MUDr. Petra Garnolová: The combination of medical cannabis with other analgesics is the ideal way to achieve the best effect with the fewest side effects
Medical cannabis is gradually finding its way to many patients with various ailments, including those with unmanageable and hard-to-influence chronic pain. For them, this therapy can offer a new chance at a quality life despite severe or terminal illness. A relatively new form that brings additional benefits is the extract of medical cannabis. We spoke with MUDr. Petra Garnolová, a specialist in clinical oncology and palliative medicine, about why it is worth considering not only as part of analgesic therapy and her experiences from real practice.
How can medical cannabis be used in palliative and oncological care?
Medical cannabis has many indications. We use it the most in the treatment of unmanageable pain, nausea, vomiting, and also in cases of loss of appetite or insomnia caused by cancer or its treatment.
Which forms are the most effective?
We can prescribe medical cannabis in various forms. Patients can receive individually prepared capsules, a blend for vaporization, but my favorite is the cannabis extract, which the patient takes in the form of a solution. It is a practical and comfortable application form for the patient, the dose is taken once a day, and I can control the actual dose the patient has taken.
Which patients clearly benefit from medical cannabis and in which cases are you more cautious?
Before starting treatment, I always ask patients about their previous experiences with cannabis use, including recreational use for its psychotropic effects. If they tolerated it poorly, such as experiencing nausea or other unpleasant side effects, I approach this therapy with great caution.
I observed a very good effect in a patient undergoing intensive chemotherapy for a generalized ovarian tumor. The treatment was accompanied by severe side effects such as vomiting and nausea, which worsened the overall condition and threatened to interrupt the therapy. Thanks to medical cannabis, her condition significantly improved, the difficulties minimized, and she could continue effective therapy for the underlying disease.
Another case that comes to mind is a patient with a generalized prostate tumor and multiple metastatic bone lesions with severe pain. He was taking high doses of long-acting fentanyl, short-acting fentanyl several times a day, and various co-analgesics, but the treatment was still not sufficiently effective, and the pain did not allow sleep longer than one or two hours. Thanks to the use of medical cannabis, the pain stabilized, so it was not necessary to further increase the opioid dose, and the patient now sleeps for 6 hours without awakening. This led to a significant improvement in his mental state, as insomnia was very frustrating, and eliminating sleep deficit improved his overall quality of life.
What are your experiences with the effectiveness of cannabis extract compared to traditional analgesics?
In pain management, I primarily use medical cannabis as a co-analgesic. That is, in patients who already take strong opioids for severe oncological pain, but the existing treatment is not sufficiently effective, and I do not want or cannot increase the opioid dose. I also use it for patients who, besides severe pain, have other difficulties such as the aforementioned insomnia or loss of appetite.
Is it possible to combine medical cannabis with other analgesics without problems?
Yes, I would say it is even the best way. Combinations allow us to reduce the doses of analgesics, thus minimizing their side effects. Treatment of chronic intense pain is about finding the best combination of drugs for the specific patient. Sometimes we can improve the condition quickly, but other times we search and titrate the combination of drugs and the dose to achieve the best effect with the fewest side effects.
What do patients and their families most often expect from medical cannabis? And are their expectations met?
Every patient with pain primarily wishes for the pain to be as minimal as possible or, even better, for it to be nonexistent. For every medicine that can help us in this, patients, their families, and we doctors are grateful. Treating poorly controlled pain requires a comprehensive approach and also patience from both the patient and the doctor in finding the optimal combination of drugs. Medical cannabis certainly has its place in these combinations; it brings significant relief for some patients, lesser for others, but every doctor dealing with this issue should remember this treatment option.
What side effects do patients report most often, and how do you address them?
Some complain of increased fatigue and sleepiness — in these cases, I try to reduce the dose to a minimum and slowly increase it to the desired effect. One young patient had a persistent feeling that the floor was moving under her, and unfortunately, I could not eliminate this side effect even by reducing the dose, so I had to discontinue the cannabis treatment.
What would you recommend to those considering the use of medical cannabis?
My recommendation is “give it a try, it makes sense”. It is clear that it won't help everyone, it's not a magical potion, but surely each of us has patients who can greatly benefit from cannabis. In practice, I sometimes encounter a slightly reserved attitude from some patients and colleagues. They are concerned about being seen as drug addicts. It's our job to explain that in this case, it's a medicine, not a recreational drug, and that medical cannabis can bring a lot of good.
How do you see the future of medical cannabis in palliative and oncological care? Where do you see the biggest challenges?
I think the indications are currently quite clearly defined. The biggest challenge, therefore, is to get all the information to doctors and patients so that as many as possible can access this treatment. Another challenge is communicating and arguing with health care payers, i.e., insurance companies, so that patients' treatment is fully covered. Today, the monthly dose for a patient is limited, and the insurance company covers 90 percent of this limit.
The basis of today's evidence-based medicine (EBM) is clinical studies and medical research, which is still needed in this area. The more solid data we have on the positive effects of medical cannabis, the better. We will then be better able to explain to patients why we are offering them medical cannabis and argue with colleagues about why they should not be afraid to use it.
MUDr. Andrea Skálová
Editorial MeDitorial
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