lumbosacral spine, with persistent
neck and back pain and various neurological symptoms,
including urinary incontinence for which he has to wear
diapers. He was placed on a disability pension. He was
prescribed various analgesic medications for his persistent
pain over the last 8 years and was eventually diagnosed with
liver damage. His medications included hydromorphone until
a year ago, at which time he developed pneumonia,
experienced chest pain, and experienced a cardiac arrest of
several minutes, but was resuscitated by paramedics who
transported him via ambulance to a nearby hospital. His
cardiologist arranged for this patient’s hydromorphone to be
discontinued due to that medication’s adverse impact on
cardiovascular functioning. Instead, this patient was placed
on oil consisting of one to one proportion of cannabidiol
(CBD) to tetrahydrocannabinol (THC). He experienced no
adverse side effects from this CBD-THC oil. When he started
this oil, his withdrawal from the prescribed opiate based
medication was associated only with relatively minimal
symptoms and he was able to cope with his pain adequately
by orally ingesting about 0.8 ml of the oil per day. He
appeared far more lucid, focused, and task oriented than in
our numerous interviews over the preceding 2 years. He was
also able to discontinue some of his other medications, thus
minimizing polypharmacy.
Unfortunately, he ran out of his supply of the CBD-THC
oil (a small bottle containing only 25 ml, purchased at about
$70) after approximately one month. Unfortunately, his
medical insurance which generously covered the relatively
higher expenses with hydromorphone and other analgesic
drugs did not cover the CBD oils even though they were, in
his case, obviously more cost effective. He now cannot afford
Open Science Journal of Psychology 2019; 6(1): 1-4 3
purchasing this oil because he is financially destitute and in
enormous debt as a consequence of his MVAs. His
physicians again prescribed the usual pharmaceutical
analgesic medications. His pain and pain related insomnia re-
intensified and his cognitive processing has again relatively
deteriorated (impaired memory and concentration, slow
speed of thinking).
3. Discussion
The cases presented in this article suggest that at least
some patients with severe pain and severe neurological
symptoms can benefit from cannabis oils, more so than from
the widely prescribed opioid and non-opioid analgesics.
Unfortunately, the chemical composition of the cannabis
oil inhaled by the first patient remains unknown. The unique
aspect of his case history is the disappearance of his terminal
pulmonary cancer after he started vaporizing and inhaling
cannabis oil. This is consistent with findings of anti-tumor
effects of certain cannabinoids in some studies [15]. This
patient died a year after our psychological interview due to
cardiac failure, perhaps partly related to his poor diet and the
cumulative long term effect of internal injuries from his 5
MVAs and of 3 decades of intense substance abuse.
Since the composition of the cannabis he inhaled is
unknown, his use of cannabis with its analgesic and anti-
carcinogenic effects cannot be simplistically replicated on
other patients. Different medical conditions causing pain and
different types of cancer presumably require some unique
ratios of CBD to THC. Furthermore, some cancers might
perhaps not respond to therapy with cannabinoids.
Most hybrids of regularly available cannabis are low in
CBD, but it is CBD that was found, in animal research by
Alvarez et al. [13], to be not only neuroprotective, but to also
have beneficial cardiac, hemodynamic, and ventilatory
effects. Strains of marijuana high in CBD are rarely available
from vendors: these special strains were developed as a
source of CBD for treatment of children with severe
intractable epilepsy. In contrast, the illegally available street
marijuana is notoriously high in THC.
CBD does not produce euphoria expected by so called
“recreational users” of cannabis: even when mixed as oil
with one to one ratio of CBD to THC, the oil is not
noticeably euphoric or addictive because CBD efficiently
counteracts the otherwise euphoric impact of THC as a form
of entourage effect.
As already mentioned, there is experimental evidence from
animal research that CBD has neuroprotective effects. Both
patients discussed in this article had sustained cerebral
concussions and exhibited signs of the post-concussion
syndrome which appeared to be attenuated by their use of
cannabinoids. Extensive evidence has now been accumulated
that endocannabinoids play an important role in the control
of synaptic transmission and the regulation of the rate of
neuronal firing, see a review in Perucca [10].
Compared to regularly prescribed medications for pain and
insomnia, CBD is relatively free of adverse side-effects.
Research is urgently needed on the use of various ratios of
CBD to THC oils on a variety of pathological conditions,
ranging from chronic pain or neurological symptoms to
cancer. Certain medical conditions might benefit only from
some particular proportion of CBD to THC, for example, as
shown in a recent case study [8] of a patient with severe
osteoarthritis for which high CBD oil (25 parts of CBD to
one of THC) had no effect on pain whereas the one to one
ratio (initially at 0.5ml per day) almost eliminated pain after
several weeks and the needed dose was eventually decreased
to a few drops per month. For ethical reasons, the research on
the CBD oils needs to be fast-tracked to potentially alleviate
the horrendous suffering of millions of patients with various
medical conditions. If legislative and administrative barriers
to this field of research are removed, it would be possible to
organize large scale double blind randomized studies with
varied daily dosing and with diverse ratios of CBD to THC.
Although CBD oil is now easily available in some
countries from unlicensed vendors on a nonprescription
basis, some such bottles sold as CBD oil were found, when
tested, to contain only THC and no CBD at all (Rubin [16]).
In Utah, some bottles contained toxins that caused more than
50 persons to seek help in the emergency department (Kuehn
[17]). It is important to emphasize to patients who consider
medical use of cannabinoids to avoid products not scrutinized
by laboratories: there is a need for a standardized laboratory
testing of such therapeutic cannabinoid products [18]. Many
patients admit that marijuana available from unlicensed
vendors may contain agricultural toxins, but some of them
opt to take this risk rather than exposing themselves to
known hepatotoxicity of common analgesic drugs such as
Tylenol associated with long term daily use.
Both patients discussed in this article were extensively
exposed to opiates: the first one via drug abuse and the second
one due to long term medical prescription of hydromorphone.
It is noteworthy that the cannabis oils/CBD oils helped both of
them to stop opiates without severe withdrawal symptoms or a
relapse. This is consistent with reports of the potential of CBD
for treatment of addictions [19].
A further area of urgently needed research is on other
cannabinoids such as cannabidivarin (CBDV), a non-
psychoactive cannabinoid which showed antiepileptic
properties in some studies [20], and also on so called
entourage effects of various cannabinoids because the
cannabinoid oils usually contain varied amounts of chemical
substances other than only CBD, THC, or CBDV.
References
[1] Cernovsky Z, Istasy P, Bureau Y, & Chiu S. Scale for
retrospective assessment of immediate concussion symptoms.
Mental Illness, 2018; 10 (2): 70-71 and Appendix (2 pages).
https://doi.org/10.4081/mi.2018.7901 and
https://www.pagepress.org/journals/index.php/mi/article/view/
7901/7661.
[2] Lu HC and Mackie K. An introduction to the endogenous
cannabinoid system. Biological Psychiatry. 2016; 1; 79 (7):
516–525. doi: 10.1016/j.biopsych. 2015.07.028.
4 Zack Zdenek Cernovsky and Larry Craig Litman: Case Studies of Analgesic Cannabinoid Use by
Persons with Chronic Pain from Car Accidents
[3] Pagotto U, Marsicano G, Cota D, Lutz BG, Pasquali R. The
Emerging Role of the Endocannabinoid System in Endocrine
Regulation and Energy Balance. Endocrine Reviews. 2006; 27
(1); 73-100. doi.org/10.1210/er.2005-0009.
[4] Viudez-Martínez A, García-Gutiérrez MS, Medrano-Relinque
J, Navarrón CM, Navarrete F, and Manzanares J. Cannabidiol
does not display drug abuse potential in mice behavior. Acta
Pharmacologica Sinica. 2018; 0: 1-7.
doi.org/10.1038/s41401-018-0032-8.
[5] Viudez-Martínez A, García-Gutiérrez MS, Navarrón CM,
Morales-Calero MI, Navarrete F, Torres-Suárez AI &
Manzanares J. Cannabidiol reduces ethanol consumption,
motivation and relapse in mice. Addiction Biology, 2017; 23:
154B164.
[6] Viudez-Martínez A, García-Gutiérrez MS, Fraguas-Sánchez
AI, Torres-Suárez AI, and Manzanares J. Effects of
cannabidiol plus naltrexone on motivation and ethanol
consumption. British Journal of Pharmacology. 2018; 175:
3369-3378.
[7] Manzanares J, Gasparyan A, Caparros E, Navarrete F.
Evaluation of cannabidiol effects in a new animal model of
Post-Traumatic Stress Disorder. World Psychiatric Congress,
Mexico City, Mexico, September 27-30, 2018.
[8] Cernovsky Z, Elias RG. Case Reports of Successful
Management of Pain by One to One Ratio of Cannabidiol with
Tetrahydrocannabinol. Archives of Psychiatry and Behavioral
Sciences. 2018; 1 (2): 4-36.
[9] Elias RG, Raheb M, Mekhaiel D, Cernovsky Z, Sidhu G,
Warren D, Sadek G, Chiu S, Bureau Y. Use of Pharmaceutical
Analgesics Versus Cannabis or Cannabidiol-
Tetrahydrocannabinol Oils to Reduce Pain. Archives of
Psychiatry and Behavioral Sciences. 2018; 1 (2): 37-40.
[10] Perucca E. Cannabinoids in the Treatment of Epilepsy: Hard
Evidence at Last? Journal of Epilepsy Research. 2017; 7 (2):
61–76. doi: 10.14581/jer.17012.
[11] Aran A, Cassuto H, Lubotzky A. Cannabidiol Based Medical
Cannabis in Children with Autism - a Retrospective
Feasibility Study (P 3.318). Neurology. April 10, 2018; 90 (15
Supplement).
[12] Leweke FM, Piomelli D, Pahlisch F, Muhl D, Gerth CW,
Hoyer C, Klosterkötter J, Hellmich M, Koethe D. Cannabidiol
enhances anandamide signaling and alleviates psychotic
symptoms of schizophrenia. Translational Psychiatry, 2012; 2:
e94. doi: 10.1038/tp.2012.15.
[13] Alvarez FJ, Lafuente H, Rey-Santano MC, Mielgo VE,
Gastiasoro E, Rueda M, Pertwee RG, Castillo AI, Romero J,
Martínez-Orgado J. Neuroprotective effects of the
nonpsychoactive cannabinoid cannabidiol in hypoxic-
ischemic newborn piglets. Pediatric Research. 2008; 64 (6):
653-658. doi: 10.1203/PDR.0b013e318186e5dd.
[14] Campos AC, Fogaça MV, Sonego AB, Guimarães FS.
Cannabidiol, neuroprotection and neuropsychiatric disorders.
Pharmacological Research. 2016; 112: 119-127. doi:
10.1016/j.phrs. 2016.01.033.
[15] McAllister SD, Soroceanu L, and Desprez P-Y, The Antitumor
Activity of Plant-Derived Non-Psychoactive Cannabinoids.
Journal of Neuroimmune Pharmacology. 2015; 10: 255-267.
doi 10.1007/s11481-015-9608-y.
[16] Rubin R. The Path to the First FDA-Approved
Cannabis-Derived Treatment and What Comes Next. Journal
of the American Medical Association (JAMA). 2018;
September 5: E1-E3.
[17] Kuehn B. Synthetic cannabidiol poisoning. Journal of the
American Medical Association (JAMA). 2018; 319 (22),
2264.
[18] Jikomes N, and Zoorob M.. The Cannabinoid Content of
Legal Cannabis in Washington State Varies Systematically
Across Testing Facilities and Popular Consumer Products.
Scientific Reports. 2018; 8: (4519), 1-15. doi:
10.1038/s41598-018-22755-2.
[19] Prud’homme M, Cata R, Jutras-Aswad D. Cannabidiol as an
Intervention for Addictive Behaviors: A Systematic Review of
the Evidence. Substance Abuse: Research and Treatment.
2015; 9: 33-38. doi: 10.4137/SART. S25081.
[20] Hill TD, Cascio MG, Romano B, et al. Cannabidivarin-rich
cannabis extracts are anticonvulsant in mouse and rat via a
CB1 receptor-independent mechanism. British Journal of
Pharmacology. 2013; 170: 679-692.
