Feature

How Does the Hospice and Palliative Care Field Relate to Cannabis for Medical Use?

By Larry Beresford

Dispensing cannabis for medical use is legal in 33 states and the District of Columbia, as well as many US territories and recreational marijuana use is allowed in 11 states plus the District of Columbia. Even where medical use is not yet legal, many seriously ill patients will have questions about cannabis or an interest in whether it might help with their symptoms. And they could be looking to their hospice or palliative care provider for guidance.

It has been said many times that the purported benefits of cannabis extolled by its advocates remain largely unproven, and that more scientific study is needed to be able to offer evidence-based answers to patients' questions. In 2020, that response—even if accurate—seems increasingly unsatisfying to both patients and clinicians, unsupportive of the helping alliance, and out of touch with what's happening in the real world. In many states where medical use of cannabis is legal, a clinician needs to certify that the patient has a qualifying medical condition to obtain such a product from a medical dispensary—but that's not the same as endorsing its efficacy.

How, then, can clinicians engage in helpful or productive conversations with their patients and families—some of whom will choose to use cannabis regardless of what the provider may say? How can these questions and choices be harmonized with the symptom-relieving treatments palliative care offers to its patients? Patients want information about products, indications, doses, efficacy, and safety. But because of the distance between the worlds of cannabis for medical use and organized medicine, answers may be in short supply.

"We know our patients are using it," said Kimberly Angelia Curseen, MD FAAHPM, director of outpatient supportive care at the Emory Palliative Care Center in Atlanta, GA. "The real issue for providers is when the patient comes to you and asks, 'Should I try this as a complement to my medical therapy?' They are asking for your advice, for your recommendations, and for the validation of medical use of cannabis as a treatment choice."

"There is a growing body of research literature trying to bring to bear scientific evidence regarding the therapeutic benefits and risks of cannabis. It's important for us to read it," Curseen said. "Does that mean we endorse cannabis? Especially given that it is still illegal at the federal level?"

Regardless of the evidence, providers should be educated enough to answer some basic questions from their patients and talk about how cannabis relates to palliative medical therapies. And patients need to feel free to talk about it with their doctors. "If you don't create a welcoming environment, then you just won't know what they're taking," Curseen added.

Cannabis and Cannabinoids

More than 100 synthetic cannabinoids have been developed in the laboratory. Two cannabinoids, tetrahydrocannabinol (THC) and cannabidiol (CBD), are the main focus when we talk about cannabis for medical use. THC produces the high that people feel when they consume it, whereas CBD does not have the same euphoric properties.

US Food and Drug Administration (FDA)–approved medications include the THC-based products nabilone and dronabinol and Epidiolex (CBD), which is used for the treatment of two forms of severe childhood epilepsy. Sativex (a combination of THC and CBD) is a prescription cannabinoid that has been approved in 22 countries but not the United States.

Perhaps the best evidence for the efficacy of cannabis for medical use includes its use as a treatment for neuropathic pain¹ and as an oral agent for chemotherapy-induced nausea and vomiting,² symptoms that are known to be hard to control. Other conditions for which medical use of cannabis has been extolled or proposed for further study include restless leg syndrome, multiple sclerosis, epilepsy, muscle spasms and movement disorders, post-traumatic stress disorder, pediatric oncology, cancer pain management, anxiety, insomnia, depression, anorexia, and cachexia. But there is a paucity of research on efficacy.

Nor have long-term consequences of regular cannabis consumption been studied systematically. A variety of questions have been raised about drug/drug interactions, the variable quality of cannabis products offered on the market, and quality control at dispensaries. Known side effects include confusion, drowsiness, somnolence, and dry mouth. THC can interfere with some anticoagulation drugs or cause an elevated heart rate. Cognitive impairment and falls in elderly patients also are an issue. "What if THC leads to disconnectedness and somnolence when the patient's goal is to be as fully present as possible at this time of life?" Curseen said.

How Is It Used by Patients?

Kathleen Broglio, DNP APRN, who works in the palliative medicine clinic at Dartmouth-Hitchcock Medical Center, Lebanon, NH, said she receives multiple requests from patients for cannabis for medical use. She started working at Dartmouth in 2016, right after New Hampshire legalized such use. But because cannabis is a Schedule I drug and thus illegal federally, clinicians can only certify that the patient has a qualifying medical condition. "Many clinicians in my own institution won't certify and feel uncomfortable due to the lack of research. I am more comfortable, but only in conjunction with patient education. I also look at my role as trying to educate some of my colleagues both within and outside the institution," she said.

"Most of the patients in our clinic have cancer with limited life expectancy, and one-third of those we asked said they use cannabis at home—typically for more than one symptom,"³ she said. These may include anxiety and sleep disorders—neither of which is a certifiable condition in New Hampshire or Vermont.

Broglio doesn't offer cannabis for medical use as a first-line palliative treatment. "In most cases, I don't offer it at all. If they come to me first, I ask if there is an FDA-approved medication we can try first. I also counsel about cost, which is not inconsiderable. But there's never been a patient I have refused to certify, although my answer might be different for a pregnant woman or a juvenile patient who is not at the end of life," she explained. "The more I read, the more ambivalent I feel about long-term use of cannabis. What will be the impact of exogenous cannabinoids on the endogenous cannabinoid system over the long term? Unfortunately, because of public perception of benefit and intensive lobbying efforts for legalization, high-quality research may not be conducted prior to legalization."

Chad Kollas, MD FACP FAAHPM, medical director of palliative and supportive care at UF Health Cancer Center–Orlando Health in Orlando, FL, said he gets asked about cannabis for medical use by 80% of his patients. It was decriminalized in Florida by a ballot measure to amend the state's constitution in 2016.

"No insurance company pays. The pathway to opening dispensaries in Florida is heavily regulated and very difficult. When patients ask me about it, I say we don't have any more randomized controlled trials than we did 10 years ago, and we still don't know much about long-term safety. That doesn't mean we know that it is dangerous. So, I say, 'This is up to you. I can't predict your response,'" he said.

The increased legality and availability of cannabis for medical use in many states is unfolding within multiple contexts, noted Drew Rosielle, MD FAAHPM, system director of palliative care at M Health Fairview in Minneapolis, MN, and editor of Fast Facts and Concepts in palliative medicine. For example, hemp production was descheduled and decriminalized through the 2018 Farm Act, opening the door for selling hemp oil, which naturally contains a significant amount of CBD.

The August 29, 2013, "Cole Memorandum" issued by US Deputy Attorney General James M. Cole states that the Justice Department would not enforce federal cannabis prohibition in states that "legalized marijuana in some form and ... implemented strong and effective regulatory and enforcement systems to control the cultivation, distribution, sale, and possession of marijuana," except where a lack of federal enforcement would undermine federal priorities.

"We're also in a moment where national marketers are extolling it as a cure-all. So, it's a confusing conversation with many patients," Rosielle said. "Another problem is generalizability of experience. How do we apply the research that was done in the late 1980s and 1990s for anorexia and cachexia to patients today who are getting a very different (and much stronger) product than what was smoked in the 1980s and 1990s? At the same time, the opioid crisis has driven a desire to be cautious about drugs ... (although) cannabis is safer than opioids because you can't fatally overdose on it," Rosielle said.

"In all of these things, our patients are getting information from different places, bringing to us their hope, curiosity, and desire to feel better. But they need to be aware that it's a real drug with real side effects," he added. "The broad perspective I take is that my patients are interested in cannabis and are using it. If we don't know about it and aren't willing to give them information, then who will? Of course, we need more research, but we have a reasonable amount of information already."

Where Do We Go Next?

As this article was being written, the 2020 Annual Assembly, scheduled for March 18–21 in San Diego, CA, was cancelled because of COVID-19-related safety concerns. The planned schedule included a preconference session, "Cannabis: A New Addition to the Palliative Care Toolkit," to be presented by Rosielle, Curseen, and Broglio; Ali Zarrabi, MD, of the Emory University School of Medicine; and Diana Martins-Welch, MD, a hospice and palliative medicine physician at Northwell Health in New York state. And this year's Town Hall meeting at the Assembly, sponsored jointly with NHPCO and HPNA, would also have addressed cannabis for medical use.

Last year, there were 400 Assembly attendees at a 1-hour session on cannabis for medical use. The aim for this year's conference was to try to present the best current evidence to give members some guideposts, Curseen explained. "We wanted to start a discussion, learn from each other, and have an honest interaction with our members about the challenges."

Ryan Costantino, PharmD, an Army clinical pharmacist at Fort Sam Houston, TX, conducted a survey of hospice professionals' comfort levels, practices, and attitudes regarding cannabis for medical use. The 37-item, anonymous online survey received 310 responses, and the results indicated overwhelming support for hospice patients to have access to cannabis for medical use, with a distinct absence of fears about its use.⁴

But barriers to achieving this goal were also cited, including variation in state-level responses, disconnects between state and federal policies, and varied documentation and educational practices by hospices. Barriers to procurement for patients, high out-of-pocket costs, uncertainty about specific products, and concerns about efficacy also were cited as issues. Hospices do not cover the costs of cannabis for medical use, and it is rare for hospice physicians to recommend or certify their patients for it; some respondents also expressed discomfort about their institution not paying for the treatment.

Only 19% of respondents said their organizations had developed cannabis policies. Having a policy spelling out how the hospice will address these issues is important, said Mary Lynn McPherson, PharmD MA MDE BCPS CPE, executive director of advanced postgraduate education in palliative care in the department of pharmacy at the University of Maryland, Baltimore. What is the agency's position on what is or is not allowed? "If you have an inpatient unit, even if cannabis is legal in your state, it's probably not a good idea to have smoking or vaping going on there," she said.

Hospice staff may not think to routinely ask patients about cannabis use as part of a medical history, and if they do, they don't know where it should go in the electronic health record. "If cannabis is effective, does it belong on the medication list? Remember that Medicare requires a qualified professional at the hospice to evaluate the patient's medical regimen," McPherson said.

Other common-sense responses include making contact with medical professionals at the nearest dispensaries.

"We can ask our patients what is prompting their desire to use it. What are they experiencing that is not being addressed by conventional medications?" she said. When it comes to cannabis for medical use, clinicians can advise patients to start low and go slow while monitoring for any adverse effects.

Best of Intentions

Georgia's law regarding medical use of cannabis, passed with best of intentions for patients, was not thought through as clearly as it needed to be, Curseen said. "It's not enough to just say: cannabis is okay. We need to be more proactive on behalf of our patients. I had a patient who tried it and then told me it's the best thing ever for his cancer pain. In fact, he no longer needed to take opioids.

"I had no scientific reasons that could explain this effect. I just had to accept that he felt great and be humble about the fact that I don't have a reason why. My job is to try to make sure he doesn't have adverse effects and to prepare him for the time when this won't be enough anymore."

Use of cannabis for medical purposes calls for patient-centered care to a high degree, Curseen said. "We're not talking about how you got to this point but dealing with what's bothering you today. Our patients live with uncertainty. We live with uncertainty. This is one of those times."

Curseen added that she would like to see the medical research community and legislatures consider the implications of cannabis for medical use more carefully, "then let's do the research that we have been saying is missing and pass laws to make it safer for our patients. I hope we don't do what we did with opioids, which turned into a national crisis. We can learn from our past mistakes."

References

1. Lee G, Grovey B, Furnish T, Wallace M. Medical cannabis for neuropathic pain. Curr Pain Headache Rep. 2018;22(1):8.
2. Badowski MD. A review of oral cannabinoids and medical marijuana for the treatment of chemotherapy-induced nausea and vomiting: a focus on pharmacokinetic variability and pharmacodynamics. Cancer Chemother Pharmacol. 2017;80(3):441–449.
3. Wilson MM, Masterson E, Broglio K. Cannabis use among patients in a rural academic palliative care clinic. J Palliat Med. 2019;(22)10:1224–1226.
4. Costantino RC, Felten N, Todd M, Maxwell T, McPherson L. A survey of hospice professionals regarding medical cannabis practices. J Palliat Med. 2019;22(10):1208–1212.

Larry Beresford is a medical journalist in Oakland, CA, with a strong interest in hospice and palliative care.

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