Social Situation
Sandra, an 84 year old female contacted a clinic that specialises in prescribing of cannabinoid-based medicines.

Sandra no longer drives and has a support worker who comes into the home to assist with household chores, shopping and transport for medical appointments. Sandra has difficulty mobilising, requires a walking frame, and has had two falls within the past week. Sandra lives with her 86 year old husband who has been her main support however two months ago he was diagnosed with dementia.

Medical History
Sandra is requesting information about medical cannabis for fibromyalgia and neuropathic pain in her left leg after a compound fracture of the tibia and associated nerve injury 6 years prior.

Her medical history includes high cholesterol, hypertension, type 2 diabetes, and anxiety. Three months ago Sandra awoke unable to move her limbs and had severe pain in her muscles – she was transferred to hospital via an ambulance and admitted for 8 days for investigations and subsequently diagnosed with fibromyalgia.

Medications
Current medications in webster pack include: Gabapentin 300mg BD (Lyrica), oxycodone hydrochloride 5mg prn for break-through pain, oxycodone hydrochloride and naloxone hydrochloride anhydrous (Targin) 10mg TDS, hydroxychlorine Hydroxychloroquine (Plaquenil) for rheumatoid arthritis; Prednisone (specialist will increase next week); captopril 12.5mg mane, chlorothiazide (Diuril) 500mg mane. Metformin 500mg BD, alprazolam 0.5mg nocte.

Sandra has not discussed the use of medical cannabis for her nerve pain with her GP nor any of her specialists. A support worker assisted Sandra to purchase a 1000mg CBD roll on ($93.00) via the internet which has had little effect.

Medical Management
Sandra went on to broach the subject of medical cannabis with her GP who stated that she needed to discuss this with her treating specialist. The specialist was open to collaborating with the clinic prescribing GP in a bid to understand the process and if there was sufficient research to support the prescription.

It was agreed that the plan would be to identify any potential drug to drug interactions between the cannabinoid based medicine and those currently prescribed. Identify potential adverse effects and adjust opioid medication dosage as required, monitoring blood pressure and BSL regularly.

Given Sandra is already considered at high risk for falls, many cannabinoid based medication would initially be administered at night to minimise this risk starting with a low dose such as 5mg CBD (Category 1 )

Sandra was educated about CBD ensuring she had realistic expectations and the monitoring that was required as well as the cost. Sandra stated that she and her husband were self-funded retirees and cost would not be an issue for them. They are also in a health fund. Sandra was advised that some funds provided a very small rebate on prescribed cannabinoid-based medicines.

Sandra was eventually commenced on a low dose CBD medicine, providing pain relief at 30 mg per day with Sandra self-reporting that she had not needed to supplement her regular pain relief with Oxycodine in the past month. Her GP reported that Sandra had increased her physical activity and the Targin was reduced to BD from TDS.

N.B. These products are not registered on the Australian Register of Therapeutic Goods (ARTG) and are only available to be prescribed through the TGA’s Special Access Scheme (SAS), the Authorised Prescriber Scheme (AP) or by clinical trial.