Survey highlights disparities in cancer pain management, need for cannabis guidelines
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Guidelines for cannabis and prescription opioid use in the management of cancer-associated pain should reflect changing patient attitudes toward these approaches, according to study findings.
Researchers reviewed survey data from four NCI-designated cancer centers in three states to evaluate patients’ perceptions of cannabis and opioid use for pain. They analyzed outcomes by race and ethnicity.
The analysis included 1,220 people with cancer (57.1% women; 81.8% white; 9.8% Black; 8.4% Hispanic or other race). More than half (59.7%) had used opioids to manage pain, and 43.4% indicated they used cannabis instead of opioids to manage pain.
Compared with white patients, Black patients were less likely to use opioids for pain (OR = 0.66; 95% CI, 0.45-0.97) and more likely to find cannabis more effective than opioids for controlling pain (OR = 2.46; 95% CI, 1.12-5.43).
Of the 506 individuals who used cannabis instead of opioids for pain, the majority indicated they opted for this approach because “cannabis is safer” (overall, 78.7%; white, 79.6%; Black, 70.4%; Hispanic or other, 80%) or because “cannabis is less addictive” (overall, 72.3%; white, 74.3%; Black, 53.7%; Hispanic or other, 76.4%). A majority also cited fewer side effects with cannabis as the reason for their choice (overall, 71.1%; white, 71.8%; Black, 63; Hispanic or other, 74.5%).
“One thing we hear repeatedly from patients in our qualitative work is that there are still concerns about stigma around these topics. They don’t feel comfortable talking to their providers about this,” Rebecca L. Ashare, PhD, associate professor of psychology in University at Buffalo’s College of Arts and Sciences, told Healio. “This can cause patients to avoid discussing what they are taking, which can lead to harmful drug interactions and can prevent the clinician from having the information they need to help.”
Healio spoke with Ashare about the disconnect between providers and patients, as well as what can be done to create more open, nonjudgmental dialogue.
Healio: Prior to your study, what did the evidence show about cannabis use among people with cancer?
Ashare: We knew patients were using cannabis, but we didn’t know a lot more than that. We knew they were using it for pain, sleep and sometimes mood symptoms, like anxiety and depression. We didn’t have a full understanding of how common it was.
Healio: Why do you think so little was known?
Ashare: There are several systemic-level barriers. In terms of cannabis, the fact that it is a schedule 1 drug has really limited our ability to do the kinds of research we need to do to develop evidence-based guidelines for providers. In some cases, there are health system barriers. We have patients who tell us that opioid prescriptions can be revoked if they are using cannabis, so that’s another barrier to discussing cannabis with providers.
Healio: Why did you conduct this study?
Ashare: We were interested in the intersection between cannabis use and opioid use, and we wanted to understand how patients make decisions about managing pain. Opioids are still a cornerstone of cancer pain treatment, but the opioid epidemic has changed that landscape. Long-term opioid therapy is associated with various risks, including the risk for abuse and other complications. Prescription guidelines — even in the context of cancer — have changed, and opioid prescribing has decreased. People have looked elsewhere for ways to manage pain, and many have turned to cannabis. We were trying to understand what factors affect that decision. We conducted the survey at 12 sites across the country. It was anonymous because we wanted patients to feel comfortable responding.
Healio: What did you find?
Ashare: We found 43% of patients said they used cannabis instead of opioids to manage pain. Even among those who had used opioids before but currently used cannabis instead, 47% of these patients said cannabis was better at managing pain.
Healio: What differences did you observe by race in terms of opioid and cannabis use?
Ashare: Patients who identified as Black were approximately 30% less likely to have ever used opioids, or to have a prescription for opioids. Also, patients who identified as Black were more likely to report that cannabis was more effective than opioids.
Healio: What can practicing oncologists do to advise patients who want information about cannabis?
Ashare: Creating a space in which patients feel comfortable talking about it is very helpful. Even if the clinician isn’t sure how to guide patients in terms of the types of cannabis to use or where to go, they can help by giving patients the tools to educate themselves. Directing patients to reputable online sources and helping them become good consumers of information is a great first step.
Healio: What is next in your research on this?
Ashare: We have a couple large, ongoing cohort studies that are in the collection phase. Both of them are observational studies. One is looking at this intersection between cannabis and opioid use for pain and to test whether cannabis has an opioid-sparing effect.
The other is looking at the benefits and harms of cannabis use among patients who are being treated with immunotherapy.
Healio: Is there anything else you’d like to mention?
Ashare: One thing we need to take into consideration is the broader context in which patients are using cannabis. Social determinants can impact what kinds of cannabis they have access to and how income, race and geography can play a role in whether they smoke cannabis or use potentially less harmful forms, like edibles or tinctures. Also, because cannabis is not covered by insurance, what a patient can afford plays a role.
References:
- Ashare RL, et al. J Natl Cancer Inst Radiogr. 2024;doi:10.1093/jncimonographs/lgad027.
- UB study points to need for developing cannabis use guidelines for treating cancer-related pain. Available at: https://www.buffalo.edu/ubnow/stories/2024/09/ashare-cannabis-cancer.html. Published Sept. 6, 2024. Accessed Oct. 25, 2024.
For more information:
Rebecca L. Ashare, PhD, can be reached at rlashare@buffalo.edu.
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