Cancer & Cannabis

by Joel Meshulam, M.D.
Dr. Meshulam is a practicing internist at Mercy Medical Center in downtown Baltimore.  He has been seeing patients for cannabis consultations since February of 2018.  More than 90% of his consultations are done with patients who have either never used cannabis or haven’t used it in decades before their consultations. His passion is in large part related to the fact that his uncle, Professor Raphael Mechoulam (still alive and actively researching at 88), pioneered this area of research.  Professor Mechoulam works tirelessly to encourage that more clinical trials be performed to gain greater understanding on how this plant and its derivatives can be used to treat persons afflicted with a host of diseases, including cancer.
Although still federally illegal, cannabis is now either medically or fully legal in 35 states and the District of Columbia.  Increasing scrutiny is being placed on both the potential benefits and negative effects of the cannabis plant. 
Patients with a multitude of illnesses, including cancer, are reasonably questioning whether they might enjoy a benefit from this highly medicinal natural “weed.”
Human beings have been using cannabis for religious, medicinal, and recreational purposes for thousands of years.  That alone should be a reason to look at cannabis as a possible treatment.
Patients will often ask me, “Dr. Meshulam, could cannabis help me with…”.  You can fill in the blank for yourself.  My answer is always, “Maybe, but it will not cause you lasting harm.”
Before I discuss use of this plant for management of cancer related pain, treatment related pain and side effects, or cancer itself, I’d like to make a few things clear.

Demystifying Cannabis

First, a patient can use cannabis, as well as oils and balms made from the plant, without getting high. 
Many cannabis detractors scoff at this idea, but I assure you that they shouldn’t.
Cannabis and its major therapeutic compounds, delta-9 tetrahydrocannabinol (THC) and cannabidiol (CBD) (as well as its many so-called minor ones), can be extremely effective when micro-dosed.  These doses are well BELOW the dose needed to cause psychoactivity (feeling high).
Second, as I alluded to in the paragraph above, there are many ways to use cannabis without smoking or inhaling it.
Third, no human or animal has ever died of a cannabis overdose.
It is possible to have an “overdose” from cannabis.  One can become uncomfortably “high”; have anxiety, paranoia, or even psychosis; feel their heart race; have nausea and vomiting.
These effects are very infrequent, and generally resolve without lasting impairment in a matter of hours.
One could also die under the influence of cannabis if they are acting irresponsibly (much as they could if they were driving under the influence of alcohol).  BUT, the plant itself cannot kill you.
Fourth, cannabis does NOT work for everyone.  No medication or treatment does. 
Those who might sing the praises of cannabis, without admitting this fact, should be regarded with at least a moderate degree of skepticism and caution.
When I meet with a patient dealing with cancer or side effects from chemotherapy or radiation, my first question is, “What are your goals for our meeting today?”
The answers are varied.  Some patients are understandably wondering if cannabis has anti-tumor effects (it does).
Others are experiencing nausea, vomiting, anorexia, weakness and weight loss (cannabis can help with all of these unpleasant symptoms). 
They may also be having symptoms related to neuropathy or treatment induced pain. 
Cannabis can also be beneficial for those problems as well.  Let’s briefly address each of these questions.
While the exact mechanism has not been fully elucidated, both THC and CBD have been shown to cause apoptosis, or the death of cancer cells.
There are numerous scholarly articles and individual case studies showing seemingly miraculous regression or remission of cancers in patients who turned to cannabis when other treatment modalities had failed.
Some of these cases are in patients who had been looking for palliation and instead saw improvement not only in their quality of life but also in their tumor burden.  High doses of CBD can be particularly effective in this way.
Two of the “lesser phytocannabinoids,” cannabinol (CBN), and cannabigerol (CBG) also show promise when it comes to antitumor effects.
Progress with these compounds has been slowed by the unfortunate schism between federal law stating that cannabis is Schedule 1 (illegal and without medicinal benefit) and the majority of states that find themselves in stark disagreement with that designation.
Also, because of its federally illegal status, not to mention the fact that the FDA does not approve the use of cannabis for the treatment of ANY medical condition, these compounds are not covered by insurance.
The cost for higher doses of CBD needed to potentially kill cancer cells can be prohibitive for many patients.

Pain & Other Symptom Management

When it comes to loss of appetite, nausea, weakness, pain, and depression related to cancer, cannabis provides an attractive option, often with fewer side effects than medications prescribed by a primary care provider or an oncologist.
THC is a potent appetite stimulant, not to mention pain reliever.  Studies have shown that cannabis (and THC) can be used in tandem with opiate medications, leading to lower doses of opiates, often with superior pain control.
In my practice, I have had numerous patients completely weaned from their opiates, or managed on much lower doses.
Those who enjoy the “recreational” effects of the plant report that while they still have pain, it no longer prevents them from enjoying other elements of their lives, freeing them from the dominant role that pain used to play in their day to day existence.
Lowering the dose of an opiate almost invariably leads to less constipation and fatigue caused by this class of medications, which are also known to cause depressed mood and restless sleep.
Both THC and CBD can be beneficial for depression, anxiety, and insomnia.  In many cases, a patient can use small doses of tinctures derived from cannabis (dosed sublingually or under the tongue) to achieve all of these effects.  There are tinctures that are made solely to help with sleep.
When effective, these treatments can reduce the need for other medications (sedatives as well as antidepressants).
Neuropathy, or nerve pain, is a common side effect of many chemotherapy protocols.
Topical balms and salves derived from the cannabis plant can be applied directly to affected areas (typically the feet and hands) to lessen the severity of this type of complaint, as well as localized joint pains related to inflammation or arthritis.

Inhaled Cannabis

Think of inhalation like an intravenous dose of medication (quick onset, quick peak, and quick dissipation of the dose).
Because of this, inhaled cannabis can be extremely effective for spikes of symptoms (think severe pain, nausea, panic attacks, migraines, difficulty getting to sleep).
Not all cannabis is high in THC, so the “high” from an inhaled dose may not be as significant as one might expect.
The negatives of inhaled cannabis, as I see them, are two: First, it is hard to standardize the dose (One second inhalation? Two second inhalation? How deeply and vigorously is the patient inhaling?).
Second, because the dose is short acting, it becomes unrealistic (for many) to use an inhaled dose every 3-4 hours while trying to remain integrated into the rest of their lives (family, friends, or work).
No two of us are alike, so cannabis will affect everyone differently.
If you choose to look toward cannabis as an option for your multidisciplinary treatment plan, remember to have patience.
If one particular plant or treatment protocol does not work, don’t give up.
When your doctor treats you with a pharmaceutical compound, most of which are just a single chemical, the only variable is the size of the dose.
Any particular cannabis plant will have more than 250 compounds in it (cannabinioids, terpenes, and flavonoids – the latter two categories found in a host of other medicinal plants).  Tinctures can be made with an infinite number of ratios and iterations.
If your first pass at symptom relief isn’t terribly effective, you may have to switch one or more elements of what you are doing.
Success will depend on having a working knowledge of how this medicine works, and a physician or other cannabis recommending practitioner willing to help guide you as you try to find the best answers.


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