Pubdate: Fri, 06 May 2016
Source: Globe and Mail (Canada)
Copyright: 2016 The Globe and Mail Company
Author: Paul Taylor
Note: Paul Taylor is a patient navigation advisor at Sunnybrook 
Health Sciences Centre. He is a former health editor of The Globe and Mail.
Page: L7



My father is 84 and has been diagnosed with terminal cancer. The 
medication he has been prescribed for pain isn't working. He wants to 
try medical marijuana. But getting a doctor to prescribe cannabis is 
like pulling teeth. His doctor says there isn't enough scientific 
evidence to support its use, even though it's legally permitted by 
the Canadian government. What can I do to get my father cannabis?


I'm surprised the doctor didn't comply with your father's wishes.

One of the main goals of medicine is to relieve suffering, explains 
Dr. David Juurlink, a drug-safety expert and head of clinical 
pharmacology and toxicology at Sunnybrook Health Sciences Centre.

When the regularly prescribed drugs don't provide adequate pain 
relief, doctors should be willing to consider a patient's request for 
medical cannabis, Juurlink says.

Of course, your father's doctor may have raised a valid point that 
far more studies have been done on conventional prescription drugs 
than on the medical uses of marijuana.

However, recent interest in cannabis is now leading to a growing body 
of research that suggests it may help treat several cancer-related 
symptoms. Not only does it appear to ease pain in some patients, but 
cannabis might also alleviate the loss of appetite and nausea caused 
by chemotherapy cancer treatments.

Dr. Vincent Maida, a consultant in palliative medicine and wound 
management at the William Osler Health Centre in Toronto, has been 
looking after dying patients for more than two decades and considers 
himself to be an "early adopter" of medical cannabis. He began 
conducting research studies on cannabis in the mid- 1990s after some 
of his patients reported feeling better when they used recreational marijuana.

Maida, who is also an associate professor at the University of 
Toronto, explains: "No one has ever died directly of a marijuana 
overdose. Yet many people die every year from opioids," which are the 
main compounds used in many prescription pain relievers.

Juurlink echoes his sentiments. "From a safety perspective, medical 
cannabis is miles ahead of many of the other drugs that sit on our 
pharmacy shelves."

He says there is a small risk that some patients may suffer from 
acute psychosis, particularly on high doses of some strains of 
cannabis. But, as a general rule, cannabis is safer than the 
opioid-based pain medications.

Although opioids can provide much-needed pain relief for dying 
patients, the drugs often cause unpleasant side effects such as 
severe constipation and sedation, Juurlink says. "And very often they 
just don't work that well," he adds.

Many patients will develop tolerance to opioids with regular use. 
That means it takes a higher and higher dose to achieve the same 
effect. At very high doses, "opioids can paradoxically make pain 
worse," Juurlink says. This intensification of pain is called 
opioid-induced hyperalgesia and it appears to result from the 
activity of these drugs on certain receptors in the brain that make 
patients hypersensitive to stimuli.

To make matters worse, prolonged use of an opioid leads to a physical 
dependence on the drug. Stopping the medication abruptly can trigger 
withdrawal symptoms such as diarrhea and abdominal pain.

For all these reasons, it's certainly worthwhile considering cannabis 
as an alternative to opioids for palliative-care patients.

Maida says it's important for patients to know that medical cannabis 
is not the same as recreational marijuana.

Medical cannabis is produced by companies that are licensed and 
regulated by Health Canada. The controlled cannabis products contain 
specific ratios of two medically active compounds - 
tetrahydrocannabinol ( THC) and cannabidiol ( CBD) which each have 
different effects on patients. The dried plant material is also free 
of pesticides, mould and other impurities. The same cannot be said 
for recreational pot, which can differ widely in intensity and may 
contain contaminants.

Maida says it's hard to predict if an individual patient will 
actually benefit from cannabis. "There is a lot of variation in 
response." He will often suggest that patients try two strains 
containing different levels of THC and CBD to see what might work. 
"The selection process involves a bit of trial and error."

With this background in mind, let's now return to your original 
question: How does your father get access to medical marijuana?

Maida says your father should ask his doctor for a referral to 
another physician who is willing to authorize its use. "If a doctor 
doesn't know the science behind prescribing medical marijuana, there 
are others who have that experience."

He points out that the referral process is used in other situations 
where physicians may have a personal objection to a certain treatment.

Doctors are not required to personally carry out the wishes of their 
patients. But in some cases, they have an ethical obligation to refer 
a patient to a physician who is willing to do so.
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MAP posted-by: Jay Bergstrom