Feb 12th, 2020
By Carey S. Clark, PhD
A landmark study by Rowland, Schumann, and Hickner (2010) found that earlier initiation of palliative care leads to better outcomes for patients with aggressive non-small cell lung cancer. The oncology patients who received earlier palliation, defined as palliation initiated at onset of treatment (or in this case within 8 weeks of initial diagnosis), had higher quality of life scores, lower prevalence of depression, less aggressive care overall (including less futilely aggressive use of chemotherapy within the last two weeks of life), and an average increase of lifespan of over around 2.7 months compared to those who did not receive palliative care. While these patients were offered traditional forms of palliation, as cannabis nurses, we are called upon to explore the role of cannabis as a palliative medicine for people with aggressive and severe medical conditions.
About 60% of all persons could benefit from palliation before they die, yet many people do not receive palliation early in the course of their treatment (Aggarwal, 2016). Palliative care is a multi-disciplinary approach to providing impeccable symptom management and supportive care for patients and their families facing serious and potentially life-limiting illnesses (Aggarwal). This paper will explore why cannabis should be included in palliative care efforts, and the role of the cannabis nurse in supporting oncology patients’ palliation through the use of cannabis.
Why Cannabis for Oncology Palliation?
The mainstream allopathic model of oncology care has historically failed to address the power of cannabis for palliation, but this is beginning to change as we move toward earlier palliation for patients. The Hospice and Palliative Nurses Association (HPNA) (2014) acknowledged that nurses must understand the evidence base of medical use of cannabis and cannabinoids to treat patients who suffer from cancer, HIV, and cachexia. Furthermore, HPNA stated that hospice and palliative nurses should be providing their patients with information, evidence-based resources, and education on the use of cannabis to manage their symptoms. Of course, the issue of educating folks around cannabis has some complexity, related directly to cannabis prohibition and the difficulty with researching cannabis as a cancer treatment and palliation option due to Drug Enforcement Agency (DEA) schedule issues; this is more true in the states where medical or recreational use remains prohibited.
Preclinical evidence has suggested that cannabinoids, in addition to palliation, enhance the anti-tumor activity of allopathic chemotherapeutic agents and decrease associated side effects, so the addition of cannabinoid-based preparations to standard cancer therapy should not be discouraged by treating oncologists (Abrams & Guzman, 2015). Cannabis nurses are likely aware that animal studies show that cannabis holds great hope and promise for treating many types of cancer, from skin cancers to lymphomas and neoblastomas. We are also aware that cannabis can be used to support successful palliation for cancer patients regardless of the types of treatment they pursue (Hall, Christie, & Currow, 2005). One of the primary responsibilities of cannabis nurses must be the empowerment of other nurses and providers, expanding the knowledge base of how cannabis supports not only cancer treatment but also, more specifically, palliation during oncological treatments. With the current concern about opioid use and addiction, even in palliation scenarios, cannabis may be a medicine of the future for supporting patients through serious medical crises.
Cannabinoid Integrative Medicine
Aggarwal (2016) suggested that we move toward the term “cannabinoid integrative medicine” (CIM) to describe cannabis use in combination with traditional allopathic treatments. Δ9-tetrahydracannabinol (THC) and other cannabinoids help to improve appetite, reduce nausea and vomiting, muscle spasms, cachexia, and alleviate severe pain (Aggarwal, 2016: Hall, Christie, & Currow, 2005). With nausea and vomiting, THC alone is fairly ineffective at controlling symptoms (think of the mediocre success of the synthetic version of THC, Marinol, with chemotherapy-associated symptoms) and we need to move toward whole plant preparations, as has been done in Canada. Although Canada allows for whole plant cannabis extract of 1:1 ration of Δ9-tetrahydrocannabinol-to-cannabidiol for import and use by pain patients, they also have stated that dried cannabis flowers are not an approved medicine. While this approach continues to distance patients from the source of healing, which is the cannabis plant itself, it also allows for cannabis to gain a perhaps more acceptable fit within the traditional allopathic approach to cancer and pain palliation.
Several studies using a CIM model for palliation with oncology patients point toward success. A study in Israel demonstrated that medical cannabis use by 131 patients undergoing oncological treatment showed that, over the course of the 8-week study, all cancer treatment-related symptoms were improved, including nausea, vomiting, anorexia, weight loss, constipation, pain, and mood disorders (Bar-Sela et al, 2013). A retrospective study in Israel that examined 17,000 authorized medical cannabis oncology patients found that they showed improvements in pain management (70% of patients), general well-being (70% of patients), appetite (60% of patients), and nausea (50%) (Waissengrin, Urban, Leshem, Garty, & Wolf, 2015). Both of these studies contribute to our understanding of cannabis as an appropriate palliative medicine for oncology patients.
Spiritual Care and Suffering
Aggarwal (2016) posited that the use of cannabis, and its associated feelings of euphoria, well-being, aversive memory extinction, sensory heightening, and spiritual insights could support those facing severe or life-threatening illnesses and their related treatments. We must also consider how CIM could address the psychological trauma associated with receiving a fatal or serious illness diagnosis. Heightened senses created by cannabis ingestion can facilitate the suffering patient into a here-and-now presence, supporting the patient’s ability to enjoy the moment, enhance their knowledge of personal spirituality, and promote quality of life at the end of life (Aggarwal).
The Nurse’s Emerging Role in Palliative Cannabis Integrative Medicine
As cannabis nurses, we are called upon to both create and support the necessity of our call toward “every cannabis patient deserves a cannabis nurse.” What can nurses do to support patient’s palliative needs as they approach oncological treatments? The following outlines some basic ideas regarding CIM and palliation for cancer patients.
Cannabis nurses need to educate themselves, other providers, and the populations we serve about how cannabis works, with particular consideration given to the needs of oncology patients’ care. Cannabis nurses need to acquire and refine their personal knowledge of the endocannabinoid system (eCS), endocannabinoid deficiency syndrome, and CIM as both a palliative tool and a potential treatment for cancer. Cannabis nurses need to have a level of comfort with discussing cannabis as a treatment and palliation option for oncology patients, and this begins with a movement toward finding safe places in healthcare to speak knowledgeably about cannabis without fear of losing our livelihoods. Cannabis nurses need to feel empowered to work as consultants with cancer and palliative care patients in the states where this activity is allowable. Cannabis nurses will generally have to seek cannabis education outside of mainstream academic settings, while also calling for our university and colleges to educate nurses and providers on the role of cannabinoids within treatment, healing, and wellness.
CIM-CIN, Palliation, and Holistic Modalities
I have met many cannabis nurses who are interested in holistic nursing modalities, as we tend to recognize that the body’s healing processes are complex. Holistic modalities such as yoga, meditation, and reiki help to decrease the stress response and support psychoneuroimmunological health, a requisite for all healing processes (Clark, 2014). Supporting patients’ ability to manage stress and lead a life of wellness is an aspect that adds depth to CIM, or perhaps supports an emerging field of cannabis integrative nursing (CIN).
CIN would consider the whole person who is facing the oncological treatment process and palliation. In addition to supporting patients with proper cannabis use, providing evidence-based information about dosages, strains, and safe use of medicine, supporting their journey through kindness, caring, compassion and presence, the cannabis nurse is ultimately concerned with patients’ spiritual well-being and supporting humans through and beyond their suffering. The practice of CIN would include use of holistic modalities to support patients’ total well-being, including meditation, yoga, art therapy, aromatherapy, reiki, therapeutic and healing touch, massage, acupuncture, acupressure, shiatsu, herbalism, diet therapy, supportive exercise, being in nature, laughter therapy, guided imagery, progressive muscle relaxation, taiji, qi gong, hypnotherapy, homeopathy, and movement therapies.
To be effective in supporting palliation, the cannabis nurse practicing CIN will be comfortable with their own spirituality and will strive to support patients in their spiritual growth and evolution. We must acknowledge the presence of a cannabis consciousness, and strive to understand better and explicate our human relationship with the sacred plant and its healing powers. Successful cancer treatment is related to a sense of emotional authenticity, and the cannabis consciousness can help to diminish negative outlooks, enhance optimism-gratitude-happiness, release suppressed and repressed emotions, promote self-acceptance, overcome resistance to healing, and promote acceptance of the disease as a divine message to heal oneself (Bleshing, 2016).
In 1971, Carl Sagan wrote:
“When I’m high I can penetrate into the past, recall childhood memories, friends, relatives, playthings, streets, smells, sounds, and tastes from a vanished era. I can reconstruct the actual occurrences in childhood events only half understood at the time. Many but not all my cannabis trips have somewhere in them a symbolism significant to me which I won’t attempt to describe here, a kind of mandala embossed on the high. Free-associating to this mandala, both visually and as plays on words, has produced a very rich array of insights.”
The CIN role would support patients in undertaking this introspective type of work that supports healing on a deep, spiritual-consciousness level.
The realm of CIN and our role as cannabis nurses in oncology and palliative care is just now emerging. As we begin to move toward recognizing cannabis as an accepted medicine for supporting palliation during intense oncological treatments, let us not forget our role as genuinely holistic cannabis nurses. We can strive to ensure that every patient has not just a nurse to guide their cannabis journey, but a nurse who can support their total holistic healing, and, in concert with the sacred herb cannabis, ameliorate suffering and enhance the evolution of the spirit.
Carey S. Clark, PhD, RN, AHN-BC, FAAN, serves as Director of Nursing, chair of the Medical Cannabis Certificate Program, and faculty in the Medical Cannabis and Holistic Nursing programs. She is the immediate Past President of the American Cannabis Nurses Association, and has been a nurse since 1994, with a wide practice background including experience within the acute care setting, pediatrics, hospice care, and parish nursing. Her previous position was at the University of Maine at Augusta, where she developed an award winning holistic-integral nursing program for RN-BSN students. Dr. Clark has over 30 publications in journals such as Advances in Nursing Science, International Journal for Human Caring, Holistic Nursing Practice, and Creative Nursing.
Dr. Clark has presented at many national and local conferences, particularly with oncology and holistic nurses, where she focuses on bringing basic knowledge about the endocannabinoid system and medicinal use of cannabis. She remains committed to including the endocannabinoid system in every nursing curriculum in the world, as she is the editor of the forthcoming Wolters-Kuhlwer Cannabis Handbook for Nurses (2020). Dr. Clark looks forward to sharing her knowledge with other like-minded nurses as we create change in healthcare systems and support the holistic healing of those we serve.
Abrams, D.I. & Guzman, M. (2015). Cannabis in cancer care. Clinical Pharmacology Therapy, 97, 575-586.
Aggarwal, S.K. (2016). Use of cannabinoids in cancer care: Palliative care. Current Oncology, 23 (Supp2), S33-S36.
Bar-Sela, G., Vorobeichik, M., Drawsheh, S., Omer, A., Goldberg, V., &Muller, E. (2013). The medical necessity for medicinal cannabis: prospective, observational study evaluating treatment in cancer patients on supportive or palliative care. Evidence Based Complementary and Alternative Medicine, 1-8. doi: 10.1155/2013/510392.
Bleshing, U. (May, 2013). Nine ways to deepen healing with cannabis and consciousness. Waking Times.
Clark, C.S. (2014). Stress, psychoneuroimmunology, and self-care: What every nurse needs to know. Journal of Nursing and Care, 3, 146.
Hall, W., Christie, M., & Currow, D. (2005). Cannabinoids and cancer: Causation, remediation, and palliation. Lancet Oncology,6, 35-42.
Hospice and Palliative Nurses Association. (2014). HPNA position statement: The use of medical marijuana.
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Sagan, C. (1971). Marijuana Revisited.
Waissengrin, B., Urban, D., Leshem, Y., Garty, M., &Wolf, I. (2015). Patterns of use of medical cannabis among Israeli cancer patients: A single institution experience. Journal of Pain Symptom Management, 49, 223–230. doi: 10.1016/j.jpainsymman.2014.05.018