Cannabis May Help Manage Cancer-Related Symptoms and AEs, But Clinical Research Remains a Challenge

An expert weighs in on the advantages of cannabis treatment for patients with cancer, and how nurses can help patients navigate the cannabis-oncology space, in spite of certain research limitations.

Medical cannabis can help alleviate adverse events from cancer treatment, like vomiting, nausea, appetite loss, and sleeping difficulty, explained Eloise Theisen, RN, MSN, AGPCNP-BC. Unfortunately, due to a lack of federal standardization for medical cannabis, navigating the cannabinoid system can be a challenge for nurses and patients alike.

Theisen, current president of the American Cannabis Nurses Association (ACNA), recently spoke to Oncology Nursing News® about the appeal of medical cannabis for patients with cancer, as well as transparency on cannabis use between patients and providers, and the direction she hopes to see in cannabis research in the coming years.

Oncology Nursing News®: What are some reasons that medical cannabis might be appealing to patients with cancer?

That's a great question. And it's a question I get a lot. Often when patients come to see me in my private practice, it's because they're looking for something to help manage their symptoms that are either related to the cancer treatment or the cancer itself. It may be because they're not getting the relief that they want from traditional therapies. They may be looking for something “more natural,” or they have family members who are insistent that they consider cannabis as a treatment option.

What are some of the advantages to cannabis as opposed to a more traditional treatment option?

We have limited research in some areas. The areas that we have really good data are with nausea and vomiting, appetite loss, chronic pain, [and] sleep. We're starting to see more research come out around chemotherapy-induced peripheral neuropathy. And one of the advantages of working with cannabis is you can really personalize the treatment plan to the patient's needs and goals. So, there's a lot of flexibility [and] there's a lot of individuality. It really allows patients to find a dose that may produce the best benefit with the least amount of side effects.

Do you believe that there might be some patients who might be interested in medical cannabis, but are nervous to ask their providers about it out of fear of the stigma?

Yeah, actually, that happens quite a bit. You know, I've been doing this work since 2013. And I've seen an evolution of how patients have come to cannabis. And there are still some that really struggle with the stigma; they're afraid that their health care provider will judge them or potentially no longer treat them if they are using it or want to use it. And we've found that, in some states, oncology providers are more favorable to their patients using cannabis, but many of them are unsure of dosages or side effects, or even different profiles to recommend to their patient. So many patients, unfortunately, end up looking to dispensary staff or “Dr. Google” or [even] friends or family to start their treatment. I always encourage [patients] to start the conversation with their health care provider, even if that health care provider doesn't know a lot about it. At least there's some transparency there.

For health care professionals looking for resources for dosage, what might be some good first steps?

Dosage is one of those things. It's very individualized and personalized, and it's an area of research that we're lacking. We don't have good double-blind, placebo studies to demonstrate what dosage should be applied for what condition.

At the American Cannabis Nurses Association (ACNA), our mission is to help educate health care professionals, particularly nurses, on the endocannabinoid system. We also have the National Council of State Boards of Nursing, who issued guidelines in 2018 on how to care for the patient using medical cannabis. We also have resources through the American Cannabis Nurses Association that we've vetted. It is challenging right now to find programs that are evidence based. And that's part of the work that the American cannabis nurses does as well. All of our companies that we work with are vetted to make sure that they're evidence based and [have] reliable information, because there's so much misinformation out there. We want to make sure that people get the right information.

Can you discuss some of the work that your organization does to try and obtain these evidence-based answers?

We've been around since 2010 and we are now about 1,500 members strong, predominantly in the United States, in all 50 states. We also have a couple members outside of United States, like the United Kingdom and Canada. And again, our mission really is to educate, collaborate, increase research, and partnerships. We do a lot of vetting around products, manufacturers, different sponsors, and education, to really ensure that, again, members are getting the most accurate and up-to-date information. We're also doing a lot of work to become an anti-racist organization, because a lot of the history in cannabis is rooted in racism, and prohibition as well.

We’re largely focusing on education because about 60% of our members consider themselves novices when it comes to cannabis. We really want to provide that foundational information to them so that they can become more empowered to talk to their patients or health care providers, lobbyists, etc. So, we're trying to educate our members, as well, on a lot of the political challenges out there around cannabis.

In states where medical cannabis is legal, what is the process like for patients to get that recommendation or prescription and then to get the actual product?

Well, it's not universal. It's not standardized. It really depends on what the state has determined to be a qualifying condition. We have 36 states, plus the District of Columbia, that have a medical cannabis program. And they vary. Some states like Oklahoma and California, that have medical programs [that] essentially allow anyone to qualify if that physician feels that their condition would benefit from the use of cannabis. And then we have other states like Texas, where they have a medical program that's incredibly restrictive, and only a few qualifying conditions. You can always check out the state website to determine whether somebody qualifies or not.

Then we have 18 states and the District of Columbia that allow for adult use, which also makes it [for] anybody over the age of 21 [who] can access it. But of course, most of those people are using it for symptom management because of an underlying health condition, but they're not getting medical guidance. So, it is challenging, overwhelming, and confusing for patients right now to navigate the space for sure.

What tips or advice would you give to these patients who are attempting to navigate the space?

Look for qualified health care professionals in their area that are knowledgeable in cannabis and the endocannabinoid system. There's a growing group of providers that have the specialized knowledge. I would really discourage them from using the internet to try to figure out what they need. There are some trusted sources out there are some nonprofit organizations that are dedicated to helping patients specifically like leaf411.org, and projectcbd.org. These are organizations that are consumer facing that are trying to help patients navigate the space and they do it free of charge.

Is there any research that you’ve seen that you are excited about?

We did have the National Academy of Sciences, Engineering, and Medicine report come out in 2017. They looked at over 10,000 peer reviewed studies. And they did publish their recommendations. They found conclusive evidence that cannabinoids are effective for chronic pain in adults. And they listed their report, you can also find where there's moderate evidence for sleep and other conditions. It also talks about some of the adverse effects, that you can get from using cannabinoids.

But I'm most excited to see the evolution of research. We are anticipating in the next few years, either for decriminalization or legalization at the Federal level, which will really open up our ability to research. We did see the DEA come out and say that they will start allowing researchers to use cannabis that is sold in dispensaries versus the cannabis that's grown by the government because there's a huge difference in the potency and the quality. So, we're going to start to really see, when patients are using these products from dispensaries, what the risks and benefits are of those products.

Should nurses be monitoring their patients for specific adverse events if they are taking medical cannabis?

It all depends on dosing. Cannabis has a biphasic or bidirectional effect. So low doses can produce 1 effect and a large dose can produce the opposite. So, you know, we always want to monitor our patients for adverse effects and whether or not they're receiving any benefits. Often, we will see many side effects, but we should always be monitoring for increased depression, increased anxiety, potential psychosis, or any suicidal ideation. Those are some of the adverse effects that we can see. There's also a condition called cannabinoid hyperemesis syndrome, where a chronic user can start having vomiting like cyclical vomiting. So those are other things that we want to monitor our patients for. And [also] make sure it's working because it's expensive, [and patients] don’t get insurance coverage for it. So, if the benefit is not there, we should really be encouraging them to discontinue their use.

And is there anything else that I haven't asked you that you feel would be useful for oncology nurses to know?

Our patients are using it. So, it's really important that we become educated on the endocannabinoid system so that we can help patients navigate this because right now, they really are relying on the internet or dispensary staff and we want to make sure that they get the most current, up to date evidence-based information so that they can be making informed choices and not potentially increasing their harm.