Canna-must or Canna-bust?
A brief look at the evolution of Cannabis and what it means for our hospice patients.
Unbeknownst to a majority of the public, the medicinal use of cannabis dates back to the 28th century B.C.E. with China being one of the first to use cannabis to help treat gout, rheumatism, malaria, poor memory, and various other illnesses. The use of cannabis as a medicinal agent continued for multiple generations and throughout different regions of the world until the 1900s when the federal government deemed it a national menace. Through propaganda and misinformation, marijuana was portrayed as a substance with fiercely addictive properties and was responsible for causing minorities committing violent crimes. The government instated the Marihuana Tax Act of 1937, imposing heavy taxes on marijuana allowing the government to regulate its use. By the 1970s, the Supreme Court repealed the Marihuana Tax Act, but simultaneously classified marijuana as a schedule 1 drug, making it a federally illegal substance.
What exactly is Cannabis? Cannabis (Family Cannabaceae) is the genus of flowering plants, branching out into the 3 following species: C. sativa, C. indica, and C. ruderalis. From these species, the extraction of marijuana and hemp constituents is possible. The principal ingredients within these plants are called phytocannabinoids and terpenoids, which are responsible for producing various effects on the body. The most prevalent and studied phytocannabinoids discovered are known as tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is the psychoactive component responsible for producing the euphoria we commonly associate with marijuana, whereas CBD displays no psychoactivity whatsoever. THC and CBD exert their effects by interacting with cannabinoid receptors found throughout the body of every mammal. These receptors are located in the brain, spinal cord, kidneys, liver, lungs, digestive tract, and peripheral tissues of the immune system. The interaction between the chemical compounds found in the cannabis plant and the specific receptors in the body, lead to regulation of the endocannabinoid system. This internal system plays an important role in maintaining balance amongst the processes of memory, anxiety, motor function, digestion, immune response, inflammation, appetite, and pain.
Understanding the endocannabinoid system and the mechanism of action of cannabis shines a light on the potential benefits and harms associated with the use of cannabis and its isolates. Cannabis can be described as having analgesic, anti-inflammatory, antiemetic, anxiolytic, and anticonvulsant properties, but has also been documented as causing delays in reaction time, impaired memory, confusion, euphoria, paranoia, alterations in heart rate and blood pressure, psychosis, dry mouth and changes in appetite. Due to the psychoactive and cardiac effects, it is not recommended for patients who have a history of psychotic and/or cardiovascular disorders. Additionally, cannabis is metabolized by liver enzymes, which can lead to several drug-drug interactions with other medications metabolized by similar enzymes. Cannabis can also reinforce the sedative effects of hypnotics, benzodiazepines, and alcohol. Although the benefits are promising, the side effects and interactions can be a cause of concern.
Reflecting upon the information discussed, the question of whether or not cannabis is a potential option for our hospice patients becomes a bit cloudy. On one hand, the benefits of cannabis reflect resolution of symptoms we commonly see in hospice patients: chronic pain, nausea, anorexia and cachexia, anxiety, and insomnia. There are also several dosage forms available for our patients running out of viable options; inhaled formulation, edibles, pills, solutions, sublingual drops, oromucosal sprays, topical creams, suppositories, and transdermal patches. It is extremely important to be cautious of the pharmacokinetics associated with different formulations helping you understand how each one should be used appropriately to maximize effectiveness and decrease adverse reactions. On the other hand, evidence from trials is mostly of poor quality or anecdotal. There is not a clear protocol for dosing or monitoring parameters, posing a great issue for our patient population. Older and naïve users have shown to be more sensitive to the effects of cannabis and prone to experience more unpleasant side effects. However, at the end of the day, most of our patients have exhausted all conventional options, and cannabis can serve as a beacon of hope; especially when it is used intelligently with a full understanding of the plant’s kinetics.
- Whiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy S, Hernandez AV, Keurentjes JC, Lang S, Misso K, Ryder S, Schmidlkofer S, Westwood M, Kleijnen J. Cannabinoids for medical use: A systematic review and meta-analysis. Journal of the American Medical Association. 2015;313(24):2456–2473.
- Van den Elsen GAH, Ahmed AIA, Lammers M, Kramers C, Verkes RJ, van der Marck MA, Olde Rikkert MGM. Efficacy and safety of medical cannabinoids in older subjects: A systematic review. Ageing Research Reviews. 2014;14(1):56–64.
- Russo E., Guy G. (2006) A tale of two cannabinoids: the therapeutic rationale for combining tetrahydrocannabinol and cannabidiol. Med Hypotheses 66: 234–246.
- NIDA. Marijuana. National Institute on Drug Abuse website. https://www.drugabuse.gov/publications/drugfacts/marijuana. June 22, 2018. Accessed September 28, 2018.