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 first of a series of articles about medical marijuana and its past, present, and future in hospice and palliative care.
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.
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.
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.
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.
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.
This Q&A is to be continued...
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.