Cannabis Helps Relieve Cancer Pain

By Pat Anson, PNN Editor

Good news for patients suffering from cancer pain or side effects from cancer treatment. Two new studies found that medical cannabis helps relieve cancer pain, and offer some lessons to non-cancer patients about which cannabis products might work best for them.

The first study involved 358 adult cancer patients enrolled in a cannabis registry created by the Quebec Medical College. The patients were being treated for a variety of different cancers and were referred to the registry by their doctors. The primary complaint of most was pain (72%), with others experiencing symptoms such as nausea, anorexia, weight loss, anxiety and insomnia.

Participants were assigned to one of three groups, using cannabis products that were high in tetrahydrocannabinol (THC), high in cannabidiol (CBD), or a balanced blend of THC and CBD. The cannabis was ingested orally, through inhalation or a combination of the two. Patients were monitored and assessed every three months for a year.

The study findings, published in the journal BMJ Supportive & Palliative Care, show that pain levels dropped significantly after 3, 6 and 9 months, with pain slightly worsening after 12 months. Patients using balanced THC-CBD products reported the most pain relief, and many were able to reduce their use of opioids and other medications.

A small percentage of patients suffered adverse events from cannabis, such as sleepiness, dizziness and fatigue. Only 5 patients had side effects so severe that they stopped using cannabis.

Researchers concluded that medical cannabis should have a role as a complimentary pain management option in cancer patients who don’t get adequate relief from conventional analgesics.

“We found MC (medical cannabis) to be a safe and effective treatment option to help with cancer pain relief. THC:CBD balanced products appear to perform better as compared with THC-dominant and CBD-dominant products. Furthermore, we observed consistent decreases in medication burden and opioid use in our patient population,” researchers said.

Less Pain = Better Cognition

The second study, by researchers at University of Colorado Boulder, involved 25 cancer patients being treated by oncologists at the CU Anschutz Medical Campus. The patients’ pain levels, sleep patterns, cognition and reaction times were assessed at the start of the study; and they were asked to select edible products from a cannabis dispensary, such as chocolates, gummies, tinctures and baked goods containing different ratios of THC and CBD.

After just two weeks of regular use, patients reported less pain, better sleep, and the unexpected benefit of improved cognition – they were able to think more clearly.

“When you’re in a lot of pain, it’s hard to think,” said senior author and cancer survivor Angela Bryan, PhD, a professor of psychology and neuroscience at CU Boulder. “We found that when patients’ pain levels came down after using cannabis for a while, their cognition got better.”

The improved cognition didn’t happen right away. Patients who used edibles rich in THC got high from it and their cognition initially decreased. But after a few days of regular cannabis consumption, a new pattern emerged. Patients reported improvements in pain, sleep and cognitive function, including reaction times.

“We thought we might see some problems with cognitive function,” said Bryan. “But people actually felt like they were thinking more clearly.”

Patients who ingested edibles high in CBD reported bigger improvements in sleep quality and pain intensity.

Bryan’s study, published in the journal Exploration in Medicine, is one of the first to assess the efficacy of cannabis purchased at dispensaries — rather than less potent government supplied cannabis or synthetic cannabis medications that are primarily used to treat nausea.

Bryan had just begun studying medical cannabis in 2017, when she was diagnosed with breast cancer. After surgery and chemotherapy, she looked to cannabis for pain relief as an alternative to opioids. Neuropathic pain is a common side effect from chemotherapy.

Bryan used her own customized regimen of potent THC products when pain was intense and took mostly CBD products when the pain was more manageable. She was not completely pain-free, but she didn’t take a single opioid during treatment. She hopes others will learn from her experience.

“I was extremely lucky because I had some knowledge about this. Most patients don’t,” Bryan said. “People are open to trying whatever they think might be useful, but there's just not much data out there to guide them on what works best for what.”

As many as 40% of U.S. cancer patients use cannabis, but only a third of doctors feel comfortable advising them about it.

Common Meds Can Cause Cognition Problems in Seniors

By Judith Graham, Kaiser Health News

By all accounts the woman, in her late 60s, appeared to have severe dementia. She was largely incoherent. Her short-term memory was terrible. She couldn’t focus on questions that medical professionals asked her.

But Dr. Malaz Boustani, a professor of aging research at Indiana University School of Medicine, suspected something else might be going on. The patient was taking Benadryl for seasonal allergies, another antihistamine for itching, Seroquel (an antipsychotic medication) for mood fluctuations, as well as medications for urinary incontinence and gastrointestinal upset.

To various degrees, each of these drugs blocks an important chemical messenger in the brain, acetylcholine. Boustani thought the cumulative impact might be causing the woman’s cognitive difficulties.

He was right. Over six months, Boustani and a pharmacist took the patient off those medications and substituted alternative treatments. Miraculously, she appeared to recover completely. Her initial score on the Mini-Mental State Exam had been 11 of 30 — signifying severe dementia — and it shot up to 28, in the normal range.

An estimated 1 in 4 older adults take anticholinergic drugs — a wide-ranging class of medications used to treat allergies, insomnia, leaky bladders, diarrhea, dizziness, motion sickness, asthma, Parkinson’s disease, chronic obstructive pulmonary disease and various psychiatric disorders.

Older adults are highly susceptible to negative responses to these medications. Since 2012, anticholinergics have been featured prominently on the American Geriatrics Society Beers Criteria list of medications that are potentially inappropriate for seniors.

“The drugs that I’m most worried about in my clinic, when I need to think about what might be contributing to older patients’ memory loss or cognitive changes, are the anticholinergics,” said Dr. Rosemary Laird, a geriatrician and medical director of the Maturing Minds Clinic at AdventHealth in Winter Park, Fla.

Here’s what older adults should know about these drugs:

The Basics

Anticholinergic medications target acetylcholine, an important chemical messenger in the parasympathetic nervous system that dilates blood vessels and regulates muscle contractions, bodily secretions and heart rate, among other functions. In the brain, acetylcholine plays a key role in attention, concentration, and memory formation and consolidation.

Some medications have strong anticholinergic properties, others less so. Among prescription medicines with strong effects are antidepressants such as imipramine (brand name Trofanil), antihistamines such as hydroxyzine (Vistaril and Atarax), antipsychotics such as clozapine (Clozaril and FazaClo), antispasmodics such as dicyclomine (Bentyl) and drugs for urinary incontinence such as tolterodine (Detrol).

In addition to prescription medications, many common over-the-counter drugs have anticholinergic properties, including antihistamines such as Benadryl and Chlor-Trimeton and sleep aids such as Tylenol PM, Aleve PM and Nytol.

Common side effects include dizziness, confusion, drowsiness, disorientation, agitation, blurry vision, dry mouth, constipation, difficulty urinating and delirium, a sudden and acute change in consciousness.

Unfortunately, “physicians often attribute anticholinergic symptoms in elderly people to aging or age-related illness rather than the effects of drugs,” according to a research review by physicians at the Medical University of South Carolina and in Britain.

Seniors are more susceptible to adverse effects from these medications for several reasons: Their brains process acetylcholine less efficiently. The medications are more likely to cross the blood-brain barrier. And their bodies take longer to break down these drugs.

Long-Term Effects

In the late 1970s, researchers discovered that deficits in an enzyme that synthesizes acetylcholine were present in the brains of people with Alzheimer’s disease. “That put geriatricians and neurologists on alert, and the word went out: Don’t put older adults, especially those with cognitive dysfunction, on drugs with acetylcholine-blocking effects,” said Dr. Steven DeKosky, deputy director of the McKnight Brain Institute at the University of Florida.

Still, experts thought that the effects of anticholinergics were short-term and that if older patients stopped taking them, “that’s it — everything goes back to normal,” Boustani said.

Concerns mounted in the mid-2000s when researchers picked up signals that anticholinergic drugs could have a long-term effect, possibly leading to the death of brain neurons and the accumulation of plaques and tangles associated with neurodegeneration.

Since then several studies have noted an association between anticholinergics and a heightened risk of dementia. In late June, this risk was highlighted in a new report in JAMA Internal Medicine that examined more than 284,000 adults age 55 and older in Britain between 2004 and 2016.

The study found that more than half of these subjects had been prescribed at least one of 56 anticholinergic drugs. (Multiple prescriptions of these drugs were common as well.) People who took a daily dose of a strong anticholinergic for three years had a 49% increased risk of dementia. Effects were most pronounced for people who took anticholinergic antidepressants, antipsychotics, antiepileptic drugs and bladder control medications.

These findings don’t constitute proof that anticholinergic drugs cause dementia; they show only an association. But based on this study and earlier research, Boustani said, it now appears older adults who take strong anticholinergic medications for one to three years are vulnerable to long-term side effects.

Preventing Harm

Attention is now turning to how best to wean older adults off anticholinergics, and whether doing so might improve cognition or prevent dementia.

Researchers at Indiana University’s School of Medicine hope to answer these questions in two new studies, starting this fall, supported by $6.8 million in funding from the National Institute on Aging.

One will enroll 344 older adults who are taking anticholinergics and whose cognition is mildly impaired. A pharmacist will work with these patients and their physicians to take them off the medications, and patients’ cognition will be assessed every six months for two years.

The goal is to see whether patients’ brains “get better,” said Noll Campbell, a research scientist at Indiana University’s Regenstrief Institute and an assistant professor at Purdue University’s College of Pharmacy. If so, that would constitute evidence that anticholinergic drugs cause cognitive decline.

The second trial, involving 700 older adults, will examine whether an app that educates seniors about potential harms associated with anticholinergic medications and assigns a personalized risk score for dementia induces people to initiate conversations with physicians about getting off these drugs.

Moving patients off anticholinergic drugs requires “slow tapering down of medications” over three to six months, at a minimum, according to Nagham Ailabouni, a geriatric pharmacist at the University of Washington School of Pharmacy. In most cases, good treatment alternatives are available.

Advice for Older Adults

Seniors concerned about taking anticholinergic drugs “need to approach their primary care physician and talk about the risks versus the benefits of taking these medications,” said Shellina Scheiner, an assistant professor and clinical geriatric pharmacist at the University of Minnesota.

Don’t try stopping cold turkey or on your own. “People can become dependent on these drugs and experience withdrawal side effects such as agitation, dizziness, confusion and jitteriness,” Ailabouni said. “This can be managed, but you need to work with a medical provider.”

Also, “don’t make the assumption that if [a] drug is available over the counter that it’s automatically safe for your brain,” Boustani said. In general, he advises older adults to ask physicians about how all the medications they’re taking could affect their brain.

Finally, doctors should “not give anticholinergic medications to people with any type of dementia,” DeKosky said. “This will not only interfere with their memory but is likely to make them confused and interfere with their functioning.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.