An Honest Look at Marijuana and Its Place in Palliative Care
Cannabis, or marijuana, is an ancient plant—one that people have used in some form or fashion for thousands of years. It turns out we humans have an endocannabinoid system with receptors found throughout our bodies, inside and outside the central nervous system, thought to be important for homeostasis and wellbeing in a dynamic world. Discovered recently, in the 1990s, this makes it clear that our species has evolved over eons with these chemicals (there are over 100 known cannabinoids).
Marijuana hasn’t always enjoyed widespread acceptance in modern times, however. It was illegal here in the United States for a long time and on spurious grounds. And there’s still some stigma around it, although that can depend on where you live.
"I believe that marijuana has a place in palliative care, as a tool that can help some of our patients not only cope with suffering but also reframe their perspectives."
But perceptions are changing. Today, thirty-seven states and the District of Columbia now allow the medical use of cannabis products, according to the National Conference of State Legislatures (NCSL). And nineteen states and the District of Columbia allow adults to use cannabis for non-medical purposes.
I believe that marijuana has a place in palliative care, as a tool that can help some of our patients not only cope with suffering but also reframe their perspectives.
The other side of the ledger
Health care in this country is disease-focused. The prevailing medical model tends to pathologize otherwise normal life events, and, as a result, many clinicians have a tendency to view marijuana as beneficial only when it’s being deployed to mitigate physical pain and other symptoms.
"We should be keen, as palliative care specialists, to look for ways in which we can help make our patients’ lives more wonderful, not just less terrible."
But we rarely move to the positive side of the ledger. Quality of life. Optimization. We should be keen, as palliative care specialists, to look for ways in which we can help make our patients’ lives more wonderful, not just less terrible. How fascinating to see euphoria listed as a side effect. We could be much more focused on augmenting our patients’ experiences, not just dimming symptoms or managing the chaos of disease. Of course, we can do both – in fact, wonder and suffering are entwined – but how often have we focused on the optimization piece? Not often enough.
Identity and getting "unstuck"
A great inroads is to talk with your patients about issues of identity. You could ask them questions like, “How did you see yourself before your diagnosis? And how do you see yourself now?” Serious injury or illness – and the fact of becoming a “patient” inside of a complex and disjointed health system – has a tendency to make us forget that we are more than a diagnosis. We may lose sight of ourselves as persons and of the fact that we are not just our wounds or our pain. We can easily become mired or stuck, and that’s scary; unhealthiness of a different kind, at the level of the persona.
As clinicians, we can turn that around. It’s important that we remind people that they are not just bundles of physiological processes, not just a diagnosis. We can help them get unstuck. We can have conversations with our patients about their identities beyond illness. More useful still, we can point to the mutability of identity. We can acknowledge that it is normal to experience existential distress in the face of pain or illness; indeed, in the throes of normal life. You don’t have to be sick to explore meaning and meaninglessness.
"The human penchant for perspective-making is one of our sharpest tools and most certainly under-utilized in the clinical setting."
To these good ends, marijuana can be one helpful tool. By wielding rather than excusing its psychoactive properties, we can alter our points of view. The human penchant for perspective-making is one of our sharpest tools and most certainly under-utilized in the clinical setting. Work with your patients on how they see things―not just on what they see. Often enough, a diagnosis is, among other things, an invitation to revisit how we see ourselves and the world we’re still part of, or to think again about how we’re living, or to strike a playful tone with reality. Not simply thinking our way forward, as an intellect, but feeling our way forward too.
How to make it happen
The field of palliative care field has continued to grow and mature. And one of the ways to continue growing is by opening up to more possibilities for improving quality of life, which just might include the use of marijuana.
In contrast to many pharmaceuticals or consciousness-altering substances, marijuana is a remarkably safe medicine that’s long been widely and routinely used. But, of course, marijuana will not be the right choice for everyone. Some do not like how it makes them feel; it may fuel anxiety, not quell it, or dampen motivation. But if there’s any doubt, where legal, given its wide therapeutic window, a thoughtful trial often makes good sense with little risk. Many of your patients are already doing this, so the therapy here is more a matter of inculcating next-level honest and open communication.
"One of the ways to continue growing [as a field] is by opening up to more possibilities for improving quality of life, which just might include the use of marijuana."
A deep commitment to reality and honesty seem especially key for our field. We want to communicate a non-judgmental attitude toward our patients, regardless of our own personal feelings or experiences with cannabis. If we can’t talk about cannabis as an option for our patients, we need to pause and reflect. Medicine runs into trouble with half-truths, withholding certain pieces of information from patients, or pretending.
We don’t want to fall into this trap. We have to create conditions where our patients feel safe to be forthright with us and expect to get honest feedback from us, too. To be heard and to listen. This should be a personal and professional point of pride for us. If we are honest and open with our patients, and we do it well, we are forever co-developing with our patients.
Access may be a challenge
But I do recognize that access may be a challenge for some of you.
I live and work in California, and access to cannabis products is not a challenge for my patients, but in some states, access is a real challenge. Legal and social landscapes are forever works-in-progress, and no doubt marijuana acceptance will continue to evolve.
In the meantime, if you practice in an area where marijuana is legal, I hope you’ll think about what I’ve written here and the best interests of your patients, especially as they themselves would have it. Marijuana isn’t for everyone, of course, but it could be right for many of your patients who are exploring ways to feel more like themselves again or to change with their circumstances. (Indeed, it already is.)
Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.