Thank you. Here's another question we received from a person in pain: My pharmacist is withholding my prescription. What are my options?
I can certainly understand the discomfort some people may feel about discussing their use of medical cannabis! Unfortunately, there is still some stigma surrounding it, even directed at those who have authorization under the Health Canada program. The risk of being judged for using it doesn’t encourage open communication between those who use it with good effect, and their health professionals. It is good to hear, though, that your doctor was willing to authorize it for you!
Having said all this, it is most definitely worthwhile to advise your pharmacist about your medical cannabis use because we know of a few potential interactions between cannabis and other medications. These are more of a concern if you are already on medications at doses that seem right for you. If you begin using medical cannabis, it can increase or decrease the effects of some other medications (examples – estrogens, some antidepressants and medications for epilepsy) by changing the rate at which your body clears them out. If they become less effective, or side effects suddenly appear, doses may need to be adjusted. If your pharmacist knows you use medical cannabis, they can help you identify potential drug interactions and can discuss with your doctor how to adjust your medications.
Yes, and some pharmacists may be better informed on the usefulness of supplements than others!
There is a lot well-meaning discussion out there about various supplements, but it is good to ask if there is objective evidence to back up the claims for them. Many pharmacists will have access to on-line resources such as the Natural Medicines database, or will know of websites that provide unbiased information on the usefulness of commonly used supplements based on properly conducted studies.
A couple of examples I can give you - studies of glucosamine don't strongly support its use, except for one, I think, that found some benefit (less pain) for osteoarthritis of the knee. There have been some limited studies that showed some effect of turmeric supplements for pain due to inflammatory conditions (things like rheumatoid arthritis).
Most have very few side effects except maybe some stomach upset, but ensure you get some sound advice on effectiveness and safety before you try any of them. Some of them are also quite expensive, and it's best to save your money for things that work!
Great! Going back to your discussion around cannabis for pain, here's a question we received in advance: I use medical cannabis to help manage my pain and I don’t feel comfortable talking to my pharmacist about it. Do I need to? Are there possible interactions it could have with some prescribed medications?
Over the counter medications that can be helpful in alleviating pain include acetaminophen (Tylenol, Tylenol Arthritis & other generic brands), ibuprofen (Motrin & generics), naproxen (Aleve & generics). Acetaminophen is safe in recommended doses – no more than 4000 mg a day for adults; no more than 3000 mg a day for those over 65 years old; and no more than 2000 mg a day for people with serious liver disease. Ibuprofen and naproxen (which are NSAIDs) should not be used by anyone with heart failure, kidney disease, or a history of stomach or intestinal ulcers, and should only be taken infrequently by anyone with high blood pressure.
There are also products that can be applied to the skin, and can be helpful for specific painful areas, such as diclofenac gel (Voltaren), menthol and wintergreen creams and ointments (e.g. Rub A-535) and capsaicin creams. These cannot be applied to areas of broken skin, or to large areas of skin, and can be irritating. A pharmacist can help you select the best product for your situation
Can a pharmacist advise me on supplements for pain?
The most common non-opioid medications that can be helpful in managing chronic pain include acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs) like celecoxib (Celebrex and generics) and many other prescription drugs in this category, and over the counter ibuprofen and naproxen (Motrin, Aleve, and generics). Some patients may benefit from adding antidepressants such as amitriptyline or venlafaxine; others may find adding gabapentin or pregabalin is helpful for nerve pain. There are others that are generally only used if none of the above are helpful or have caused intolerable side effects. Medical cannabis (marijuana), as we just mentioned, also fits in this category, and is helpful for chronic pain in some patients. We are learning much more about cannabis with new research.
Terri, are there any alternative medications to opioids, whether prescription or over the counter medications, that can be helpful for some people with chronic pain?
This is a difficult situation, for sure. Some of the newer opioids that have other actions than the usual opioid effects might be more helpful, but this is hard to predict. The ones I have in mind here are tramadol and tapentadol, that have some minor effects that are similar to some of the antidepressants. Having said that, for some people the side effects may be worse, or just as bad, but different - in other words not any better.
It has certainly become more common, especially in the last year or so, for people in pain who don't tolerate opioids very well to look into medical marijuana as an option. It can be a challenge to find physicians who are comfortable with recommending and authorizing it, and experienced in prescribing it so they can advise you on how to choose products and what doses to start with. But, if trying new opioids has not been helpful, this may be worth considering if you can get access to good medical advice.
How long should I keep trying different opioids? It's hard to know whether I just have to put up with the side effects or if there's another, better opioid I could be using?
Are there any opioid medications with fewer side effects?
Great, thanks for answering the first 2 questions Terri. Another question we received in advance asks if you can go over some of the common side effects of opioid medications.
How do I find a good pharmacist?
Hello, everyone, I'm happy to be here and ready to do my best at answering your questions about medications, pharmacies and pharmacists.
Welcome Terri! We're very thrilled to have you on today's Ask the Expert live forum discussion. Let's get started. Here's a question that was submitted to us in advance: besides dispensing medications, what can a pharmacist do for a person in pain?
Good morning and hello to everyone joining us on today's Ask the Expert series, where you'll be able to live chat with clinical pharmacist Terri Betts regarding your pain-related questions. We will be getting started in approximately 15 minutes.