Medical marijuana's benefits for those in cancer treatment

Host Amber Smith: Upstate Medical University in Syracuse New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Almost half of patients in cancer treatment never obtained medical marijuana that was prescribed, and a team of researchers from Upstate wanted to understand why. With me to talk about the study that was published recently is Dr. Karna Sura. He's an assistant professor of radiation oncology at Upstate. The study was called "Experience with Medical Marijuana for Cancer Patients in the Palliative Setting," and it was published in The Curious Journal of Medical Science. Before we get into the goal of the study and what you found, can you first tell us what palliative setting means?

Karna Sura, MD: Palliative setting is usually for patients in pain, or, classically,in stage four (late stages of cancer) settings. But I think the idea of palliative medicine has actually expanded across every patient just to kind of help with pain and discomfort, as well as just symptom management.

Host Amber Smith: Regarding medical marijuana, why might it be used in cancer treatment?

Karna Sura, MD: Marijuana in general, people use it for that euphoric feeling, but it can be used for nausea, vomiting, and the munchies. Those different options are very effective for cancer patients, because usually that's the biggest problem is weight loss, nausea, vomiting. So, marijuana, being a natural substance, may be an option for these patients, and actually fix a lot of problems with one medication.

Host Amber Smith: Does it have to be smoked?

Karna Sura, MD: No, it doesn't have to be smoked. Actually, the nice part about medical marijuana is, although classically most people try to smoke marijuana, you can obtain it in a powder form, vaping form, lozenges. There's a lot of options for patients, and usually dispensaries have a variety of choices, and the pharmacist at the dispensary will discuss different options for the patient and what would be beneficial for them. So I think that's one of the misunderstandings about medical marijuana that everyone thinks, "Oh, you have to smoke it, and I'm not a smoker," but you could use many options.

Host Amber Smith: Does medical marijuana differ from regular marijuana in other ways?

Karna Sura, MD: Medical marijuana, the main difference is, when people purchase on the street, you actually don't know what percent marijuana you're getting or what you're actually obtaining. With medical marijuana, there are very strict regulations. The bottle, basically everything has to be tested and approved. The amount of THC (tetrahydrocannabinol) and CBD (cannabidiol) is all very regulated and has to be approved and tested by the, dispensary. And so the New York State department of medical marijuana (Office of Cannabis Management) that regulates this is very strict about this. So you know you're getting very pure marijuana, and what percentage of each -- CBD and THC -- you're obtaining with anything that you take.

Host Amber Smith: And CBD and THC are the more active ingredients?

Karna Sura, MD: Yes, that is correct. Yes. So, although marijuana has multiple different components or ingredients in it, the CBD and THC are probably the most well known, of being the most, or the strongest or the potent parts of it. THC is more of that high euphoric feeling, usually used for eating and the munchies and nausea and vomiting, as well as some sleep. And CBD helps with more like neuropathic pain. Actually over the counter, you can find CBD now and buy it. But usually, the type of CBD you're getting under the medical marijuana is usually much more regulated and much purer than you would get really over the counter.

Host Amber Smith: Now, why did you decide to research this topic?

Karna Sura, MD: I think it's a really interesting topic. You know, patients really want kind of non-pharmaceutical methods of treatment, and I think medical marijuana is one of those really, potent non-pharmaceutical that we could potentially use for patients. And I think there's a lot of questions and stigma, and there's not enough information about this. And the big problem is federal research is kind of limited on medical marijuana. And obviously it's not a prescription drug, so there's no money for trying to find information or trying to actually study it in a randomized fashion. So I was really interested in just our patient population. Does it work? Are people using it? You know, these are questions that we actually didn't know, and it was very helpful to actually get the basic data so that we could better inform our patients as well as think of future studies that we can actually use and try to get more information.

Host Amber Smith: So you focused on patients that are treated at Upstate from Central New York?

Karna Sura, MD: Yes. The goal was to look first here because we use medical marijuana quite a bit for our patients here in Upstate. And actually a lot of the providers Are in the palliative care department that actually will prescribe it. So we have a very focused method, a multidisciplinary method that we all work together in a framework, but our palliative medicine providers are the ones who do the pain management and medical marijuana. So it's really nice, and it was an easier study because there's not too many bodies that are involved in this. There's only a couple people (providers.) So we can kind of focus on those patients and the patient population.

Host Amber Smith: So how did the study work? I'm curious how many patients enrolled and how long this was underway.

Karna Sura, MD: This was a retrospective study, so we did like a retrospective chart review of the patients. The goal was to kind of start when the database was, whatever information it kind of started from. And our endpoint was just basically when we data collected. And so the goal was to see 1. patients enrolled in the database, or people who obtained a certificate. And then actually chart check them and see how did they do during this time period? So, the hope is from this retrospective study that we can actually do prospective studies and collect patients and have more direct impact and understanding as they're going through the process. But retrospective studies are kind of our first level of, to learn of the information that we have so far.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast with your host, Amber Smith, I'm talking with Dr. Karna Sura. He's an assistant professor of radiation oncology at Upstate, who, along with a team of researchers, examined the experiences of cancer patients who were prescribed medical marijuana during treatment.

What did you discover and were you surprised?

Karna Sura, MD: One of the discoveries was, as you pointed out, the number of patients who did not use the medical marijuana program, even though they were enrolled. I think we found a lot of different reasons for that. And, I think the biggest issue is, a lot of times, is patients are referred too late or they may be going into hospice care, where medical marijuana is not easily obtained in that setting. This has changed since then, but medical marijuana, the biggest problem is that you can't go to a pharmacy. You have to go through a dispensary to actually obtain it. And so these dispensaries are limited at certain places, but you have to either send yourself or caregiver to obtain it. Now the regulations have started to ease a little bit, so there's more ability or more access, but it will take some time for patients to have more access to obtaining medical marijuana.

Host Amber Smith: Well, walk me through this, if you would. If a person is prescribed medical marijuana, what happens after that? What do they have to do to actually fill that prescription?

Karna Sura, MD: So the first step is, patients come and are identified for being accepted for medical marijuana. We talk about the reasons, the rationale, pros and cons of them with the patient. Once that happens, how the New York State program works is, we enroll them into the database. So, we accept and say as a prescriber, that this patient would be eligible for medical marijuana. We have to write the reason, the rationale behind it, fill their information. Once that's done, we give them the certificate saying that they are acceptable for medical marijuana, and the patient actually has to go to the database themselves and fill in their information. They're then sent an ID card, actually, in the mail, which is a medical marijuana card, and the card is what they need to actually go and get the medical marijuana. So once they have the ID card, they go into the dispensary with the card, and the dispensary will have a pharmacist there who will actually talk through them about the different options. And then the patient can buy the medical marijuana right there. So it's a little bit of a different process. We don't really, the doctor is not giving them a script to say that you need to take so much medical marijuana. It's usually more so the patient and pharmacist driven. We're just giving them the barrier to access it, basically.

Host Amber Smith: So are the dispensaries inside existing pharmacies, or are they separate structures?

Karna Sura, MD: They are all str separate structures. There're a bunch of dispensaries in Syracuse. There's a couple in the outskirts in, around the area, but they're all separate structures and separately regulated. And the worst part is they're all cash. There's no credit card, nothing like that, because of how the law works. So everyone has to have an ATM there that you can use. But you have to pay everything in cash.

Host Amber Smith: Is it covered by health insurance, generally?

Karna Sura, MD: No. Nothing is covered by health insurance. Like I said, it's basically a cash transaction. It's pretty expensive, or can be expensive, for patients who are on fixed incomes. There's really no options. No insurances will cover it. And again, part of this has to do with the federal laws behind it. Part of it is the medical marijuana and the DEA classification, but part of it is the federal banking classification that basically certain activities are regulated. So it gets complicated. And a lot of credit card manufacturers and banks don't want to get involved with it, so there's a little bit more of a restriction on that.

Host Amber Smith: How do you counsel patients who are reluctant because they fear becoming addicted?

Karna Sura, MD: The biggest problem with addiction is, in general, even with pain medication and medical marijuana, I think we are trying to fix a specific problem with a goal in mind of an ending, OK? And I think a lot of times with addiction is that you're kind of trying to fix a problem with not actually fixing the underlying issue. So a lot of times with cancer treatment, it's a symptom control for a reason, meaning the cancer pain or nausea, vomiting from chemotherapy. So once you stop the chemotherapy, that goes away, and we really don't need the medication anymore. Or usually the patients are less reliant on that. So it's a little bit different, I think. And, and I think there's a lot of stigma for that, like, "oh, I'm going to use it, and I'm gonna be addicted to it." But I think that with patients who you have an endpoint, addiction is really difficult because you basically are monitoring that, and you're actually changing the values or changing what you would recommend based on the symptom that you're trying to fix goes away. So I do try to counsel them to say that we want to put you on this to get you better so that you can do your normal activities, but then we will try to take it away, over time, so that you, again, you won't be addicted to this.

Host Amber Smith: Among the people in your study who did use medical marijuana during their treatment, what were their experiences?

Karna Sura, MD: The experiences are really positive. One part of medical marijuana is that, patients who benefited, benefited pretty well. It's usually helped their symptom management, so like the nausea, sleep, vomiting, weight gain. I think those are the big ones that actually helped a lot. Pain was one of the things that we were looking at, which seems like some people benefited while others didn't. And that may be related to how much they were doing or what they were taking in. And so that needs to be better clarified. And the other side of it is that there's really not that much side effects that we could see from medical marijuana. So I think it's a good drug that, if you compared it to other medications that we can use or prescription medications, it would be pretty much on a very high benefits for low risk, and so it would be a pretty useful medication overall.

Host Amber Smith: Does it replace the need for narcotic pain control?

Karna Sura, MD: Right now how we are prescribing it, it's supposed to be like a supplement for narcotics, so it's not supposed to be a complete replacement. Now, some patients can benefit and have a complete risk replacement. Like in the study we did find a couple patients who basically did not need to take opioids anymore after starting medical marijuana. But for right now how it's supposed to be prescribed for patients is as a supplement.

Host Amber Smith: Is there other research you would like to see done on medical marijuana usage in cancer patient?

Karna Sura, MD: A lot of people in the United States want to see randomized clinical trials done with cancer patients. I think actually the good news is yesterday President Biden released some information that they're going to change the whole marijuana classification as well as to change the federal law behind it, which will change a lot. So once they move the DEA (Drug Enforcement Administration) classification down for marijuana, actually research can be done on it, and federal dollars can go into research. So that's gonna be a huge difference. And I think that's the biggest problem is, once we get access to federal dollars or even state dollars, that would allow us do research, it's gonna be a whole game changer. And so I think that's kind of the biggest hurdle right now is the finance part of it, not the actual enthusiasm to do it. I think a lot of people want to use medical marijuana, and I think that patients really want to understand what's the benefits of it before using it.

Host Amber Smith: So with the previous restrictions on studying medical marijuana, do we even have a consensus among doctors about the best dosage, or the best delivery to get the best results for patients?

Karna Sura, MD: We have none of that information. That's the biggest problem is that we don't know what is the best delivery, what is the best dose. Is there a dose response to pain or nausea, vomiting? What's better, THC or CBD? These are all questions that we want to know answers, because the biggest problem is how do you counsel patients what's better for them? Unfortunately at the dispensaries, there's a lot of different options, but, we don't have the data to say which one is better for each patient or customize it. And, there's a lot of frustration because you can spend lots and lots of money to get each different thing. But if you're not using it, it's a lot of money wasted. So, I think it's really hard for patients to decide which one's better. Usually my recommendation is to start with a kind of balance, and then move away and see which one you like better. This is the biggest problem is that even the pharmacist, they try to give them counseling, but each patient's a little bit different. And, it's really hard to know for right now, what's beneficial for them.

Host Amber Smith: Would medical marijuana potentially be able to help people with earlier stage cancers?

Karna Sura, MD: Yeah, medical marijuana could be used for anyone. It's perfect for any type of patient as long as we're aiming for a specific symptom to kind of improve. So I think I've had a couple patients who benefited. They were going under treatment for head neck cancer, where we have a lot of weight loss, and, unfortunately, because of the weight loss, they need medical marijuana, and they maintained their weight with that.

Host Amber Smith: With more and more states legalizing marijuana, including New York, is that going to change the accessibility or the usage, do you think, among people? And will they still need a prescription for medical marijuana?

Karna Sura, MD: I'm not sure how that's gonna change in the New York State system, in terms of, will there be a more access or more dispensaries available? I do think it's gonna be a good thing that it will remove the doctor a little bit out of the system and allow people to go and pick it up themselves. But I also think that will be a barrier for certain patients because of the fact that, patients may meet not as easily accessible for that becausedoctors may not bring it up because it's available. So I think we need a better way to maybe incorporate it or use it in a better fashion.

Host Amber Smith: Well, Dr. Sura, thank you for taking time to share your research with us.

Karna Sura, MD: Thank you so much for having me.

Host Amber Smith: My guest has been Dr. Karna Sura. He's a professor of radiation oncology at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at Upstate.edu/Informed. This is your host, Amber Smith, thanking you for listening.