Change is afoot in the hospice and palliative care industries for managing pain in dying patients. For the longest time, the standard medications have ranged from something as low-grade as Tylenol or Benadryl to something as hardcore as Fentanyl or Roxanol (aka morphine). However, with the legalization of medicinal marijuana in certain states, preceded by decades of medical research, cannabinoids are changing the way things are done. Their use in pain management plans, typically to lessen the negative impact of opioids, is still far from standard practice, but it’s gaining ground.
Morphine remains the most common hospice medication used to treat pain, which is the most common end-of-life symptom, according to “American Nurse Today.” For terminally ill cancer patients in particular, morphine is the go-to for controlling severe acute pain. It’s reliable and generally preferred, even when taking into account the plethora of undesirable side effects (e.g., trouble swallowing, confusion, shallow breathing). So, if morphine gets the job done and everyone wants it, why add anything to it in a pain management plan? Why involve cannabis at all? Why? Because a plan centered on nursing a bottle of morphine until departing earth isn’t as cozy as it sounds. I know. I’ve seen it.
My mom chose one of those morphine- and codeine-centric pain management plans when she was put on hospice care for cancer. And because of that plan, she ended up being semi-comatose for the final week of her life. According to the hospice company’s representative, my mom could still hear and understand what was going on around her, even though she couldn’t respond to any of it. In my mind, that’s comparable to being buried alive. She deserved so much better.
How different might my mom’s situation have been if she had included cannabinoids in her pain management plan? According to the research, quite a bit. Recent studies[1] in “Annals of Palliative Medicine” revealed that cannabinoids supplementing opioid regimens improved patients’ quality of life substantially. The cannabinoids not only countered opioid side effects but also enabled reduced opioid intake. Dr. Donald Abrams, chief of the Hematology-Oncology Division at San Francisco General Hospital, explained how this works in his 2016 paper “Integrating cannabis into clinical cancer care” in “Current Oncology”:
“To date, two types of cannabinoid receptors … have been identified in humans and other animal species. The cb1 receptor, initially identified in the brain, is found in high concentrations in areas involved in the processing of noxious stimuli. The cb2 receptor is predominantly located in cells of the immune system and likely has a role in the control of inflammation and cell proliferation. …
“Clinically, I have observed that many cancer patients benefit from adding cannabis to their pain regimen. Although the effect on chemotherapy-induced peripheral neuropathy has not been glaringly obvious, other sorts of cancer-related pain appear to respond. Patients who have been put on high doses of opiates at the end of life by their well-meaning oncologist or palliative care team frequently feel totally unable to communicate with their loved ones in their precious remaining time because of altered cognition. Many have successfully weaned themselves down or off their opiate dose by adding cannabis to their regimen. Although it would seem that thc-dominant strains of cannabis would be most likely to have analgesic effects, patients often report significant pain reduction from strains that are predominantly cbd-rich.”[2]
Cannabinoids are so effective at treating pain that they can – in some instances – even replace opioids. Dr. Tomasz Dzierżanowski of the Medical University of Warsaw, Poland, stated in his 2019 paper “Prospects for the Use of Cannabinoids in Oncology and Palliative Care Practice: A Review of the Evidence”: “Regarding pain treatment, [cannabinoids] might be considered as an adjuvant to opioid therapy, but also (in less severe cases) before opioids. In many cases, a moderate dose of cannabinoids is sufficient and without the negative effects that opioids bear.”[3] That means my mom might have been able to take something much less harmful and still been comfortable as she spent time with us in the end. How wonderful that would have been!
Further, cannabinoids offer the chance to expand options available to hospice patients, who are in dire need of a greater selection. As Dzierżanowski observed: “There is a very narrow armamentarium available to palliative or supportive care specialists. Any novel medicine that adds value to the currently available treatment would be appreciated.” If cannabinoids were more widely used in hospice care, the representative treating my mom might have recommended them once my mom started needing morphine every two hours instead of every 12 hours. I sorely wish my family and I had been given the chance to do more for her.
Cannabinoids, by the way, are not an arbitrary alternative to opioids for hospice patients. In fact, they were specifically singled out for their application to end-of-life pain management for terminally ill cancer patients. A 2018 article in the “European Journal of Internal Medicine” declared, “Cannabis as a palliative treatment for cancer patients seems to be well tolerated, effective and safe option to help patients cope with the malignancy related symptoms.” The article’s authors cited results from multiple scientific studies to support this claim:
“We analyzed the data routinely collected as part of the treatment program of 2970 cancer patients treated with medical cannabis between 2015 and 2017.
“After six months of follow up, 902 patients (24.9%) died and 682 (18.8%) stopped the treatment. Of the remaining, 1211 (60.6%) responded; 95.9% reported an improvement in their condition, 45 patients (3.7%) reported no change and four patients (0.3%) reported deterioration in their medical condition.”[4]
The reason for which cannabinoids aren’t included among the standard hospice medications despite the evidence of their potential in that capacity is multifaceted. Dr. Sunil Kumar Aggarwal, hospice and palliative medicine subspecialist (and self-described “cannabinologist”), explained this paradox in his 2016 paper “Use of cannabinoids in cancer care: palliative care” in “Current Oncology”:
“Well-documented and evidence-based indications for [cannabinoid integrative medicine] cim include its use in severe pain … With regard to conditions relevant to oncology, cannabis medicines, both orally administered and inhaled, have been shown in randomized double-blind placebo-controlled trials to have efficacy for a number of symptoms, including opioid-refractory cancer pain …
“All cannabis-related medicinal products have yet to be well-integrated into health care, indicative of the translational gap between available scientific evidence on cannabis and cannabinoids, and current practices. The benefits of integrating cim into palliative care have been stifled by conflicting regulations, lingering stigma, research barriers, and product scarcity—much of which stems from poor awareness and knowledge gaps for patients, clinicians, and other stakeholders.”[5]
As the research cited here shows, if people on hospice add cannabinoids to their pain management plan, they might require less morphine. That, in turn, could free them to be alert. Rather than being paralyzed and suffering through the lost opportunity to interact with everyone huddled around them, they – and their loved ones too – could savor the time spent together. And those are the kinds of memories that should shape someone’s legacy: a tender smile and hug while whispering “I love you,” not limp limbs and the unsettling gurgling of a morphine nap. I wish that my memories from my mom’s final days resembled the former and not the latter. And I hope that more people have happier endings as science marches onward in refining the application of medicinal marijuana to end-of-life pain management.
Note: Cannabis-derived medications vary in CBD and THC content – particularly non-FDA-approved formulations. Accordingly, there can’t be a uniform response in using them to treat pain, and results are never guaranteed. Patients considering these for pain management should consult with their doctors to determine the right compound, dosage and means of consumption.
[1] Alexia Blake et al., “A selective review of medical cannabis in cancer pain management,” Annals of Palliative Medicine 6(2) (December 2017): S215-S222, https://doi.org/10.21037/apm.2017.08.05.
[2] D.I. Abrams, “Integrating cannabis into clinical cancer care,” Current Oncology 23(2) (March 2016): S8-S14, https://dx.doi.org/10.3747%2Fco.23.3099.
[3] Tomasz Dzierżanowski, “Prospects for the Use of Cannabinoids in Oncology and Palliative Care Practice: A Review of the Evidence,” Cancers (Basel) 11(2) (January 22, 2019): 129, https://dx.doi.org/10.3390%2Fcancers11020129.
[4] L. Bar-Lev Schleider et al., “Prospective analysis of safety and efficacy of medical cannabis in large unselected population of patients with cancer,” European Journal of Internal Medicine 49 (March 2018): 37-43, https://doi.org/10.1016/j.ejim.2018.01.023.
[5] S.K. Aggarwal, “Use of cannabinoids in cancer care: palliative care,” Current Oncology 23(2) (March 2016): S33-S36, https://doi.org/10.3747/co.23.2962.
