Part Two: Management

Continues from part one. Both parts are available together as a PDF.

During the first six months of 2014, after returning home from inpatient rehabilitation, my pain medication remained unchanged. Just getting through a day where I was completely inactive involved intense discomfort, and I was pouring most of my energy into physiotherapy, so decreasing my intake of methadone and oxycodone was the last thing on my mind. Improved fitness had led to a mild reduction of pain in some parts of my body, but it had not yet had a significant impact, and my hip was still a throbbing beacon that was impossible to ignore.

Greener Pastures

I had done plenty of reading about pain medication while I was in hospital, and come across lots of interesting research and anecdotes about cannabis and its wondrous analgesic properties. Of particular note was a study that had shown it to be very effective when paired with opioids, allowing patients to manage on a significantly lower dose of the opioids than they would have otherwise. I had tried cannabis before and knew I was not bothered by its side-effects, so it was my plan from as soon as I arrived home to eventually try using it to lessen my reliance on the harder, legal drugs I was taking. It took a while before I had the energy to actually acquire some, but after about six months at home I started using it daily to complement my other medication. I used a small portable vaporiser, which made it easy to be consistent with the dose, and allowed me to use a conservative amount multiple times a day without wasting any.

Before this point, any reduction in the opioids I was taking was unthinkable. Rehabilitation left me physically and mentally exhausted come late afternoon, even on the days I hardly did anything. To actually feel remotely human I had to basically spend two days in bed recuperating, but that was too much of an interruption to do very often, so most of my time was spent worn out and in lots of pain. My evenings were spent constantly monitoring my pain scores, internally debating whether I could justify popping more pills, or if the need to minimise consumption outweighed the minor difference taking more would actually make given my tolerance. It was impossible to find enjoyment in anything, and I would just distract myself as best I could until it was late enough to go to bed for some reprieve. Cannabis changed all of this very quickly.

Over a couple of months, I was able to reduce my morning and evening doses of methadone from 10mg to 5mg, and my oxycodone intake went from being 45mg of slow-release at lunch plus 10-20mg of instant-release later in the day, to usually only one 5mg instant-release tablet at lunch. In the afternoon and evening, when my pain was most severe, I used cannabis in place of oxycodone, and this worked extremely well for my needs. Since I still had to deal with the strong pain of walking with a dislocated hip, and the general aches that came from the rest of my body, I decided it would be counterproductive to try and decrease the opioids further at this time. I knew I would definitely have to use them for a while after future surgery, so it seemed sensible to just maintain a minimal dose.

Even without cutting the opioids out completely, the improvement in my quality of life was profound. My workouts suddenly stopped seeming like such a chore. I actually had traces of a libido again. The dulling shroud of apathy that surrounded my daily existence began to relinquish its hold, and pain stopped taking such a huge toll on my mental reserves. It became possible to find contentment from the small things in life again, and I would experience unexpected feelings of happiness at random moments of the day. While the improvements in libido and apathy can definitely be attributed to the reduction in opioids, the other benefits occurred as soon as I started using cannabis for pain management, and were largely a result of its psychoactive effects, which play a central role in making it such a powerful tool for coping with pain.

Cannabis does help to dull pain to some extent, but it has much more in common with the ketamine and nitrous oxide I used as an inpatient than it does with opioids. The relief it provides is directly tied to its psychoactivity, and cannot be separated. Among other things, cannabis is a mild dissociative, which is part of what produces the ‘high’ feeling it is known for, and, just like inhaling large amounts of nitrous oxide was an appropriate way to escape from the boundless breakthrough pain of my first few months in hospital, inhaling small amounts of cannabis makes it much easier to decouple oneself from constant chronic pain.

While it is nowhere near as intense in its effects as a true dissociative anaesthetic, cannabis provides a similar sort of relief in a way that is mild enough to integrate into daily life. I am sure it would be unwise to try and work out on ketamine, but by having a small amount of cannabis before exercising, I was able to get into a nice distracted state where I could zone out from the constant ache of my hip, and focus on the movements I was doing and the music I had playing. Before I had my hip replaced, when active, if I stopped and thought about it, I might still have rated my pain as being four out of ten. (Keep in mind that a four for me probably constitutes substantially more pain than a four for someone who has not been run over by a truck.) With the dissociative effects of cannabis at a four too, however, I had far more interesting concerns.

It is impossible to overstate how much easier it is to deal with chronic pain when you are able to spend most of the day in this mildly dissociated state. The pain is still there, somewhere, but it is so much easier to tune out and ignore. One thing the average person might not realise is how mentally draining it can be to spend all day tolerating pain signals. Sure, the pain sucks, but that becomes normal after a while, and what is often more of a nuisance is how completely sapped of will to exist you are by the end of the day. Maintaining a steady rehabilitation routine in these circumstances can be very difficult to say the least. Without the forceful encouragement of an inpatient setting, it can be hard to string more than a few days together before the burnout becomes too much. By freeing the mind from its obsessive focus on pain, cannabis helps an incredible amount in preventing and mitigating this burnout.

The period when I first managed to stick to a consistent routine for any extended amount of time was very soon after beginning to use cannabis for pain management, and I attribute a great deal of my success since then to the mental benefits it provides as a part of its function as pain relief. A comfortable recliner chair and good home theatre setup were also important parts of the equation, but with them in place it was finally possible to escape my pain enough to actually relax and unwind for a few hours in the evening. It was like I had been gifted a mental reset button, allowing me to expunge the purchase pain had gained on my psyche throughout the course of the day, and start with a clean slate the following morning.

The analgesic effects of cannabis were of course very helpful in getting through my daily routine, but just as big an asset was being able to look forward to the evening with the knowledge that no matter how terrible I currently felt, after dinner I would be able to collapse into my chair, use a slightly larger amount of cannabis than I did during the day, and within ten minutes my head would be in the clouds with all recent tribulation but a distant memory. It was actually possible to feel pretty damn good for a few hours, all things considered, and my once futile attempts at distraction became an exquisite elated escape. I could completely lose myself in music or television, drift undisturbed through the evening hours, then arrive at bedtime relaxed and refreshed instead of dully dreading the next day.

This easily-accessible state of euphoria is an incredibly powerful positive force for a pain patient to have at their fingertips, especially when contrasted against the effects a long-term opioid user receives from their medication. For someone who has spent an extended period on extreme amounts of opioids and developed a tolerance, using a responsible amount of oxycodone is a very underwhelming experience. You put off taking more as long as possible, and when you finally pull the trigger there is a half-hour wait for it to begin to kick in. Once it finally does, there will be a mild dulling effect at best, and often your pain has increased by then anyway so it hardly makes a difference. Compare this to the creeping contentment that begins to envelop your body just minutes after inhaling cannabis, and is in full force by fifteen, then it is no surprise that I was able to make such a significant cutback in my opioid consumption. As with other medication, repeated use at a consistent dose leads to the side-effects becoming less pronounced, but some level of mood elevation has always remained, which has been a much needed ally in the time since the accident.

In Australia’s current political climate, with cannabis finally being acknowledged for some of its medicinal effects, I think what I have alluded to so far is an extremely important point to reiterate. In the context of chronic pain, any attempts to separate the recreational and medicinal aspects of cannabis will only rob it of a great deal of its utility. I have read that cannabidiol (CBD) can work well for neuropathic pain, but the dissociative relief I have received from cannabis is a result of the THC-rich blend of cannabinoids found in the buds of the plant, which is exactly what makes it appealing to recreational users. (This is not in any way a valid argument against raw medicinal cannabis. Nearly every painkiller I have been prescribed can get you high — some to a much greater extent.)

While it is certainly worth exploring the various cannabinoids further, and in other areas such as epilepsy it seems like isolating them will provide more effective treatments, for chronic pain the buds of the plant work extremely well, and should be made available to patients immediately. A comprehensive review of the current scientific literature on the health effects of cannabis was recently completed in the USA by the National Academies of Sciences, Engineering, and Medicine. They concluded “there is substantial evidence that cannabis is an effective treatment for chronic pain in adults” (p. 89). Do we really need to waste years and millions of dollars discovering this for ourselves? Cannabis has far less potential for dependence than opioids, and none of the overdose risk. The power it has to help mitigate the global oxycodone epidemic is immense. Any attempts to convince otherwise are at best misguided by outdated science or antiquated morals, and at worst a cold-hearted conspiracy led by powerful pharmaceutical companies eager to hold on to the money they stand to lose if an effective natural painkiller goes to market.

When speaking with a doctor at the pain clinic recently I was told, unsurprisingly, that it is quite common for the people they deal with to use cannabis. It seems unjust laws are not the strongest deterrent when following them leads to inescapable pain. Surely it would be better to provide a regulated environment that encourages responsible usage patterns, and stop forcing suffering citizens into black market dealings where bikie-grown buds of questionable quality abound. A system similar to what California has been pioneering since the 90s needs to be implemented with haste. Patients should be able to go to licensed dispensaries, select from a variety of strains of high quality raw cannabis and cannabis extracts, then experiment with them under professional guidance to find out what works best. Allowing patients to grow their own would also make perfect sense, and doing so could greatly reduce the strain on government coffers currently brought about by subsidised synthetics.

Less Pain, More Gains

After managing to cut back so significantly on the opioids, my medication regime remained mostly unchanged from the last half of 2014 until the second quarter of 2016, when I finally had my hip replaced. I settled into a consistent routine using cannabis, and the amount I consume has remained similar from then until today. Although I have used it multiple times a day for most of the last two-and-a-half years, the overall amount I use is quite small by most standards. Depending on my level of activity, I will usually use my vaporiser on 2-5 occasions throughout the day, taking 1-2 hits each time. Depending on the strain and quality of product, with this level of usage half an ounce (14 grams) will last me 4-6 months. I took a few 1-2 week breaks from cannabis throughout this time when having rare extended rests from working out, and this was not difficult to do at all, which could not be said about trying to do the same thing with opioids.

As the months turned into years and surgery remained just around the corner, my pain improved a great deal, and this was mainly thanks to the improvements in my body that resulted from working hard at rehabilitation. The fact I was so used to the pain probably played some part, but stretching and strengthening the muscles around my hip did a great deal to reduce its severity, and eventually I had largely eliminated the other aches that plagued my body. Overall, I would rate improved fitness as having just as big an impact in reducing pain as the hip replacement itself, if not bigger, and without using cannabis I never would have achieved what I did.

The first six months at home were hellish. When I think back and compare it to my quality of life now there is no other way to describe it, although at the time I was comparing it to a year in hospital, so it did not seem as bad. I was extremely motivated by the desire to walk unaided again, so I still managed to make significant progress, but it was unsustainable. If I had not been able to find such strong solace in cannabis when I did then I doubt I could have kept it up much longer. Maybe in another six months, with surgery still an intangible promise, I would have been so discouraged that I gave up and just rode things out from my recliner chair. I am glad that did not happen, and although cannabis itself has not caused a long term reduction in pain, the improvements it enabled most certainly have.

With the betterment of my body, I did eventually manage to cut my morning methadone and lunchtime oxycodone to just 2.5mg of each sometime in 2015, and I remained on that amount until the hip replacement. There was always strong pain when I walked or spent extended periods sitting up, but by the last half of 2015, I had reached a point where I could tune out from pain fairly successfully while relaxing in my recliner chair, even without the distracting power of cannabis.

After the hip replacement, I was planning to increase my cannabis intake to see if I could avoid using extra opioids, but the pain ended up being a lot more severe than I anticipated. In the end I decided it would be better not to risk ruining the good thing I had going by increasing my tolerance, and I just used the same amount of cannabis and additional opioids while necessary. Cannabis was able to distract me from the elevated pain scores during the day, but pain significantly impacted my ability to sleep. Fortunately I still had some 30mg slow-release oxycodone tablets lying about, as the medication I was discharged with would have been insufficient on its own. I took them for a few weeks in the evening, as well as some 10mg instant-release throughout the night if required, then gradually reduced my dose, and by six weeks post-surgery I was back to my previous level of medication.

I began to work extremely hard at physiotherapy at this point, so it was a while before I felt game to make any further cutbacks, but in August of 2016 I stopped taking oxycodone and noticed no difference. A couple of weeks after that I began to chip away at the methadone. My 2.5mg morning dose went without any trouble too, with cannabis nicely masking any negative effects during the day. I waited another week, and then I halved the 5mg evening dose. This was the first time I noticed any significant difference, and although the pain was no worse, my sleep was substantially impacted for a few nights. It slowly returned to normal over the next two weeks, after which I decided to be done with it and stopped the methadone completely in September 2016.

Once again my pain remained unchanged, but without any methadone in my system sleep was even harder to come by than two weeks prior. The first week was a real struggle because of this, and cannabis made getting through the day a lot easier than it would have otherwise been. Coffee helped too, and I spent extra time on the exercise bike to help wear myself out. After a week my sleep started to stabilise, and after two weeks I was able to get seven hours most of the time, which has been the case since then. This is less sleep than I could manage while using opioids, but with the help of an extra cup of coffee I am generally more energetic throughout the day than I was before. There was not as dramatic an improvement from being opioid free as there was when I made the substantial cutback two years earlier, but as well as the extra energy I felt a bit less numb and slightly more libidinous. I suppose that is not surprising since I was on a fairly minimal dose when I began my final taper. I was also very burnt-out from pouring all my energy into rehabilitation, which probably had some influence.

If not for cannabis, I have no doubt that I would still be using opioids at this point in time. It is quite possible I would have never felt capable of reducing my dose before the hip replacement without it, and being on 20mg of methadone and 50mg of oxycodone a day for two more years would have made tapering far more challenging than it was. Take into account the reduction in pain through fitness that cannabis enabled, and I think it is fair enough to say that I would have remained on opioids for at least another year or two. It is possible I would have felt unable to face tapering at all until I had stopped focusing on rehabilitation, and I might have even ended up another lifelong user like so many similar patients out there today.

I have not noticed any significant long-term side-effects from using cannabis to manage my pain. While there are definitely some short-term downsides, such as mildly impaired concentration and memory, they do not have any significant impact on my life in its current form, and are most noticeable in the hour after consuming. When I took breaks I always enjoyed the novelty of a clearer mind, but I never felt like I was doing harm by not being in that state more often. I was always back to normal a few days after stopping. I have completed the bulk of this account under the influence of cannabis, and, in the right amount, the added creativity it provides can in fact be quite useful for tasks like writing.

As things currently stand, I think daily cannabis use will continue to be the best way forward while I am still working full time at rehabilitation. Although my pain has improved a great deal in the last six months, and I am now almost never conscious of hip-specific pain, I am not pain free, and cannabis will no doubt allow me to direct all my focus towards exercising without being distracted by discomfort. It seems likely that back pain resulting from my pelvic misalignment will be the main concern in the future, but with further strengthening efforts I hope I will be able to minimise its frequency and severity.

Nerve pain will also continue to be an issue, and I am unsure if I will ever be able to completely come off the medication I use to manage it. I have recently been able to reduce my morning dose of Lyrica from 300mg to 175mg, but initial experiments indicate that reducing the evening dose will prove difficult. I tried taking 225mg in the evening on my GP’s recommendation, but I gave up after two nights as the lack of sleep was impacting my workout routine. I will try a more conservative taper next time to see if that helps. It will be nice if I can discontinue it, but I have been on the highest allowed dosage for a long time, and there are lots of accounts online from people struggling to come off far less. That being said, my nerve pain is largely unchanged since I did reduce the morning dose, so I think I will at least be able to make further cutbacks. I have had one flare-up since then, and that was the worst it has been in a long time, but apart from that the subjective difference has been negligible. Maybe it will even be possible to go for periods without taking any medication, and have something on hand for when it does get bad.

Cannabis does seem to have at least some effect on nerve pain, but how much it helps on top of my other medication is hard to gauge. The times nerve pain is most bothersome is often while in bed, when I do not have any cannabis in my system, but it does get bad occasionally when under the influence, so that could be a coincidence. Cannabis certainly helps to distract attention from nerve pain in the same way it does for regular pain, and continuing to use it will no doubt make life more pleasant while I experiment with reducing my doses of Lyrica and nortriptyline. If it is possible to acquire a strain that is high in CBD in the future, it will be interesting to see if that helps.

Regardless of pain, I think it will be worth continuing to use cannabis for now if for nothing other than the burnout mitigation it has so reliably provided me. With my body, working out for twenty-five hours a week has a similar mental effect to being in lots of pain by the end of the day, and I think using cannabis will be the only way to continue to do so for extended periods whilst retaining a shred of sanity. Doing endless isolation exercises would probably get pretty boring without sensory-enhanced music to enjoy, too.

I think eventually, once I stop expending all my energy on rehabilitation, it will be fairly easy to cease using cannabis daily. At the very least I hope to restrict use to the evening most of the time, but less than that should be possible. I am sure my life will always be a balancing act between being active and minimising pain, and it is hard to imagine ever reaching a point where having access to cannabis will not significantly improve my quality of life. Ideally I will take a few months break, but after that I think a sporadic usage pattern will be warranted. It is possible occasional opioid use might even allow me be more active in the future. I plan to go at least a year without taking any, but after all this I consider myself quite capable of using them responsibly if doing so proves beneficial. It will be very nice if I never have to, though, and I think with access to cannabis, there is a good chance of that being the case.