Discussions on Medical Cannabis: Addressing Missed Opportunities in Cancer Education

As background, more than 20 states in the USA have legalized marijuana for adult use, and an even larger number of states have established medical cannabis programs for patients with qualifying conditions. For example, the medical marijuana program in Florida dates to 2016 after the passage of a constitutional amendment, and in 2017, a framework for the industry was created [6]. While state medical cannabis programs are now widespread, marijuana remains illegal at the federal level as a Schedule I drug, and consequently, there are continued gaps in discussions between patients and medical professionals regarding recommended use and dosing.

In 2020–2021, our research team reviewed the evidence on medical cannabis [6] and conducted a mixed methods pilot study with medical marijuana patients in Florida to understand more about their usage patterns, health conditions, and symptom management strategies [8]. The pilot study was funded by Florida A&M University (FAMU) and administered by the then newly created FAMU Medical Marijuana Education and Research Initiative. While most patients in the pilot study were using medical cannabis for conditions other than cancer, one patient in our pilot study was using it for pain relief to relieve symptoms from a brain tumor. This patient stated that she had stopped using opioids after 19 years and was afraid she would overdose as her physician kept increasing her dose to address her pain symptoms. Consequently, she switched to medical cannabis. In our pilot study, survey participants used medical cannabis as adjunctive therapy to treat a variety of symptoms including anxiety, pain, insomnia, post-traumatic stress disorder (PTSD), and lack of appetite. In addition, there was a notable pattern of patients substituting medical cannabis for opioids to treat neuropathic pain. Overall, patients perceived opioids as harmful in terms of the risk of drug dependence and side effects such as liver damage, which highlighted the need for better communication with their health care provider [8].

Currently, to be eligible to purchase medical cannabis in Florida, patients need to become certified at a medical marijuana clinic to receive their Florida medical marijuana card and then receive a recommendation for medical cannabis from the doctor. However, in our pilot study, there was scant communication between the patient’s other healthcare providers or specialists and the doctor at the medical marijuana clinic who had recommended the treatment [8]. According to Braun and colleagues [4], there needs to be improved patient-provider communication on both the potential benefits and harms of medical cannabis.

Medical cannabis is commonly used by cancer patients to ameliorate chemotherapy-induced nausea, cancer-related pain, insomnia, depression, and loss of appetite [1]. A medical cannabis study with 73 glioma patients treated at Moffitt Cancer Center reported one-third of the patients were using medical cannabis at the recommendation of friends or family members and reported symptom relief for pain, nausea, poor appetite, and anxiety; however, only half had received the recommendation from their oncologist [11]. This is not surprising, as a national study reported 70% of oncologists did not feel they had enough information to make clinical recommendations for medical cannabis and fewer than half had ever recommended it, thus endorsing the need for greater education on medical cannabis for cancer care providers [5].

A key word search using the term “marijuana” identified only one peer-reviewed article in the Journal of Cancer Education, a survey study [10] conducted with 194 cancer patients from 28 states; therefore, there is a need for more studies in the field of cancer education on this topic. In this survey study, cancer patients reported using opioids and medical cannabis to cope with pain as well as stress or anxiety. However, in terms of motivation to use the different drugs, it was notable that patients reported using opioids primarily for pain symptom relief but reported using medical cannabis primarily to cope with depression or to improve their mood.

Unlike a prescription drug that is prescribed for a specific health condition, patients using medical cannabis may be administering it for a variety of complaints, such as pain relief and appetite stimulation [8]. A clinical review by Worster and colleagues concluded that cancer patients are aware of the risks from prescription opioids and more patients are turning to medical cannabis to manage pain and anxiety symptoms [13]. The review recommends a role for medical cannabis in symptom management and improving quality of life for cancer patients; however, oncologists need to discuss risks and benefits with patients, as well as dosage and administration counseling. The authors recommend oncologists use a motivational interviewing approach to better understand the patient’s perspective before providing information. Such information may be to suggest the patient work within a state-approved medical cannabis program, where recommendations on dosing for either pain or appetite loss symptoms can be tailored to the individual by a doctor in the medical cannabis clinical setting [13]. Research has shown that some patients are reluctant to share their use of medical cannabis with their primary health care provider and people outside of their family, so a motivational interviewing approach can help to broach the subject [9, 12].

One of the major challenges for having more open discussions regarding medical cannabis concerns its illegality at the federal level. Lawmakers in the U.S. House of Representatives filed a bipartisan bill to legalize and regulate marijuana on October 25, 2023, titled the States Reform Act (H.R. 6028) [7]. Under the bill, marijuana would no longer be on the list of Schedule 1 drugs and would be regulated like alcohol, with the U.S. Department of Agriculture regulating growers and the Food and Drug Administration regulating medical uses. Regarding medical uses, the bill would grandfather State medical cannabis products into interstate commerce and allow the use of medical cannabis for the treatment of arthritis, cancer, chronic pain, sickle cell disease, HIV/AIDS, PTSD, and other qualifying conditions. The shifting legal landscape of marijuana at the federal level would facilitate access to more strains of marijuana for clinical studies and increase access to medical cannabis for patients across the country. These federal policy developments in the USA suggest there is momentum to decriminalize marijuana for both recreational and medical use.

In conclusion, as the policy landscape shifts at the state and federal level, there will likely be less stigma regarding the use of medical cannabis and more open patient-provider discussions about therapeutic benefits. Nevertheless, there remain several factors that present obstacles to cancer care professionals in discussing medical cannabis which include legality issues, underdeveloped evidence base due to impediments to research, societal stigma around marijuana use, concerns about drug interactions, and limited access to continuing education opportunities on medical cannabis [3]. Therefore, there are multiple communication opportunities for cancer education professionals to contribute to the research evidence-base and provide education to clinicians, health educators, patients, and other members of the cancer care team to improve the quality of life for cancer patients and survivors. Such opportunities are available by presenting at the annual International Cancer Education Conference, American Association for Cancer Education Engagement Lounges (i.e., educational webinars), and publishing articles in the Journal of Cancer Education.