Page 45 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 16 of 26 Guideline

72
are beginning to emerge (see Table 5). An observational BOX 3: Thomas Browne, The Religio Medici. 75
study in > 3000 cancer patients found that cannabis improved Men that look no further than their outsides, think health an appurtenance unto
life and quarrel with their constitutions for being sick; But I that have examined
sleep, anxiety and depression levels and reduced the fatigue, the parts of man, and know upon what tender filaments that fabric hangs, do
nausea and vomiting caused by chemotherapy. A report of wonder that we are not always so; And considering the thousand doors that lead
73
to death, do thank my God that we can die but once.
198 HIV-infected ‘heavy’ cannabis users found reduced – Thomas Browne, 1642. The Religio Medici
activation of inflammatory markers compared with non- Source: Ferry G. Thomas Browne: A rarity among rarities. Lancet. 2017;389:1687–1688.
https://doi.org/10.1016/S0140-6736(17)31067-X
cannabis using controls; however, there is clearly a need to
better clarify the role of the cannabinoids in evidence-based, overcrowded, ageing facilities in need of renewal and a
well-planned RCTs of the HIV-infected and uninfected department facing extraordinarily high levels of litigation. 77,78
people. The 2016 Johns Hopkins-Lancet Commission on
74
Drug Policy and Health makes the additional point: ‘At a Developing a discipline of palliative care and fitting it into
time of policy-level concern about dependence on prescription this failing system at this time will be a testing experience,
opioids, a few ecological studies suggest that greater access but it must happen. Somehow.
75
to cannabis could reduce use of opioids for pain relief’.
75
The private sector must find a reliable tool that funders can
Cannabinoid side effects are common, usually dose- use when providing capital for home nursing and hospice
dependent, that is, higher doses tend to produce more side admission. A life expectancy of 6 months or less is a widely
effects, and are often specific to individual compounds (see used rule of thumb in the United States, although available
Table 3). These side effects include cardiac (tachycardia, models are generally insensitive to the gains of ART and the
hypo- and hypertension), CNS (arousal and depression treatment of opportunistic disease. No local RCTs answer
this question; nonetheless, our recommendation has been to
states, for example cognitive impairment, euphoria, psychosis follow the US approach and use the 6-month probability of
and paranoia), and gastrointestinal toxicity such as diarrhea, survival or the SPICT tool.
TM
vomiting and abnormal liver enzymes, with higher doses
(see Table 6). The defining treatment ethos of HIV and ID clinicians is
72
curative. There is no conflict between curative and
With regard to the role of cannabinoids in the palliative care symptomatic management provided the goal to treat
of HIV-infected patients, several ‘unknowns’ remain, for suffering is central to care. Is there a time where curative care
example : is no longer appropriate? Is there a time to let go of ART? Yes.
72
Those of us who are hospital-based clinicians encounter these
• Indications for use of cannabinoids require urgent questions daily in our wards and clinics. The answers are not
clarification. usually found in textbooks but at the patient’s bedside.
• The pharmacokinetics and pharmacodynamics of
cannabinoids in people naïve to and those with prior Acknowledgements
exposure (to cannabinoids) in the context of palliative
care. Does this differ? Do cannabinoid-exposed people Competing interests
require a higher dosing of cannabis? The authors have declared that no competing interests exist.
• Drug–drug interactions between the cannabinoids, ART
and TB drugs have minimal or no data.
• Which route of administration should be recommended: Authors’ contributions
oral, inhaled (smoked)? D.C.S. conceived the format and wrote the guidelines. R.K.,
T.R., M.-Y.S.M., S.B., A.M. and E.M. provided specialist
Final remarks material. R.K. and T.R. reviewed individual sections as the
guideline developed. All authors participated in the initial
It was the general belief in the 1980s that a vaccine and cure guideline committee meeting and comments on the final
would have been found by the end of that decade or at the latest, manuscript prior to submission.
that is, the middle of the 1990s. That did not occur, and the HIV
epidemic is now firmly rooted in southern African soil.
Antiretroviral therapy has transformed the infection into a Ethical consideration
chronic, manageable disorder yet the condition remains incurable. This article followed all ethical standards for a research
About 8 million HIV-infected South Africans need care and will without direct contact with human or animal subjects.
die from or with the virus. Their suffering is the concern of these
guidelines as many will require palliative care (see Box 3).
Funding information
The ‘total pain’ that accompanies suffering arises from This research received no specific grant from any funding
multiple causes. Analgesics alone do not effectively control agency in the public, commercial or not-for-profit sectors.
this pain although palliative care teams throughout the
country’s health service would go a long way to answer this Data availability statement
need. Even highly motivated teams require funding,
organisation and the support of colleagues and government Data sharing in not applicable to this article as no new data
in a country where its public health is in trouble: underfunded, were created or analysed in this study.

http://www.sajhivmed.org.za 38 Open Access