Jeffrey's Story- Medical Testimony
Dustin Sulak, D.O.
Traditional Osteopathy & Integrative Medicine
228 Water Street, Halowell, ME 04347
office (207) 509-0645 fax (207) 621-0985
www.drsulak.com office@drsulak.com NPI#1427212059
June 14, 2010
Medical Testimony for Jeffrey Kennedy, DOB 9/19/58
This medical testimony is based on a one-hour telephone interview on April 7th, 2010,
and the review of the following medical records:
• Dr. Allen Bezner
o Electromyogram 12/23/02
o Office notes 12/23/02, 1/28/03, 3/3/03, 4/7/03
• Palm Beach Pain Management
o Office Notes 12/4/09, 12/30/09, 1/27/10, 2/24/10
Present Complaints:
Jeff’s primary compliant is bilateral foot pain. The pain is burning and needle-like,
begins in the calves, and radiates to the distal feet. The sensation often intensifies for 5
seconds to 2 minutes unilaterally. The pain is worse at night and is exacerbated by
standing and walking. It is somewhat ameliorated by hot soaks and medication. There
is also a constant tingling sensation in both feet. On a scale of 1 to 10, with 10 the
worst pain, Jeff rates his average pain level at 7-8. The foot pain affects his ability to
stand and walk, and is present all day, every day. In addition to the foot pain (lumbar
radiculopathy and peripheral neuropathy), Jeff experiences low back pain (lumbago),
neck pain (cervicalgia), and osteoarthritis of multiple joints.
Past Medical History:
In the late 1980s Jeff was involved in a motor vehicle accident when he hit a deer with
his motorcycle and sustained a skull fracture. He right frontal bone was repaired with a
metal plate.
In 1999 Jeff fell backwards and injured his lumbar spine. In 2000 he was diagnosed
with L4/L5 disc herniation and underwent surgical fusion by Dr. Theofilos.
Unfortunately, the surgery was not helpful in correcting his low back pain and actually
exacerbated the radiculopathy into the legs. He now carries a diagnosis of lumbar failed
back surgery syndrome. Past medical history is also significant for hepatitis C, which he
contracted over 20 years ago during a period of his life when he was involved in
intravenous drug abuse. He has long since avoided any drug abuse, and has a history of
responsible use of opiate pain medications and adherence to the narcotic
agreement/guidelines of Palm Beach Pain Management.
Current Medications:
Restoril 15 mg qHS (for sleep)
Soma 700mg qHS (for muscle relaxation and sleep)
Duragesic patch 200mg q72 hr (opiate pain medication)
Oxycodone 30mg QID (opiate pain medication
Lovastatin 20mg qHS (cholesterol management)
Past medications:
Jeff has tried several approaches to help the peripheral neuropathy, including Neurontin,
Elavil, Trileptal, and Topamax. All these medications were either ineffective or had side
effects that were intolerable.
Medical Cannabis Usage:
Approximately 3 years ago Jeff was introduced to cannabis as a potential treatment for
neuropathic pain. He found that this medicine instantly decreased the burning and
throbbing in his feet, with an average reduction in pain from 7-8 down to 2-3 out of 10.
Furthermore, the cannabis helped decrease his need for opiate pain medication by 50%,
removed his need for Soma, and improved his sleep. Jeff began growing this herbal
medicine himself to avoid the dangers and high prices of acquiring it on the black
market. His average cannabis consumption, when he has access to this medicine, is one
ounce per month. He smokes 2-6 puffs BID-QID out of ceramic pipe. His dosage
depends on the potency of the herb.
Review of Systems:
In addition to the above-mentioned symptoms, Jeff also experiences headache
approximately twice weekly.
Social History:
Jeff smoke 1 pack of cigarettes daily, drinks plenty of water, 2-3 caffeinated beverages
daily, and denies the consumption of alcohol or soft drinks. For exercise he swims
regularly. He sleeps an average of 3-4 hours per night because his sleep is disturbed by
pain. When he takes both Restoril and cannabis he is able to sleep 8 hours.
Discussion:
Failed back surgery syndrome is a common diagnosis: approximately 5–10% of patients
who have back surgery return home without relief of their radicular pain. One
proposed mechanism of the worsening radiculopathy and neuropathy seen in these
patients involves nerve roots being encased in a web of scar tissue, causing pain, spasm
and nerve compression whenever movements of the spine and legs affect the paraspinal
tissues. In many ways failed back surgery syndrome resembles multiple sclerosis: the
conditions have the same range of symptoms of pain and numbness, weakness and
spasm in the limbs, and bladder and bowel difficulties. Talbot describes,
“Patients with failed back surgery syndrome live with the constant anxiety of relapse and
steady deterioration of a range of neurological symptoms, yet current medical
management focuses narrowly on relieving pain. This is another strand in the web in
which patients are caught: good pain relief brings the illusion of improved physical
ability. However, for many patients, after a brief honeymoon period pain, spasm and
weakness appear at a lower activity level, and the web tightens to immobilize the
ensnared nerve roots (and patients) even more.”
Medical Cannabis:
Originating from Central Asia, cannabis is one of the oldest psychotropic drugs known
to humanity. The beginnings of its use by humans are difficult to trace, because it was
cultivated and consumed long before the appearance of writing. According to
archeological discoveries, it has been known in China at least since the Neolithic period,
around 4000 BC .
Despite the prohibition of cannabis in the United States for over 70 years, many patients
have found access to this medicine via the underground market, and there is a large
body of anecdotal evidence supporting its efficacy in treating a wide range of medical
conditions, in both a palliative and curative manner.
Preclinical research on cannabinoid medicines has lagged behind other classes of drugs
because the lipid-soluble properties have provided laboratory technique challenges in
elucidating active ingredients and cannabinoid receptors. Finally, THC was discovered
in the 1960s and the first cannabinoid receptor was discovered in 1990. Since that
time, the published research on cannabinoid medicines has grown quickly, with over
12,000 papers published to date. For a concise overview of cannabinoid physiology
and biology, see Baker et al.’s “The therapeutic potential of cannabis.” (Appendix)
Marijuana prohibition has posed challenges to human clinical research on the
effectiveness of cannabis. In the last few years, however, a growing number of well-
designed, placebo-controlled trials have been published. Several of these studies
focuses on the efficacy of cannabis to treat chronic pain, neuropathic pain, and muscle
spasm.
Four studies funded by the University of California’s Center for Medical Cannabis
Research (CMCR) have demonstrated that cannabis has analgesic effects in pain
conditions secondary to injury (e.g. failed back surgery syndrome) or disease of the
nervous system. This result is particularly important because three of these CMCR
studies utilized cannabis as an add-on treatment for patients who were not receiving
adequate benefit from a wide range of standard pain-relieving medications. This
suggests that cannabis may provide a treatment option for those individuals who do not
respond or respond inadequately to currently available therapies. See appendix __ for
the CMCR’s full report.
The Institute of Medicine published in its Mar. 17, 1999 report titled "Marijuana and
Medicine: Assessing the Science Base, "In conclusion, the available evidence from
animal and human studies indicates that cannabinoids can have a substantial analgesic
effect."
Aggarwal, et al reported in the Journal of Opiod Management, “In general, the three
properties that make cannabinoids well-suited for analgesia are their established safety,
remarkably low toxicity, and documented efficacy for relieving a wide range of pain
states, from neuropathic pain to myofascial pain, to migrainous pain.”
Specifically addressing the question of efficacy in Jeff’s peripheral neuropathy, Wilsey,
et al. completed a placebo-controlled trial of 38 patients with neuropathic pain, which
demonstrated an analgesic effect superior to placebo.
Furthermore, cannabis has been shown to potentiate the effects of opiod pain
medications, which when used alone can lead to tolerance and opiod-resistant pain.
This is important considering the narrow therapeutic window, high potential for abuse,
and undesirable side effect profile of these medications. Cichewicz, et al. concluded,
“the administration of low doses THC in conjunction with low doses of morphine seems
to be an alternative regimen that reduces the need to escalate opioid dose while
increasing opioid potency.” As mentioned above, Jeff has been able to significantly
reduce his dependence on opioids when using cannabis as an adjunct.
In addition to analgesia, cannabis can also improve several common confounding factors
in chronic pain, including insomnia , decreased appetite, and depression .
Finally, cannabis is an extremely safe medicine, with no possible lethal overdose and a
side effect profile more desirable than most other treatments for peripheral neuropathy.
The IOM’s 1999 report states,
“Marijuana is not a completely benign substance. It is a powerful drug with a variety of
effects. However, except for the harm associated with smoking, the adverse effects of
marijuana use are within the range tolerated for other medications. Thus, the safety
issues associated with marijuana do not preclude some medical uses."
When evaluating safety of any herbal medicine, issues of contamination with fungus,
pesticides, herbicides, and chemical fertilizers must be considered. It is well known that
the underground market does not make these issues a high priority, and in the effort to
maximize profit, many potentially toxic horticultural agents are used. It is therefore
advisable that patients be able to cultivate their own medicine in the absence of any legal
means of obtaining medicinal-quality cannabis.
In my own practice I have recommended medical cannabis to over 200 patients. I am
constantly skeptical of any medicine that purports a panacea-like effect on such a wide
range of conditions. The more I delve into cannabinoid research, however, the more I
understand that cannabis works with the body’s inherent healing mechanism with a
synergy of homeostatic effects in almost every tissue in the body. The clinical scenario
of chronic neuropathic pain, following surgery or injury, which responds better to
cannabis and with fewer side effects than any other treatment, is well known to me. Jeff
Kennedy is certainly not an anomaly to my clinical experience; on the contrary, his
response is common and predictable. And now we have the biochemical research and
clinical studies to support these results.
Summary:
There is a large body of evidence that supports the safety and efficacy of using cannabis
to treat Jeff’s ailments. The dosage he describes is appropriate and effective. It is clear
from his medical history that he has tried a variety of conventional therapies over many
years and has not found any medicine with effects comparable to cannabis. Any other
conventional treatments left to be considered (i.e. implantable spinal stimulator) have a
much worse risk/benefit ration than cannabis, which is already known to be effective in
this particular case. If Jeff were living in any of the states that currently protect patients
who use medical cannabis, he would certainly qualify for a recommendation. I strongly
encourage the court to remove any criminal charges and support this patient’s quest for
relief from constant suffering.
Resnick D. Failed back surgery syndrome. In: Medcyclopaedia. www.amershamhealth.
com/medcyclopaedia.com (accessed 17 Sep 2003).
Talbot L. Failed back surgery syndrome. BMJ 2003;327:985-986.
McKim, W.A., 2000. Drugs and Behavior. An Introduction to Behavioral
Pharmacology, 4th ed. Prentice-Hall, Upper Saddle River, 400 p.
Janet E. Joy, Stanley J. Watson, Jr., John A. Benson, Jr. Marijuana and Medicine:
Assessing the Science Base. Division of Neuroscience and Behavioral Health, Institute
Of Medicine. National Academy Press, Washington, D.C. Published March 17, 1999.
Aggarwal SK, Carter GT, Sullivan MD, ZumBrunnen C, Morrill R, Mayer JD.
Medicinal use of cannabis in the United States: historical perspectives, current trends,
and future directions. J Opioid Manag. 2009 May-Jun;5(3):153-68.
Wilsey B, Marcotte T, Tsodikov A, Millman J, Bentley H, Gouaux B, Fishman S. April
2008 A Randomized, Placebo- Controlled, Crossover Trial of Cannabis Cigarettes in
Neuropathic Pain. Journal of Pain, 9 (6); 506-521.
Cichewicz, D. Synergistic interactions between cannabinoid and opioid analgesics. Life
Sciences 74 (2004) 1317–1324.
Ethan B. Russo, Geoffrey W. Guya, Philip J. Robsona. Cannabis, Pain, and Sleep:
Lessons from Therapeutic Clinical Trials of Sativex, a Cannabis-Based Medicine.
Chemistry & Biodiversity. Vol. 4, 2007:1729-1743.
Kurt Blaas. Treating depression with cannabinoids. Cannabinoids 2008;3(2):8-10
Traditional Osteopathy & Integrative Medicine
228 Water Street, Halowell, ME 04347
office (207) 509-0645 fax (207) 621-0985
www.drsulak.com office@drsulak.com NPI#1427212059
June 14, 2010
Medical Testimony for Jeffrey Kennedy, DOB 9/19/58
This medical testimony is based on a one-hour telephone interview on April 7th, 2010,
and the review of the following medical records:
• Dr. Allen Bezner
o Electromyogram 12/23/02
o Office notes 12/23/02, 1/28/03, 3/3/03, 4/7/03
• Palm Beach Pain Management
o Office Notes 12/4/09, 12/30/09, 1/27/10, 2/24/10
Present Complaints:
Jeff’s primary compliant is bilateral foot pain. The pain is burning and needle-like,
begins in the calves, and radiates to the distal feet. The sensation often intensifies for 5
seconds to 2 minutes unilaterally. The pain is worse at night and is exacerbated by
standing and walking. It is somewhat ameliorated by hot soaks and medication. There
is also a constant tingling sensation in both feet. On a scale of 1 to 10, with 10 the
worst pain, Jeff rates his average pain level at 7-8. The foot pain affects his ability to
stand and walk, and is present all day, every day. In addition to the foot pain (lumbar
radiculopathy and peripheral neuropathy), Jeff experiences low back pain (lumbago),
neck pain (cervicalgia), and osteoarthritis of multiple joints.
Past Medical History:
In the late 1980s Jeff was involved in a motor vehicle accident when he hit a deer with
his motorcycle and sustained a skull fracture. He right frontal bone was repaired with a
metal plate.
In 1999 Jeff fell backwards and injured his lumbar spine. In 2000 he was diagnosed
with L4/L5 disc herniation and underwent surgical fusion by Dr. Theofilos.
Unfortunately, the surgery was not helpful in correcting his low back pain and actually
exacerbated the radiculopathy into the legs. He now carries a diagnosis of lumbar failed
back surgery syndrome. Past medical history is also significant for hepatitis C, which he
contracted over 20 years ago during a period of his life when he was involved in
intravenous drug abuse. He has long since avoided any drug abuse, and has a history of
responsible use of opiate pain medications and adherence to the narcotic
agreement/guidelines of Palm Beach Pain Management.
Current Medications:
Restoril 15 mg qHS (for sleep)
Soma 700mg qHS (for muscle relaxation and sleep)
Duragesic patch 200mg q72 hr (opiate pain medication)
Oxycodone 30mg QID (opiate pain medication
Lovastatin 20mg qHS (cholesterol management)
Past medications:
Jeff has tried several approaches to help the peripheral neuropathy, including Neurontin,
Elavil, Trileptal, and Topamax. All these medications were either ineffective or had side
effects that were intolerable.
Medical Cannabis Usage:
Approximately 3 years ago Jeff was introduced to cannabis as a potential treatment for
neuropathic pain. He found that this medicine instantly decreased the burning and
throbbing in his feet, with an average reduction in pain from 7-8 down to 2-3 out of 10.
Furthermore, the cannabis helped decrease his need for opiate pain medication by 50%,
removed his need for Soma, and improved his sleep. Jeff began growing this herbal
medicine himself to avoid the dangers and high prices of acquiring it on the black
market. His average cannabis consumption, when he has access to this medicine, is one
ounce per month. He smokes 2-6 puffs BID-QID out of ceramic pipe. His dosage
depends on the potency of the herb.
Review of Systems:
In addition to the above-mentioned symptoms, Jeff also experiences headache
approximately twice weekly.
Social History:
Jeff smoke 1 pack of cigarettes daily, drinks plenty of water, 2-3 caffeinated beverages
daily, and denies the consumption of alcohol or soft drinks. For exercise he swims
regularly. He sleeps an average of 3-4 hours per night because his sleep is disturbed by
pain. When he takes both Restoril and cannabis he is able to sleep 8 hours.
Discussion:
Failed back surgery syndrome is a common diagnosis: approximately 5–10% of patients
who have back surgery return home without relief of their radicular pain. One
proposed mechanism of the worsening radiculopathy and neuropathy seen in these
patients involves nerve roots being encased in a web of scar tissue, causing pain, spasm
and nerve compression whenever movements of the spine and legs affect the paraspinal
tissues. In many ways failed back surgery syndrome resembles multiple sclerosis: the
conditions have the same range of symptoms of pain and numbness, weakness and
spasm in the limbs, and bladder and bowel difficulties. Talbot describes,
“Patients with failed back surgery syndrome live with the constant anxiety of relapse and
steady deterioration of a range of neurological symptoms, yet current medical
management focuses narrowly on relieving pain. This is another strand in the web in
which patients are caught: good pain relief brings the illusion of improved physical
ability. However, for many patients, after a brief honeymoon period pain, spasm and
weakness appear at a lower activity level, and the web tightens to immobilize the
ensnared nerve roots (and patients) even more.”
Medical Cannabis:
Originating from Central Asia, cannabis is one of the oldest psychotropic drugs known
to humanity. The beginnings of its use by humans are difficult to trace, because it was
cultivated and consumed long before the appearance of writing. According to
archeological discoveries, it has been known in China at least since the Neolithic period,
around 4000 BC .
Despite the prohibition of cannabis in the United States for over 70 years, many patients
have found access to this medicine via the underground market, and there is a large
body of anecdotal evidence supporting its efficacy in treating a wide range of medical
conditions, in both a palliative and curative manner.
Preclinical research on cannabinoid medicines has lagged behind other classes of drugs
because the lipid-soluble properties have provided laboratory technique challenges in
elucidating active ingredients and cannabinoid receptors. Finally, THC was discovered
in the 1960s and the first cannabinoid receptor was discovered in 1990. Since that
time, the published research on cannabinoid medicines has grown quickly, with over
12,000 papers published to date. For a concise overview of cannabinoid physiology
and biology, see Baker et al.’s “The therapeutic potential of cannabis.” (Appendix)
Marijuana prohibition has posed challenges to human clinical research on the
effectiveness of cannabis. In the last few years, however, a growing number of well-
designed, placebo-controlled trials have been published. Several of these studies
focuses on the efficacy of cannabis to treat chronic pain, neuropathic pain, and muscle
spasm.
Four studies funded by the University of California’s Center for Medical Cannabis
Research (CMCR) have demonstrated that cannabis has analgesic effects in pain
conditions secondary to injury (e.g. failed back surgery syndrome) or disease of the
nervous system. This result is particularly important because three of these CMCR
studies utilized cannabis as an add-on treatment for patients who were not receiving
adequate benefit from a wide range of standard pain-relieving medications. This
suggests that cannabis may provide a treatment option for those individuals who do not
respond or respond inadequately to currently available therapies. See appendix __ for
the CMCR’s full report.
The Institute of Medicine published in its Mar. 17, 1999 report titled "Marijuana and
Medicine: Assessing the Science Base, "In conclusion, the available evidence from
animal and human studies indicates that cannabinoids can have a substantial analgesic
effect."
Aggarwal, et al reported in the Journal of Opiod Management, “In general, the three
properties that make cannabinoids well-suited for analgesia are their established safety,
remarkably low toxicity, and documented efficacy for relieving a wide range of pain
states, from neuropathic pain to myofascial pain, to migrainous pain.”
Specifically addressing the question of efficacy in Jeff’s peripheral neuropathy, Wilsey,
et al. completed a placebo-controlled trial of 38 patients with neuropathic pain, which
demonstrated an analgesic effect superior to placebo.
Furthermore, cannabis has been shown to potentiate the effects of opiod pain
medications, which when used alone can lead to tolerance and opiod-resistant pain.
This is important considering the narrow therapeutic window, high potential for abuse,
and undesirable side effect profile of these medications. Cichewicz, et al. concluded,
“the administration of low doses THC in conjunction with low doses of morphine seems
to be an alternative regimen that reduces the need to escalate opioid dose while
increasing opioid potency.” As mentioned above, Jeff has been able to significantly
reduce his dependence on opioids when using cannabis as an adjunct.
In addition to analgesia, cannabis can also improve several common confounding factors
in chronic pain, including insomnia , decreased appetite, and depression .
Finally, cannabis is an extremely safe medicine, with no possible lethal overdose and a
side effect profile more desirable than most other treatments for peripheral neuropathy.
The IOM’s 1999 report states,
“Marijuana is not a completely benign substance. It is a powerful drug with a variety of
effects. However, except for the harm associated with smoking, the adverse effects of
marijuana use are within the range tolerated for other medications. Thus, the safety
issues associated with marijuana do not preclude some medical uses."
When evaluating safety of any herbal medicine, issues of contamination with fungus,
pesticides, herbicides, and chemical fertilizers must be considered. It is well known that
the underground market does not make these issues a high priority, and in the effort to
maximize profit, many potentially toxic horticultural agents are used. It is therefore
advisable that patients be able to cultivate their own medicine in the absence of any legal
means of obtaining medicinal-quality cannabis.
In my own practice I have recommended medical cannabis to over 200 patients. I am
constantly skeptical of any medicine that purports a panacea-like effect on such a wide
range of conditions. The more I delve into cannabinoid research, however, the more I
understand that cannabis works with the body’s inherent healing mechanism with a
synergy of homeostatic effects in almost every tissue in the body. The clinical scenario
of chronic neuropathic pain, following surgery or injury, which responds better to
cannabis and with fewer side effects than any other treatment, is well known to me. Jeff
Kennedy is certainly not an anomaly to my clinical experience; on the contrary, his
response is common and predictable. And now we have the biochemical research and
clinical studies to support these results.
Summary:
There is a large body of evidence that supports the safety and efficacy of using cannabis
to treat Jeff’s ailments. The dosage he describes is appropriate and effective. It is clear
from his medical history that he has tried a variety of conventional therapies over many
years and has not found any medicine with effects comparable to cannabis. Any other
conventional treatments left to be considered (i.e. implantable spinal stimulator) have a
much worse risk/benefit ration than cannabis, which is already known to be effective in
this particular case. If Jeff were living in any of the states that currently protect patients
who use medical cannabis, he would certainly qualify for a recommendation. I strongly
encourage the court to remove any criminal charges and support this patient’s quest for
relief from constant suffering.
Resnick D. Failed back surgery syndrome. In: Medcyclopaedia. www.amershamhealth.
com/medcyclopaedia.com (accessed 17 Sep 2003).
Talbot L. Failed back surgery syndrome. BMJ 2003;327:985-986.
McKim, W.A., 2000. Drugs and Behavior. An Introduction to Behavioral
Pharmacology, 4th ed. Prentice-Hall, Upper Saddle River, 400 p.
Janet E. Joy, Stanley J. Watson, Jr., John A. Benson, Jr. Marijuana and Medicine:
Assessing the Science Base. Division of Neuroscience and Behavioral Health, Institute
Of Medicine. National Academy Press, Washington, D.C. Published March 17, 1999.
Aggarwal SK, Carter GT, Sullivan MD, ZumBrunnen C, Morrill R, Mayer JD.
Medicinal use of cannabis in the United States: historical perspectives, current trends,
and future directions. J Opioid Manag. 2009 May-Jun;5(3):153-68.
Wilsey B, Marcotte T, Tsodikov A, Millman J, Bentley H, Gouaux B, Fishman S. April
2008 A Randomized, Placebo- Controlled, Crossover Trial of Cannabis Cigarettes in
Neuropathic Pain. Journal of Pain, 9 (6); 506-521.
Cichewicz, D. Synergistic interactions between cannabinoid and opioid analgesics. Life
Sciences 74 (2004) 1317–1324.
Ethan B. Russo, Geoffrey W. Guya, Philip J. Robsona. Cannabis, Pain, and Sleep:
Lessons from Therapeutic Clinical Trials of Sativex, a Cannabis-Based Medicine.
Chemistry & Biodiversity. Vol. 4, 2007:1729-1743.
Kurt Blaas. Treating depression with cannabinoids. Cannabinoids 2008;3(2):8-10
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