Medical Cannabis in the Palliation of Malignant Wounds—A Case Report

A 44-year-old man was referred to our consultative palliative medicine clinic with an exophytic (fungating) wound involving his right cheek area. His clinical course over five months of follow-up are summarized in Table 1. Three years earlier, he was diagnosed with a squamous cell cancer of his right buccal cavity. He had the tumor surgically resected, followed by external beam radiotherapy and chemotherapy. Despite this appropriate cancer treatment, he developed a buccal recurrence that eventually eroded through his cheek, creating an oral cutaneous fistula and associated exophytic lesion. Over the two-year period before his referral to our clinic, he had elected to forego further conventional oncologic therapies in favor of mostly naturopathic treatments. Despite using high-dose hydromorphone, pregabalin, and dexamethasone, he continued to experience continuous (background) generalized right hemifacial pain along with volitional incident pain (wound-related procedural pain) occurring with wound dressing changes. He rated his average daily pain score as 9 of 10. In addition, he also reported having side effects from his analgesics, such as constipation and drowsiness. He also reported suffering severe aesthetic distress from his facial disfigurement along with right-sided trismus, depression, insomnia, nausea, and anorexia. In the course of his initial visit, the patient expressed dissatisfaction with his current analgesic regimen and inquired about obtaining MC. After fully evaluating his overall medical status, it was concluded that he had neither contraindications nor likelihood of drug-drug interactions. He also was counseled about potential side effects. Thus, he was offered a trial of vaporized MC (ARGYLE™; THC 7.25% + CBD 8.21%) from TWEED, Inc. delivered through a certified Volcano™ vaporizer unit. The particular strain was strategically chosen to maximize the analgesic potential of both THC and CBD while mitigating against the sedation and psychotomimetic side effects commonly experienced with high-dose THC strains.

On his second clinic visit, he reported significant reductions in both baseline and volitional incident pain. He indicated that he used 0.5–1.0 g of dried cannabis per day and vaporized every two to four hours and 15 minutes before his daily wound dressing change. His pain relief was so significant that he was able to discontinue pregabalin and dexamethasone while reducing hydromorphone to approximately 25% of his pre-MC dosage. He also reported experiencing less trismus and nausea, along with improved appetite, sleep, and effect. Importantly, he reported no negative effects from the MC. Furthermore, his overall performance status and symptom control was good enough to allow him to be working modified hours as a health care professional.

During his third and fourth clinic visits, his malignant wound was observed to have increased in size, yet his performance status only marginally declined, and his average daily pain scores remained within tolerable limits, while needing only small increases in daily opioid utilization. Unfortunately, his trismus and oral cutaneous fistula rendered the continued use of vaporized MC technically difficult. Because the patient had experienced such positive outcomes with MC therapy, he was eager to continue it through an alternate delivery system. Thus, we offered him a trial of topical MC compounded in nongenetically modified organic sunflower oil (ARGYLE THC 5.24% + CBD 8.02% from TWEED, Inc.). The patient was informed that this empiric trial was being offered in the complete absence of published human experience with it being applied topically to malignant wounds. The patient provided informed consent for the use of the MC oil topically. He was instructed to apply, and digitally spread, 1–2 cc of the MC oil to the entire malignant wound, both externally and intrabuccal. He also was advised to swish any residual oil throughout his oral cavity and swallow any residual.

On his fifth clinic visit, he reported having consistently used the topical MC four times daily. He stated that pain relief commenced with 10–15 minutes after application and lasted for up to two hours after application. He did not report any negative experiences from the use of topical MC. Between his fourth and fifth clinic visits, his condition began to globally deteriorate, and he required a doubling in his daily opioid utilization. Interestingly, the size of his malignant wound decreased by about 5% over the four-week interval.

Four weeks after his last clinic visit, he was admitted to an acute general hospital with hypovolemia. As a result, he was lost to follow-up and ceased to use MC on his admission. He expired three weeks later.