Chesson-Riedel 1

Brooke Chesson-Riedel

English 1201

Professor Flores

28 April 2019

Medical Cannabis in the Hospice and Palliative Care Field: What is it good for anyway?

Facebook is a wonderful tool. It keeps track of so much information for us. A lovely

woman by the name of Kendall whom was a very close friend popped up in the memory section

of Facebook. Kendall was an amazing woman. She was a daughter, a mother, and a best friend

to many. Ten years ago, a mole developed on her face and nothing was thought about it at first.

Then it started to bleed. Kendall was 31 years old, and like many others her age, did not have

insurance. Eventually, at the begging and pleading of those who loved her, she went to the

doctor. Stage four malignant melanoma was the diagnosis. She went through surgeries to

lengthen her life, not for the cure. She was in so much pain. Her prescriptions ranged from

OxyContin to morphine. She studied, read, and researched. She decided to try medical

cannabis. This made the pain more tolerable and controlled. Knowing she only had a short time

left, she did not want the horror of pain. She wanted comfort. When it came time for Hospice

care, she went willingly. She knew they would care for her, or that is what they said. Come to

find out, that they did not agree with her self-medicating. Her last days were full of discomfort

and pain. Those that surrounded her felt helpless and frustrated. They would not allow her to

have what had worked. There was a feeling of hopelessness, and it felt as if we had failed.
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Medical cannabis and its byproducts should be legalized to use at least in the hospice and

palliative care medical fields because there have been proven benefits to people nearing end of

life or suffering from a life-limiting illness. The ability to use this additional treatment can

provide another method to limit suffering, especially if drugs and medication either do not work

or have become ineffective for a patient. The goal of treatment should be to help people live as

well as possible for as long as possible.

There are a wide range of reasons in which cannabis could be used from recreational use

to mild sickness to hospice and palliative care. The researched information will only focus on

the hospice and palliative care aspect. Hospice care is defined as care of the terminally ill. Like

my friend Kendall and many others, those that are nearing end of life usually go into hospice

care. Palliative care is caring for those that are chronically ill or have a life-limiting illness.

Authors Alex Chan RN, Miguel Iglesias PhD, Luke Molloy RPN, and Joy Pertile RN mentioned

in an Australian medical journal article titled “A review for Australian nurses: Cannabis use for

anti-emesis among terminally ill patients in Australia” stated, “The principle of palliative care is

to improve the quality of life of patients living with life-limiting conditions based on the best

evidence available.” (Chan, et al 43-44). This type of care can be a precursor to hospice care.

Diagnosis such as congestive heart failure(CHF), chronic obstructive pulmonary disease(COPD),

Amyotrophic Lateral Sclerosis(ALS), Parkinson’s disease, and Alzheimer’s disease are some

illnesses that palliative care may treat. In many medical settings, patients have a higher tendency

to respond to prescription drugs and other medications. However, in hospice and palliative care

settings, sometimes other options may be needed as the desired effects of prescription drugs and

other medications may not be as effective as they previously were.

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Based on this information, the option to have an alternative treatment such as medical

cannabis could offer additional hope to those suffering. According to the article “Knowledge,

Skills, and Attitudes Regarding the Use of Medical Cannabis in the Hospice Population: An

Educational Intervention” by Kelly Mendoza, MS, PharmD and Mary Lynn McPherson,

PharmD, MA, MDE, BCPS, CPE, cannabis “refers to the genus of the flowering plant, which

encompasses the varieties Cannabis sativa, Cannabis indica, and Cannabis ruderalis. The crude

plant product contains up to five hundred forty-five active chemicals”(Mendoza, et al 759-760).

The number of combinations of chemical element compositions that can be generated from

cannabis allows various desired effects, strengths, and outcomes to be achieved because of its

effects on the body.

The most common forms of the cannabis plant are marijuana,

THC(tetrahydrocannabinol), and CBD(cannabidiol) oil. THC and CBD are cannabinoids.

Gregory Carter, Aaron Flanagan, Mitchell Earleywine, Donald Abrams, Sunil Aggarwal, and

Lester Grinspoon, authors of an article in the American Journal of Hospice and Palliative

Medicine called “Cannabis in Palliative Medicine: Improving Care and Reducing Opioid-

Related Morbidity”, explained cannabinoids best. “They are the chemical compounds secreted

by cannabis flowers that provide relief to an array of symptoms including pain, nausea, anxiety,

and inflammation.” Cannabinoids emulate compounds that are naturally produced in our

bodies(endocannabinoids), which activate to maintain internal stability and health. Essentially,

endocannabinoids facilitate communication between cells. When there is a deficiency or a

problem with our endocannabinoid system, negative complications can occur as can physical.

Carter goes on to say that “when cannabis is consumed, cannabinoids bind to receptor sites

throughout our brain(CB-1) and body(CB-2)”. Cannabinoids bind to many different receptors,
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which can cause diverse effects. THC and CBD bind to receptors in the brain and receptors

located throughout the body, respectively(Carter, et al 297-302). Cannabinoids and opioids have

many similarities. They have both been around a long time, both affect specific receptors, and

both types of compounds are made inside the human body to assist with homeostasis or body

regulation. Cannabinoids are more natural to the body than opioids are. Many people have died

from overdose of opioids, but not from cannabinoids.

Cannabis is a product that has origins back to the ancient world. According to Mary

Berna Bridgeman, PharmD, BCPS, BCGP and Daniel Abazia, PharmD, BCPS, CPE in a

scholarly article titled, “Medicinal Cannabis: History, Pharmacology, and Implications for the

Acute Care Setting”, evidence suggests the use of cannabis more than five thousand years ago in

what is now Romania. There is a direct source of evidence that THC was found in ashes and was

used as early as 400 A.D. In the United States, cannabis was used in the last few centuries. It

has been noted that it was used as a patent medicine in a medical book from the 1850’s. A patent

medicine meant that it was a proprietary medicine made and marketed under a patent and

available without prescription. Most details confirm that it was used to help with pain primarily

and as a mood stabilizer. Federal restrictions began around 1937. After this occurred, there have

been federal laws and acts that have prohibited the use of legal cannabis. California became the

first state to “permit legal access to and use of botanical cannabis for medicinal purposes under

physician supervision with the enactment of the Compassionate Use Act” in 1996. As of January

2017, twenty-eight states in conjunction with Washington, D.C., Guam, and Puerto Rico had

passed legislation governing medicinal cannabis sale and distribution(Bridgeman, et al 180-184).

With many medical benefits, cannabis is expected to be legalized in additional states.

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Legalization of cannabis has been an ongoing debate for some time, however support for

medicinal cannabis has been increasing. There have been many research studies that show,

despite varying results, an increasing number of Americans are supporting the idea to use

cannabis for medical purposes. Tanya Uritsky, PharmD and Mary McPherson, PharmD, BCPS,

CPE, and Francoise Pradel, PhD authors of an article in the Journal of Palliative Medicine called

“Assessment of Hospice Health Professionals’ Knowledge, Views, and Experience with Medical

Marijuana, showed that the public was in favor of medicinal cannabis, and it is growing stronger.

Around 75% of Americans are in favor of doctors prescribing marijuana. An ABC

News/Washington Post poll reported that 81% of respondents supported legalizing marijuana for

medical use, compared to 69% of those similarly surveyed in 1997. Also, close to 90% of

hospice care professionals agreed on legalizing medical cannabis due to its numerous medical

benefits. More than 75% of hospice providers in the survey stated that they would “turn a blind

eye” if a patient was able to control symptoms with smoked marijuana. As far as acquiring

medical marijuana, research data showed that nearly 89% of providers were in favor of

acquisition from a pharmacy, 70% of providers were okay with family members being able to

obtain marijuana for another family member, and 51% were in favor of individuals growing

cannabis for medical use(Uritsky, et al 78-83). The studies that Uritsky and the other authors

discuss demonstrates a strong willingness to implement medicinal cannabis for patients who

need it in the hospice and palliative care field. A higher percentage preferred the structure of

obtaining marijuana from a medical facility versus growing independently because of the

additional variables on how it was grown.

As support grows to legalize marijuana for medical use, a healthy portion of support is

from medical professionals based on many studies and research such as the Uritsky surveys.
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Professionals such as doctors, nurses, STNAs, along with hospice and palliative care

professionals have been some of the strongest supporters to legalize cannabis medically. These

professionals usually are at ground level with seeing first-hand the benefits that can be provided

to those who are ill, sick, and dying. In hospice and palliative care specifically, medical cannabis

would provide another treatment option. This is important because sometimes the treatment

options do not always work, and patients being taken care of in these fields need to have hope

that something else could help them. Most are willing to try anything that might make them feel

better and believe that, even though marijuana can be addictive, it is not as addictive as drugs

usually. It provides a more natural option for the patient.

Fig. 1. According to Jessica Assaf in a graphic called, “A Plea for Cannabis in

Hospitals”(Assaf), medical cannabis would provide a more natural option for the patient than

drugs and offer a potentially effective alternative treatment solution for hospice and palliative

patients.

Another point that has been discussed a lot in the legalization of cannabis for medical use

is the drug schedule that is categorized by the Drug Enforcement Agency. Cannabis is

considered a schedule I drug. Based on Carter and others’ article, the drug schedule is as

follows: Schedule I drugs are not considered legitimate for medical use because of limited
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effectiveness and a high potential for dependence. Drugs such as cannabis, heroin, and

methamphetamine are listed here. Schedule II drugs are considered to have a strong potential for

abuse or addiction, but that also have legitimate medical use. Opium, morphine, cocaine, and

oxycodone are listed here. Schedule III drugs are rated to have less abuse or addiction potential

than schedule I or II drugs and have a beneficial medical use. Drugs such as dronabinol,

hydrocodone, amphetamine-based stimulants, and short-acting barbiturates are listed in this

category. Schedule IV and V drugs have even less risks. Schedule IV drugs include

benzodiazepines and schedule V drugs include antidiarrheals and antitussives that contain opioid

derivatives(Carter 299). This drug schedule has been in place for some time and many believe

cannabis should be re-scheduled based on belief that other drugs have more danger and addiction

than cannabis, but are currently scheduled as less dangerous.

Being schedule I, cannabis is rated as having no medical value, which is not an accurate

depiction of the medical benefits that have been shown for those using medically. In an

independent documentary called A Life of its Own-the truth about medical marijuana directed by

Helen Kapalos, it discusses that medical cannabis is illegal under federal law, but has been

legalized at the state level for medical purposes. The federal government regulates drugs

through the Controlled Substances Act, which does not differentiate a difference between the use

of medical and recreational cannabis(Kapalos). Using cannabis for medical purposes in the

hospice and palliative care field and re-scheduling cannabis or at least a medical separation is

necessary as it has been proven to have therapeutic and medical benefit to people using. Also,

this would help to bring more education and information to the medical use of cannabis and

potentially allow for more regular implementation into the medical fields of hospice and

palliative care.
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Bringing more awareness of cannabis for use in these care fields is something very

important to help illustrate the uses and benefits of this treatment on patients. To support the

idea of at least separating cannabis between recreational use and hospice and palliative care use,

Gregory Carter brings up the point that unlike what sometimes occurs with people using

cannabis recreationally, a medical patient does not need to be intoxicated to achieve medical

benefit(Carter, et al 299). Based on research by Bridgeman and Abazia, they mention that “there

are three most common methods of administration. They are inhalation via smoking, inhalation

via vaporization, and ingestion of edible products. The method of administration can impact the

onset, intensity, and duration of psychoactive effects; effects on organ systems; and the addictive

potential and negative consequences associated with use”(Bridgeman, et al 186).

There has been research performed that demonstrates many uses and benefits of using

medical cannabis. Because of the multitude of chemical element compositions of this possible

treatment, the effects of the treatment can be used to cover a broad range of effects and can be

altered as needed by using different compositions. According to Uritsky and McPherson, and

Pradel, there are other uses for medical cannabis, but in the medical scope that we are discussing,

the most prominent uses are to help with fatigue, pain control, anorexia(diet control),

cachexia(weakness or wasting away of body chronically), dyspnea(difficulty breathing or

shortness of breath), anxiety, depression, insomnia, nausea and, vomiting(especially in

chemotherapy). Fibromyalgia could also be added, however in hospice and palliative care, there

are usually other treatments to be handled. Although there has not been extensive research

performed with cannabis on all these uses, results have shown that there has been some

therapeutic effect with each of these treatments(Uritsky, et al 83).

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According to an article called “Cannabis in Palliative Care: Current Challenges and

Practical Recommendations” by Claude Cyr, Maria Arboleda, Sunil Aggarwal, Lynda

Balneaves, Paul Daeninck, Andree Neron, Erin Prosk, and Antonia Vigano, there are also

physiological and psychological effects of using cannabis. There have been studies on THC and

CBD about these effects. The authors discuss that THC binds to cannabinoid receptors in the

body and research points to it being responsible for most of the therapeutic effects linked to

cannabis, such as decreasing pain, spasticity(muscle contraction or tightness), nausea, insomnia,

and appetite loss. THC is also responsible for some psychoactive effects of cannabis such as

paranoia, anxiety, euphoria, or relaxation. CBD is generally tolerated better and does not appear

to have the psychoactive effects that THC does due to not binding to receptors at physiologically

meaningful concentrations. CBD has effects such as pain relief, reduction in nausea and

vomiting, anti-psychotic, anti-ischemic(increased blood supply to the tissues), less anxiety, and

anti-epileptic. Both THC and CBD effects can vary based on the dosages given to the

patient(Cyr, et al 463-473). In researching this topic, there are plenty of guidelines on how to

prescribe medical cannabis in terms of dosage amounts, means of administration, reacting to

signs and symptoms of the patient, and many other situational information on how to properly

treat the patient. As mentioned previously in this paper, the amount of research is enough to use

medical cannabis as treatment to those in hospice and palliative care because of hope for a

different, effective treatment and the need for treatment to patients at end of life or with life-

limiting illnesses.

The supporting side of the legalization of cannabis for medical use in hospice and

palliative care and the positive uses and benefits of cannabis in treatment have been illustrated.

However, there are some counterarguments or concerns and barriers to the legalization of
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medical cannabis, its uses, and its benefits. According to Samuel Wilkinson, MD, in his article

for the Missouri Medicine Journal titled “More Reasons States Should Not Legalize Marijuana”,

there are many reasons to not support or legalize the use of cannabis for recreational or medical

use. One reason is lack of evidence and knowledge that cannabis provides a therapeutic benefit.

Wilkinson states that while “some research” does show evidence of therapeutic benefit, the side

effects it could provide makes the small amount of evidence not worth implementing. Another

reason he states is that cannabis has unknown effective properties and formulas. There are many

properties and formulas that have not been feverishly studied and Wilkinson has concern that

there could be unanticipated negative and lasting effects for individuals who smoke these strains

of cannabis.

Another reason given is that cannabis is considered a schedule I drug, which as was

mentioned earlier in the paper states that it has no legitimate medical use and high potential for

addiction. Wilkinson also states that the approval process and criteria for cannabis is not as strict

or consistent as the process in place for drugs. He mentions that cannabis is not subject to

central regulatory oversight and regulatory standards range from strict to almost non-existent,

which could lead to products being contaminated or grown inconsistently. This could also create

problems with consistency on how products are produced and distributed along with growers

potentially bypassing regulations to save money and undercutting dispensary prices.

Wilkinson goes on to discuss the stigma of using cannabis creates negative implications

to the public and that use can cause negative side effects and long-term negative health effects.

The author lists some side effects as schizophrenia and other psychotic disorders, sedation,

hunger, respiratory problems and other harmful effects to organ systems, brain function
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concerns(slower processing, altered mental states, and decline in cognition), increased mood,

effects on driving due to impairment, and risk perception(if legalized, less concern on how to use

could cause recklessness)(Wilkinson 524-528). While some of the reasons listed might have

varying degrees of merit based on what Wilkinson mentioned, he discusses it in relation to all

types of cannabis use, recreationally and medically. His credibility is good, but the article only

gives points about why legalizing and using cannabis should not occur. Wilkinson’s stance does

not consider the various ways that cannabis can be used for medical care in the appropriate

fields. The relevance of the argument is not as substantial to the subject matter of only

considering medical use. Because of this, discussion should be had to essentially debunk these

reasons for not legalizing and using cannabis at least in the medical scope. The reason given

about having a lack of knowledge and evidence that cannabis provides therapeutic effect is not

accurate. If legalized, more research could be done to provide more evidence and knowledge.

Legalization federally would encourage and accelerate the research of cannabis and its effects

without legal ramifications. As additional states enact laws at the state level, more research can

be done, but not as effectively as if federal law would allow its use. Also, there definitely has

been factual evidence that cannabis does provide therapeutic benefit to varying degrees

depending on how it is administered in the hospice or palliative field, side effects can be more

closely monitored to reduce actual impact. Wilkinson mentions about cannabis having too many

properties and formulas. The positive side of that in the medical field is that using a variety of

compositions, a broader array of treatments can be performed and there are already guidelines

available on how to treat with respect to dosage size, administration, and adapting treatment

based on patient reaction and effectiveness.

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The point about cannabis being a schedule I drug, which labels it as having no therapeutic

benefit is also false. As was mentioned earlier, it does have a varying degree of benefit. The

drug schedule lists many drugs that are rated “safer” than cannabis, such as methamphetamines,

opium, cocaine, and oxycodone. With legalization, the schedule could be reclassified to

unscheduled or at least a schedule III or higher based on its actual benefits and downfalls. The

reason about the approval process and criteria not being the same as drugs has some merit. But

again, hospice and palliative care’s purpose is to provide therapeutic benefit by alternative

treatments for the patients being cared for. Lastly, the stigma surrounding cannabis can help be

changed with legalization because more research would be performed, and people will become

more comfortable with cannabis. The side effects or long-term effects of cannabis that Wilkinson

is concerned with is more applicable to recreational use, but not as prevalent in hospice and

palliative care where contraindications and precautions can properly be taken. Long-term effects

may not always be as applicable to those in this type of care. Wilkinson does have some valid

concerns and points when discussing cannabis for all types of uses, but many of his points are

not accurate or baseless in relation to medical use only. For a more effective article, he should

have discussed recreational and medical use separately for a more effective, balanced argument.

Finally, a personal interview was done with a friend, Shari Caines RN, who has medical

credibility from being in nursing for over thirty years about cannabis and its benefit. She had a

sudden hemorrhagic stroke in the thalamus and she had tried all types of medications to no avail.

She used CBD oil to help with anxiety, mental issues, and pain control. She went on to say how

she still uses it and that some time ago, she would not have considered it a treatment. Now that

she knows more about it, she would recommend it especially to those being cared for in the

hospice and palliative care area. “If a person is educated properly and the uses and
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administrations are appropriate, cannabis can definitely be a strong and helpful alternative

treatment(Caines).

In conclusion, there are definite reasons to legalize cannabis at least for medical use in

the hospice and palliative care field. There are many therapeutic benefits and uses for patients

using cannabis that are being cared for in this field with minimal negative effects. With more

research and knowledge through legalization, things could only get better with insight and

studies. Providing another helpful, alternative treatment to those in need of trying to feel better

and gain hope in relation to how they feel is something worth pursuing. Medical professionals in

these fields are trained to help patients at all times under a watchful eye. The goal of hospice

and palliative care is to help people live as well as possible for as long as possible. Who would

not want to live or provide that opportunity?

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Works Cited

Assaf, Jessica. “A Plea for Cannabis in Hospitals.” Healthcare in America”, 5 January 2018,

https://healthcareinamerica.us/a-plea-for-cannabis-in-hospitals-4497c1048a5a. Accessed

24 April 2019.

Bridgeman, Mary Barna; Abazia, Daniel T. “Medicinal Cannabis: History, Pharmacology, and

Implications for the Acute Care Setting.” Ncbi.nlm.nih.gov, vol. 42, no. 3, 2017, pp. 180-

184, 186. www.ncbi.nlm.nih.gov/pmc/articles/PMC5312634.

Caines, Shari. Personal interview. 1 April 2019.

Carter, Gregory T.; Flanagan, Aaron M.; Earleywine, Mitchell; Abrams, Donald I.; Aggarwal,

Sunil K. and Grinspoon, Lester. “Cannabis in Palliative Medicine: Improving Care and

Reducing Opioid-Related Morbidity.” American Journal of Hospice and Palliative

Medicine, 28 Mar. 2011, pp. 297-302. www.ajh.sagepub.com/content/28/5/297.

Chan, Alex; Iglesias, Miguel; Molloy, Luke; Pertile, Joy. “A review for Australian nurses:

Cannabis use for anti-emesis among terminally ill patients in Australia.” Australian

Journal of Advanced Nursing, vol. 34, no. 3, 2017, pp. 43-44.

Cyr, Claude; Fernanda Arboleda, Maria; Aggarwal, Sunil Kamar; Balneaves, Lynda G.;

Daeninck, Paul; Neron, Andre; Prosk, Erin; and Antonio Vigano. “Cannabis in Palliative

Care: Current Challenges and Practical Recommendations.” Annals of Palliative

Medicine, Vol. 7, No. 4, October 2018, pp. 463-473,

dx.doi.org/10.21037/apm.2018.06.04.
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A Life of Its Own: The Truth About Medical Marijuana. Directed by Helen Kapalos. Ronin

Films. 2017. Netflix, www.alifeofitsown.com.au.

Mendoza, Kelly S., and Mary Lynn Mcpherson. “Knowledge, Skills, and Attitudes Regarding

the Use of Medical Cannabis in the Hospice Population: An Educational Intervention.”

American Journal of Hospice and Palliative Medicine, vol. 35, no. 5, 2017, pp. 759–760,

doi:10.1177/1049909117738246.

Uritsky, Tanya J.; McPherson, Mary Lynn and Pradel, Francoise. Journal of Palliative Medicine,

vol. 13, no. 12, 2011, pp. 78-83, doi: 10.1089.jpm.2011.0113.

Wilkinson, Samuel T. “Medical and Recreational Marijuana: Commentary and Review of the

Literature”. Missouri Medicine, vol. 110, no. 6, 2013, pp. 524-528.