Journal Article Annotations
2024, 3rd Quarter

Palliative Care

Annotations by Barbara Lubrano, MD and R Garrett Key, MD
October, 2024

Medical Marijuana for Pain Management in Hospice Care as a Complementary Approach to Scheduled Opioids.
The Stresses of Surrogate Decision-Making: Contributing Factors and Clinicians’ Role in Mitigation.

PUBLICATION #1 — Palliative Care

Medical Marijuana for Pain Management in Hospice Care as a Complementary Approach to Scheduled Opioids.

Theodore Zanker, Joseph Sacco, James Prota, Michelle Palma, Kyoung A Viola Lee, Ruixiao Rachel Wang, Yixuan Liang, James Cunningham, Mona Mackary, Polina Ovchinnikova.

Abstract: Am J Hosp Palliat Care. 2024 Sep;41(9):1002-1010. doi: 10.1177/10499091231213359. Epub 2023 Dec 15.

Opioid therapy is critical for pain relief for most hospice patients but may be limited by adverse side effects. Combining medical cannabis with opioids may help mitigate adverse effects while maintaining effective pain relief. Aim: This single-arm study investigated the impact of combined medical cannabis/opioid therapy on pain relief, opioid dose, appetite, respiratory function, well-being, nausea, and adverse events in hospice inpatients. Design: Adult hospice inpatients using scheduled oral, parenteral, or transdermal opioids for pain were administered standardized oral medical cannabis, 40 mg CBD/ 1.5 mg THC or 80 mg CBD/3 mg THC. Descriptive statistics detailed demographic and clinical baseline characteristics, the Mann-Whitney test compared outcomes, and the longitudinal mixed effects regression model analyzed longitudinal effects of combined therapy. Setting/Participants: Sixty-six inpatients at The Connecticut Hospital, Inc. were assessed over 996 treatment days; average age was 68.2 ± 12.9 years, 90.9% were white. Cancer was the most common diagnosis. Results: The medical cannabis/opioid combination showed a significant longitudinal reduction in pain intensity (P = .0029) and a nonsignificant trend toward lower opioid doses. Well-being, appetite, nausea, and respiratory function showed non-statistically significant changes. Three patients (4.5%) experienced minor, reversible adverse events potentially related to medical cannabis. No serious or life-threatening adverse events were seen. Conclusion: Combination medical cannabis/opioid therapy showed statistically significant pain relief and may have the potential for reducing opioid dose and mitigating opioid toxicity, offering a safe pain management alternative to opioids alone for patients in end-of-life care settings, and warrants further investigation in larger controlled trials

Annotation

The finding:
The study, in which medical cannabis was administered with opioids over 996 treatment days to 66 mostly white, female, older patients, demonstrated a statistically significant reduction in pain intensity over time, with pain falling from a narrative mean of mild to moderate to mild to none, a possible enhanced impact in patients with GI cancers and heart failure, a non-statistically significant trend toward improved well-being, and non-statistically significant, negligible impacts on appetite, nausea, and oxygen saturation. Though not statistically significant, the down-trending of opioid dose from baseline to end of study may suggest that opioid dose is reduced or stabilized by its combination with medical cannabis. In this study where medical cannabis was combined with opioids over 996 treatment days involving 66 mostly white, female, older patients, a statistically significant reduction in pain intensity was observed over time. Pain levels decreased from a narrative mean of mild to moderate to mild to none. There appeared to be a possibly enhanced impact in patients with GI cancers and heart failure. Furthermore, there was a non-statistically significant trend towards improved well-being. However, the effects on appetite, nausea, and oxygen saturation were negligible and not statistically significant. Though not statistically significant, the down-trending of opioid dose from baseline to end of study may suggest that opioid dose is reduced or stabilized by its combination with medical cannabis.

Strength and weaknesses:
Weaknesses: As outlined by the authors, the study sample size was small and comprised almost entirely by white patients, which may limit generalizability of the findings. The study’s single-arm nature introduced the potential for confounding factors that may influence the outcomes. Additionally, the relatively short duration of the study subjects enrolled in the study limited the understanding of the long-term effects of the combination on patients in longer-term hospice and other end-of-life care settings, including the outpatient setting.

Strengths:
This study highlights the potential benefit of medical cannabis co-administration with opioid therapy for pain management in hospice inpatients, demonstrating statistically significant pain reduction over time with minimal adverse events. These findings contribute to the growing body of evidence supporting the use of medical cannabis as an adjunctive treatment for pain management.

Relevance:
With states legalizing its use, medical marijuana/cannabis products consumption has increased over the recent years. CL psychiatrists are often called to render evaluations and opinions regarding patients’ use of medical cannabis products. It is therefore important that CL psychiatrists are informed of the risks, benefits and the pharmacokinetic interactions between medical cannabis, opioids and other psychotropic medications. Recent studies highlighting the potential benefits of combination therapy using opioids and medical cannabis for patients with life-limiting illness and cancer pain represent a crucial aspect of care that CL psychiatrists need to be informed about.

PUBLICATION #2 — Palliative Care

The Stresses of Surrogate Decision-Making: Contributing Factors and Clinicians’ Role in Mitigation.

Adrienne D Mishkin, Nicole C Allen, Stephanie G Cheung, Maria Carla Faccini, Lauren S Flicker, Daniel Shalev.

Abstract: Am J Hosp Palliat Care. 2024 Aug;41(8):895-905. doi: 10.1177/10499091231198750. Epub 2023 Sep 13.

Abstract

Background:
Surrogate Decision-Makers (surrogates) are frequently employed in decision-making for critically ill adults. There are insufficient data considering the surrogate experience, stress, and potential for mitigation.

Methods:
An anonymous online survey queried (1) medical situation (2) total stress (3) demographics (4) potential factors, including sources of information about patient wishes, external sources of support or competing stressors, and their interactions with the medical team through the experience.

Results:
108 respondents were included; 91 completed all items. Most respondents ranked their experience as a surrogate as one of the most stressful experiences of their lives; this was associated with whether it was an end-of-life decision (P = .003), Respondent Religion (P = .015), or religious or spiritual beliefs (P = .024), and having their own health problems (P = .008). On individual Likert responses, surrogates reported significant stress mitigation when they felt they had been helpful (P < .001), knew the patient’s wishes (P = .0011), specifically discussed patient wishes (P < .001), or patient’s wishes were documented (P < .001). Items about surrogate-team interaction also met significance, including the physician being communicative and available (P < .001), respectful (P = .007), honest (P < .001), and validating (P = .001).

Conclusions:
Surrogate stress is an evolving area for research. Significant factors included relationship with the medical team, making this an important area for HPM to play a key role in mitigating surrogate stress.

Keywords:
Caregivers; end-of-life care; medical decision-making; medical ethics; stress; surrogate decision-maker.

Annotation

The finding:
In this survey of surrogate decision makers (SDMs), respondents indicated that acting as an SDM as one of the most stressful experiences of their lives, particularly in an end-of-life context. This significant stress was mitigated by feeling helpful, prior discussion with the patient about their wishes, or the presence of well documented wishes of the patient. Several factors related to surrogate-healthcare team interactions mitigated distress including physicians being available and communicative, honest, respectful, and validating towards the SDM. When these elements were absent, they became additional sources of stress.

Strength and weaknesses:
The main strength of this paper is exploration of a minimally examined area of interaction in the hospital that is of great psychosocial significance to both patients and healthcare team members. Little is known about the experience of SDMs and the impact of activation into the SDM role, thus this information is novel and useful. Limitations are small sample size, primarily white women, and from a background with limited diversity. The survey was not psychometrically validated, and the recruitment strategy tended to preferentially enroll people with healthcare background.

Relevance:
CL psychiatrists are often involved in cases where the patient in unable to communicate their healthcare preferences effectively and SDMs become activated. We have an opportunity to enhance communication regarding clinical details, explore the SDMs’ understanding of their roles, responsibilities, and grasp of the patient’s wishes, and offer support that can help alleviate the extreme distress often present in these situations.