The New MM: Medical Marijuana

Most oncology nurses associate the abbreviation MM with multiple myeloma, but there’s a new MM now in use: medical marijuana. To date, 31 states, the District of Columbia, Guam, and Puerto Rico have approved MM for certain medical uses, including cancer-related adverse events (AEs).¹ Patients are asking their oncology nurses if MM might help them and in some cases, after researching the topic themselves, asking very specific questions. Nurses need to be prepared to respond to questions on how MM is supplied and taken, its risks and benefits, and efficacy and safety considerations.

The Cannabis plant, commonly referred to as cannabis and known as marijuana, among other names, produces psychoactive compounds called cannabinoids. Synthetic medications containing cannabinoids, available by prescription, include dronabinol (Marinol) and nabilone (Cesamet). Cannabinoids can be inhaled as smoke or vapor or taken orally (eg, in brownies and other foods).²

Little information is available on the benefits of using whole-plant cannabis versus synthetic cannabinoid formations. Researchers have explored the use of pharmaceutical cannabinoids, which contain 1 or 2 active ingredients. In contrast, MM often is derived from the entire plant and contains other compounds as well, including the cannabinoids and terpenes (fragrant oils that give cannabis its aroma). Therefore, MM cannot easily be compared with pharmaceutical cannabinoids. Some clinical trials have tested inhaled MM for its antiemetic properties, but not enough data exist for conclusive recommendations.²

Potential benefits of MM for adult patients with cancer include appetite stimulation, chronic and neuropathic pain management, improved sleep, and control of chemotherapy-induced nausea and vomiting (CINV). AEs associated with MM include tachycardia, hypotension, muscle relaxation, and decreased gastrointestinal motility. Because cannabinoid receptors are not located in the brainstem areas that control respiration, lethal overdoses from cannabis and cannabinoids do not occur.²

Safety considerations include MM use by children and young adults. At this time, the American Academy of Pediatrics has not endorsed pediatric MM use because of concerns about its effect on brain development.² Plant-derived MM does not have a standardized dose and its optimal dosage is unknown, although the most common advice is to “start low and go slow.”³

With inhaled MM, patients “self-titrate,” or adjust the dosage as needed. The goal is to consume the minimum amount needed for symptom relief. Most MM dispensaries also carry edibles that have been tested in independent labs to help ensure safety, and they are labeled with the amount of their ingredients. MM edibles are available as infusions (teas), powders to dissolve in drinks, gummies, mints, chocolate bars, and butter or oils. There are numerous websites that provide guidance on preparing foods containing MM; brownie recipes are among the most popular. MM brownies and other MM edibles should be stored securely in homes in which children and pets reside. In order to qualify for MM, a patient needs to have an approved diagnosed medical condition, which varies by state. After receiving a signed MM recommendation from a licensed physician, the patient applies for an MM card, also known as an MM identification, or cannabis card. This card allows the patient to enter medical dispensaries and purchase MM. The process is simple enough, but do patients really understand MM?

MM misinformation abounds on the internet, and personal accounts of MM use are limited to individual experiences and are not generalizable to others. People using marijuana recreationally also share their recommendations online. Recreational use of marijuana differs from medicinal use, which can lead to confusion about MM dosing, preparation, and frequency of use. In response to the growing need for clinicians with cannabis expertise, the Society of Cannibas Clinicians was formed, and a US referral directory is maintained on its website.⁴

Patients interested in exploring MM often start by asking their oncologists about it. However, only 30% of 237 US oncologists in a recent survey felt knowledgeable enough about MM to make recommendations (55% practiced in states in which MM wasn’t legalized). Nearly 80% reported discussing MM with patients, and 78% noted these conversations were initiated by patients and their families. The researchers concluded that there is a need for education about MM, as well as clinical trials and further study of MM.⁵

More education is needed for clinicians and patients who may be interested in MM. The National Center for Complementary and Integrative Health maintains a web page containing information for healthcare professionals and con-sumers, some of which is in Spanish.⁶ The site also includes links to clinical practice guidelines and scientific literature.

Further research is needed because information about MM indications, dosing, drug interactions, and safety considerations is lacking. Comparative studies of MM and other treatments for CINV, anorexia, sleep disruption, and pain management are also needed to further define evidence-based management of these common conditions.

All oncology nurses should have a basic understanding of MM and be prepared to respond to patients’ questions about it. Patients using MM need to be educated to include it in their medication lists when talking with medical providers, especially those patients using edible MM products. Both patients and nurses need to stay abreast of developments in the emerging field of MM and be aware that more research is needed before MM can be considered an evidence-based symptom management approach.

References

• State medical marijuana laws. National Conference of State Legislatures website. ncsl.org/research/health/state-medical-marijuana-laws.aspx. Updated June 27, 2018. Accessed August 1, 2018.
• Cannibis and cannabinoids (PDQ)—health professional version. National Cancer Institute website. cancer.gov/about-cancer/treatment/cam/hp/cannabis-pdq#section/_1. Updated June 19, 2018. Accessed August 1, 2018.
• MacCallum CA, Russo EB. Practical considerations in medical cannabis administration and dosing. Eur J Intern Med 2018;49:12-19. doi: 10.1016/j.ejim.2018.01.004.
• Society of Cannibas Clinicians website. Cannabisclinicians.org. Accessed August 1, 2018.
• Braun IM, Wright A, Peteet J, et al. Medical oncologists’ beliefs, practices, and knowledge regarding marijuana used therapeutically: a nationally representative survey study. J Clin Oncol 2018;36(19):1957-1962. doi: 10.1200/JCO.2017.76.1221.
• Medical marijuana. National Center for Complementary and Integrative Health website. nccih.nih.gov/health/marijuana. Updated September 24, 2017. Accessed August 1, 2018.