In our oncology palliative care clinic, we have many patients requesting medical cannabis. To date, there are over 120,000 medical cannabis licenses for all indications in Israel almost 2% of the adult population — 14,000 of which are for cancer. There is little high-quality research showing that cannabis relieves major medical symptoms. The justification is ad hoc and by word of mouth. Anecdotally, it helps some people with insomnia and to cope with certain types of pain.
It is our clinical impression that in oncologic palliative care, medical cannabis is frequently chosen by patients — consciously or otherwise — to relieve existential angst. For many people, it “relaxes” them, which is probably a euphemism for experiencing a “high” or causing a mild dissociative state which relieves existential angst.
The price some people pay for the chronic use of medical cannabis appears to be a life-long severe dependence, which not infrequently rises to the level of addiction. The other price is a philosophical one — that they will never have to struggle against the demons and fears, as did John Donne in Sonnet X: “One short sleep past, we wake eternally; And death shall be no more; Death, thou shalt die.” (Donne, Reference Donne1633).
The medical profession is infamously known for its acronyms — NED, CVA, PRN, BKA, DKA, NOF, IHD, AMI, and so forth. Some are eponymous, but most of their origins are lost.
Acronyms are useful for three reasons. One, is they save time in writing or typing. Two, the message is communicated at a glance. Three, they are used as a code to keep medical information secret.
In our palliative care clinic, we have coined the acronym BRSFootnote 1 — Becker-Rank Syndrome — to describe the existential angst that drives the use of medical cannabis.
Ernest Becker extensively referenced Otto Rank while developing his ideas of existential angst. Becker understood that the fear of death is universal, is often ineffectively suppressed, and significantly influences our cultural behavior: “Modern man is drinking and drugging himself out of awareness, or he spends his time shopping, which is the same thing.” (Becker, Reference Becker1973).
Benzodiazepines, alcohol, heroin et al., all relieve angst although some have unacceptable side effects, including addiction and death. Today in Israel owing to a nexus of factors, cannabis is chosen by cancer patients and families as the medication-drug of choice to relieve existential angst and its apparitions. Often they are not aware that cannabis is being used for this reason. They often dissimulate to themselves that they have pain, tension, fatigue, nausea, or insomnia.
The BRS is defined as:
1. angst that interferes with daily functioning;
2. an inability to resolve angst with talking or other therapies;
3. an anxiety that has become chronic, like a neurosis; and
4. in the context of an illness, that actually or symbolically threatens life.
Patients often describe cannabis as helping them to dissociate the fearful thought from the terrible feeling. In this way, cannabis helps them to forget for a while. Interestingly, endocannabinoids have a specific neural function of encouraging forgetfulness in the normal situation.
Many patients prefer something “natural” (the cannabis flower) over medications, such as benzodiazepines and serotonin-based drugs which in their mythology are “chemicals.” The patients by and large continue to behave and function normally, although they may do so at a lower level and become unmotivated. I have asked a number of patients to try “life” without a cannabis fog — to get to know themselves again. In general, this suggestion is not received with enthusiasm. I was reminded of this by the book “Listening to Prozac,” wherein the author describes a patient who had benefitted from the anti-depressive effects of fluoxetine but no longer felt “himself.” He wanted to go back to wearing his old clothes (Kramer, Reference Kramer1993). It is worth noting in passing that some patients unwittingly use the anxiolytic and euphoric properties of opioids to relieve angst, which may be a prime to developing dependence and addiction.
The skill of the clinician is to strike the best balance between angst and side effects of medical cannabis. Just as the oncologist must do with chemotherapy.
The acronym BRS succinctly summarizes the clinical picture. When reviewing the patient later for a possible renewal of the cannabis license the acronym enables a rapid assessment, all the more so if a different clinician is seeing the patient.
