Sampling from Library: Cannabis in Palliative Medicine: Improving Care and Reducing Opioid-Related Morbidity
American Journal of Hospice and Palliative Medicine 2011; 28(5) 297-303.
Gregory T. Carter, MD, MS
Aaron M. Flanagan, MD
Mitchell Earleywine, PhD
Donald I. Abrams, MD
Sunil K. Aggarwal, MD, PhD
Lester Grinspoon, MD
Unlike hospice, long-term drug safety is an important issue in palliative medicine. Opioids may produce significant morbidity. Cannabis is a safer alternative with broad applicability for palliative care. Yet the Drug Enforcement Agency (DEA) classifies cannabis as Schedule I (dangerous, without medical uses). Dronabinol, a Schedule III prescription drug, is 100% tetrahydrocannabinol (THC), the most psychoactive ingredient in cannabis. Cannabis contains 20% THC or less but has other therapeutic cannabinoids, all working together to produce therapeutic effects. As palliative medicine grows, so does the need to reclassify cannabis. This article provides an evidence-based overview and comparison of cannabis and opioids. Using this foundation, an argument is made for reclassifying cannabis in the context of improving palliative care and reducing opioid-related morbidity.
Keywords: cannabis, medical marijuana, opioids, hospice, chronic pain, palliative medicine
Palliative care medicine is a relatively new subspecialty, arising out of a need for better ways to treat patients with advanced, potentially ‘‘life-limiting’’ conditions. As palliative medicine emergences as a sovereign entity, distinctly different from hospice care, more practitioners are broadening the scopes of their practice to include these services. However, this will require a distinct paradigm shift, away from the ‘‘hospice mindset’’ with respect to the way drugs are prescribed, with drug safety becoming an increasingly important issue. When treating pain in a terminal cancer patient, using opioid drugs will typically provide good relief.1 However, in hospice, mortality is a forthcoming and expected outcome. This may not be the case in palliative medicine where the patients seek aggressive treatment for pain yet death may not occur for some time. Here, the successful use of opioids will warrant more frequent patient reassessments and significant pharmacovigilance.
This growth in palliative medicine comes at a time when there have been near epidemic increases in deaths related to prescription of opioid analgesics. 2-13. A number of studies have now clearly linked risk of fatal and nonfatal opioid overdose to prescription use, with the risk increasing with the prescribed dosages. 12-14. According to the Centers for Disease Control and Prevention (CDC), from the years 1999 to 2006, the number of prescription opioid poisoning deaths in the United States (US) nearly doubled, from approximately 20 000 to 37 000. 15 This increase coincided with a nearly 4-fold increase in the use
of prescription opioids nationally.
In 2006, Washington State had a rate of poisoning involving opioid painkillers significantly higher than the national rate.15 A subsequent analysis of overdose deaths involving prescription opioids from 2004 to 2007 revealed that 1668 persons died from prescription of opioid-related overdoses during that time period.15 Nearly 60% of decedents were male, with most deaths occurring in the 45 to 54 years of age range.15 A 7-fold higher death rate was noted among persons enrolled in Medicaid programs, compared to those not enrolled. The opioids most commonly involved in the deaths were methadone (64%), oxycodone (23%), and hydrocodone (14%), which highlights he particular toxicity of methadone.15
Contrast these morbid trends with this well-documented fact: no one has ever died from an overdose of cannabis.16-20 Cannabis has no known lethal dose.16-20 If cannabis-based medicines were more widely used to treat pain, potentially thousands of deaths from opioid toxicity may have been prevented. In the past decade, many states have relegalized cannabis for medicinal purposes.21 This is based on a continually growing body of evidence demonstrating the efficacy of cannabis in treating neuropathic pain, muscle spasms, fibromyalgia, cachexia, among others conditions.21-36 Yet, the laws differ considerably from state to state, with considerable ambiguity as to what constitutes acceptable medical use.23 Despite state laws, the Federal United States Drug Enforcement Agency (DEA) laws, as determined by the Controlled Substances Act (CSA), still classify cannabis as a Schedule I drug, the most tightly restricted category, reserved for drugs that have no currently accepted medical use. Thus, there is uniform set of quality control standards in place to assure the quality, consistency, and availability of medicinal cannabis for patients receiving palliative care.
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To Contact Dr. Aggarwal, please email sunila at uw dot edu