After a successful surgery to remove a cancer-ridden section of Jeff Moroso’s large intestine in the spring of 2013, the oncologist sat down with his patient to prepare him for what would come next: 12 rounds of punishing chemotherapy, once every two weeks for six months—standard practice for the treatment of colon cancer.
Moroso’s oncologist spent most of that appointment writing prescriptions for medications he said would minimize the debilitating side effects of chemotherapy. He gave Moroso scripts for ondansetron (Zofran) and prochlorperazine (Compazine) for nausea, and lorazepam (Ativan) for anxiety and insomnia. Because the nausea drugs are known to cause gastrointestinal problems and headaches, he also recommended three over-the-counter medications for constipation and one for diarrhea, as well as ibuprofen for pain. In total, he instructed Moroso to take more than a dozen prescription and nonprescription drugs and supplements.
Moroso says the first three rounds of treatment were more awful than he could have ever imagined. After chemotherapy, he felt so ill and weak that he could barely stand up, and it took him days to rebound. And the prescription drugs just made him feel worse. “I felt real sick, incapable of doing anything except for lying there and trying to hang on,” says Moroso, who is 70 and now cancer-free.
Moroso couldn’t afford to lose days of work while he was doing his chemo. He’d heard from friends and read in the paper that cannabis can help a patient through chemotherapy, so he got a letter from his oncologist that allowed him to obtain medical marijuana. (He chose coffee beans infused with 5 milligrams of cannabis, a low dose that he took when he felt he had to.) By the seventh round of chemotherapy, Moroso had dumped his prescription pills. “I would get blasted on the stuff and be happy as a clam, no problems,” he says.
A growing number of cancer patients and oncologists view the drug as a viable alternative for managing chemotherapy’s effects, as well as some of the physical and emotional health consequences of cancer, such as bone pain, anxiety and depression. State legislatures are following suit; medical cannabis is legal in 23 states and the District of Columbia, and more than a dozen other states allow some patients access to certain potency levels of the drug if a physician documents that it’s medically necessary, or if the sick person has exhausted other options. A large number of these patients have cancer, and many who gain access to medical marijuana report that it works.
“A day doesn’t go by where I don’t see a cancer patient who has nausea, vomiting, loss of appetite, pain, depression and insomnia,” says Dr. Donald Abrams, chief of hematology-oncology at San Francisco General Hospital and a professor of clinical medicine at the University of California, San Francisco. Marijuana, he says, “is the only anti-nausea medicine that increases appetite.”
It also helps patients sleep and elevates their mood—no easy feat when someone is facing a life-threatening illness. “I could write six different prescriptions, all of which may interact with each other or the chemotherapy that the patient has been prescribed. Or I could just recommend trying one medicine,” Abrams says.
A 2014 poll conducted by Medscape and WebMD found that more than three-quarters of U.S. physicians think cannabis provides real therapeutic benefits. And those working with cancer patients were the strongest supporters: 82 percent of oncologists agreed that cannabis should be offered as a treatment option.
Dr. Benjamin Kligler, associate professor of family and social medicine at Albert Einstein College of Medicine, says there has been enough research to prove that at a bare minimum cannabis won’t actually harm a person. In addition, “given what we've seen anecdotally in practice I think there's no reason we shouldn't see more integration of cannabis in the long run as a strategy,” he says. “We have this extremely safe, extremely useful medicine that could potentially benefits a huge population.”
Some years ago, Dr. Gil Bar-Sela, director of the integrated oncology and palliative care unit at the Rambam Health Care Campus in Haifa, Israel conducted two rounds of phone interviews with 131 cancer patients who used cannabis while in chemotherapy; just less than 4 percent of participants reported that they experienced a worsening of symptoms when they started using cannabis and the majority said it helped, according to the resulting paper published, in Evidence-Based Complementary and Alternative Medicine in 2013.
But self-reported data like this is limited when it comes to proving the clinical impact of cannabis. Patients may be biased in their opinions that cannabis is effective, may not accurately document their use of the drug, or may confuse the effects with those of the cancer treatment. In addition, symptoms such as pain are subjective and difficult for a physician to measure.
A paper published recently in JAMA analyzed the findings of 79 studies on cannabinoids for a variety of indications, including nausea and vomiting from chemotherapy, appetite stimulation for patients with HIV/AIDS, chronic pain and multiple sclerosis, among other conditions. This review, which accounted for 6,462 patients, found most who used cannabinoids reported improvements to symptoms compared with patients in placebo groups. However, the researchers say these improvements were not statistically significant. The analysis also indicated that cannabinoids had limited impact on symptoms of nausea and vomiting, and a number of patients reported adverse effects from the drug, including dizziness, disorientation, confusion and hallucinations.
Perhaps the biggest challenge in understanding marijuana stems from the fact that it is not a bespoke drug designed to act in a specific way on the body — it's a complex plant that appears to provide a wealth of health benefits. The cannabis sativa plant contains more than 85 cannabinoids, a variety of chemical compounds that also exist in the body. Just as opioid pills activate the opioid receptors (and limit a person’s perception of pain), cannabinoids in marijuana activate the cannabinoid receptors, located throughout the body, including in the brain, liver and immune system.
To date, we really know about only two of these cannabinoids: tetrahydrocannabinol and cannabidiol. Research into THC and CBD has led to the development of drugs such as dronabinol (Marinol), a synthetic cannabinoid approved by the U.S. Food and Drug Administration for nausea and vomiting from chemotherapy and as an appetite stimulant, anti-nausea and anti-pain medication for AIDS patients. Nabiximols (Sativex), another cannabinoid drug, is THC and CBD that is derived from the plant and delivered as a mouth spray. It’s available in Europe and several other countries—but not yet FDA-approved—for multiple sclerosis patients to treat neurological pain and spasticity. One study on nabiximols for the treatment of cancer-related pain produced disappointing results. However, the GW Pharmaceutical Company, the maker of Sativex, is pushing through with further trials to evaluate the drug as a potential adjunctive therapy for opioids for pain management in patients with advanced cancer.
But how other cannabinoids work together is still much of mystery, says Dr. David Casarett, a professor of medicine at the University of Pennsylvania’s Perelman School of Medicine and the author of Stoned: A Doctor’s Case for Medical Marijuana. This means researchers aren’t entirely sure why the plant could help people manage symptoms like nausea and pain. “Marijuana is not as much of a science as it should be,” he says.
In large part, says Casarett, that’s because medical marijuana has proved to be most effective in palliative care, the medical specialty that focuses on managing symptoms of disease and improving a patient’s quality of life—and there is very little funding for palliative care in this country. “That's changing slowly,” he says, “but it's still much easier to get funding to test disease-modifying treatments than it is to develop and test palliative therapies, including cannabis.”
We are starting to get some idea of the palliative power of cannabis, Abrams says. “The reason we think we have this whole pathway of the receptors and the endocannabinoids is to get us to forget things, and particularly to get us to forget pain,” he says. In addition, cannabinoids relieve symptoms of nausea because that’s also a physiological reaction stemming from the central nervous system.
With the public perception of marijuana changing rapidly, barriers to studying the plant’s medicinal potential are beginning to fall. Earlier this spring, for example, the Obama administration announced it would remove some of the restrictions on medical marijuana research. In the meantime, though, it is clear that marijuana has a unique and important role to play in cancer care.
“People are realizing that even when patients do well in terms of survival, there’s a lot of suffering along the way that needs to be addressed,” says Casarett. “For many patients, [marijuana] is an opportunity to take control over their disease and symptom management when they can't get the relief they need from the health care system.”