Medicinal cannabis in palliative care

    17-Jan-2020
Dr Sona A Pungavkar
As the aging population of India grows along with increase in life-expectancy, so is the incidence of cancer increasing.  Also, better treatment options in cancer, are prolonging survival, there is a need to focus on issues pertaining to quality of life and palliation. These issues are also pertinent in other chronic illnesses, such as multiple sclerosis, post-tratumatic stress disorder etc. This aspect is under-regarded in India, due to lack of knowledge and resources amongst patients and the families as well as most treating clinicians who are in the periphery and not connected to multidisciplinary oncological establishments as well as lack of manpower in the government medical care systems.
Inspite of a robust system in place for palliative care and hospice, for terminally ill patients, Canada, United States (US), Australia and parts of Europe are leading the practice of using Cannabis in patients for palliation. There is a widespread knowledge and belief amongst clinicians and patients regarding the benefit of Cannabis in the symptoms that a patient with advanced cancer suffers from. Yet, the clinicians feel inadequately informed to encourage the use of Cannabis. In a survey, where more than two hundred oncologists in US were interviewed, more than 80% discussed use of Cannabis with the patients, though only 30% felt confident of the information they themselves had. About 65% of the oncologists felt that Cannabis was useful in management of patients, though only 45% actually prescribed it. It means that even in countries, where medicinal Cannabis is legal, the usual methods for palliation are used.
For the layman, palliative medicine is all about accepting that the end of life is near, and the focus of the palliative care team is not to prolong life but on improving the quality of life of the patient. It is about preserving happy memories for the patient and the family and not losing these, while firefighting the severe symptoms of pain, insomnia, loss of appetite, fatigue, anxiety, depression, nausea and vomiting. How peaceful can the last days of a person’s life be in the face of certainty of death, is what every concerned family member asks the treating physician, after being told that the end is near. The approach of the physician in terminally ill patients is variable, depending on the financial condition of the patient and the concurrent ongoing treatment.
The information gap about the effectiveness and safety of medicinal Cannabis needs to be bridged, with more studies and interphysician and interpatient discussions. This is particular true in India, due to the divisive nature amongst various religiousgroups, various recognized systems of medicine, in addition to allopathy, traditional use of Cannabis as a household plant in many parts of the country, and the added difficulty and long duration in bringing about modifications in the legislative system.
Cannabis due to a possibility of easily availability can be used as a first line of treatment, once legalised. Medicinal Cannabis provides a mild relief in all the symptoms, a palliative care patient suffers from.
Most often, patients under palliation have severe unresponsive pain. A simple goal of the treating physician to help decrease this pain and improve the quality of life as much as possible.Opioid – based medications are used to treat pain but because of strict regulations and high cost are not easily available to the people in the low income group. People who can have the capacity to spend for the expensive and inaccessible opioid based medication can do so and bring some relief to the ailing patient, though not all patients benefit.
Some studies have suggested Cannabis could be administered to patients in palliative care as a pain treatment. One study of 1,000 patients found a significant reduction in the pain they experienced.
Being sensitive to the suffering of a dying patient, every option, which is available, needs to be tried. There is a group of people with a genetic mutation in whom opioid-based medications are ineffective and these patients do not find relief from the symptoms, inspite of high doses. Such patients are definitely candidates for use of Cannabis. Similarly, as research continues, there may be some patients who do not get relief with Cannabis and who may require another option of treatment.
Also, the psychoactive effect of Cannabis may help in the existential anxiety, the patient experiences as he or she nears death and the uncertainty and deprivation associated with it. Better to be happy and in an elevated mood by using Cannabis, than to be depressed and low. Though a small percentage of patients may experience paranoia and anxiety in some patients, most patients feel euphoric and relaxed. Benefits from use of medicinal cannabis also include increase in appetite, decrease in nausea and vomiting, change in taste connected to increased pleasure. All these translate into weight gain and increased capacity to endure the traditional anticancer treatment. Overall, patients using medicinal cannabis generally reported that there was a definite improvement in the their quality of life. In a study conducted by an Israeli company, about 95% of the surviving patients, who had continued use of medicinal cannabis as part of treatment of symptoms of cancer, reported benefit of symptoms, with less than 4% reporting no change and less than 0.5% reporting deterioration of symptoms.
Also, patient must be taken into confidence for his or her preference of palliative treatment.Right to die with dignity campaign could also be associated with use of Cannabis in the patients who are terminally ill, to maintain the quality of life. Hence, as so many areas can be addressed by Cannabis, patients who do not find relief by the current medical therapies, can be offered Cannabis to see if it is able to treat the symptoms, after tolerance is established, by careful monitoring of the doses to avoid unwanted effects.
Smoking or vaping is not suggested as a form of administration in palliation, as dose control is not easy and also to avoid the effects of smoking. Instead, alternative ways are used  in the form of oil or tincture placed in the oral cavity, ingestibles such as food or drinks or capsules and in the form of suppositories, which can be placed either, in the vagina, or rectum. The advantage of arectal suppository is that the psychoactive effect is less than experienced by the oral route.
Precautions to be taken before use of medicinal cannabis by patients, include information about the ratio of THC and CBD. Patients with psychosis and who are receiving inhibitors for treatment may be advised to not start Cannabis till more data is available, as symptoms related to psychosis can be aggravated and efficacy of some treatment can be lowered.
We, the team at Cannabis Health and Sciences, strongly believe in the multifaceted effectiveness of Cannabis and completely endorse the view that it can not only be a medicine, once legalised  but also a general approach to a better quality of life, similar to the thoughtsof the Indian ancestors, in particular the mythological Lord Shiva.
The author is a Cannabis researcher, a senior radiologist and Vice President, Cannabis Health and Sciences