Patients suffering from cancer (many of whom undergo chemotherapy or radiation therapy) or HIV/AIDS, commonly report symptoms such as the loss of appetite, nausea, and vomiting. To treat the side effects, doctors typically prescribe a cocktail of drugs that come with a whole host of side effects. Musician Melissa Etheridge knows too well. In 2004, she was diagnosed with stage 2 breast cancer and went through chemotherapy. She recounts how doctors wanted to prescribe “half a dozen” medications to treat chemo’s brutal side effects. “For the pain, it was Vicodin. But, of course, aside from being highly addictive, opioids cause constipation,” recalls Etheridge. “So they prescribe another drug to treat the constipation. But, then of course, that drug causes diarrhea.”
Each additional drug seems to cause another interaction that causes more side effects, a complaint shared by most patients. Etheridge turned to medical marijuana. “After the chemo, all I could do was lay there. I was in pain, I couldn’t eat, and I had nausea,” recounts Etheridge. It didn’t take much convincing for Etheridge to try medical marijuana, which she praises for helping make her treatments much more tolerable.
Etheridge claims cannabis, “almost instantly — within a minute — got rid of the pain, brought back my appetite, and relieved my nausea.” She found vaporizing her medicine, or using a cannabis-infused butter to add to her food worked best. To get her through her the side effects of chemotherapy, she found medicating approximately every four hours worked best.
Patients, like Etheridge, have been turning to cannabis to treat the effects of cancer-related symptoms for years. And, in fact, the very first conditions mainstream doctors acknowledged cannabis could treat, were nausea and vomiting.
Reports of medical marijuana’s efficacy in treating nausea go back years, and, in fact, it was the treatment of this condition that influenced now deceased US Drug Enforcement Administration (DEA) law judge, Hon. Francis Young, to issue what should have been a landmark precedent-setting ruling that would have paved the way for cannabis to be transferred from Schedule I (considered the most dangerous drugs with no accepted medical use) to a lower schedule.
In the Sep. 1988 ruling, Judge Young stated:
"The overwhelming preponderance of the evidence in this record establishes that marijuana has a currently accepted medical use in treatment in the United States for nausea and vomiting resulting from chemotherapy treatments in some cancer patients. To conclude otherwise, on this record, would be unreasonable, arbitrary and capricious."
The body has its own internal cannabinoid system called the endocannabinoid system, or ECS. The ECS has two receptors — CB1 and CB2. Cannabinoids — like THC — bind to receptors (and periphery) to order to exert specific responses. Taming nausea is one such response. In fact, the ECS plays an important role in helping modulate appetite, inflammation, and other important physiological functions. When cannabis is consumed, its active constituents manipulate the endocannabinoid system to affect these functions — this is why cannabis can be an effective, remarkably versatile medicine, treating numerous conditions. Unlike most commonly prescribed anti-nausea medications, not only does cannabis prevent vomiting, but it also limits the sensation of nausea. (And, as well know, it helps with other associated symptoms like pain.)
How exactly does it do this? The brainstem circuitry relating to vomiting response is well understood: CB1 antagonists — anti-cannabinoids — induce vomiting, while CB1 and CB2 agonists — like THC — block vomiting response by reducing the release of excitatory transmitters. How cannabinoids inhibit nausea is less clear, but, it’s effective nonetheless.
While we mainly hear about cancer and HIV/AIDS patients — when it comes to treating nausea and vomiting — anecdotal evidence suggests cannabis can treat nausea and vomiting symptoms related to a number of ailments: including everything from appendicitis to meningitis, overeating to motion sickness.
Millions of patients have used whole-plant cannabis to treat their symptoms, but because of research barriers, most research has been limited to synthetic cannabinoid treatments. While there have been several dozen pharmaceutical trials, studies of botanical cannabis to treat nausea are virtually non-existent. In fact, there have been just three cannabis trials. Of these trials, patients for the studies were selected only after having tried pharmaceutical cannabinoid treatments that weren’t effective (suggesting they may be less responsive to cannabinoids).
Nonetheless, Dr. Donald Abrams, a leading cannabis researcher, oncologist and professor, states, “My clinical experience as an oncologist practicing in San Francisco for 35 years is that cannabis is an effective antiemetic [anti-nausea medication], even in situations where other pharmaceuticals have failed.”
Abrams believes one of the key benefits of cannabis is that it can take the place of multiple pharmaceuticals that often carry significant side effects:
“Why wouldn’t I recommend cannabis to patients going through chemotherapy?” Abrams explains, “If I have a single medicine that I can recommend to assist with nausea, anorexia, insomnia, depression, and pain — rather than prescribing five or six pharmaceuticals that may interact with each other or the patient’s chemotherapy, I consider [cannabis] an attractive option for my patients.”
Abrams continues, “Many patients choose cannabis over serotonin antagonists in hopes of avoiding the troublesome constipation often associated with those medications. Cannabis is also the only antibiotic that is an appetite stimulant.”
Abrams reports that he encounters many patients who initially have issues getting over the stigma of cannabis, but once they’ve overcome that, they find the benefits of cannabis over pharmaceuticals to be unparalleled: “I recall one 45-year-old patient with metastatic colon cancer receiving FOLFOX (leucovorin, fluorouracil, and oxaliplatin) who told me that it took him 5 cycles of his treatment to finally get over this stigma and try cannabis,” said Abrams. “He reported that it did what no other medicine could do—completely eliminate his CINV (Chemotherapy-Induced Nausea and Vomiting), and allow him to function quite normally. “
GW Pharma, a small pharmaceutical company — by pharma standards — that focuses on the developing plant-extracted cannabinoids, rather than the conventional pharmaceutical approach (lab-developed synthesized isolated compounds), published a paper: "Nausea Associated with Cancer Chemotherapy." In the paper, they articulated a number of compelling arguments in favor of cannabis:
In another survey of 128 patients conducted by the National Drug and Alcohol Research Centre, University of New South Wales, found 20% of reported using cannabis to treat nausea. Nearly two-thirds (62%) decreased or discontinued their use of other medicines when they started using cannabis medicinally. Further, they reported that most patients perceived cannabis to be superior to pharmaceuticals in eliciting relief, while mitigating undesirable effects. On effectiveness, 53% reported “great relief,” 44% “good relief,” while only 3% reported “no effect.”
Patients seem to prefer the “holistic delivery of all the compounds present when using the natural plant.” — National Drug and Alcohol Research Centre Survey
Dr. Abrams warns that elderly patients need to be more cautious than younger patients, particularly if they have an underlying heart condition. He reasons that because cannabis can acutely raise heart rate, while lowering blood pressure, they could put themselves unnecessarily at risk.
Overall, however, the safety profile of cannabis is superior to many medications. In its May 2006 article "Medical Marijuana - The FDA Loses More Credibility,” Cancer Monthly, argued that compared to the “risks of a typical chemotherapy agent such as cytoxan which includes [issues such as urinary bladder infections, potential sterility, cardiac toxicity, significant suppression of immune responses, and sometimes fatal, infections], the risks of marijuana pale in comparison...[F]or cancer patients with advanced cancers who want to improve the quality of their life, a risk versus benefit analysis weighs heavily on the benefit side."
In addition to whole-plant cannabis preparations — flowers, edibles, tinctures, etc. — several synthetic cannabinoid medications are approved to treat nausea and vomiting, including:
Predictably, most patients complain that pharmaceutical variations of cannabis aren’t as effective as whole-plant cannabis, and often come with unwelcome side-effects. Many of the approved medications contain only THC. However, CBD — the most active non-psychoactive constituent in cannabis — tempers potential adverse effects that can come from THC.
Further, given the variable bioavailability of orally ingested synthetic cannabinoids (5% to 20% of the ingested dose), these medications can take two to three hours to reach peak concentrations. Moreover, after delta-9-THC passes through the liver it metabolizes into more psychoactive 11-hydroxy-THC, which explains why patients often report oral administration makes them feel more “high” than when they inhale. Many patients complain pure THC medications make them feel uncomfortably “high,” and for far too long.
Another key benefit of cannabis over pharmaceuticals is that patients — who are already having issues keep down food — don’t have to take a pill that they risk regurgitating. In a publication, “Marijuana and Medicine: Assessing the Science Base,” the (generally cautious and skeptical) Institute of Medicine (IOM) noted the challenges of pill-based medicines: “The purpose of an anti-nausea medication is to prevent nausea and vomiting, but typically patients must take a pill. In patients experiencing severe vomiting, complain pills are hard to swallow, keep down and slow onset.”
One of the key benefits to botanical cannabis is that patients appreciate the fact they don’t have to swallow the medication — often problematic in patients suffering nausea — and, by smoking (or, preferably “vaping”), they can self-titrate their medication. By self-titrating, a patient can gradually increase ingestion as they deem appropriate. Through oral administration — given the need to metabolize — patients are unable to self-titrate.
Further, when patients inhale cannabis (smoked or vaporized), onset of effects is rapid, generally within two to five minutes.. Generally, patients don’t care for the extra effects or duration, however, when consumed before sleep, it can help them sleep through the night.
Dr. Abrams notes that for some patients, the greater psychoactivity of orally consumed cannabis can create psychoactive levels that make them feel uncomfortable, even frightening. He notes, however, many patients report that before bedtime, edibles can be superior to inhaling because the effects last far longer allowing them to sleep comfortably through the night. But, cautions, this would be prudent only after effective dosing had been ascertained.
Dr. Abrams offers this advice to patients:
“I generally advise patients that if they want better control over the onset, depth, and duration of the effect, inhalation may be the better mode of delivery. However, I have heard from some patients who feel that while eating is a normal function, inhalation is not and may present additional health problems. As a result, they chose to go to a dispensary, where they were instructed to eat only a quarter of a cannabis cookie, but when the effects weren’t felt right way, they ate the entire cookie.”
Marijuana for Trauma head physician, Dr. Mike Hart, is fond of saying, “less is more.” He advises patients to find the lowest dosage that works, and notes that the constituents in cannabis have a biphasic effect. By biphasic, Hart explains, “low to moderate doses elicit the most desired effects, while too high of a dose produce the exact opposite effects you want.”
“How a patient responds to cannabis is influenced by a number of factors. Not only is it dose-dependent, a person’s past experiences can influence the outcome, and so can environment,” continues Hart. “I don’t provide patients with an exact dose as every patient’s physiology is different; instead, I advise patients to self-titrate, starting with a low dose and gradually increasing until they find the optimal dosage.”
Hart admits, “While some scientific literature reports the psychoactive — euphoric effects — as adverse, that’s not what my patients tell me. They tell me the mild psychoactive effects help them adapt better to their situation and conditions.”
Bottom line: There is no magic formula that determines what strain you’ll react best to, so you may take a little trial and error.
Most physicians, educated prior to science’s discovery of the endocannabinoid system, lack the confidence in their knowledge about the potential therapeutic benefits of cannabis, and often don’t feel comfortable recommending it. Nonetheless, while most physicians will still not write a recommendation for medical marijuana, a majority of physicians aren’t opposed to its use and are aware that they have patients who may elect to use it by obtaining a physician’s recommendation elsewhere. When on a treatment protocol, it’s important you have a supportive physician with whom you can maintain an open and honest dialogue.
All drugs have potential interactions with other drugs, so it’s important to be able to openly discuss your decision to use cannabis as an adjunct to your therapy. Some physicians may be knowledgeable about cannabis, while others may be less so. Don’t hesitate to print of legitimate, credible, information to share with your physician, as they’re generally very busy and may not be knowledgeable in every aspect of medical marijuana.
Finally, even if your physician is knowledgeable about cannabis, it’s highly unlikely he or she will get into specifics on dosage or strains. Dr. Abrams remarks, “Even if physicians were aware of the strains and products available, in all likelihood they still would not be comfortable recommending one strain over another because of the total lack of evidence on which to base their decision (eg, whether CBD works for nausea, what the best ratio of THC:CBD is for sleep, or which oil is the most potent for pain relief).” With that being said, do your research, get recommendations from friends, and don’t be afraid of conducting a little “trial-and-error” to find the mix that works best for you.