Monday, April 20, 2015

Medical marijuana in hospice and palliative care

Just in time for the unofficial holiday celebrating marijuana (4/20), there is a lot more cannabis chatter. President Obama is expressing more support for decriminalization of medical marijuana. The new Surgeon General, Dr. Vivek Murthy, notes that in some medical situations 'marijuana can be helpful.' It made me curious to see what are hospice and palliative care advocates saying about the topic.

Palliative care clinicians are often concerned about access to symptom controlling medications and therapies when it comes to relieving suffering. For example with opioids, you can hear clinicians advocate for access to these important medications, but also recognize the public health risk which comes from diversion and inappropriate/non-prescribed use. Similarly with integrative medicine, you may also hear people in hospice and palliative care advocating for access and use of massage, acupuncture, hypnosis, biofeedback, aromatherapy among others, even though the research may not be strong for any one particular complementary/alternative therapy.

Data accurate as of April 1, 2015
Yet when it comes to marijuana for symptom control, hospice and palliative care as a field is relatively quiet in comparison to these other areas mentioned above, in addition to being much quieter than the 'medical marijuana' and 'recreational marijuana' movements happening across the United States. In Kansas and Missouri, where I currently practice there are no current laws which allow for medical marijuana or recreational marijuana. In a quick search I found hospice organizations in Arizona, Colorado and Illinois advocating medical marijuana use for their patients. So, I'm wondering from those of you who work in states where there is either form of allowed cannabis use, do you see a different level of engagement (e.g., advocacy or prescribing) from local hospices or physicians that care for people with serious illness? Please share in the comments.

If you would like to know more about what hospice and palliative care clinicians are saying about marijuana as an option for symptom control here are links I discovered while researching this post. If you have quality links, please share in the comments below and I will check them out and potentially add them in the original post. All links are open access unless otherwise noted.

Reader provided links (added after the initial article ran)
The research literature on marijuana use exclusively in hospice and/or palliative care patient populations is quite thin. Only 87 articles on PubMed with the search criteria of (palliative OR hospice) AND (cannabis OR marijuana)

Medical marijuana is not without potential medical risk, especially in a population that may be seriously ill.  There have been case reports of significant Aspergillosis infections of the lung in neutropenic patients, and it is not uncommon to see transplant patients (who are necessarily immunocompromised by their treatment) to be counseled against smoking marijuana expressly because of this reason.

This post is not about taking a side, but instead a reflection on what are our (meta-)responsibilities as symptom control advocates. As we gain a larger foothold in the halls of our hospitals and our statehouses, like Oklahoma who recently passed (ACS-supported) laws that encourage more input from palliative care experts, we need to ask ourselves, "With limited time and resources, how do we help out patients best?"

It seems like the medical/recreational marijuana movement has considerable inertia behind it when it comes to changing state laws. How do you think will this change our clinical practice, our fellow education, and our research opportunities?

Christian Sinclair, MD, FAAHPM, is a palliative care physician at the University of Kansas Medical Center, editor of Pallimed, and president-elect of the American Academy of Hospice and Palliative Medicine. He has a significant interest in questions that don't always have clear answers and likes to be able to hear other people's opinions on challenging topics.

HPNA = Hospice and palliative Nurses Association
PPT = Powerpoint
NHPCO = National Hospice and Palliative Care Organization
AAHPM = American Academy of Hospice and Palliative Medicine
JPSM = Journal of Pain and Symptom Management
ACS = American Cancer Society

Image credit: Medical marijuana neon sign by Laurie Avocado Wikimedia Commons via CC

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