Arkansas, California, Florida, Maine, Massachusetts, Nevada, and North Dakota passed some form of marijuana legalization on Election Day 2016, potentially reducing barriers for patients with cancer hoping to use marijuana to relieve symptoms of pain or to increase appetite as an alternative to approved medications.
On November 8, voters in California, Maine, Massachusetts, and Nevada approved initiatives for the legalization of marijuana, while people in Arkansas, Florida, North Dakota voted to approve marijuana for medical usage. Voters in Montana also approved an initiative to repeal a 3-patient limit for medical marijuana providers.
The American Society of Clinical Oncology (ASCO) does not have a position on the legalization of marijuana, though the psychoactive drug is listed as a potential adjuvant analgesic and as a possible management strategy for refractory pain conditions in the ASCO clinical practice guideline for the management of chronic pain in survivors of adult cancer.
“As of this writing, 23 states and the District of Columbia allow for medical cannabis, although it is illegal on the federal level. Currently, there is insufficient evidence to recommend medical cannabis for the first-line management of chronic pain in cancer survivors,” the ASCO guideline states. “Evidence suggests it is worthy of consideration as an adjuvant analgesic or in the management of refractory pain conditions. There is also insufficient evidence to recommend 1 particular preparation of cannabis over another, and the Food and Drug Administration has not approved any drug product containing or derived from botanical marijuana.”1
Based on intermediate quality of evidence, ASCO recommends that clinicians follow specific state regulations that allow access to medical cannabis or cannabinoids for patients with chronic pain.
Cancer Therapy Advisor spoke with guideline author Judith A. Paice, PhD, RN, a professor of medicine at Northwestern University Feinberg School of Medicine and an oncology nurse at Lurie Comprehensive Cancer Center in Chicago, Illinois, to better understand how oncology clinicians are reacting to these legalizations and how she responds to patients asking about cannabis use.
Cancer Therapy Advisor: How often do patients ask about marijuana use and for what reason are they asking?
Dr Paice: Patients frequently ask about the use of marijuana or cannabis. One reason they are asking is that they have unrelieved symptoms. They might have adverse effects to the medications that we are providing to treat their pain or other symptoms. For example, because opioids cause constipation, people are looking for alternatives to traditional medicine. Because there has been so much media attention to the cannabinoids, people think that they must be really quite effective.
Cancer Therapy Advisor: How do you counsel patients asking about cannabis use?
Dr Paice: The 2 most important points that I counsel patients about are the 3 the types of cannabis that exist and the different routes of administration. The 3 different types of cannabis are: our body’s own endogenous cannabinoids, the phytocannabinoids, which is what most people are doing when they are smoking cannabis, and synthetic cannabinoids like dronabinol (Marinol). The reason it’s so important to talk about those 3 types is because patients may be listening to reports that are not specific as to the type studied.
There are more data about synthetic cannabinoids, but there are a few studies about the phytocannabinoids for nerve pain, particularly in cancer and in HIV. The reason that there are not many studies about the phytocannabinoids is because up until recently, the National Institutes of Health (NIH) was not awarding many grants.
The different routes of administration are also important for patients to understand. Cannabis can be inhaled via a joint or vaporizer, which may limit the amount of harsh chemicals that might be inhaled. The ingested route includes eating food substances that contain cannabis oil, and there are oils that can be applied topically at the site of pain. We really have data only about inhaled forms with respect to analgesic efficacy, but the challenge about oils is we have no data on those.
We do have a bit of knowledge about the onset, which has important implications for patients. When you smoke or inhale, you get blood levels in 2 to 5 minutes, but when you ingest it, the bioavailability is delayed and the onset can be 2 to 6 hours. This has been causing some difficulties in states where cannabis is legal recreationally where tourists are consuming more cannabis because they are not feeling immediate effects.
Cancer Therapy Advisor: Anecdotally, for what are patients using phytocannabinoids and synthetic cannabinoids, and do they think these agents have been helpful?
Dr Paice: Dronabinol is now approved by the U.S. Food and Drug Administration for the use of AIDS-related anorexia. I do find for some patients that dronabinol can be useful for improving appetite, and I certainly see that with the phytocannabinoids too.
The benefits that patients report from using phytocannabinoids include pain control, improved appetite, anxiolysis, and improved sleep. Those are the most common uses that I hear anecdotally from patients. Some patients tell me taking a few puffs before bedtime helps to relax and reduce pain.
Cancer Therapy Advisor: Do you think that the approval of these ballot initiatives is a positive step toward increased access to cannabis for patients seeking additional symptom relief?
Dr Paice: There are insufficient data on the use of medical cannabis in patients with cancer. We would like to see more data about both the benefits and the potential harms. In all of the studies conducted in patients with cancer pain, they were studying patients who were already taking opioids, and as a result, we do not know whether cannabis should be used in the first-line setting.
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