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Role of Cannabis in Palliative Care: From Symptom Burden to Existential Distress




Healthcare is a comprehensive practice that involves several different facets of wellbeing. There are, however, certain life-limiting and incurable health conditions that require specialized medical services and care plans. As research into cannabis and cannabinoids, Cannabidiol (CBD), and Tetrahydrocannabinol (THC) progresses, there are more identified benefits for health care. While a lot of these benefits do not 'cure' medical conditions, they have been proven to relieve the symptom burden on the patient. Therefore, cannabis may be introduced into the medical management plan for palliative care.

What is palliative care?



The World Health Organization (WHO) defines palliative care as "the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems, is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families."

Essentially, palliative care is a form of specialized medical care for people with serious illnesses and it is focused on providing them with relief from the symptoms, pain, and stress of a serious illness. The care team’s main objective in palliative care is to improve the quality of life of the patients and relieve some of the stress from their loved ones.



-Symptom Burden and Existential Distress

Palliative care is provided for patients with illnesses such as cardiovascular diseases, cancer, chronic respiratory diseases, AIDS, and diabetes. These complex illnesses are associated with physical and emotional/mental symptoms that are distressing for patients .

The symptom burden that patients under palliative care go through is extensive and gets intense over time. In cross-sectional studies of patients with terminal illness ,report 8–12 symptoms, with fatigue, pain, anorexia, cachexia, dyspnea, anxiety, and depression being particularly common in those with cancer.

The feeling of existential distress about the thought of death and the disconnect or anxiety about interacting with others, which terminally ill patients go through is another concern for palliative care teams. As a result, palliative care is not only limited to physiology (medication), it has to involve the emotional, mental, spiritual, and social aspects of the patient's wellbeing.

Cannabis and Palliative Care



The legalization of cannabis/marijuana, in line with ongoing research of its medical benefits, has created a reputation for its efficiency in the management of pain, anxiety, and nausea. In fact, the United States has one FDA-approved CBD-based medication (epidiolex), which is used in the treatment of refractory seizures from disorders such as Lennox-Gastaut syndrome and Dravet syndrome. With the progress in incorporating cannabis for healthcare, the discussion of cannabis in palliative care is very essential. Palliative care is focused on managing the symptoms of these chronic terminal illnesses and improving the quality of life of the patient. The published benefits of cannabis fit this description.

Cannabis has two main components Tetrahydrocannabinol (THC) and Cannabidiol (CBD), which have slightly different effects on the human body and mind when consumed. THC is mostly used recreationally for the ‘high’ it gives consumers, while CBD has been researched more for medical purposes because it doesn't cause any 'high' psychological effects. Researchers have found that CBD has benefits for relieving inflammation and chronic pain, as well as managing the symptoms of epileptic seizures, cancer symptoms, insomnia, anxiety, and depression. These are conditions often associated with the symptom burden of patients receiving palliative care, leading to the incorporation of CBD in palliative care.

The benefits of cannabis (CBD) in calming anxiety and stress, aiding sleep, reducing pain, and managing physiological disorders provide a suitable alternative in managing the physical, psychological, and social symptom burden of palliative care. Palliative care teams can administer controlled doses of cannabis to help patients ease the pain they're going through and also regulate their moods to help them with their existential distress. In an ongoing trial, the use of oral medicinal cannabinoids to relieve symptom burden in the palliative care of patients with advanced cancer is being studied. The objective of this trial is to rigorously evaluate the efficacy, safety, and acceptability of 1:1 THC/CBD for symptom relief in advanced cancer patients. The trial will observe the change in total physical and emotional scores, anxiety, and depression, opioid use, quality of life, and adverse effects on the patients.



Publication guidelines from Australia and Canada suggest that cannabis could be considered after other options have failed and with careful consideration weigh the risk versus benefit. The NHPCO(National Hospice and Palliative Care Organization ) statesit’s use on palliative and Hospice is evident in treating patients with Cancer, Neurodegenerative disorder, inflammatory disease, end of life angst , uncontrolled seizures and HIV cachexia.

A publication and prospective analysis in European Journal of Internal Medicine published by Israel , studied the safety and efficacy of medical use of cannabis in cancer patients .The study revealed cannabis was well tolerated and safe in patients with malignancy related symptoms.




Cannabis interaction with other drugs

Studies on the extent of benefits of cannabis in palliative care are not conclusive, but they are progressing.It is advised that cannabis in palliative care is not considered first line treatment. The interaction of cannabis with drugs can have untoward effects such as with antidepressants or anticoagulants like warfarin .

While the interactions of cannabis with other drugs are dependent on the dose of cannabis, type of medication, and health condition, older people, who are a common demographic in palliative care patients, are more susceptible to the side effects. As a Geriatrician and Palliative physician we always say ”start low go slow”.

Conclusion

Relief of pain and distressing symptoms, as well as the enhancement of quality of life, are the essential elements of palliative care. In the exploration of options for providing this care, cannabis can be suggested. Though cannabis can be highly beneficial for the patient, especially regarding symptom burden and existential distress, it must be assessed and prescribed by your healthcare team .



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