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Using Cannabis to Control Blood Pressure After Spinal Cord Injury: A Case Report

Using Cannabis to Control Blood Pressure After Spinal Cord Injury: A Case Report Background: Spinal cord injury disrupts autonomic pathways, which impairs cardiovascular control and leads to episodes of transient hypertension in a process termed autonomic dysreflexia. These episodes can be severe enough to cause life-threatening medical emergencies (1). They can be triggered by routine peripheral stimuli, such as bladder or bowel events or management, and by the pain and spasticity that frequently accompany spinal cord injury (2). Cannabis alleviates chronic pain and spasticity in adults with multiple sclerosis and has been shown to modulate blood pressure (BP) in humans (3). Objective: To document how a patient with spinal cord injury self-manages autonomic dysreflexia. Case Report: The patient is a 41-year-old man with a C5 spinal cord injury that occurred 21 years ago and produced complete loss of sensory and motor function below the injury. He has been using cannabis daily for 13 years. He uses a vaporizer throughout the day to inhale about 1000 mg of a cannabis concentrate that contains 20% tetrahydrocannabinol (THC) and 5% cannabinol (assayed by Anandia). He also consumes 2 to 3 edibles per day that contain approximately 2000 to 2500 mg of THC. We measured his BP stability using a 24-hour ambulatory BP monitor (Meditech Card(X)plore), which he wore on his left upper arm on 4 separate occasions— twice while he adhered to his standard cannabis routine and twice after abstinence from cannabis, once for 3 days and once for 7 days. His BP stability was worse on days when he did not use cannabis (Figure 1, top) and better on days when he did (Figure 1, bottom). We calculated that cannabis use reduced the frequency of autonomic dysreflexia by 80% and its severity by 36%. Occasionally, when he experienced extreme symptoms of autonomic dysreflexia, this patient would also smoke 1.2 to 1.8 g of cannabis (about 239 to 358 mg of THC). In 1 such situation after 8 days of cannabis abstinence, cannabis smoking successfully treated a refractory episode of autonomic dysreflexia but also produced prolonged hypotension (Figure 2). In addition, we measured global pain intensity, the overall frequency and severity of spasms, and selfreported drug psychoactive effects over the prior 24 hours using an 11-point numerical rating scale (where 0 indicates no pain and 10 indicates the worst pain imaginable), the Penn Spasm Frequency Scale, and visual analogue scales, respectively. Sleep quality and quantity were self-reported using the Consensus Sleep Diary-M on waking. We found that cannabis use reduced global pain intensity, spasm frequency, and spasm severity; improved sleep; and improved overall wellbeing by reducing anxiety, impairment, confusion, and sensation and enhancing motivation and attention (data not shown). Discussion: We believe that our findings document that cannabis use improved BP stability in this patient by reducing the intensity and frequency of the visceral stimuli, such as pain and spasms, that are known to trigger autonomic dysreflexia. Nevertheless, we note that our study has limitations. We did not use blood samples to measure THC levels or confirm abstinence from cannabis. In addition, data collected after 3 days of cannabis abstinence may have reflected a degree of cannabis withdrawal, but this patient's symptoms were more pronounced after 7 days of abstinence, when we believe withdrawal symptoms were less likely. Nevertheless, we recognize that additional research is necessary to identify the best doses and cannabis compounds to manage specific secondary conditions for patients with spinal cord injury. In the meantime, current pharmacologic approaches to provide analgesic, antispastic, and antihypertensive treatment for patients with spinal cord injury are expensive, are often ineffective, and can result in adverse effects and drug–drug interactions (4). Patients with spinal cord injury are consequently exploring alternative therapeutic strategies to manage these conditions, and survey data suggest that cannabis provides these patients as much relief as opioids (5). We hope that the findings in this report will help patients and their physicians make more intelligent decisions around the management of secondary conditions associated with spinal cord injury.