Updated: August 2019
Medical Marijuana in Hospice and Palliative Care
The SONO family had the pleasure of having Dr. David Sine join us at the 2019 SONO Symposium. Dr. Sine brings vast experience in the use of medical marijuana in the hospice and palliative care setting and was willing to share his experience and answer some questions about medical marijuana. Below is the list of questions covered about medical marijuana and its past, present, and future in hospice and palliative care.
Click on any of the below topics that interest you to go directly to that section:
- What is the biggest misconception about medical marijuana?
- What is the biggest symptom management opportunity for medical marijuana in hospice and palliative care?
- Can medical marijuana be addictive?
- Can medical marijuana be curative?
- If CBD oil is an effective anti-inflammatory, could this be used as a nutraceutical for general anti-inflammatory effects?
- What are the repercussions of using medical marijuana in a hospice setting if it's not yet legal in your state.
- What can the hospice community do to get the ball rolling on legalization in their state for medical use?
- What do you what do you think is is holding our country back from just legalizing medical marijuana across the multiple facets of healthcare?
- Is part of the holdback on research for medical marijuana the classification of the plant?
- As far as the case for legalizing medical marijuana, what does the opposition argue that you think is a legitimate concern.
- Has this largely been trial and error in the development of your medical marijuana standard of care?
- Is there an online resource out there where you're sharing these anecdotal stories or learning from other people’s experiences?
- Are there any resources out there that validate whether what you're getting is safe or not?
- What is the major drug that medical cannabis can replace?
- Would Hospices save money by moving to Medical Marijuana in place of other common prescription drugs?
- If you were able to get out a message to the hospice community regarding medical marijuana what would you say?
1. What is the biggest misconception about medical marijuana?
Well, there are a couple of big ones worth addressing. First, the majority of people, especially the people that I see when I do a consult, think that medical marijuana involves smoking. And honestly I think this is a good representation of the public impression as a whole. And if they don’t think it’s smoking, they picture having to eat edibles like at a college party or something. Neither of these are methods of administration that we use to administer marijuana in a clinical setting.
So you’re probably asking yourself how in the world it’s administered if it’s not smoked or baked into foods, right? The current form of administration for medical marijuana is actually liquid form that can be compounded into capsules. It’s as simple as determining the right dose of CBD and THC (in milligrams) then it can be compounded just like any other medication.
I’d say the second biggest misconception about medical marijuana is that in order to get the beneficial effects, you have to “get high.” Interestingly enough, pretty much across the board whether I am doing consults with children or elderly adults one of the biggest things they worry about is getting “high.” You almost can’t blame them because that’s what they have come to link marijuana with from movies, TV, etc. So I have to explain to them that marijuana in the recreational world is much different than marijuana in the medical world. We aren’t going to be giving them Presidential OG or Island Sweet Skunk (both of which are actual names of strains of recreational marijuana) we are going to be carefully blending specific ratios of CBD and THC oil and giving it to them just like a daily medicine. One thing that surprises most people is that if you are intentional about the ratios of THC to CBD with enough CBD to counter the THC, you literally cannot get high. It’s a chemical thing. It’s actually very easy to be treated with medical marijuana without getting high. You know the expression, “Start low and go slow?” That’s the name of the game here as everyone has different levels of tolerance.
As it occurs in the natural world, marijuana is about 90% CBD and 10% THC give or take a few percentage points. In the clinical setting, we do our best to match this as closely as possible. I’m a strong believer that if we want to maximize the positive effects of the plant in the clinical setting, we should keep it as close as possible to how it occurs in the natural world, then customize it to the specific needs and tolerance of the patient.
I also want to mention that there’s a lot of information out there about different strains of recreational marijuana - Emphasis on the “recreational” part there. It’s important that people understand that we aren’t going to our local dispensary and buying “Godfather OG” then bringing it into the hospital and giving it to our patients. We need to get away from this idea of wondering what strain is best in the clinical setting and understand that it’s all about the ratios of CBD and THC. I am not saying that dispensaries do not want to help or lack the necessary knowledge. I am saying that for medical use, it needs to be treated like any other “medicine.” We actually use mg/kg calculations for children just like we do for other medicines for pediatrics.
I’d say those are the two biggest misconceptions about medical marijuana. If you’re using medical marijuana, you aren’t going to be smoking a joint or eating a pot brownie, nor are you going to be “stoned” when your family comes to see you. This is why we must be very clear about the distinction between medical and recreational marijuana because while there are some similarities, the differences in effects, administration, and purpose are profound.
2. What is the biggest symptom management opportunity for medical marijuana in hospice and palliative care? What can this plant replace or complement?
This is a big question and an important one. I’ve been using medical marijuana for my patients in a clinical setting for over 7 years now and I got started using it to help manage pediatric seizures. After that, I started to use it to help with pain management. I’ve probably been most impressed with medical marijuana’s effectiveness with pain management. Again, it’s all about the ratios (CBD/THC). CBD is really more of an anti-inflammatory and that’s where it contributes to the picture. This is at least what we think. It’s extremely difficult to get clinical trials done here in the United States to study medical marijuana so a lot of the data and learnings are coming from boots on the ground experience and use and from studies coming out of Israel and Germany. THC is the bomb when it comes to treating neuropathic pain. The nice thing about using medical marijuana for pain management is that there are no receptors for THC or CBD on our brain stem. Why does this matter? It matters because you can’t overdose someone to the point of stopping their breathing with medical marijuana. But you can do this with opioids. This is huge and it’s something I didn’t even know until recently.
I got started using medical marijuana for two of my patients battling cancer who were on morphine drips. And as we all know, if you’re on morphine, you’re dealing with some serious pain. Interestingly enough, after a month of using medical marijuana, I was able to wean them off of morphine and get them back into school. Additionally, we were able to stop their bowel regimen medications once opiates were significantly reduced.
Another thing to note is that with opioids, you develop a tolerance which means you have to continually increase the dose to reach the same effect for your patients. Not only is this extra work for the clinician, but it’s dangerous for the patient because as you increase the dose, you increase the risk of all the negative side effects of the opioids. With medical marijuana, once we find a dose that works, it works. It’s very rare that we have to adjust the actual dosing. One example of why we might have to change the dose is if we have drastic weight changes with our patients. Additionally, we’ve seen zero tolerance for medical marijuana among our patients. My guess is that our body reacts much differently to man-made products versus naturally occurring products.
As far as other opportunities go for medical marijuana and symptom management, a big one is nausea and vomiting usually coming from cancer patients going through chemotherapy. I’m continually surprised about how well this works in helping people get through chemo and manage its side effects.
Probably not surprising to most people, anxiety is really common when someone’s dealing with a potentially life-threatening diagnosis. I am able to write a lot less for antidepressants and anxiolytics because medical marijuana is very effective for helping manage anxiety. Insomnia and poor sleep seem to really be helped by taking medical marijuana as well. There are other opportunities for symptom management, but these are the big ones.
“The sum is greater than the parts.”
Of the 1,000 or so patients we are treating right now with medical marijuana, very few of them are on THC or CBD alone. As mentioned earlier, we try our best to mimic how the substances occur naturally in the plant. Have you ever heard the expression “The sum is greater than the parts?” That basically means that sometimes 1+1=3. What we have found is that having THC coupled with CBD actually makes the CBD much more effective and vice versa. We rarely administer these compounds independent of one another, because we have found that in the clinical setting, the sum is actually greater than the parts.
3. Can medical marijuana be addictive?
The issue and the uphill battle that the medical community faces is that up to now, all the research that has been done on marijuana and its negative side effects is research done on recreational use which I’ve stressed is fundamentally different than clinical use. That’s to say that I’m not aware of any studies that examine the potential of a link between medical marijuana (oral administration) and addiction. All the historical research has been based on smoking.
That being said, from my 7 years of experience with close to a thousand patients, there has been no evidence of addiction whatsoever. We’ve had patients get admitted to a hospital that doesn’t allow medical marijuana so those patients are forced to stop using it altogether. After stopping, they do not go through withdrawal symptoms, although their original symptoms that were being managed by medical marijuana do eventually return. If you’re not showing signs of withdrawal, it’s hard to say that you have an addiction.
4. Can medical marijuana be curative? Or is it always just temporary relief of symptoms?
This one is tough. Because we can’t do clinical trials and produce irrefutable proof due to U.S. federal restrictions. Despite all the information we have, the only way to really get this going is to have our government allow studies to go forward.
You’re asking whether we’ve had patients with symptom X get put on medical marijuana, stop experiencing symptom X, then after coming off medical marijuana, continue to stop experiencing symptom X. The answer here is, “Yes.” We’ve used medical marijuana to treat kids that have had hemiplegia (in utero stroke) mainly for their muscle pains or contractures, spasms, those kinds of things. Three kids over the last 6 years have started using their hemiparetic side after using medical marijuana. These are kids who were having to use walkers to get around and over time have gotten better. In fact, these 3 kids now walk independently and are completely off of oil. We’ve had 4 kids that we graduated out of hospice/palliative care who were sent to me also with a terminal diagnosis with no other curative therapy available. We used medical marijuana for their pain symptom relief and 3 of the 4 ended up in a last-ditch trial. They all survived and are currently cancer free and discharged. So I suspect it’s not the medical marijuana by itself, but it’s possible the medical marijuana is helping make something else more effective.
One of my kids was 7 years old when we started him on medical marijuana. One of the neuropsychologists thinks that medical marijuana affects the laminar flow of nerves or the chaos in the brain which is why we think it's so effective in managing seizures. We think there’s something with the medical marijuana that allows more direct signal flow within the brain. Think of it like having a highway with tons of off ramps and traffic piling up everywhere, then after using medical marijuana all the off ramps are gone and the highway is now just a straight, smooth road with traffic flowing beautifully.
The same thing happens with Parkinson's patients. They’ll oftentimes come in and have tons of spastic movements and tremors, then 15 minutes after taking medical marijuana, they get up and walk out of your office with a completely normal gait. We have a handful of examples where we’ve seen this thus far, including a father who was told he would be bed bound before his youngest daughter’s wedding. With the addition of medical marijuana to his treatment, his tremors subsided enough to be able to walk his daughter down the aisle.
5. If CBD oil is an effective anti-inflammatory, could this be used as a nutraceutical for general anti-inflammatory effects? Could CBD be an eventual replacement for NSAIDS?
Yes, this is all possible, but with questions like these, we are going to need research. We have patients with arthritis that are on Humira, two of which were young adolescent females with scleroderma. After two months of medical marijuana therapy, we saw a drop in their sedimentation rates by 70%. Both had increased exercise capabilities and are still maintaining that today. Granted, this is just representative of 2 patients, but this is all we have to go off of until the doors to more research and clinical trials are opened.
6. What are the repercussions of using medical marijuana in a hospice setting if it's not yet legal in your state.
At this point, if it's not legal in your state, you're better off looking at other alternatives. If it's against the law, it's against the law. My personal feeling is that medical and recreational needs to be completely separate and I don't personally endorse legalizing recreational because I think it takes away from the validating aspects of medical marijuana.
My frustration with what’s happened in California is that when recreational gets legalized, everybody and their uncle opens up a dispensary and then it becomes all about money and taxes and this all takes away from the medical focus of trying to help people with it. If there's too many people doing the same thing, that dilution means that less and less people are doing a good job.
Additionally, regardless of what the state law is, it's still federally against the law. The feds won't come after individuals, but they will go after practitioners. So if it's illegal in your state, I would recommend completely refraining as a provider.
Now, if it's legal in your state, my recommendation would be to get your own legal advice and find a medical cannabis attorney, which is what I did. They’re still out there. They just have less business now because of all the legalization.
I have a medical cannabis attorney who I worked with early on. He's very clear with me what the rules are and with what I can and can't do. And if I ever have questions about something different or new, I consult him. And that's not my style at all, I'm usually like, "Whatever my patients need, I'm gonna do it." But in this area, I don't do that at all. I'm very cautious about it.
The last thing you want is your pioneers of medical marijuana going to federal prison for breaking the rules or being on youtube and getting negative publicity. So that’s my advice - get legal backing.
7. What can the hospice community do to get the ball rolling on legalization in their state for medical use?
You can get started by pushing for restricted medical marijuana use. It's hospice agencies that have to get things started because regardless of whether medical marijuana is legal or not, they’re still going to have patients that are going to be using it in their home. So they need to decide how they do or don't want to document its use.
We need to get hospices to show evidence of how it has improved symptom management and that it’s not hurting patients. And in my experience, if it does anything at all it just improves people’s quality of life.
In the 20 years that I’ve been a palliative care doctor, the one thing I can guarantee is that reliably tested medical marijuana will do no harm. And if anything, it will most likely improve someone’s overall quality of life.
And that's huge for Hospice and Palliative Care. If the hospices could push that message and push that they have documentation of their findings, then we could possibly get it passed for hospice use and that would be a huge victory.
Hospices in those states where medical marijuana is not legal are really the key to getting the door open. And again, even if that door was only opened for Hospice and Palliative care patients, that would still be a great start.
8. What do you what do you think is is holding our country back from just legalizing medical marijuana across the multiple facets of healthcare including acute?
I think the initial hold back was the stereotype that we were all raised with. Maybe not the current teenage generation, but all the generations prior all the way back to the 60s. After the 60s, it's basically been a gateway drug. “You're going to be lazy.” “You're not going to accomplish anything.” That's the way it’s always been perceived. So we have to get over that misconception first and I think the public is almost there.
It's way less stereotypical than it was even 10 years ago. Now I can have a 60 year old lady with hip pain from her hip replacement surgery that comes in and says, “You know I don't want to be on that wacky weed, but I want this medical cannabis thing. I want CBD oil.” And I’m thinking, “Well, they’re actually all the same thing.” But I think the stereotype with regards to the public is being overcome on its own just by sheer information and the power of the Internet.
The second thing is, from a provider standpoint, the lack of studies to support its use.
“There's nothing to support it. We don't know how it works. There are no studies, there are no studies, there are no studies.”
I have two things to say to that. First, there are limited studies because the federal law makes it almost impossible to get a study approved.
Second, we don’t really understand how it works. The reason we don’t know how it works is because we can’t get any studies approved. But there are many, many, many medications that we use for patients with no idea how they work. The mechanism of action is “unknown.” Think about ADHD medications, for example. We don't know how they work, yet we use them all the time. We don't have a clue for most of them.
And then from the provider standpoint, I think providers fear legal action against them. So my advice to all providers out there is, “Get legal counsel with someone that's well versed in cannabis law in your particular state.”
9. Is part of the holdback on research for medical marijuana the classification of the plant?
Yes, It's pretty hard if not impossible to get public funding. But then you have to go through a lot of hoops because it's a schedule one drug. Additionally, hospitals and universities which is where most of those studies are going to be done are very, very nervous about doing anything because they already get federal funding that they’re dependent on. So if you are allowing any medical cannabis on your campus for any reason whatsoever and you have federal funding, then you're at risk of losing that federal funding if the feds decide to come in.
Where I am there's only one children's hospital in all of central California and it serves 600 square miles and 80% of the population is underserved like MediCAL non-private, non-commercial. So if they lost federal funding, the hospital would close. So that's a big deal and that’s why the hospitals are not going to take any chances.
I get asked a lot if we’re doing harm to patients by not allowing them to continue their use of marijuana while in the hospital. And I thought that was a great question because if you've got kids that are managed at home on medical cannabis who get admitted for something unrelated, like an infection or surgery, and they're not allowed to continue their use of medical marijuana in the hospital, this begs to question, “Are we causing them harm?" And the answer is unequivocally, "Yes".
10. As far as the case for legalizing medical marijuana, what does the opposition argue that you think is a legitimate concern.
First, there aren't enough studies to support its use. So you don't know how it works and what doses to use. And that is legitimate.
I came from a family of four and all three of them have died of cancer and I was a hospice provider for all three. In that time frame, I watched a lot of Netflix with them. Certain shows would make me think about how we wouldn't get anywhere if people didn't try stuff. You know?
So I agree that the biggest concern is the lack of research and guide for dosing. But unfortunately with the current federal law, we can’t overcome this problem. And so all we can do is look at a couple of other countries, Germany and Israel, who are doing clinical trials and researching. We try to glean as much as we can from the work being done in these countries.
The second thing that I think is a legitimate concern is we don't know what the long term effects are. We do know about some of the deleterious effects that smoking marijuana can cause and there is some concern that all kinds of marijuana drop your IQ a few points, but in this area with marijuana administered via oil, we don’t have the same information.
I think when you're dealing with someone with a terminal illness, it probably doesn't matter because you don't have long term concerns. On the other hand, when I'm talking about kids that are brain damaged at infancy and then I'm using it for seizures and things like that, I can't say that it's not going to potentially have some long term outcome because we haven't been using it long enough to know. I utilize informed consent of the unknown in this particular situation.
So I think it really comes down to the complaint that there's not enough research which I agree with. But, this means that the medical community must petition the government and make it clear that we all want the research.
11. Has this largely been trial and error in the development of your medical marijuana standard of care?
Yes. Our first cohort of patients were children with uncontrollable seizures. Our second cohort was for pain management. Third, was behavioral, primarily autism which we were looking for something that could help with their anxiety and aggression.
There was some information out there, mostly anecdotal studies that talked about CBD kind of having a calming effect. There was something in Newsweek magazine I think last year that said, “The potential cure for autism.” And they're talking specifically about CBD. In my opinion, they were completely wrong. CBD by itself did not help my most aggressive autistic kids at all.
Then I started thinking about how some of my high school kids would smoke a bowl of marijuana before they went to school to help deal with their anxiety. It was actually two twin brothers with Asperger's in college. Their first year at college, I figured out they were smoking weed and they said, “Oh Dr. Sein, that helps us deal with the social anxiety at school.”
So my pharmacist and biochemists started adjusting and increasing the THC and we realized that, first, the metabolism of autistic kids is completely different than everybody else. I don't know if there's actually studies that look into that, but they definitely metabolize things differently. Second, it was the THC that helped them the most. And so then as long as you balance it with the CBD, they weren't getting high. Autistic kids can handle significantly higher doses of THC. So after we increased the THC, their anxiety improved, and with the improved anxiety, they pay more attention to their behavioral therapy and then everything gets better.
I just saw one of my patients at a movie and it was the first movie that he and his family had been to in 5 years. Prior to that, he couldn't handle all the sensory overload, so they couldn't take him and they didn't want to go to the movies without the entire family.
12. Is there an online resource out there where you're sharing these anecdotal stories or learning from other people’s experiences?
There isn't an online resource yet. So that's our next big step because I have to be careful about what I share because of the federal law. It looks like we're doing research, but we’re not. What we're trying to do is work with a research group in Boulder Colorado to get hooked up with a remote web site in either Israel or Germany so that we can share what we've found and let them disseminate it.
The second thing I'm looking at is my Alma Mater. I went to McMaster University for pre-medical, nursing, and medical school in Canada. Now that it's legalized in the whole country, my medical school actually set up a research lab for medical cannabis. So I contacted them and as soon as they get their website up and going I'm going to start dumping the information to them because we want to share our experiences and get the information out there. As you can imagine, we’ve learned a lot from 7 years of doing this.
It’s critical to remember that people are using it on their own, whether it’s legal or not, and may be using unsafe products with potential interactions and deleterious effects.
We may be one of the few if any medical practices where you have some type of medical management of pharmacists and nurse practitioners. And you really need to know where you're getting your stuff because when we tested some of the stuff that people were using whether it was bought online or from dispensaries, we found roundup, arsenic, poo bacteria, like all kinds of disgusting things and people would say, "But it's got a label on it!" But because the FDA is not involved, there's no real regulations on these dispensaries. You can go to vistaprint and print out a label. Most of the testing is done internally or in their own labs so you don't necessarily know and the sophistication of that testing varies. So you really need to make sure that you have a safe product.
13. Are there any resources out there that validate whether what you're getting is safe or not?
Not that I’m aware of. Currently, they're looking at making everybody go through the same testing centers which isn't going to work. And then they want to charge exorbitant amounts like $1,000 dollars per patient. My advice is, “If you are getting it, look for the most reliable place that you can find and try to find out where they are getting their testing done.”
The hardest part for me as a provider is making sure that the patients are getting a product for the desired treatment effect. The challenge is, if I recommend medical cannabis, I'm not saying “Oh, and make sure there's no roundup in it!” But that's the reality of it.
I think the future requires us to push the government and the laws to really be loosened up to the point where we can do appropriate testing and there can be guidelines and dosing and all that. My fear is that it is going to be blocked by pharmaceutical companies because they can't patent a plant.
14. What is the major drug that medical cannabis can replace?
With the opioid crisis, we started a program. It's been about three years now and that's right around the time that the opioid crisis peaked. We call it “Opioid Displacement” which basically involves us starting people that are either tolerant or “addicted” to opioids and then attempting to displace them off and move them over to medical cannabis. And it's been extremely effective.
In my area, I have adult pain specialists that are referring their patients to me, which is a pretty strong statement because these are pain doctors. That's where they make their money, right? They make their money by prescribing medications and doing procedures for pain, yet they're referring patients to me because they’ve seen the overwhelming evidence.
There may not be a lot of studies, but there are some inter-observative criteria that is helpful because you have blinded providers like these pain specialists who don't necessarily know that the patients are on medical marijuana. And then they see this patient doing better and find out that they're on medical marijuana. That's a blinded assessment, and that's where I think there has been some good describers.
There's a rehab doctor who I work very closely with now who called me 6 years ago and said, “Hey, I have these 12 kids of yours out of a couple hundred that had contractions, seizures and spasms. I haven't had to give them their botox treatments for their contractions lately and I'm noticing that the only kids I'm skipping treatments for are yours. What are you doing?”
And I responded, "Oh, I'll talk to you in person." Again that is a blinded assessment. You know she botoxes hundreds of kids a month, but she started to see a pattern where she was skipping treatments on a few kids here and there and they all turned out to be my patients who were on medical cannabis.
Then the question was, “What are you doing that's treating their contractors?”
And I'm thinking, “Well, I don't know. I wasn't treating their contractors, I was treating their seizures or something else." But those would be good for descriptive studies if nothing else. It's just a matter of having time to do that.
My oldest patient was 93 when I started her on medical marijuana. She's 97 now and she was started for pain management because she was on opioids for hip replacement surgery. She got drugged out on Norco and Oxy and ended up falling and breaking her other hip. She told me she didn’t want that “Wacky weed” because she didn’t want to be high all the time around her kids and grandkids.
After explaining that she wouldn’t feel the euphoric effects, she agreed to start treatment with medical marijuana and she's still on it now four years later with no opioids.
She weaned off her opioids within two weeks she's been off ever since. She's my oldest patient at 97. My youngest patients were a group of four 6-month olds and they're all 7 years old now.
Two months ago, we treated a 6 week old who had refractory seizures and was having 40 to 50 seizures a day on five seizure medications. The next step was a hemispherectomy, which is basically where they are separating the brain. So it's almost like a lobectomy. They're taking a vital part of the brain. So I told them, “Okay just go home and try something else first.” And in three days the baby was down to two seizures a day and is now down to a couple of seizures a week and the surgery was canceled and she's already off three of the five seizure medications.
15. Would Hospices save money by moving to Medical Marijuana in place of other common prescription drugs?
Yes, Tons and tons of money. The new FDA approved cannabis drug for seizures is an estimated cost of $4,000-$30,000 per month versus the natural product which is between $200 and $400 a month out of pocket.
It would be no question how much money it would save. But most of those hospices are getting some form of federal funding, whether it's coming from the state or directly from the feds. That's the issue.
Because of the federal funding, it puts them at risk from a legal standpoint. That's where it all kind of comes into play and this has to change. Hospice and palliative care patients should be somehow exempt from the federal issues too so that the institutions like hospice, palliative, and home care don't have to be all cloak and dagger about it.
16. If you were able to get out a message to the hospice community regarding medical marijuana what would you say?
If it's legal in their state, they should encourage their patients to look at it because it can displace a lot of the other medications, decrease the side effect profile, and improve the quality of life. I absolutely, 100% believe that on all levels.
The second thing is, if it's not legal in your state, I strongly encourage hospices to join together and push for it to be approved at least for hospice. This can take the form of some type of waiver or exemption for Hospice/Palliative care patients. Again, the pain symptom management and quality of life improvement is not something we should ignore.
David Sine, MD FAAP FHPC BScN RN
Dr. David Sine received his Doctor of Medicine in 1993 and immediately pursued specialized credentialing in pediatric medicine, in which he became board certified in 1998. He received his board certification in 2002 from the American Board of Hospice and Palliative Medicine and began his career in providing compassionate care to the most critical of pediatric patients. He serves to guide both the patients, and their families, throughout their most difficult transition and has positively affected hundreds of families in the most grim of situations.
Dr. Sine currently serves as the Medical Director of Pediatric Palliative Care for Central Valley Children’s Hospital, Hinds Hospice, and Tulare Hospice in Central California. He and his interdisciplinary care teams provide holistic care to children with life-threatening illnesses and those who are terminally ill. His program specializes in providing families with symptom management for chronically ill children and children at the end of life through communication, medical decision making, spiritual and psychosocial guidance. In addition to the clinical and administrative duties related to these palliative care programs, Dr. Sine is involved in Complementary Alternative Medicine and specializes in the use of medical cannabis in his pediatric patient populations. Dr. Sine also works closely with local regulators and law enforcement to help establish best practices for the use of cannabis in children.