Rethinking End of Life Care: Marijuana vs Opioids
Rethinking End of Life Care: Marijuana vs OpioidsJune 15th, 2018 by Cindy Perlin
Lillian, my closest friend, is gravely ill. For the last two weeks she has been in the ICU hooked up to a respirator. Just a few days before we were at our favorite meeting place, the local Chinese buffet. She was scarfing down her favorite selections and we had no idea this was coming.
By the time I heard about it and got to the hospital, Lillian was hooked up to IVs and breathing tubes. She has COPD (Chronic Obstructive Pulmonary Disorder), in addition to a myriad of other health problems. She also had sepsis, a life-threatening complication from an infection. Her breathing had deteriorated to the point that she could not breathe adequately on her own. Because being on the respirator can be painful, they had her on two pain relievers: Precedex, a drug specifically designed for people on respirators that does not suppress breathing, and fentanyl, a powerful opioid 50-100 times more powerful than morphine that does suppress breathing. Lillian was too sedated to know I was there.
Lillian’s infection was brought under control and her medical team has tried several times to get her off the respirator. Each time the attempt failed—Lillian’s breathing was too weak for her to adequately oxygenate her body on her own. Each time her fentanyl was reduced prior to the attempt so it would interfere less with her breathing. However, fentanyl administered intravenously takes between 11 and 22 hours to fully leave the system. Given Lillian’s deteriorated medical condition, it is most likely that the elimination of fentanyl was taking on the longer side, making it impossible to give her the best chance of breathing on her own without fentanyl’s respiratory suppression.
Now there are only two bad choices: take her off the respirator and let her go, or operate and give her a tracheotomy and feeding tubes.
The heavy sedation is also rendering Lillian unable during what are possibly her last days and hours of her life to spend quality time with her loved ones, who would like the opportunity to communicate what she has meant to them and say good-bye.
There is a better way—medical marijuana. Medical marijuana, also known as cannabis, does not suppress breathing. In dosages that are sufficient to control severe pain, it does not cause the severe sedation that opioids do. It also does not cause constipation or nausea or vomiting—frequent side effects of opioids that can add to patients’ misery.
Marijuana has been shown to be an effective treatment for pain, anxiety, loss of appetite, spasms, sleep problems and nausea. When used along with opioids, it can significantly reduce the amount of opioids required for pain relief, thus reducing the number and severity of side effects.
The fact that marijuana is still illegal under federal law makes it very difficult for hospitals and hospices to use medical marijuana, even in states where medical marijuana is legal. The threat of federal sanctions against these facilities, most of whom receive federal funds through Medicaid and Medicare, is real. In addition, research into marijuana for any medical use has been constrained by federal policy that classifies marijuana as a schedule I drug—highly addictive with no known medical benefits. As a result, most physicians are reluctant to recommend it.
The Wo/Men’s Alliance for Medical Marijuana, a hospice in Santa Cruz, California has been helping patients ease dying using whole plant marijuana since California legalized medical marijuana in 1993 with good results. In 2002, 20 to 30 armed DEA agents appeared with a search warrant at a farm that grew medical marijuana for the hospice. The 250 hospice patients suffered from AIDS, multiple sclerosis, cancer, and other terminal illnesses. Valery Corral, the owner of the farm, also owned the hospice and was herself a medical marijuana patient. The DEA agents entered the farm premises by force, pointed loaded firearms at Valery Corral and her husband, forced them onto the ground, and then handcuffed them. The Corrals were brought to the federal courthouse in San Jose and then released without being charged. DEA agents seized 167 marijuana plants that were the hospice patients’ weekly supply of medication, which resulted in an increase of pain and suffering for the affected patients and hastened the death of some of them. All the hospice patients were prescribed medical marijuana by their physicians in accordance with local laws. In a subsequent court case challenging the federal action, as in all other cases involving medical marijuana dispensaries, the federal law was upheld. Since that time, there has been a significant expansion of support for medical marijuana and some attempts by Congress to constrain the DEA from interfering with state-legal medical dispensaries.
A federally funded study of the use of medical marijuana for end of life care started in 2017 at The Connecticut Hospice, the nation’s oldest hospice. The study uses capsules with a high CBD marijuana extract. The study will enroll 66 patients and run for at least a year. Hopefully, favorable results from this study will help inform saner federal policies on medical marijuana.
In the meantime, if you are able to access medical marijuana for a loved one with a terminal illness, Dr. Paul Bregman, an MD and medical cannabis specialist, says, “There are many strains of marijuana and routes of administration as well as individual variations in dosing requirements. To optimize results, a medical cannabis consult with an experienced clinician is strongly recommended for quality of life issues, especially pain.”
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