Cannabis and its Effects on the Cancer Patient Population
Cannabis and its Effects on the Cancer Patient Population
Cannabis has been studied over the past decades for its therapeutic benefits in treating a multitude of diseases and conditions, with cancer being one of them. According to Backes (2017, p. 200), “cannabinoids can stimulate appetite, encourage sleep, reduce anxiety and depression, and lift the spirits of patients undergoing cancer treatment, all of which can contribute significantly to quality of life”. Though more research is undoubtedly necessary, there have been promising studies thus far about how various cannabis strains and products can help alleviate chemotherapy-related adverse effects. This report will study the use of cannabis on cancer and its associating adverse effects. Additionally, it will look at the limitations of the current research and how changes to the research process can be implemented. Finally, it will display a sample treatment plan for a cancer patient interested in utilizing medical cannabis for symptom management and relief.
Evidence/ Literature Review
Cancer is one of the leading causes of death worldwide. According to the National Cancer Institute (2020), there were 18.1 million new cases and 9.5 million cancer-related deaths worldwide in 2018; and they estimate that almost forty percent of men and women will be diagnosed with cancer at some point in their life. Based on current research, cannabis has been shown to induce apoptosis (cell death) and inhibit tumor proliferation, vascularization, and metastasis (Turgeman & Bar-Sela, 2017). A growing number of individuals are using cannabis to help treat cancer-related pain and symptoms related to chemotherapy, including nausea and vomiting, loss of appetite, anxiety, and sleep disturbances. A survey full of 926 patients at a cancer research center in Seattle found that 66% of patients had used cannabis previously. Of the 24% (n = 222) of active users, about seventy five percent used cannabis for physical symptoms (pain, nausea, appetite) and about sixty three percent used it for neuropsychiatric symptoms (stress, coping with illness, depression, sleep). Legalization in Washington was an important factor for individuals in their decision-making to use cannabis (Pergam et al., 2017).
Sexton et al. (2021) suggest that cancer-related pain is one of the most common and undertreated symptoms in cancer patients. One study discovered that out of 11,590 patients using at least one medical cannabis product at a specific New York State medical cannabis dispensary, 17.2% (n = 1990) had cancer; and these patients were using cannabis to treat primarily treat neuropathy (n = 145, 7.3%) and chronic pain (n = 95, 4.8%). Additionally, results showed that cancer patients used a higher THC:CBD ratio compared to noncancer patients, which could be due to differences in pain perception or recommendations by providers. Cancer patients were also more likely to use a sublingual method of administration (n = 1098, 55.2%) because of this method’s longer-lasting effects compared to inhalation (Kim et al., 2019).
In addition to pain, chemotherapy-induced nausea and vomiting (CINV) is a major adverse effect that many cancer patients endure. Grimison et al. (2020) completed a randomized, double-blinded, placebo-controlled study looking at the use of an oral THC:CBD extract in treating refractory chemotherapy-induced nausea and vomiting. A total of 81 participants were randomized to begin with; and by the end, 72 participants completed both cycles of the trial and 78 participants did not withdraw their consent. Response with the THC:CBD extract was improved from 14% to 25% (P = 0.041). Though 31% of patients did experience moderate or severe adverse effects related to cannabis including sedation, dizziness, or disorientation, 83% of patients stated they preferred cannabis to the placebo. This research has prompted the start of similar clinical trials with a larger population study.
Currently, the U.S. Food and Drug Administration (FDA) approves two cannabis-based pharmacotherapies for the treatment of chemotherapy-associated adverse effects. Dronabinol and Nabilone are both forms of synthetic THC that are approved to treat chemotherapy-induced nausea and vomiting if first-line antiemetics fail to work. The FDA has not approved cannabis or cannabinoids for the treatment of cancer thus far (National Cancer Institute, 2020). Trials using THC-dominant products have shown effectiveness in reducing nausea, although they also carry their own unpleasant side effects.
According to Reuter and Martin (2016), anorexia can affect up to 90% of patients with struggling with advanced cancers. Cannabis has been suggested to stimulate appetite and improve the quality of life in patients with various types of cancer. One study in Israel used various combinations of THC and CBD in a capsule form to treat cancer-related cachexia and anorexia syndrome (CACS) in patients with advanced stages of cancer. The capsules contained either 10 mg (9.5 mg of THC and 0.5 mg of CBD) or 5 mg (4.75 mg of THC and 0.25 mg of CBD) of active cannabinoids. Though this was a rather small cohort, three of the six patients that completed the entire study demonstrated a greater than ten percent weight increase. Furthermore, an overall increase in appetite, sleep improvement, and pain reduction were all noted as positive responses by various participants (Bar-Sela et al., 2019).
Sativex (nabiximols) is a whole plant medical cannabis extract containing both THC and CBD as well as terpenoids, fatty acids, and flavonoids that is delivered in the form of an oral mucosal spray. It is currently approved in counties such as the UK, Germany, and Switzerland for multiple sclerosis (MS)-related spasticity and in Canada for pain associated with MS and cancer. Sativex is not currently FDA approved in the United States; but it is undergoing rigorous clinical trials with hopes that it will soon be approved (Pagano et al., 2022). A double-blind, randomized, placebo-controlled trial looked at the use of nabiximols in treating cancer patients and specifically pain management where opioids were proven to be unsuccessful. Patients randomly received nabiximols (n = 199) or a placebo (n = 198) and self-titrated their medications over a two-week period, followed by a three-week treatment period at the titrated dose. The findings showed that nabiximols was statistically superior to the placebo on two of three quality-of-life instruments at Week 3 and on all three at Week 5. This means that patients reported overall enhanced pain control when using nabiximols in addition to their opioids compared to the group that only received the placebo (Lichtman et al., 2018).
Though many current studies are primarily anecdotal considering cannabis remains illegal at the federal level, there is still encouraging evidence that cannabis can alleviate various symptoms related to cancer, chemotherapy, and opioid use. A study by the European Journal of Internal Medicine comprised of 2970 cancer patients looked at the effectiveness of medical cannabis in palliative treatment. The main types of cancer included breast, lung, pancreatic, and colorectal and the main concerns noted were sleep problems, fatigue, pain, nausea and vomiting, and anxiety and depression. After about six months, the remaining 1211 patients (60.6%) responded and 95.9% reported an improvement in their overall condition and quality of life (Bar-Lev Schleider et al., 2018). Though this study did not list specific cannabis strains, dosages, and routes of administration, it did show that overall, patients are experiencing positive benefits from using cannabis and more evidence-based research is imperative to verify these studies.
Many health care professionals feel inadequate in their personal knowledge on the topic of medical cannabis and as a result, patients are not recommended cannabis use by their providers. A study comprised of 103 various oncology health care practitioners utilized an anonymous survey to assess their own opinions and beliefs about cannabis use. Of the participants, 84% believed they lacked appropriate knowledge on the topic of medical cannabis. Barriers to making recommendations to patients included: monitoring the patient’s use of cannabis, prescribing accurate dosages or strains, and having overall insufficient research (McLennan et al., 2020). In a similar study, 400 medical oncologists were surveyed about their own knowledge on the topic of medical cannabis and how safe they felt prescribing or recommending it to patients. Results showed 80% of practitioners reported beginning discussions with their patients about medical cannabis and 46% reported recommending the actual use of medical cannabis in the past year. On the other hand, only 30% of oncologists felt they were knowledgeable enough to make recommendations and 56% of those who made recommendations claimed they lacked adequate knowledge to do so (Braun et al., 2018). It is crucial that practitioners receive proper training and education on medical cannabis in relation to their specialty so they can confidently and safely recommend it their patients.
Assessment
A thorough health history for patients planning to use medical cannabis is necessary so practitioners can make proper dosage and treatment recommendations. Pertinent patient information includes treatment history, comorbidities, results of any tests or exams, list of current medications, food and medication allergies, and any prior cannabis or substance use. During an initial visit, topics to be discussed include current health concerns, goals of cannabis therapy, hours of sleep each night, daily water and alcohol amounts consumed, daily exercise regimen, stress management techniques, life changes in the last year, cannabis experience and use, employment status, education level, and anything else that may seem relevant. Open-ended questions about the patient’s ideal outcomes and continual active listening can set the patient and practitioner both up for success. It is essential to convey a nonjudgmental approach as there continues to be a stigma surrounding medical cannabis use and patients may feel hesitant to share their full story.
Plan/Implementation
Medical Recommendations and Safety & Legal Concerns
The Maryland Medical Cannabis Commission (MMCC) is Maryland’s Medical Cannabis Program that allows for safe access through necessary testing and proper regulations. Qualifying patient criteria includes the following:
Lives in Maryland or is in the State to receive in-patient care at a Joint Commission Accredited Medical Facility.
Registers with the MMCC (for patients under age 18, a parent or legal guardian must register with the MMCC as a caregiver before registering the patient).
Has been provided a written certification for a qualifying condition by a certifying provider who is registered with the MMCC. Qualifying conditions include but are not limited to cachexia, anorexia, PTSD, chronic or severe pain, severe nausea or any other chronic severe medical condition for which other treatments have been ineffective as well any medical condition requiring hospice or palliative care (Maryland Medical Cannabis Commission, 2021).
According to the Maryland Medical Cannabis Commission (2021), for every 30 days, patients are allowed to obtain a total of 120 grams of cannabis and up to 36 grams of THC. A certified provider may increase or decrease the amount based on their professional judgment. Possession and use of medical cannabis directly violates the federal Controlled Substances Act; and although the Department of Justice (DOJ) can enforce federal cannabis laws even in states with a medical cannabis program, current federal legislation prohibits the DOJ from interfering with the implementation of State medical cannabis programs.
Implementation: Safe Access and Education
Cannabis can play an integral role in the palliative care process for cancer patients, as outcomes have shown to improve when palliative care begins around diagnosis (Clark et al., 2021). While cannabis can treat certain cancer-related symptoms, research shows it can also be used as an additional treatment to current traditional and medical therapy used in fighting cancer (Konieczny, 2018). CBD is still considered a Schedule I drug by the FDA; and therefore, many products fail to undergo proper, regulated testing; yet, it is sold legally throughout the United States and can be bought without a prescription. Contrastingly, products containing high levels of THC are only legally sold by medical and recreational dispensaries in certain states. It is important to educate the patient on important details to look for, such as product labels, extraction methods used in product development, and test results of the product, including the Certificate of Analysis (COA).
An ideal beginning point is having the patient “start low and go slow”, meaning: start with a low dosage and titrate slowly as indicated. Cannabis needs will depend on various factors, including previous cannabis use (if any) and the degree to which their endocannabinoid system is regulated (MacCallum & Russo, 2018). For analgesic relief, products containing low-THC and high-CBD content is recommended. This may be due to the fact that at low doses, THC has analgesic, anxiolytic, and anti-inflammatory effects compared to opposite effects on anxiety and analgesia when administered in high doses Additionally, high doses of CBD have been shown to have anticonvulsant, sedative, anxiolytic, and anti-inflammatory properties (Sexton et al., 2021). Konieczny (2018) highlights the fact that THC and CBD working together can produce synergistic effects that can effectively help treat cancer. Administration method recommendations are very patient specific and are based on factors such as cancer type, previous cannabis use, primary health concern and patient preference. Inhalation, one of the most common and fast-asking methods, is ideal for immediate pain, anxiety and nausea relief; transdermal patches have a long-lasting effect and can beneficial for a patient experiencing swallowing difficulties; tinctures may be advantageous for a first-time user as they are a more discreet method and can offer more precise dosing (Backes, 2017). As with all administration methods, each carries its own strengths and weaknesses; it ultimately comes down to proper education on each type and the patient’s preference.
Education is extremely important in patient care and treatment planning, especially with individuals new to using medical cannabis. As shown in the above evidence, cannabis exhibits various healing and therapeutic benefits; yet, it still accompanies various adverse effects, including dizziness, dry mouth, disorientation, euphoria, anxiety, and hallucinations (Turgeman & Bar-Sela, 2017). The state of Maryland offers training for interested health care professionals through The Medical Cannabis Institute to increase their knowledge on medical cannabis and how it may pertain to their specific patient population. Along with an open in-person discussion between the provider and patient, various websites, books, and educational resources can be given to the patient to enhance their knowledge and formulate questions on their own. Additionally, Maryland dispensaries are required to have a clinical director available in-person or electronically to answer any questions regarding medical cannabis use and treatment for the patient’s condition, such as drug interactions and adverse effects to consider (MMCC, 2021).
Holistic Modalities
The endocannabinoid system is a highly complex and individualized physiologic system responsible for reaching and maintaining homeostasis in our bodies through various mechanisms. It also works to regulate integral bodily functions, including appetite, sleep, memory, mood, digestion, and energy balance (Sexton et al., 2021). In addition to a patient-specific cannabis regimen, holistic modalities can benefit patients in upregulating their endocannabinoid system. Lifestyle risk factors can largely contribute to cancer progression and patient outcomes. Stress can produce negative physiologic effects on the body and may even promote cancer growth and progression. Exercise and mind-body practices, such as yoga and meditation, can reduce stress levels and improve a person’s overall quality of life. Other holistic modalities that may be of benefit for this population include acupuncture, incorporating more unprocessed and plant-based foods into one’s diet, and abstaining from tobacco and alcohol use (Danhauer et al., 2017).
Professional and Ethical Considerations
Nursing is grounded in ethical and moral principles that contribute to the safety and care of all patients. Some primary principles include autonomy, beneficence, justice, and non-maleficence (Russell, 2019). The American Cannabis Nurses Association (ACNA) devised the Scope and Standards of Practice for Cannabis Nurses that contains 17 “standards” for nurses to follow and adhere to in the setting of treating medical cannabis patients (Clark et al., 2019). The National Council of State Boards of Nursing (NCSBN) also created its own set of nursing guidelines for cannabis nurses to be able to provide trustworthy care and knowledgeable information to patients using medical cannabis. It is the cannabis nurse’s responsibility to follow these standards and guidelines while serving as an educator, advocate, coach, and support system for patients as they navigate the evolving subject of medical cannabis.
Evaluation
Having the patient keep a journal is a useful tool to guide them along this exploratory process. They can record items such as administration methods, dosages and titrations, and effects of each, in terms of symptom relief and side effects noted. Then after a certain amount of time, the journal can be reviewed with the practitioner and patient and the treatment plan can be adjusted as necessary (MacCallum & Russo, 2018). It is important to keep an open dialogue between the patient and practitioner and to always remind the patient they are not alone in this journey.
Conclusion
Current barriers to effective medical cannabis treatment plans for cancer patients include lack of evidence-based clinical research and insufficient knowledge felt by practitioners, leading to limited conversations between practitioners and patients about cannabis use. Nonetheless, an increasing amount of cancer patients are attempting to use cannabis to alleviate symptoms they experience with cancer and associating treatments, such as chemotherapy, radiation and opioid use. Standardized, randomized clinical trials are a necessary component to exploring marijuana’s potential medicinal effects in treating cancer. Additionally, educational programs for health care practitioners, such as nurses and oncologists, is warranted to promote safety and improve patient outcomes (Braun et al., 2018). As health care professionals, we have a professional, moral, and ethical obligation to provide safe, nonjudgmental, and compassionate care to all.
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