Pharmacists can help to usher in a new era of patient-centered end-of-life care.
Since the passage of proposition 215 in 1996, California has been at the forefront of medical cannabis acceptance.1 However, the therapeutic application of cannabis has remained on the fringe of modern health care. Now, thanks to passionate advocates and forward-thinking legislators, medical cannabis is making substantial progress in California with the enactment of Ryan’s Law (Senate Bill 988), which gives patients with terminal illness the option to use medical cannabis within the health care setting.2
After receiving a diagnosis of terminal pancreatic cancer and told he had only months to live, Ryan Bartell struggled to tolerate the opioids prescribed by his doctor. He found the adverse effects unbearable and requested that his doctor permit him to use medical cannabis. Even though he received permission from his oncologist and had his family’s support, hospital administration refused to allow Ryan to use cannabis while in the facility, even in the face of a terminal diagnosis.
After his request was denied, Ryan’s family transferred him to another hospital where he was permitted to palliate his pain with cannabis, the medication of his choosing. Ryan found relief with medical cannabis and was able to spend quality time with his loved ones at the end of his life. He died only a few weeks later but was able to remain lucid and share some of his last moments in dignity with the individuals he loved. Ryan’s poignant story showcases the power of medical cannabis, providing relief where traditional painkillers and end-of-life medicines sometimes fail.
Ryan’s Law was born from this story and subsequently written into California legislation to ensure that no other patients would experience the difficulties that Ryan encountered; it represents a turning point in medical cannabis legislation. The law requires California health care institutions to permit the use of medical cannabis by terminally ill patients, but it is not without stipulations. It allows for the use of medical cannabis in specific health care settings but prohibits inhalable products and requires patients to possess a legal medical marijuana recommendation from a licensed medical provider. As specified in Ryan’s Law, patients or caregivers are to retain control over their medical cannabis throughout their stay and are responsible for acquiring, storing (in a locked container at bedside), administering, and removing it from the premises. Although the law extends to various institutional settings, including long-term and acute care facilities, it currently does not apply to emergency departments.
The benefits of medical cannabis in end-of-life care remain a subject of debate in the literature, and many end-of-life providers remain either unaware of the potential benefits or hesitant to bring it into their practice.3 Although there is significant evidence to support the efficacy of medical cannabis in the management of chronic pain and as an antiemetic for chemotherapy-induced nausea and vomiting, the evidence for utilizing cannabis in various other painful conditions remains uncertain. Additionally, there is no substantiated evidence to assert that cannabis could serve as a treatment for cancer. Nevertheless, the use of cannabis to alleviate insomnia and anxiety, frequently experienced by individuals with terminal illnesses, has also been demonstrated.4,5 Considering the limited options for effective end-of-life therapies, medical cannabis may offer an alternative with fewer sedating adverse effects (AEs). By avoiding commonly prescribed and more sedating drugs, such as opioids or benzodiazepines, medical cannabis patients can better tolerate pain while maintaining alertness, allowing them to engage in meaningful moments with loved ones during their final days.
Equipped with our patient counseling skills, pharmacists can provide guidance to patients and caregivers on proper use, documentation, AEs, and potential drug interactions, ensuring that medical cannabis is thoughtfully and safely integrated into the patient’s existing medication regimen. Pharmacists are excellent liaisons among patients, families, and health care professionals and are suited to facilitate coordinated and comprehensive patient care in long-term as well as acute care settings. Based on our expertise in medication management and patient communication, pharmacists are uniquely positioned to play a leading role in supporting the successful implementation of Ryan’s Law.
The role of pharmacists in supporting Ryan’s Law begins with education; it is imperative that we educate pharmacists about the benefits and risks of medical cannabis. By doing so, we can begin to destigmatize its use and cultivate a more informed, open-minded, and patient-centric health care environment. The development and integration of cannabis pharmacology into the pharmacy curriculum are critical if we are to ensure that our profession is prepared to provide evidence-based guidance to patients and other health care providers, irrespective of the current federal status of marijuana.6-8
In California, the recently proposed Senate Bill 302 seeks to open the institutional use of medical cannabis to all individuals with chronic illness older than 65 years, greatly expanding access within the health care setting.9 Although it is a clear win for advocates aiming to improve access, this change is a major shift from status quo and will require the support of cannabis-informed health care professionals. This bill represents a monumental opportunity for pharmacists to take the lead and play a vital role in driving the shape of health care laws, advocating for policy change, and developing strategies for implementation.
Ryan’s Law represents progress for medical cannabis in US health care. It has created an opportunity for pharmacists to showcase our role as risk mitigators, experts in pharmacology, and adept patient counselors. As more US states explore medical cannabis legislation, pharmacists (and the institutions where they work) must be prepared to embrace these transformative changes in health care. By championing Ryan’s Law, pharmacists can help to usher in a new era of patient-centered end-of-life care and protect the right of patients to die with dignity.
1. The Compassionate Use Act of 1996, HSC §11362.5 (1996). Accessed Aug 4, 2023. https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=11362.5.&lawCode=HSC
2. Compassionate Access to Medical Cannabis Act, or Ryan’s Law, HSC §1649 (2021). Accessed Aug 4, 2023. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202120220SB988
3. Luba R, Earleywine M, Farmer S, Slavin M. Cannabis in end-of-life care: examining attitudes and practices of palliative care providers. J Psychoactive Drugs. 2018;50(4):348-354. doi:10.1080/02791072.2018.1462543
4. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Health Effects of Marijuana: An Evidence Review and Research Agenda. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. National Academies Press (US); 2017.
5. Vuckovic S, Srebro D, Vojovic KS, Vucetic C, Prostran M. Cannabinoids and pain: new insights from old molecules. Front Pharmacol. 2018;9:1259. doi:10.3389/phar.2018.01259
6. Schmitz N, Richert L. Pharmacists and the future of cannabis medicine. J Am Pharm Assoc (2003). 2020;60(1):207-211. doi:10.1016/j.japh.2019.11.007
7. Zolotov Y, Metri S, Calabria E, Kogan M. Medical cannabis education among healthcare trainees: a scoping review. Complement Ther Med. 2021;58:102675. doi:10.1016/j.ctim.2021.102675
8. Gardiner KM, Singleton JA, Sheridan J, Kyle GJ, Nissen LM. Health professional beliefs, knowledge, and concerns surrounding medicinal cannabis: a systematic review. PLoS One. 2019;14(5):e0216556. doi:10.1371/journal.pone.0216556
9. Compassionate Access to Medical Cannabis Act or Ryan’s Law. S302. 2023-2024 Session (Ca 2023). Accessed Aug 4, 2023. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202320240SB302
About the Author
The Pharmacists’ Cannabis Coalition Of California (PCCC) is a nonprofit organization established in 2020 to provide evidence-based education about cannabis to health care professionals and the public. PCCC looks to integrate the pharmacist more fully into the cannabis patient-care model for the betterment of patient health and health outcomes.