Cannabis and Cancer Pain Management

Introduction

Cancer pain management is one of the most critical issues of modern oncology, while its pathophysiology remains poorly researched. The use of opioids is the key strategy used to alleviate chronic pain and increase patients’ quality of life. The recent study shows that there is a connection between a neural system, cancer cells, and host’s immune, which allows assuming the potential beneficial role of Cannabidiol (CBD) that impacts on a person’s endocannabinoid system (ECS) (Chwistek, 2017). In this connection, this paper aims to propose the investigation of the role of CBD in cancer pain management as a therapeutic means with less unwanted side effects compared to opioids.

PICOT Question and Available Literature

The following PICOT question is proposed to be explored: in cancer patients (P), how does Cannabidiol (CBD) (I) compared with opioids (C) affect pain over chemotherapy treatment (O) in 2 months (T)? The patients having chemotherapy are selected for the proposed study as the category of people who often encounter peripheral neuropathic pain due to their treatment (Wiffen, Wee, Derry, Bell, & Moore, 2017). It makes them socially inactive and poses the threat of mental complications. These patients receive opioids, such as tramadol, morphine, methadone, and others, the effectiveness and safety of which are under the question. Page and Blanchard (2019) report that the opioid epidemic is escalating: “43% of patients with cancer and 10% of survivors use opioids to manage chronic cancer pain”, of which 47, 000 die due to overdose annually (p. 229). Since the majority of cancer patients and survivors experience chronic pain, there is a need to find a more relevant way to assist them in managing their health and maintain their life quality.

Today, cancer is treated with chemotherapy therapy, which can cause inflammation and destruction of healthy tissues, which is complicated with the main problems associated with this disease, including pain, loss of appetite, and nausea. CBD that is selected as the intervention for the proposed study interacts with the cannabinoid cell receptors on its surface to activate and enhance the response of the nervous system (Degenhardt et al., 2015). Two cannabinoid receptors are present in the human body, such as CB1 and CB2. CBD has the effect that is similar to the one that one’s body reproduces in a natural way. There are scientific works that testify in favor of the fact that CBD has anti-inflammatory and analgesic features. In this regard, it is possible to suggest that this substance will help in the development of effective drugs against moderate and sever pain caused by cancer and chemotherapy.

A 2-months period is selected for the study to reveal any impact of CBD on cancer patients since this timeframe will allow understanding the rapid pain relief. It is suggested that the mentioned period is sufficient to identify the positive and negative effects of the discussed intervention. Among the expected outcomes, there is a substantial or complete pain relief for patients who pass chemotherapy and need to increase their comfort levels. Considering that the implementation of new projects in healthcare environment requires high costs, 60 days seem to be the most pertinent timeline to understand the impact of CBD on patients’ health outcomes.

The proposed research is consistent with the principles and standards applied in the nursing area. In particular, Kolcaba’s Theory of Comfort implies that nurses should assess the needs of the patients and adjust their services in order to increase their comfort in such dimensions as ease, relief, and transcendence. Since the adopted method based on opioids cannot properly reduce or eliminate patients’ pain, it is critical for nursing to strive to find and introduce new processes and procedures that would better work towards the mentioned goal. More to the point, not only physical pain but also psychological and emotional discomfort should be taken into account by nurses caring about cancer patients. The former are expected to provide recommendations regarding social support, which is an integral part of of their profession and also consistent with the PICOT question formulated.

The current evidence is not homogenous regarding the potential of CBD in treating the pain syndrome in patients receiving chemotherapy to treat cancer. Nevertheless, significant efforts are made towards comprehending how to strengthen the impact of cannabis and achieve better pain alleviation. According to Bar-Lev Schleider et al. (2018), who conducted the retrospective study based on data of 2970 patients, fewer side effects are associated with CBD. It is also noted that this option is safer compared to opioids, which is concluded from the number of avoided side effects. In their turn, Lichtman et al. (2018) and Martell et al. (2018) state that some decrease in pain levels was noted among those patients who took cannabis, and the use of this substance was found in many patients. The article by Degenhardt et al. (2015) pinpoints the combined consumption of CBD and opioids, emphasizing a greater therapeutic impact of such a strategy. These studies demonstrate that the utilization of cannabis has some potential of reducing cancer pain, yet the medication still needs to be elaborated.

There are several medications that contain cannabis as the major active substance, the examination of which is performed in various studies. Turcott et al. (2018) focus on Nabilone investigation based on the two groups of patients having lung cancer. It is revealed that the control group was marked with more severe pain compared to the intervention group. At the same time, the problems with appetite and nausea that are characteristic of this type of cancer were decreased. Another study that targeted Nabiloid research found that it is not potent enough to ensure significant pain alleviation or facilitate other chemotherapy symptoms (Côté, Trudel, Wang, & Fortin, 2016). However, Sativex, another derivative of cannabis, is regarded by Fallon et al. (2017) as having zero effect on pain management since the results of the intervention group and placebo group were similar. Likewise Turcott et al. (2018), Fallon et al. (2017) assume that further trials should be conducted to calibrate doses for cancer patients to accomplish sufficient pain relief. Thus, as it can be observed from the above review, the current literature verifies the relevance and accuracy of the PICOT question, indicating the need for further research in this field.

Evaluation Strategies

In order to obtain pertinent and representative data, a quantitative research design should be employed in the proposed study. In particular, a randomized-controlled trial would be conducted to collect numerical data on pain levels, depending on the use of CBD. Two groups, a control and intervention, would be composed to compare their data and made credible conclusions. The effectiveness of pain management would be measured on the basis of self-report pain questionnaires, which allow considering the intervention from the perspective of patients and their perceived comfort level. In addition, cold pressor tests and Pain Treatment Satisfaction Scale (PTSS) are two more options to evaluate the outcomes, namely, pain intensity as well as frequency. These instruments are identified as rather reliable and accurate, which especially important to the project implementation. The dosage of CBD will also be taken into account as this point is noted as a concern in the existing evidence. Among the expected outcomes, one can enumerate moderate or significant pain relief and positive impact on patients’ nausea and vomiting as critical side effects of chemotherapy.

Personal Experience and Evidence-Based Practice

Every nurse has a specific background and work-related experience, which are regarded as the factors that impact his or her ability, competence, and approach in implementing evidence-based practice (EBP). The EBP can be described as the explicit, judicious, and conscientious utilization of current evidence in delivering services to the patients in order to meet their individual needs (Malik, GMcKenna, & Plummer, 2015). Accordingly, nurses who thoroughly work on the preparation and implementation of EBP are likely to be more confident in their services, ensuring that patients would receive the services they expect. The sense of meaningfulness is another benefit that is promoted by the use of evidence-based interventions since care providers learn to apply the most advanced tools and procedures, making their services positive with regard to patients’ needs.

Personal experience of nurses largely determines the effectiveness of employing EBP in practice. In case they have positive experience and succeeded previously in implementing interventions, they are more likely to be effective and conscious in the future. However, the negative experience creates additional challenges on the path of adopting suggested interventions (Malik et al., 2015). For example, those who failed can express resistance to change, claiming that their work is good enough to adjust it. In this connection, a nurse leader should reveal the causes of resistance by asking proper questions yet remaining non-judgmental and objective. The age and the years of practice as components of experience can also prevent nurses from being open to innovations to enter in their daily routine they used to master and perfect.

Change Strategies and Implementation Barriers

A set of strategies is necessary to use to motivate nurses and assist them in implementing change in the workplace environment. Communication is an integral part of any change process as it contributes to the creation of a transparent and friendly atmosphere, when every employee is welcome to ask questions. It is especially advisable to apply a strategy based on communication in anticipation of the group resistance of personnel whose individual interests are clearly affected by the planned transformations (Sadeghi‐Bazargani, Tabrizi, & Azami‐Aghdash, 2014). A plan for change should be developed and implemented by management, but staff is to be given the right to express their wishes and requests, which should be perceived with understanding. The resistance of personnel is to be reduced by providing them with certain benefits in the form of financial bonuses and non-material encouragement.

One more strategy that can be applied refers to the clear presentation of the issues that should be altered with the explanation of the reasons and expected advantages. An information campaign should use all possible ways of communication, involving personal, written, electronic, et cetera. The managers should speak to employees with an explanation of the strategic goals of transformation since the evidence shows that information is better perceived if presented by the leaders. This is due to the fact that employees are well aware of the style of communication and the behavior of their managers.

Education is another option to prepare nurses to changes and decrease potential failures. The corporate training programs may be considered effective only if they are organically integrated into the outline of positive systemic changes aimed at implementing the organization’s mission. The opportunity of training for personnel is one of the core motivational tools that create additional conditions for attracting and retaining key employees. The care facility can develop the best qualities of its employees so that they contribute to its success more efficiently and effectively. In other words, this is the case when the goals of the organization and those of the employee match perfectly.

Speaking of barriers to change implementation, it is essential to focus on such issues as a lack of skills, time, and resources nurses may encounter. Even though they would consider the suggested project useful, they may have no time or idea of how to introduce it in practice. More to the point, one of the main problems of unsuccessful implementation of changes is the attitudes of employees along with the presence of their potential to resist newness (Sadeghi‐Bazargani, et al., 2014). It is quite obvious that organizational change entails the need to abandon the established behavior, reassess the criteria and management structure, and this, as a rule, affects the interests of people, which causes their resistance. There are different forms and degrees of resistance, while some nurse express it through delaying the adoption and implementation of new decisions, which leads to unexpected delays, additional expenses, and overall instability of the change process.

There are several reasons for barriers that should be discussed and prevented by management before the project implementation. The first category is composed of the economic concerns, such as a potential threat of loss of wages or sources of income, and fear of unemployment and deprivation of benefits and privileges. Second, the organizational points also require precise attention: unwillingness to change the existing system and personal relationships, established routine, fear for a future career, or reactions to previous unsuccessful experience of change matter. Ultimately, there are personal barriers, including an unwillingness to change habits, inertness, the threat of losing a position held, a personal status in an organization, loss of respect in the eyes of management and colleagues, and awareness of their incompetence to accept new things. The disbelief in personal abilities and unwillingness to take on new responsibilities and making decisions also prevent many nurses from accepting innovations. In order to avoid negative consequences, it is necessary to thoroughly plan the implementation of changes, timely identify the causes and sources of resistance, and learn to overcome them.

Conclusion

To conclude, this paper proposes the future research on the role of CBD in advancing the current pain management of cancer patients. It is stated that the current practices of opioid use cannot sufficiently address patients’ pain and is associated with significant side effects. The recent evidence shows that cannabis has a potential to improve pain relief, being a safer and effective therapeutic means. It is proposed to conduct the quantitative study based on the randomized-controlled trial to accurately present data to be collected during the experiment. The impact of personal experience, barriers, and strategies to implement EBP were also discussed.

References

Bar-Lev Schleider, L., Mechoulam, R., Lederman, V., Hilou, M., Lencovsky, O., Betzalel, O.,… Novack, V. (2018). Prospective analysis of safety and efficacy of medical cannabis in large unselected population of patients with cancer. European Journal of Internal Medicine, 49, 37-43. doi: 10.1016/j.ejim.2018.01.023

Chwistek, M. (2017). Recent advances in understanding and managing cancer pain. F1000Research, 6(945), 1-10. doi:10.12688/f1000research.10817.1

Côté, M., Trudel, M., Wang, C., & Fortin, A. (2016). Improving quality of life with nabilone during radiotherapy treatments for head and neck cancers: A randomized double-blind placebo-controlled trial. The Annals of Otology, Rhinology, and Laryngology, 125(4), 317-24. doi:10.1177/0003489415612801

Degenhardt, L., Lintzeris, N., Campbell, G., Bruno, R., Cohen, M., Farrell, M., & Hall, W. D. (2015). Experience of adjunctive cannabis use for chronic non-cancer pain: Findings from the Pain and Opioids In Treatment (POINT) study. Drug and Alcohol Dependence, 147, 144-50. doi:10.1016/j.drugalcdep.2014.11.031

Fallon, M., Albert Lux, E., McQuade, R., Rossetti, S., Sanchez, R., Sun, W…. Kornyeyeva, E.(2017). Sativex oromucosal spray as adjunctive therapy in advanced cancer patients with chronic pain unalleviated by optimized opioid therapy: Two double-blind, randomized, placebo-controlled phase 3 studies. British Journal of Pain, 11(3), 119-133. doi:10.1177/2049463717710042

Lichtman, A. H., Lux, E. A., McQuade, R., Rossetti, S., Sanchez, R., Sun, W…. Fallon, M. T. (2018). Results of a double-blind, randomized, placebo-controlled study of nabiximols oromucosal spray as an adjunctive therapy in advanced cancer patients with chronic uncontrolled pain. Journal of Pain and Symptom Management, 55(2), 179-188. doi:10.1016/j.jpainsymman.2017.09.001

Malik, G., McKenna, L., & Plummer, V. (2015). Perceived knowledge, skills, attitude and contextual factors affecting evidence‐based practice among nurse educators, clinical coaches and nurse specialists. International Journal of Nursing Practice, 21, 46-57. doi:10.1111/ijn.12366

Martell, K., Fairchild, A., LeGerrier, B., Sinha, R., Baker, S., Liu, H., Ghose, A.,… Kebra, M. (2018). Rates of cannabis use in patients with cancer. Current Oncology, 25(3), 219-225. doi:10.3747/co.25.3983

Page, R., & Blanchard, E. (2019). Opioids and cancer pain: Patients’ needs and access challenges. Journal of Oncology Practice, 15(5), 229-231.

Sadeghi‐Bazargani, H., Tabrizi, J. S., & Azami‐Aghdash, S. (2014). Barriers to evidence‐based medicine: A systematic review. Journal of Evaluation in Clinical Practice, 20(6), 793-802.

Turcott, J. G., Del Rocío Guillen Núñez, M., Flores-Estrada, D., Oñate-Ocaña, L. F., Zatarain-Barrón, Z. L., Barrón, F., Arrieta, O. (2018). The effect of Nabilone on appetite, nutritional status, and quality of life in lung cancer patients: A randomized, double-blind clinical trial. Supportive Care in Cancer, 26(9), 3029-3038. doi: 10.1007/s00520-018-4154-9

Wiffen, P., Wee, B., Derry, S., Bell, R., & Moore, R. (2017). Opioids for cancer pain – An overview of Cochrane reviews. Cochrane Database of Systematic Reviews, 7, 1-23. doi:10.1002/14651858.cd012592.pub2