The months after a breast cancer diagnosis can be frightening as patients weigh the pros and cons of treatment approaches. Patients may discuss radiation, chemotherapy, mastectomies and reconstruction with their oncologists. These days, there’s another thing that patients might add to that list: cannabis.
Many people who have never tried cannabis before may seek it out while undergoing cancer treatment because they’ve heard it relieves pain, suppresses nausea or stimulates appetite. Yet many oncologists are not willing to discuss marijuana because possessing it remains a federal offense despite its legalization in Washington and Oregon.
“I think patients get in a bad situation,” said Dr. Eric Roeland, a medical oncologist and palliative care specialist with OHSU Knight Cancer Institute. “They have symptoms that aren’t well controlled. They’re feeling desperate. They go to an oncologist who says, ‘I’m not going to talk to you about that.’ ”
This leads to a “don’t ask, don’t tell” situation between patients and their doctors, Roeland said.
But many patients are already using cannabis under the care of a licensed naturopathic doctor or state-certified medical cannabis consultant like Jeff Hickock, who works as a budtender at High End Marketplace in Vancouver and teaches classes about medical marijuana at Clark College. He said it’s uplifting when customers come in and say their pain is gone, but cannabis’ efficacy depends on many variables.
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“In some people, it works so well. In other people, it doesn’t. It’s really person to person and it’s just trying to pinpoint what’s wrong,” Hickock said. “When we look at radiation and chemotherapy, they have terrible detrimental side effects, like nausea, loss of hair and loss of appetite. When cancer patients describe using cannabis, they tell me that as opposed to dying from cancer, they’re living with cancer.”
Cancer patients cannot get a prescription for marijuana, but they can get a medical marijuana card. It’s not necessary to purchase marijuana in Washington but offers some advantages. A card gives the bearer the right to grow a certain number of plants and it may entitle the cardholder to discounts at some dispensaries. It also increases the amount of cannabis that the card-carrier is legally allowed to have, which comes in handy for medical-marijuana users stopped by the police. (The exact amounts of legal and recreational marijuana that a person is allowed to carry can be found at doh.wa.gov.)
Before getting a medical marijuana card, patients must obtain a medical marijuana authorization form.
“In Washington state, there’s a list of conditions that qualify,” said Jason Petersen, a state-licensed naturopathic doctor with Green Wellness Clinic in Vancouver.
Petersen prints out a form from the Washington Department of Health and consults with applicants. Then he checks the boxes noting their diseases and symptoms and signs off on the form. Patients take the signed form to a dispensary and the dispensary issues a medical marijuana card. Some issue it for free, Petersen said, and some charge $10 or $20. Green Wellness charges $175 for a medical marijuana consultation, Petersen said, and it costs $145 to renew the card every year.
Even for those willing and able to pay for it, marijuana is not a one-size-fits-all remedy. What helps some may harm others. What works at a particular stage of treatment for one type of cancer may not work at all for another person with a different type of cancer who is undergoing a different regimen.
“I think that the overwhelming support that the community has around cannabis needs to be tempered,” said Roeland, who does not endorse its medical use.
“Before you start a conversation about use of cannabis, it’s important to figure out why you’re wanting to use it,” Roeland said. “What symptom are you targeting? What is the evidence available for the uses of medical cannabis in this setting? Sadly, the evidence across the board is really poor. Most of that is because the federal government has designated cannabis as a Schedule I drug, similar to cocaine, and you have to have a special license even to do clinical research in this setting.”
Roeland said that marijuana can interact poorly with other drugs like benzodiazepines (Valium, Xanax or Klonopin) and opioid painkillers. He noted that combining drugs can result in “cumulative toxicity” with intensified effects, slowing brain function and triggering extreme fatigue. Older or especially frail patients may suffer confusion or falls that could disrupt cancer treatment altogether. Very high doses of cannabis can, in some people, trigger uncontrollable vomiting, Roeland said.
The way that marijuana is taken into the body is also an important factor. Hickock recommends edibles to first-time users but it can be up to an hour before users feel any effect. Hickock said that some cancer patients choose to smoke or vape because the effects are more immediate.
Roeland said that oncologists generally discourage cancer patients from smoking or vaping. For those who don’t want to risk smoking and can’t wait for edibles to take effect (or are too nauseous to eat an edible), Peterson said suppositories are available.
Whenever and however a cancer patient uses cannabis, Roeland urges caution. A patient may feel no immediate effects, then consume another edible, doubling the dose and producing extreme disorientation or a distressingly long high, he said. Accidentally ingesting, inhaling or absorbing too much cannabis can mean the difference between temporary pain relief and a medical emergency.
“If you want to try it for a symptom, it’s probably OK, but you need to start very low and you need to be clear about what symptom you want to alleviate. You want to be talking to your doctor,” Roeland said. “If you’re using it, let’s try to use it safely. If you have not used it before, using it while you’re on cancer therapy could be risky because your body is so weak and there are many drug-drug interactions.”
Hickock said that some cancer patients do come in and say up front that they don’t want to get high, they just want the pain-relieving or nausea-quelling aspects of marijuana use. He said he’s careful when counseling cancer patients who want to ease into cannabis use and would never go against a medical doctor’s advice. Some strains may be contraindicated because they affect blood pressure, suppress appetite or increase anxiety. Petersen said he has seen varying responses, depending on the person.
“Based on the patients I’ve seen, 95 percent of them, it helps with stress and anxiety, where 5 percent say that it makes anxiety worse,” Petersen said. “If you’re using it medicinally, you should know what your threshold is.”
Before ingesting, smoking or vaping anything, Hickock stressed the importance of using a “clean product,” meaning marijuana and marijuana derivatives without residual solvents and that have been cultivated, harvested and processed responsibly without pesticides.
Even so, Roeland emphasized that it’s hard to be sure what you’re getting. Certain strains may be labeled as containing a particular percentage of THC (the element of cannabis that produces a high) or CBD (the element of cannabis that may help relieve pain and tension) but because testing and oversight isn’t uniformly rigorous, it may be impossible to confirm those claims. Roeland described this new frontier of cannabis legalization as “the Wild West” because there’s so much that’s still unknown about how the substance interacts with humans, especially humans with cancer, and no meaningful way to enforce standards.
“I just want people to be really careful,” Roeland said. “We need to get treatment that’s evidence-based.”