Medical Marijuana, Fibromyalgia, and PTSD

Medical Marijuana, Fibromyalgia, and PTSD Posted By:
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Have you made up your mind about the use of medical marijuana in your practice? I haven't yet, but writing this posting has improved my knowledge of its use.

In rheumatology we have many patients with chronic widespread pain syndromes that carry the diagnosis of fibromyalgia (FMS). There are many similar symptoms that cross over with patients who are labeled with posttraumatic stress disorder (PTSD). No matter which diagnosis these patients carry, they are often a management challenge.

I practice in Connecticut, where medical marijuana can be used to treat multiple painful syndromes, and over 30 debilitating medical conditions are presently on that list. A patient with a diagnosis of PTSD can register for medical marijuana when actively treated by either a physician or nurse practitioner (Connecticut-specific).

The prevalence of PTSD in patients with FMS ranges from 15% to 56%. Major traumatic events in childhood, adolescence, and adulthood have been reported more frequently in clinical trials and population samples. Interestingly, in patients with FMS who have PTSD, the sudden loss of a close relative or friend or diagnosis of life-threatening illness was reported to be the most common association. I find parental alcoholism, neglect, and conflict in early and late adolescence to be the most common link, along with sexual and physical abuse.

Approved medications by the FDA for FMS include two SNRIs and one antiseizure medication. Other medications used (but not approved) are muscle relaxants, SSRIs, and tricyclics. Lifestyle and nonpharmacologic management for these patients include physical therapy, physical exercise, sleep hygiene, and reducing anxiety and depression. Some respond to NSAIDs, especially those with underlying osteoarthritis, but most do not. Additional complementary and alternative therapies include acupuncture, chiropractic care, massage, biofeedback, meditation, and herbal supplements. Opioids initially may be helpful but may add to pain over time and should be avoided due to their addictive potential.

Medical marijuana is also listed as an adjunctive therapy, but there is continued debate over its use. Some pain experts say it may improve sleep and help with pain and mood. Others see no role for it and believe patients don't know what they are getting into. For Connecticut patients there is a $100 registration fee annually and a product cost between $80 and $120 monthly. This sticker-shock eliminates many from the start.

So where do I stand on the use of medical marijuana in patients with FMS/PTSD? I elect to try lifestyle changes first with sleep hygiene and physical exercise. I would suggest counseling where appropriate, judicious use of both FDA-approved and off-label medications, followed by complementary and alternative therapies. As of yet, I have no clear idea of where I stand on the use of medical marijuana for these disorders. However, I am curious to see how patients react to this management in the long term. Stay tuned.

References
  • Cohen H, Neumann L, Haiman Y, Matar MA, Press J, Buskila D. Prevalence of post-traumatic stress disorder in fibromyalgia patients: overlapping syndromes or post-traumatic fibromyalgia syndrome? Semin Arthritis Rheum. 2002;32:38-50.
  • Fietta P, Fietta P, Manganelli P. Fibromyalgia and psychiatric disorders. ACTA Biomed. 2007;78:88-95.
  • Häuser W, Galek A, Erbslöh-Möller B, et al. Posttraumatic stress disorder in fibromyalgia syndrome: prevalence, temporal relationship between posttraumatic stress and fibromyalgia symptoms, and impact on clinical outcome. Pain. 2013;154:1216-1223.
  • Häuser W, Kosseva M, Ãœceyler N, Klose P, Sommer C. Emotional, physical, and sexual abuse in fibromyalgia syndrome: a systematic review with meta-analysis. Arthritis Care Res (Hoboken). 2011;63:808-820.
  • Paras ML, Murad MH, Chen LP, et al. Sexual abuse and lifetime diagnosis of somatic disorders: a systematic review and meta-analysis. JAMA. 2009;302:550-561.
  • WebMD. Treatment & care. www.webmd.com/fibromyalgia/guide/fibromyalgia-treatment-care. Accessed August 16, 2019.

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Filed under: Rheumatology

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