Palliative Care can be defined as an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with life-threatening illness. It prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual.

The majority of adults in need of palliative care have chronic diseases such as cardiovascular diseases (38.5%), cancer (34%), chronic respiratory diseases (10.3%), AIDS (5.7%) and diabetes (4.6%).

Pain and difficulty in breathing are two of the most frequent and serious symptoms experienced by patients in need of palliative care. The search for therapeutic strategies is ongoing as poor symptom control and/or intolerable adverse effects are attributed to opioids and other medications currently utilized among palliative care patients.

Current guidelines

It has been stated by Dr. Claude Cyr that “if we are going to integrate cannabis products into medicine, palliative care is the best port of entry”.

Integrating cannabinoid based therapies into palliative care has been delayed by limited clinical research data, little knowledge in dosing guidelines, conflicting regulation, and stigma. Surveys in recent years have shown that a decent majority of US oncologists view cannabinoid therapies as a helpful adjunct to standard pain management strategies. In 2019, the Dutch government agreed to fully reimburse medical cannabis for terminally ill patients. 

There is a disconnect between substantial research and interest by patients and families, making it difficult for healthcare professionals when it comes to recommendations and support. Because of this, there is a sense of urgency to understand the pharmacology, mechanisms of action, and available research to support cannabis use in these circumstances. 

Pain

Definition of clear, clinical objectives with patients and their families is incredibly important among palliative care. The focus is often pain. 

Cannabis use for pain can be traced back thousands of years. Observationally in research, the response to pain in individuals has been favorable when compared to baselines or controls. 

A review of literature published through June 2017 examined trials regarding cannabinoid use for pain in patients with neuropathy and malignant diseases. Out of 18 trials, 15 demonstrated a significant analgesic effect of cannabinoids as compared to placebo, the reduction in pain intensity was considered clinically significant. The most commonly reported adverse effects were well tolerated. 

To date, however, the widespread use of medical cannabis is still controversial even in palliative care settings mostly because the plant may produce both therapeutic and psychoactive effects. There is strong evidence suggesting that the non-intoxicating cannabinoids, such as cannabidiol (CBD), can also alleviate chronic inflammation and pain in animals. CBD has been characterized as an ideal therapeutic agent for inflammation and neuropathic pain as it may suppress both without causing significant intoxicating side effects or analgesic tolerance. 

Difficulty breathing

This is another topic of major concern among the palliative care population. Based on the neurophysiology of labored breathing and the distribution of cannabinoid receptors within the central nervous system, it has been hypothesized that the unpleasantness of breathlessness will be relieved in humans by cannabinoids. Observational studies have shown some promise among individuals with Chronic obstructive pulmonary disease (COPD). However, there is still a need in clinical trials to observe significantly positive or negative effects on airway function and exertional breathlessness in adults. 

Other Symptoms

Many patients in palliative care may want to address other common symptoms at end of life, such as anxiety, depression, nausea, anorexia, or insomnia, which may all be relieved by cannabinoid therapy. Others may be looking to reduce or stop altogether certain medications, specifically opioids with serious adverse effects. 

An Israeli study published in 2018 on cannabis use in nearly 3,000 cancer patients showed significant improvement in the control of common symptoms other than pain, including sleep disorders (70.8%), fatigue (55.9%), anxiety and depression (74.1%) and nausea and vomiting (54.7%). 18.7% reported a good quality of life prior to treatment initiation while 69.5% reported good quality of life after 6 months. 

These findings align with published results from Realm of Caring’s observational research registry, where cannabis users self-reported significantly better quality of life, greater health satisfaction, improved sleep, lower average pain severity, lower anxiety, and lower depression compared with controls. Therefore, cannabinoid therapies may be beneficial across a broad range of symptoms realized in palliative care settings, beyond pain management. The argument may then be made that the role of cannabinoid therapy should not only be under consideration for a palliative care setting, but earlier in the course of palliative care strategy. 

Preclinical evidence and case studies have shown the potential for cannabinoids to have disease-modifying effects. Several studies have demonstrated their anti-tumoral, anti-inflammatory, and neuroprotective properties, for example. However, more clinical research is necessary to provide evidence necessary to fully support disease-modifying effects.

Opioid-sparing effects

When it comes to pain management, opioids in particular have considerable side effects, including constipation, impaired sleep, and respiratory depression. In recent decades, we have witnessed an increase in the prescription of opioids – therefore an increase in opioid use disorders and opioid-related mortality. Therefore, the need has increased to discover combinations of medications that complement each other’s actions for maximizing pain-alleviating responses to allow lower doses of each. The endocannabinoid system represents an ideal target because it is a key endogenous system in modulating pain-processing pathways. 

It has been observed that CB2 receptors indirectly stimulate opioid receptors located in the central nervous system. Therefore, in addition to having direct pain-relieving effects on their own, cannabinoids may work synergistically to enhance opioid effects. 

A published review looked at 28 studies providing data relating to the potential opioid-sparing effects of cannabinoids in the context of pain management. Most of the pre-clinical studies examined reported reduced opioid requirements when co-administered with cannabinoids. Two controlled clinical studies found no effect of cannabinoids on opioid dose requirements. One case provided low quality evidence and few controlled clinical studies measured opioid sparing as a goal, so findings relating to pain management were mixed. Controlled clinical studies demonstrated some beneficial effects of co-administration on outcomes of pain, sleep, and functioning in chronic pain patients. 

Despite the potential for cannabinoids to reduce opioid dose requirements and extend pain relieving effects, it is recommended that increased studies be carried out and observed as there is inconsistent data thus far. Future study considerations should carefully document adverse effects from co-administration to better understand potential harms and examine dose range and tolerability.

Spiritual and Existential Suffering

Cannabinoid therapy approaches may offer unique potential benefits known more through traditional medicinal and cultural uses and shown through anecdotal reports from patients and caregivers. Mild euphoria, sensory enhancement, and overall sense of well-being could play an important therapeutic role for patients faced with the despair of terminal conditions and the loss of function that tends to accompany it. 

Patient’s right to access

In cases where individuals expect medical cannabis to be presented as a strategy for their advanced health condition, this leads into a topic of palliative care that deserves to be mentioned: personal autonomy in medical decisions for alleviation of pain and suffering. The facilitation of a patient’s right to access experimental treatments and therapies in line with their wishes and beliefs, is something to be considered as research continues to evolve in this specific area of care.

Questions that remain

Finding support with cannabinoid therapy and palliative care can be difficult, but that is where Realm of Caring may step in to help. Our care specialists are trained to help with product and practical administration suggestions – whether you be an experienced user or novice. In general, cannabis is safe but responsible use and guidance, as well as oversight by a healthcare professional, are always recommended. We are here to help start and facilitate those conversations along the way through these extremely difficult times. 

If you want to reach out to our care team to discuss anything cannabinoid therapy related one on one – we are here for you! You can call our free hotline at 719-347-5400, email info@realmofcaring.org, or schedule an appointment.