Jane, a 50-year-old woman with metastatic ovarian cancer was presented to me in pain and with anorexia (a decrease in appetite). Jane had been started on Carboplatin/Paclitaxel, a common chemotherapy regimen for her cancer that often depresses appetite. Effective pain management in this patient population often presents difficulties. These patients are at risk of malignant bowel obstruction (clogging of the intestines) due to how the cancer spreads through the walls of the abdomen. Opioid pain medications, such as morphine, codeine, dilaudid, and oxycodone, are not the optimal agent for pain control for such patients as they commonly slow bowels as a side effect.. Healthier patients commonly experience constipation. In sicker patients, the combination of bowel disease and opioids increases the risk of a potentially fatal bowel obstruction. Given that Jane had previously tolerated exposure to marijuana quite well, reporting that it helped her relax and cope with the pain, the decision was made to begin a medically prescribed marijuana regimen.
Jane’s initial medical marijuana regimen included two different formulations: a 1:1 THC to CBD oral formulation (~10mg of THC and 10mg of CBD per dose) to be taken three times per day before meals, as well as a high THC sublingual formulation (~25-50mg of THC per dose) for episodes of severe pain. Consistent dosing with the low-THC formulation, with the high-THC formulation for breakthrough symptoms, enabled us to prevent pain and improve appetite, while limiting the side effects of high-THC formulations (ex: fatigue, dry mouth/eyes, dizziness), thus achieving the goal of improving symptoms while maintaining optimal quality of life.
Jane responded well to the regimen, which allowed her to be less reliant on opioids for symptom management.
Take Home Messages:
In patients at risk for bowel obstruction, opioid-based pain regimens have the potential to exacerbate symptoms and may lead to fatal obstruction. This case demonstrates how medical marijuana, when appropriately used, can not only manage symptoms such as pain and anorexia but also decrease the burden of opioids in patients whom they could potentially harm. It also demonstrates how different formulations of medical marijuana can be used as either long- or short-acting medications, in a way similar to how many physicians prescribe opiates.