Social Situation
Tom is a 35-year-old male who works on housing construction sites as a carpenter and is using power tools every day. Currently his apprentice is acting as a driver and doing the heavy lifting. His business was affected by the mandatory lockdowns during the pandemic and was doing well until he had weeks of not working, nor was he able to go to the gym where he usually worked with a qualified exercise physiologist (personal trainer) once a week to maintain the strength in his trunk and core muscles. He admits that he was not motived to keep this up alone at home and had gained over 26kg in that time. He noticed that when he returned to work, he was getting twinges in his back especially when he was bending or twisting, however he pushed on and started to go to the gym again although he was no longer able to afford the personal trainer fees.

Tom admitted that his alcohol use had increased during lockdown, firstly from boredom and then to help him sleep with the pain. He stated that his wife is really concerned that his drinking is impacting their relationship and his interactions with his young children.

Tom admitted that he does not stick to the diet his wife has him on and eats fast food for breakfast, morning tea and lunch and a home cooked meal at night. A blood screen ordered three months earlier was not completed.

Tom described the pain he was experiencing especially when he turned over at night and the need to consume alcohol to help him get to sleep. Tom stated that his lack of sleep impacted his ability to function the next day and making him irritable and was affecting his relationship.

Medical History
Tom is a long-term patient complaining of an exacerbation of chronic low back pain. Tom’s medical history includes obesity, mild depression, insomnia, chronic low back pain and high alcohol consumption. Tom had a L4/5 laminectomy for a herniated disc 6 years earlier. He had a non-eventful recovery.

The back pain has been more severe for three days and Tom wanted to ‘tough-it-out’, however, he can no longer cope as he has had very little sleep due to the pain. The pain is ‘constantly there’ and disturbs his sleep when he changes his position in bed. He uses pillows to support his upper leg when he lies on his side which helps but does not eliminate the background pain.

He is requesting pain medications but wants to avoid opioids as he has tried them before. The opioid medication made him ‘dopey’, and he was affected the next day even when taking them at night.

Tom consulted a pain specialist a few years earlier and was offered a range of options ranging from pain education; consultation by a psychiatrist; opioids; to surgical interventions such as a spinal nerve stimulator to alleviate the pain. Tom was not keen to have any further surgery if he could avoid it and cancelled his follow up appointment.

Medication
Tom’s current medications include nortriptyline 12.5mg nocte, gabapentin 900mg BD, ibuprofen PRN. Before presenting for consultation he took Ibuprofen 800mg (taken 2 hours earlier) with little to no effect.

Tom stated that he has tried conventional therapies and wants to avoid invasive therapies. He is asking if there was any evidence that medical cannabis may be of any benefit. He has limited knowledge of medical cannabis and the endocannabinoid system

Medical Management
Upon examination the low back pain increased with twisting and bending. Recent investigations revealed a mild impingement of L3/4 with mild L3-6 vertebral degeneration as a result of an osteoarthritic process.

Discussion included an explanation about sleep hygiene, the impact of alcohol on sleep architecture, the perception of pain when sleep deprived, weight management and the need to continue with the physical strengthening exercises he was taught by the exercise physiologist.
Tom asked about the cost of cannabinoid-based medications and indicated that if he stopped buying takeaway food he could afford up to the $20-30 per day.

Tom agreed to look at lifestyle interventions first such as limiting his high caloric, high fat fast foods; cut down on his alcohol intake; and continue with the exercises he was given by the exercise physiologist. He was to come back weekly for monitoring of his progress and how he was feeling.

By the fourth week Tom’s general wellbeing had improved, he had lost 13 kg, had less pain however sleep remained an issue. Discussion followed with the aim of focusing on sleep quality now he had applied some sleep hygiene strategies. Tom would be sleepy yet when he went to bed he would take 1-1.5 hours to fall to sleep. Tom was prescribed Full Spectrum CBD 5mg nocte, increased every three days by 5mg until he reached 60mg with the view to commence a blended THC:CBD medication if it was needed. Driving restrictions were discussed and Tom indicated that his apprentice was already doing most of the driving and heavy lifting.

For review in 2 weeks.

References
Vučković, S., Srebro, D., Vujović, K. S., Vučetić, Č., & Prostran, M. (2018). Cannabinoids and Pain: New Insights From Old Molecules. Frontiers in pharmacology, 9, 1259. https://doi.org/10.3389/fphar.2018.01259

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.