Page 1 - Top Ten Tips Palliative Care Clinicians Should Know About Medical Cannabis

JOURNAL OF PALLIATIVE MEDICINE Palliative Care Specialists Series
Volume XX, Number XX, 2019
ª Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2018.0641 Feature Editors: Christopher A. Jones and Arif H. Kamal

Top Ten Tips Palliative Care Clinicians Should
Know About Medical Cannabis

Joshua Briscoe, MD, 1,2 Arif H. Kamal, MD, MBA, MHS, FACP, FAAHPM, 1,3,4
and David J. Casarett, MD, MA, FAAHPM 1,3

Downloaded by Gothenburg University Library from www.liebertpub.com at 01/15/19. For personal use only.
Abstract
The use of medical cannabis is increasing significantly throughout the United States in spite of limited and
sometimes contradictory data about its effectiveness. Palliative care providers are being asked to consider
cannabis as part of symptom-directed treatment regimens although many providers have limited experience
recommending medical cannabis and were trained before it was commercially available. This article seeks to
dispel myths about medical cannabis and provides a balanced view of the benefits and burdens of this thera-
peutic option, providing evidence where it exists and offering practicing clinicians guidance on conditions in
which medical cannabis is likely to be helpful or burdensome.

Keywords: cannabinoids; medical cannabis; medical marijuana; palliative care; route of administration;
symptom control

Introduction this confusion are the many routes of administration, the
criminalized and stigmatized history of marijuana use, and
igh-quality palliative care (PC) practice requires clinicians’ greater familiarity with cannabis as a substance of
Hincorporating novel and evolving supportive care treat- abuse (marked by the diagnosis of ‘‘cannabis use disorder’’ in
ments into the routine care of patients with serious illness. A the fifth edition of the Diagnostic and Statistical Manual). This
growing conversation in the profession centers around the may lead clinicians to avoid discussing cannabis use with their
potential role of medical cannabis, paralleling several efforts patients, remain biased against medical cannabis where evi-
across the country to approve and legalize medical cannabis dence for its use exists, or, under the sway of public opinion,
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use. At the federal level, cannabis remains illegal, including prematurely adopt cannabis as a treatment even where evidence
continued designation by the Food and Drug Administration is lacking.
(FDA) as a Schedule I drug. In contrast, many states are For the purposes of this review, we will refer to ‘‘medical
moving away from decriminalization to actively promoting cannabis’’ as those products that contain cannabinoids and
various amounts and formulations of cannabis for medical and/ are used for medical indications. There are three medications
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or recreational purposes. Coupled with an evolving evidence that are themselves cannabinoids: dronabinol (synthetic
base, clinicians face challenges to stay current with changes in THC), nabilone (a synthetic cannabinoid similar to THC),
regulatory approvals and clinical best practices. Further and nabiximols (a combination of CBD and THC not avail-
complicating PC practice is the relative scarcity of evidence, able in the United States). CBD was also recently approved
guidance, and best practices to guide clinicians in prescribing by the FDA in the United States under the brand name Epi-
and managing these medications (e.g., dose, route of admin- diolex for the management of refractory pediatric epilepsy,
istration, timing of administration, and interactions). although off-label use has been described in chemotherapy-
3–5
Any discussion of cannabis must start with clarifying no- induced neuropathy, social phobia, and psychosis. Other
menclature. Depending upon settings, products are referred to synthetic cannabinoids exist that are substances of abuse and
by various names, including ‘‘medical marijuana,’’ ‘‘medical are not the focus of this review (e.g., ‘‘K2’’ and ‘‘spice’’).
cannabis,’’ ‘‘cannabis,’’ ‘‘marijuana,’’ ‘‘cannabinoids,’’ and These differentiations are nevertheless important to make so
the individual chemical components of cannabis such as tet- clinicians have a clearer understanding of the landscape of
rahydrocannabinol (THC) and cannabidiol (CBD). Adding to cannabinoid use and misuse. Herein we present our thoughts

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1
Departments of Medicine and Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina.
3
Duke Cancer Institute, Duke University, Durham, North Carolina.
4 Duke Fuqua School of Business, Duke University, Durham, North Carolina.
Accepted December 3, 2018.
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