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Palliative care aims to improve quality of life through optimal symptom control and pain management. Cannabis-based medicinal products (CBMPs) have a proven role in the treatment of chemotherapy-induced nausea and vomiting. However, there is a paucity of high-quality evidence with regards to the optimal therapeutic regimen, safety, and effectiveness of CBMPs in palliative care, as existing clinical trials are limited by methodological heterogeneity. The aim of this study is to summarise the outcomes of the initial subgroup of patients from the UK Medical Cannabis Registry who were prescribed CBMPs for a primary indication of palliative care, cancer pain and chemotherapy-induced nausea and vomiting, including effects on health-related quality of life and clinical safety. A case series from the UK Medical Cannabis Registry of patients, who were receiving CBMPs for the indication of palliative care was undertaken. The primary outcome consisted of changes in patient-reported outcome measures including EQ-5D-5L, General Anxiety Disorder-7 (GAD-7), Single-Item Sleep Quality Scale (SQS), Pain Visual Analog Scale (VAS) and the Australia-Modified Karnofsky Performance Scale at 1 and 3 months compared to baseline. Secondary outcomes included the incidence and characteristics of adverse events. Statistical significance was defined by p-value< 0.050. Sixteen patients were included in the analysis, with a mean age of 63.25 years. Patients were predominantly prescribed CBMPs for cancer-related palliative care (n = 15, 94%). The median initial CBD and THC daily doses were 32.0 mg (Range: 20.0–384.0 mg) and 1.3 mg (Range: 1.0–16.0 mg) respectively. Improvements in patient reported health outcomes were observed according to SQS, EQ-5D-5L mobility, pain and discomfort, and anxiety and depression subdomains, EQ-5D-5L index, EQ-VAS and Pain VAS validated scales at both 1-month and 3-months, however, the changes were not statistically significant. Three adverse events (18.75%) were reported, all of which were either mild or moderate in severity. This small study provides an exploratory analysis of the role of CBMPs in palliative care in the first cohort of patients since CBMPs legalisation in the UK. CBMPs were tolerated with few adverse events, all of which were mild or moderate and resolved spontaneously. Further long-term safety and efficacy studies involving larger cohorts are needed to establish CBMPs role in palliative care, including comparisons with standard treatments. End-of-life care is one of the less frequently discussed uses of medical cannabis. Palliative care, however, is perhaps the area of medicine that would most benefit from its clinical use. End-of-Life Care: Dying With Dignity and Comfort — The Role of Medical Cannabis The principal goal of palliative care is to reduce suffering experienced by patients who are at or near end of

UK Medical Cannabis Registry palliative care patients cohort: initial experience and outcomes

Palliative care aims to improve quality of life through optimal symptom control and pain management. Cannabis-based medicinal products (CBMPs) have a proven role in the treatment of chemotherapy-induced nausea and vomiting. However, there is a paucity of high-quality evidence with regards to the optimal therapeutic regimen, safety, and effectiveness of CBMPs in palliative care, as existing clinical trials are limited by methodological heterogeneity. The aim of this study is to summarise the outcomes of the initial subgroup of patients from the UK Medical Cannabis Registry who were prescribed CBMPs for a primary indication of palliative care, cancer pain and chemotherapy-induced nausea and vomiting, including effects on health-related quality of life and clinical safety.

Methods

A case series from the UK Medical Cannabis Registry of patients, who were receiving CBMPs for the indication of palliative care was undertaken. The primary outcome consisted of changes in patient-reported outcome measures including EQ-5D-5L, General Anxiety Disorder-7 (GAD-7), Single-Item Sleep Quality Scale (SQS), Pain Visual Analog Scale (VAS) and the Australia-Modified Karnofsky Performance Scale at 1 and 3 months compared to baseline. Secondary outcomes included the incidence and characteristics of adverse events. Statistical significance was defined by p-value< 0.050.

Results

Sixteen patients were included in the analysis, with a mean age of 63.25 years. Patients were predominantly prescribed CBMPs for cancer-related palliative care (n = 15, 94%). The median initial CBD and THC daily doses were 32.0 mg (Range: 20.0–384.0 mg) and 1.3 mg (Range: 1.0–16.0 mg) respectively. Improvements in patient reported health outcomes were observed according to SQS, EQ-5D-5L mobility, pain and discomfort, and anxiety and depression subdomains, EQ-5D-5L index, EQ-VAS and Pain VAS validated scales at both 1-month and 3-months, however, the changes were not statistically significant. Three adverse events (18.75%) were reported, all of which were either mild or moderate in severity.

Conclusion

This small study provides an exploratory analysis of the role of CBMPs in palliative care in the first cohort of patients since CBMPs legalisation in the UK. CBMPs were tolerated with few adverse events, all of which were mild or moderate and resolved spontaneously. Further long-term safety and efficacy studies involving larger cohorts are needed to establish CBMPs role in palliative care, including comparisons with standard treatments.

Introduction

Achieving optimal pain and symptom control is a crucial component of palliative and end-of-life care. There is a pertinent need for the provision of effective treatment with up to 40 million people requiring palliative care globally each year (World Health Organization, 2020). Furthermore, evidence suggests that the pain incurred by life-limiting illnesses, particularly cancer, remains largely under-treated (Breivik et al., 2009).

A growing body of literature suggests that cannabinoids, terpenes, and flavonoids exert widespread effects on neurotransmission, neuroendocrine signalling, and inflammatory processes (Huang et al., 2016). This potentially makes cannabis-based medicinal products (CBMPs) an emerging multi-faceted therapeutic option in managing primary chronic pain, cancer pain and neuropathic pain (Romero-Sandoval et al., 2018). CBMPs, generally refer to pharmaceuticals and non-approved compounds which interact with the endocannabinoid system. However, they can also refer to cannabinoid-based medicines, endocannabinoid system modulators or cannabinoid receptor modulators, in light of lack of consensus of nomenclature. Possible benefits have also been shown for some neurological and psychiatric conditions, such as anxiety-predominant disorders. Combined, these effects make the use of CBMPs as part of end-of-life care for patients a promising yet relatively unexplored avenue.

There is a paucity of evidence to guide best prescribing practices and optimal therapeutic regimes. Whilst randomised control trials (RCTs) constitute the highest quality evidence, current research remains limited in providing CBMP patient data. Formalised patient registries can be the source of high-quality, naturalistic observational data to answer these questions until RCTs are conducted. We therefore describe a preliminary exploratory analysis of outcomes of patients from the UK Medical Cannabis Registry who were treated with CBMPs for diagnoses related to palliative care. We aimed to investigate therapeutic formulations, adverse events incidence and character, and patient-reported outcome measures pertaining to the quality of life.

Methods

A case series of the initial participants of the UK Medical Cannabis Registry treated with CBMPs for indications of palliative care, cancer pain and chemotherapy-induced nausea and vomiting was undertaken. Palliative care was defined as treatments for physical and psychological symptoms caused by life-threatening or life-limiting conditions. Participants who had recorded PROMs at baseline with at least 1 follow-up date (1 and/or 3 months) were included in the study (n = 16).

The UK Medical Cannabis Registry is the first registry in the UK that collates prospective longitudinal clinical data from patients treated with CBMPs. It was set up in 2019, and captures patients treated within the United Kingdom and outside of the National Health Service (NHS). The UK Medical Cannabis Registry is privately owned and managed by Sapphire Medical Clinics. Clinicopathological information, comorbidities, drug and alcohol history and medication details are inputted into the registry prospectively by clinical staff. Data on cannabis use status was also collected, and for those who had previously or were presently taking non-prescription cannabis, a novel metric of “gram years” was calculated as previously described by our group (Erridge et al., 2021). Pseudonymised clinical data on patient-reported outcome measures (PROMs) and adverse events were collected.

All participants completed five validated quality of life PROMs, including the EQ-5D-5L (Herdman et al., 2011), a health status measure assessing quality of life amongst 5 domains (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) with 5 levels of severity (no problems, slight problems, moderate problems, severe problems, and extreme problems), General Anxiety Disorder-7 (GAD-7) (Löwe et al., 2008), Single-Item Sleep Quality Scale (SQS) (Snyder et al., 2018), the Australia-Modified Karnofsky Performance Scale (AKPS) (Abernethy et al., 2005) and the Pain Visual Analog Scale (VAS), a unidimensional measure of pain intensity anchored by “0 – no pain at all” and “10 – pain as bad as it could be” (Hawker et al., 2011). Adverse events were recorded according to the Common Terminology Criteria for Adverse Events (CTCAE v4.0).

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PROMs data were compared from baseline to 1- and 3-month follow-ups. Paired matched Wilcoxon rank sum tests were utilised for non-parametric data sets and paired t-test were used for parametric data sets, as determined by Shapiro-Wilks normality tests. Statistical significance was defined as p-value 0.050. All statistical analyses were conducted using Statistical Package for Social Sciences (SPSS) version 27.0.

Results

Sixteen patients were included in the analysis. The mean age of participants was 63.25 ± 12.27 years, with equal sex distribution. Half of the participants (n = 8, 50%) had never used cannabis previously, 4 (25%) were current cannabis users, and 4 (25%) were ex-users. Amongst the current users, gram-years ranged from 1 to 10, with the mean of 2.4; amongst ex-users gram-years ranged from 0.1 to 1, with an average of 0.35. Amongst current users, the average daily THC consumption (estimated based on 18–20% THC content in cannabis) was 20–400 mg, with an average of 120 mg per day. 6 (37.5%) participants died during the study period.

The most common primary diagnosis was palliative care (n = 12, 75%), followed by cancer pain (n = 3, 18.75%) and chemotherapy-induced nausea and vomiting (n = 1, 6.25%).

Most participants (n = 14, 87.5%) were prescribed two different CBMPs, all of which were oil preparations. The median initial CBD dose was 32.0 mg (Range: 20.0–384.0 mg). The median initial THC dose was 1.3 mg (Range: 1.0–16.0 mg). The most commonly used preparations were 50 mg/ml CBD oil (Adven 50, Curaleaf International) and 20 mg/ml THC oil (Adven 20, Curaleaf International).

In total, there were three adverse events (n = 3, 8.75%). Adverse events experienced by participants included lethargy (n = 1, 6.25%), ataxia (n = 1, 6.25%) and dysgeusia (n = 1, 6.25%). Of these, 2 (12.5%) were reported as mild and 1 (6.25%) was reported as moderate. When analysed based on the cannabis use status, ex-users, current users and those who never used cannabis had equal adverse event rates, with one event in each subgroup.

Pain VAS was initially reported as ‘severe’ (6.5 ± 2.07) however reduced to ‘mild to moderate’ (4.24 ± 2.91) at 1 month, and to ‘mild’ (1.00 ± 1.41) at 3 months. Mean SQS scores improved from 4.89 (± 2.32) at baseline to 6.89 (± 2.03) at 1 month, and 5.25 (± 3.02) at baseline to 7.75 (± 1.71) at 3 months. Mean SQS scores improved by 40.9% from baseline to 1 month, and 46.7% from baseline to 3 months. Overall, there were no significant improvements in mean SQS, median EQ-5D-5L Mobility, EQ-5D-5L Pain and Discomfort, EQ-5D-5L Anxiety and Depression, EQ-5D-5L Index, EQ-VAS and Pain VAS at 1-month and 3-month, when compared to the baseline (p > 0.05).

Discussion

CBMPs were well tolerated with few adverse events, all of which were mild to moderate in severity and resolved spontaneously. No significant improvements were found in any of the outcome measures due to the small sample size of the study (n = 16). A post-hoc power calculation using data from this case series determined a sample size of 56 would be required to determine a significant difference at 3 months in reported EQ-5D-5L index values. An updated analysis shall be performed when this is available.

Conclusion

This preliminary exploratory study provides an initial analysis of the role of CBMPs in palliative care in the first reported cohort of patients since the legalisation of CBMPs in the United Kingdom. CBMP treatment was well-tolerated with few adverse events, which were all mild to moderate in severity and resolved spontaneously. This data provides an insight into the safety and outcomes of CBMP treatment amongst palliative care patients and may help guide future clinical studies and prescribing practice. Further long-term safety and efficacy studies involving larger cohorts are needed to evaluate long-term prescribing outcomes, with comparisons with placebo and standard treatments for palliative symptom control.

Availability of data and materials

Data that support the findings of this study are available from the UK Medical Cannabis Registry. Restrictions apply to the availability of these data. Data specifications and applications are available from the corresponding author.

Abbreviations

Cannabis-based medicinal products

General Anxiety Disorder-7

Visual Analog Scale

Australia-Modified Karnofsky Performance Scale

Patient-Reported Outcome Measures

Common Terminology Criteria for Adverse Events

Statistical Package for Social Sciences

References

Abernethy A, Shelby-James T, Fazekas B, Woods D, Currow D. The Australia-modified Karnofsky performance status (AKPS) scale: a revised scale for contemporary palliative care clinical practice. BMC Palliative Care. 2005;4(1):7.

Breivik H, Cherny N, Collett B, de Conno F, Filbet M, Foubert AJ, et al. Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes. Ann Oncol. 2009;20(8):1420–33. https://doi.org/10.1093/annonc/mdp001.

Erridge S, Salazar O, Kawka M, et al. An initial analysis of the UK medical cannabis registry: outcomes analysis of first 129 patients. Neuropsychopharmacol Rep. 2021;41:1–9.

Hawker G, Mian S, Kendzerska T, French M. Measures of adult pain: visual analog scale for pain (VAS pain), numeric rating scale for pain (NRS pain), McGill pain questionnaire (MPQ), short-form McGill pain questionnaire (SF-MPQ), chronic pain grade scale (CPGS), short Form-36 bodily pain scale (SF-36 BPS), and measure of intermittent and constant osteoarthritis pain (ICOAP). Arthritis Care Res. 2011;63:S240–52.

Herdman M, Gudex C, Lloyd A, et al. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res. 2011;20(10):1727–36.

Huang WJ, Chen WW, Zhang X. Endocannabinoid system: role in depression, reward and pain control (review). Mol Med Rep. 2016;14:2899–903 Spandidos Publications.

Löwe B, Decker O, Müller S, et al. Validation and standardization of the generalized anxiety disorder screener (GAD-7) in the general population. Med Care. 2008;46(3):266–74.

Romero-Sandoval EA, Fincham JE, Kolano AL, Sharpe BN, Alvarado-Vázquez PA. Cannabis for chronic pain: challenges and considerations. Pharmacotherapy. 2018;38(6):651–62.

Snyder E, Cai B, DeMuro C, Morrison MF, Ball W. A new single-item sleep quality scale: results of psychometric evaluation in patients with chronic primary insomnia and depression. J Clin Sleep Med. 2018;14(11):1849–57.

Cannabis in Palliative Care

End-of-life care is one of the less frequently discussed uses of medical cannabis. After all, most of us who turn to cannabis, want to continue living, right? And yet, thanks to the ability of cannabis to ameliorate the heavy symptom burden experienced by patients with minimal side effects, palliative care is perhaps the area of medicine that would most benefit from its clinical use.

Dying is a journey all of us will inevitably take, however how to ‘die well’ is something we tend not to consider. Dignity with dying is only possible, I believe, when there is a certain amount of consciousness and acceptance of the process. Something that a skinful of morphine doesn’t allow. But cannabis does, and I experienced this for the first time with a friend’s mother.

As Jose neared the end of her life after battling pancreatic cancer, morphine failed to control her pain, leaving her confused and unable to connect with loved ones. Thanks to an open-minded doctor who recommended cannabis oil, the last few weeks of her life became the gift her family longed for. The pain no longer troubled her, the anxiety lessened, sleep returned, as did her appetite. Not only that, Jose remained fully lucid until moments before she died.

This changed me forever and it’s why I’m sitting here today writing about cannabis.

Holistic Medicine

Sadly, when my mother became terminally ill with advanced cancer, this option was not available in the UK . Sure, I had a few offers from my cannabis contacts. But for an 82-year-old Irish ex-nurse, trusting a funky tasting oil (that I couldn’t say for sure how much to take) over the pharmaceutical meds prescribed in precise dosages was never going to happen.

Instead, I found myself administering a list of medications that just kept growing and growing as the disease progressed. This included morphine for the pain (which incidentally my mum couldn’t tolerate), antiemetics for nausea, laxatives for the constipation caused by both the cancer and the pain medication, as well as Lorazepam for the middle-of-the-night agitation.

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The frustration was overwhelming. I knew that instead of the sledgehammer approach to her symptom control, a far more holistic, person-centred alternative existed that could not only ease her pain, take the edge off her anxiety and agitation, stimulate her appetite and help with the nausea, but also allow her to be present for the time that remained.

What is Palliative Care?

According to the World Health Organization, palliative care is “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”

Palliative care encompasses end-of-life care, but a patient receiving palliative care is not necessarily approaching death.

In other words, palliative care encompasses end-of-life care, but a patient receiving palliative care is not necessarily approaching death.

However, when a patient enters the end-of-life stage in a hospice setting, the emphasis on quality of life means rules often get bent in a bid to fulfil a dying patient’s wishes and beliefs. Dogs and family pets are welcome guests in a patient’s room, and a glass of wine is not unheard of, if that’s what the patient wants. So why not allow access to medical cannabis if that will help ease the suffering of a dying patient?

In some countries and states in the US , palliative and end-of-life care is considered a qualifying condition for the prescription of medical cannabis.

Using Cannabis in Palliative Care

Since 2007, the Israeli Ministry of Health has approved medical cannabis for palliative care in patients with cancer. This led to a prospective study analysing the safety and efficacy of cannabis in 2970 patients and the responses were overwhelmingly positive. 1

Ninety-six percent of patients who responded in the 6 month follow-up reported an improvement in their condition, 3.7% reported no change and 0.3% reported deterioration in their medical condition. Furthermore, while only 18.7% of patients described themselves as having good quality of life prior to cannabis treatment, 69.5% did six months later. Tellingly, just over a third of patients stopped using opioid pain medication.

Cannabis can improve symptoms commonly found in advanced cancer, as well as improving quality of life.

While observational studies such as these suggest cannabis can improve symptoms commonly found in advanced cancer, as well as improving quality of life, in practice physicians often feel insufficiently informed to prescribe cannabis to their patients.

A 2018 survey found that of the 237 US oncologists interviewed, 80% conducted discussions with their patients about cannabis, while only 30% actually felt they had enough information. 2 However, an encouraging 67% viewed cannabis as a helpful additional way to manage pain, and 65% said that it was equally or more effective than the standard treatments for the rapid weight loss often found in advanced cancer. And yet, only 45% of them actually prescribed cannabis to their patients.

These discrepancies mean that even in countries where cannabis can legally be prescribed for palliative care, many physicians prefer to stick to the usual methods of symptom control.

A Physician’s View

Claude Cyr, MD , a Canadian family physician and author of “Cannabis in palliative care: current challenges and practical recommendations,” believes palliative care is uniquely suited to cannabis. 3

“If we’re going to integrate cannabis products in medicine,” he told Project CBD , “palliative care is the best port of entry because of the fact that doctors have more time, and patients also have the time to deal with possible issues of the medication.”

However, in order for cannabis to fulfil its potential in palliative care, Dr. Cyr believes a shift in how physicians view symptom control is needed.

Cannabis is mildly effective for a wide range of symptoms common to people in palliative care.

“What seems to be coming through with the research for symptom control,” says Cyr, “is that cannabis is mildly effective for pain, mildly effective for nausea, mildly effective for insomnia and anxiety. It doesn’t treat any one of these conditions dramatically better than the other medications that we have. So, many physicians are like ‘why would we take a medication that is mildly effective when I can take a much more incisive approach with specific symptoms.’ Instead of saying ‘Do you have a bit of pain, a bit of anxiety, a bit of insomnia, a lack of appetite and a bit of nausea? So why don’t we start with something that’s mildly effective for all that and then we’ll be able to work on more specific symptoms in the long run’.”

Cyr is also critical of fellow physicians’ tendencies to rely on clinical evidence while dismissing the validity of their patients’ positive experiences.

“Palliative care is a specific situation where we can actually put into question the core philosophy of medicine which is the evidence based paradigm. I think physicians need to stop obsessing over the evidence when their patients are dying and clearly telling them, ‘I’m really enjoying this, I’m getting huge benefits from this, I’m sleeping better, I’m eating better.’ But the physicians are nodding their heads and saying, ‘I hear you, but I can’t accept this because I’m still lacking evidence.’

“But I think there is enough data out there to convince physicians that it’s safe for palliative care patients, and it’s predictable.”

Psychoactivity in Palliative Care

Cyr urges doctors to find peace with the idea that cannabis is psychoactive, which he believes could actually help patients process the existential anxiety often experienced at the end of their lives.

“When you look at the studies of psychedelics in depression and existential anxiety in cancer patients, some of these results have been dramatic,” says Cyr. “Although cannabis isn’t a true psychedelic, there are some similar experiences that patients tell us about. 4 At smaller doses patients experience a psycholytic effect, a lowering of the defenses allowing people to explore other aspects of their psyche, and that’s when they start making connections between different aspects of their reality.”

THC ’s ability to reduce activation of the default mode network, the area of the brain involved in cognitive processing and where our ego or sense of self is thought to reside, could also potentially bring a sense of peace to dying patients. 5 6

Cyr explains: “Existential anxiety is rooted in the loss of the self, but when you can dissolve the ego temporarily and you realize it’s not all about me, that can be liberating.”

For the last fifty years, activists have been campaigning for the right to use cannabis to treat their health conditions in order to be well. This must also be extended to using cannabis to maintain quality of life in life-threatening illnesses, and when this no longer becomes possible, to die well and with dignity.

In memory of Jose and Agnes.

Mary Biles, a Project CBD contributing writer, is a journalist, blogger and educator with a background in holistic health. Based between the UK and Spain, she is committed to accurately reporting advances in medical cannabis research.

Copyright, Project CBD . May not be reprinted without permission.

End-of-Life Care: Dying With Dignity and Comfort — The Role of Medical Cannabis

The principal goal of palliative care is to reduce suffering experienced by patients who are at or near end of life. Palliative care is multidimensional, attending to the physical, emotional, psychological, and spiritual needs of patients with life-limiting disease. Hospice and palliative care services may be provided in a patient’s home, a nursing home, or an inpatient hospice unit.1 Historically, end of-life palliation utilizes a combination of opioids, benzodiazepines, serotonin 5-HT3 receptor antagonists, and antipsychotic medications to help ease patients’ suffering. While often necessary, these medications come with many unwanted—and sometimes dangerous—side effects, particularly at the increased doses typically needed to achieve relief of symptoms. Integrating cannabis has been shown to reduce harm and unwanted side effects when used in combination with medications.

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The benefits of using medical cannabis for improving quality of life among palliative care and hospice patients are numerous. Several benefits are explored here.

The Synergistic Relationship Between Cannabinoids and Opioids
The overlap of the endocannabinoid and endogenous opioid systems offers an understanding of why cannabis and opioids work well synergistically. Both provide analgesic effects, with evidence of cannabis producing analgesia at both the central and peripheral levels.1 Both systems consist of G-coupled protein receptors found throughout the brain,2 and both cannabinoids and opioids are produced endogenously and are part of the homeostatic processes necessary for life.3

Cannabis is an ancient medicine with millennia of safe usage. With a toxicity profile that’s less harmful to the body than water, cannabis is particularly effective when dosed consistently and appropriately. Opioids are also an ancient medicine, regarded as most effective for treating pain but with a much more harmful toxicity profile that includes respiratory depression from overdose. With morphine, the most common opioid used in end-of-life care, difficulty breathing is a common side effect. Constipation, nausea, vomiting, and drowsiness are also commonly reported at the doses often required for comfort.

Many of these side effects can be mitigated with the use of medical cannabis. Research has demonstrated that subanalgesic doses of morphine and THC are equally unsuccessful at mitigating pain. However, the combination of morphine and THC shows a significant reduction in affective pain, and preclinical trials suggest coadministration attenuates tolerance.4 This translates to the patient requiring lower doses of opioid medication for symptom control, thereby reducing respiratory depressive effects that are commonly experienced at higher doses.

Medical cannabis also has been shown to reduce the doses of antidepressant or antianxiety drugs in patients at the end of life.5

These examples support the concept of combining cannabis with conventional medications to reduce the doses of prescribed opioids, anxiolytic, and antidepressant medications, all of which are often titrated up significantly at end of life.

Cannabis Promotes Presence of Mind for Dying Patients
Cannabis has been associated with euphoria, aversive memory extinction, and sensorium enhancement, and can serve as a spiritual insight catalysis. This experience may mitigate any number of anxious thoughts and behaviors that accompany the end of life. Cannabis has also been used as an enhancer to heighten sensory perceptions and awareness.6 People with terminal illnesses may be looking to evaluate the meaning of their lives and deepen their connections with loved ones during the limited time they have left. If used properly, euphoria and enhanced sensorium may help overcome the barriers to achieving mindfulness at the end of life. This may help patients achieve a moment-to-moment presence and abstain from focusing only on the future.

Cannabis also holds potential to ease the psychological trauma that a terminal diagnosis often brings. This spiritual growth and development may offer a more dignified experience for patients. Families may also benefit as they witness their loved ones experience a more peaceful state of being. The resultant lucidity makes possible a more conscious, connected, and dignified passing.

Barriers to More Widespread Use
In a national survey examining the knowledge, experience, and views of hospice professionals toward medical cannabis, 91% of individuals support cannabis use in hospice. Three-fourths of these clinicians care for patients for whom cannabis was most successful in managing their nausea, vomiting, pain, and anxiety; however, less than 50% certify their patients. The most common reason for providers not utilizing cannabis is a general confusion and discomfort over their insufficient knowledge and training.7 This inadequate preparation begins at the core of providers’ careers, with traditional education at medical, nursing, and pharmacy schools neglecting to include appropriate cannabis education.

Additionally, hospices and other health care settings that receive federal funding preclude the use of cannabis, as it remains a federally illegal substance. Many hospice settings are left to either look the other way or maintain a hands-off policy, leaving someone close to the patient to procure and administer the medicine.7 The result is typically a “don’t ask, don’t tell” approach that can lead to an unsafe and ineffective combination of cannabis with other medications. With patients and families continually asking hospice clinicians about cannabis, we’ve clearly reached a time in which hospice clinicians must either receive appropriate cannabis education or refer their patients to a provider who specializes in medical cannabis.

Overcoming the Roadblocks
While rescheduling or descheduling cannabis would certainly be helpful, patients are suffering now. We cannot wait for hospice clinicians to educate themselves, as cannabis therapeutics is a specialty in and of itself that requires time and experience. Being in such high demand, most cannabis providers don’t provide in-home or nursing home visits. One silver lining in the dark COVID-19 cloud is telehealth. With telehealth, cannabis therapeutics specialists, such as recommending providers and cannabis nurses, are able to consult with suffering patients and their families from the safety of their residences. To meet patients’ needs, many medical dispensaries are implementing or expanding their delivery services so patients have access to cannabis during this unprecedented time.

Death With Dignity
In summary, medical cannabis holds the potential to help terminal patients remain comfortable mentally, emotionally, and physically at the end of their lives. The synergistic effect of combining cannabis with opioids, anxiolytics, or mood stabilizers reduces the necessary dose of both cannabis and these medications. This offers patients an approach that can better manage many symptoms associated with the end of life, while reducing the unwanted side effects of interventions. With appropriate guidance and support, hospice patients have an opportunity to die peacefully, comfortably, and with the dignity we all deserve.

— Ryan D. Zaklin, MD, MA, PC, is trained in internal, geriatric, integrative, mind-body, and cannabinoid medicine. He earned his MD from the University of Virginia and completed his training in internal medicine at Massachusetts General Hospital and served on the faculty at Harvard Medical School. He works with Partners Network in skilled nursing facilities and maintains a private practice in integrative medicine.

— Meghan Clements, FNP-BC, graduated with her bachelor’s degree in biochemistry from Merrimack Collage (2009) and her master’s in nursing from Simmons University (2013). Starting her career as a nurse practitioner, she cared for geriatric patients during their short term rehabilitation or long term care stay, helping to manage their acute illnesses, chronic conditions, and end-of-life care. She also works as an orthopedic nurse practitioner.

— Marissa Fratoni, BSN-RN, LMT, RYT, INHC, is a holistic nurse and multidisciplined health practitioner specializing in women’s health and behavioral health and further specializing in cannabinoid therapeutics. She’s well versed in complementary healing modalities including massage therapy modalities, yoga, and integrative nutrition. Her published work and adventures in the cannabis space can be found at holisticnursemama.blog.

References

1. Russo EB. Clinical endocannabinoid deficiency (CECD): can this concept explain therapeutic benefits of cannabis in migraine, fibromyalgia, irritable bowel syndrome and other treatment-resistant conditions? Neuro Endocrinol Lett. 2008;29(2):192-200.

2. Befort K. Interactions of the opioid and cannabinoid systems in reward: insights from knockout studies. Front Pharmacol. 2015;6:6.

3. Carter GT, Flanagan AM, Earleywine M, Abrams DI, Aggarwal SK, Grinspoon L. Cannabis in palliative medicine: improving care and reducing opioid-related morbidity. Am J Hosp Palliat Care. 2011;28(5):297-303.

4. Roberts JD, Gennings C, Shih M. Synergistic affective analgesic interaction between delta-9-tetrahydrocannabinol and morphine. Eur J Pharmacol. 2006;530(1-2):54-58.

5. Bar-Sela G, Vorobeichik M, Drawsheh S, Omer A, Goldberg V, Muller E. The medical necessity for medicinal cannabis: prospective, observational study evaluating treatment in cancer patients on supportive or palliative care. Evid Based Complement Alternat Med. 2013;2013:510392.

6. Strouse TB. Cannabinoids in medical practice. Cannabis Cannabinoid Res. 2016;1(1):38-43.

7. Costantino RC, Felten N, Todd M, Maxwell T, McPherson ML. A survey of hospice professionals regarding medical cannabis practices. J Palliat Med. 2019;22(10):1208-1212.

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