In today’s American cannabis culture that celebrates and idolizes youth in an industry with a historical demographic of young 20-something millennials, talking about marijuana and the inevitable mortality associated with end-of-life and palliative care issues may seem like a polar opposite. However, cannabis is far more than a party drug and a growing number of cannabis converts are discovering that marijuana is a unique and diverse plant and there is space for discussion of its properties along a broad spectrum of both recreational and medicinal topics.
It is no doubt unpleasant to discuss tragic end-of-life issues. Hospice and pain management surrounding palliative care analgesics are serious matters and can illicit incredibly sad memories and uncomfortable emotions. But even if we understandably choose to brush aside painful thoughts to focus our daily lives on happier moments, at some point all of us will be faced with making decisions regarding medical treatment in our final days or, if incapacitated, relying on decision-making by others on our behalf.
This begs the question: Should marijuana be administered to assist with pain relief to help ease suffering during hospice and palliative care?
This question came to mind when I recently attended a gathering of the Medical Cannabis Cooperative in the expansive Laguna Woods retirement community in Southern California. Even in the midst of California’s historic drought the gated community grounds are lush and verdant with rolling golf courses and community gardens.
As I sat amongst the walkers, canes and wheelchairs of more than 140 pro-cannabis enthusiasts with an estimated median age of 75 years, I was reminded of my own mother’s passing at age 79. So, when the well-versed club organizer Lonnie Painter opened the floor to questions, I felt compelled to ask about marijuana use for hospice pain management. A touchy subject, but apropos perhaps, given the silver-haired audience.
I recounted the story of the hospice bedside vigil with my own mother. She was given only morphine during the final days and hours before her passing. In her insentient state she was cognitively unaware of my presence. No cathartic farewells were heard. I now wonder if medical marijuana could have helped.
According to Dr. Joseph Morgan of Philadelphia, “People who use cannabis medically can reduce their opioid use by perhaps up to fifty percent.” Morgan said this during a panel discussion held at the highly regarded College of Physicians of Philadelphia, with the panel being moderated by palliative care specialist David Casarett, M.D., M.A, Professor of Medicine at Perelman School of Medicine, who recently published a book titled, “Stoned: A Doctor’s Case for Medical Marijuana.”
Casarett recounted how he began researching medicinal marijuana at the request of a terminally ill patient, even though skeptical at the onset as to the true medicinal properties of cannabis, he subsequently became fascinated with the plant’s possibilities. After publication of Casarett’s new book, he is now considered an expert on medicinal marijuana use for hospice and palliative care. When I asked him how other physicians might also become better educated about the medicinal benefits of marijuana, he replied, “I wrote Stoned at least in part for my physician colleagues.” He acknowledged that he did not write a medical textbook, but “many of my physician colleagues have told me it was very helpful for them.”
I also had the opportunity to specifically pose the question, “Can cannabis help keep hospice or palliative care patients more alert and more cognizant of their surroundings and the presence of loved ones?” Casarett gave a qualified response, “If using a strain of marijuana that is very high in THC, then that might impair someone’s ability to be alert as much as an opioid will.”
To expound, Casarett pointed to the work of a specialist in Pain Medicine and Anesthesiology, UC Davis researcher Barth Wilsey, M.D., M.M.S. According to Casarett, Wilsey suspects that the cannabinoid Cannabidiol may be responsible for much of marijuana’s pain relieving properties. If Wilsey’s promising federally funded study on the analgesic and neuropsychological effects of cannabis bears fruit, Casarett postulated that, “A strain that’s high in CBD and low in THC might well provide good pain relieve (sic) with fewer psychological effects than opioids.”
Terry Gross of NPR’s Fresh Air recently interviewed Casarett in her typical probingly candid and enlightening manner. In the podcast, Casarett indicated that when advising patients and family members during such incredibly challenging times as hospice, he would be remise in his duty as a physician to ignore discussing the medicinal benefits of marijuana.
When I asked about the best way to administer medical marijuana in an end-of-life situation where a patient may be physically unable to smoke or use a vaporizer, Casarett first clarified that, to the best of his knowledge, no scientific studies have been conducted on this specific topic. However, based on his professional research, he is inclined to recommend using a marijuana-infused tincture that can be sprayed or dropped into the patient’s mouth, for fast absorption.
Although he finds edibles to be a safe, reliable and socially acceptable way to ingest beneficial cannabinoids, he also pointed out that the absorption rate of edibles can be unpredictable. While Casarett finds edibles to be “very successful for insomnia” because ingested cannabinoids are slowly absorbed into the body; conversely, tinctures, smoking and vaping have been known to provide faster analgesic relief for pain and nausea.
When Casarett began his research about 18 months ago, he admitted to knowing very little about the medicinal properties of marijuana. Today he is an advocate for more scientific research, not only in his specialized field of hospice and palliative care, but also for studies on the benefits of marijuana for treatment of debilitating post-traumatic stress disorder and the field of pediatric medicine to help control epileptic seizures in young children.
Perhaps as more physicians like Casarett and Morgan come forward with compelling case studies and pragmatic engagements in the public dialogue on the benefits of medical marijuana, the era of unscientific demonization of cannabis will begin to fall by the wayside in much the same manner as the rights of same sex partners to marry. If marijuana were to emerge as a logical, compassionate and integral aspect of modern society, perhaps a patient’s right to medicate and an adult individuals right to responsibly partake of recreational marijuana will be accepted and respected. To quote the lyrics of Sam Cooke, “What a wonderful world this would be.”