Cannabinoids in palliative care

Palliative care focuses on quality of life when cure is no longer the goal. Medicinal cannabis is sometimes raised by patients or whānau as an option for symptom control in this setting. The strongest data for cannabinoids in palliative care covers three symptom clusters: chronic pain, chemotherapy-induced nausea and vomiting (CINV), and refractory spasticity. The findings are not uniform, so each symptom must be judged separately.

A prescription from a medical practitioner is the only legal route in New Zealand. The product must be a manufactured pharmaceutical dispensed by a pharmacy, not raw plant material. Products are not funded by Pharmac; the patient pays the full cost, and cost is a major barrier.

Symptom-by-symptom findings

Every claim below names the condition, the outcome, the formulation studied, and the strength of the data. Strength follows the usual hierarchy: systematic reviews and meta-analyses are highest, then randomised controlled trials (RCTs), then cohort studies and expert consensus.

Condition	Outcome measured	Formulation studied	Strength of data (as of 2025)
Chronic pain (cancer and non-cancer)	Pain intensity reduction	Nabiximols (THC:CBD oromucosal spray), smoked/inhaled THC, oral THC	Moderate for neuropathic pain; weaker for nociceptive pain. Systematic reviews show a modest but consistent analgesic effect, yet many trials are short-term and industry-funded.
Chemotherapy-induced nausea and vomiting (CINV)	Reduction in nausea and vomiting episodes	Oral THC (e.g., dronabinol, nabilone)	Moderate; superior to placebo, but not clearly superior to standard antiemetics (e.g., ondansetron) in head-to-head trials.
Cancer-related pain	Pain score reduction, opioid-sparing	THC-dominant flower/oil, balanced THC:CBD	Low-to-moderate; effect is often small and inconsistent across studies.
Refractory epilepsy	Seizure frequency	Epidiolex (pure CBD), not generic cannabis	High for specific syndromes (Dravet, Lennox-Gastaut); NZ indication is narrow.
Anxiety in palliative care	Symptom score reduction	CBD-dominant formulations	Low; limited trials, mixed results.
Appetite stimulation	Weight change or appetite score	THC-dominant formulations	Low; findings are mixed and mostly from HIV cohorts, not palliative populations.
Sleep disturbance	Patient-reported sleep improvement	THC or THC:CBD balanced formulations	Low to moderate; improvements are often secondary to pain relief.

Chronic pain (cancer and non-cancer)

Outcome: Pain intensity reduction. Formulation studied: Nabiximols (THC:CBD oromucosal spray), inhaled THC-dominant flower, oral THC/CBD oils. Strength of data: Moderate for cancer pain, low-to-moderate for chronic non-cancer pain. A 2021 systematic review in BMJ Supportive & Palliative Care (Boland et al.) found that cannabinoids produced a small but statistically significant reduction in cancer pain compared with placebo, but the number needed to treat was high and many patients withdrew due to adverse effects. The same review noted that neuropathic pain responds better than nociceptive pain, but the overall effect size is modest. For chronic non-cancer pain, the 2023 systematic review in the Journal of the American Medical Association (JAMA) concluded that cannabis and cannabinoids were associated with a small improvement in pain at 6 months, but with a significant increase in dizziness and sedation; the authors rated the findings as low to moderate certainty.

The regulatory frame in New Zealand

Under the Misuse of Drugs Act 1975, medicinal cannabis is a controlled drug. The Medicinal Cannabis Scheme, established by the Misuse of Drugs (Medicinal Cannabis) Regulations 2019, sets the rules for lawful access. The scheme became fully operational on 1 April 2020. The Misuse of Drugs (Medicinal Cannabis) Amendment Act 2018 created the separate regulatory framework.

• The Ministry of Health runs the scheme. Medsafe, through the Medicinal Cannabis Agency, approves formulations and issues licences.
• A prescription from a medical practitioner is the only legal route. The Ministry of Health (2022) states that the scheme does not allow people to possess or use cannabis for general purposes; it is a prescribed medicine.
• Formulations must meet GMP standards and be approved by the Ministry of Health. Raw plant material is not a legal product; the lawful pathway is a manufactured pharmaceutical dispensed by a pharmacy. (Ministry of Health, 2022)
• Prescribers can be any doctor in the country, but they must be satisfied that conventional treatments have failed and that the potential benefit outweighs the risks. Nurse practitioners cannot prescribe cannabis formulations under the current scheme.

Goals of care: matching the formulation to the symptom

Work through the condition, the expected outcome, the formulation type, and the strength of the data before discussing a cannabinoid trial with a clinician.

Chronic neuropathic pain

Choose nabiximols or a balanced THC:CBD oil. Expect a modest analgesic effect. Document your baseline pain score and schedule a review at 2 weeks.

Chemotherapy-induced nausea and vomiting

Ask about oral THC (dronabinol, nabilone). Try this only after standard antiemetics have failed. Monitor sedation and dizziness daily and report worsening to the prescriber.

Cancer-related pain (opioid-sparing)

Consider a THC-dominant oil or flower. The effect is small and inconsistent across studies. Weigh the possible benefit against cognitive adverse effects and agree on a stop date before starting.

Refractory epilepsy (specific syndromes)

Epidiolex (pure CBD) has high-quality data for Dravet and Lennox-Gastaut syndromes. The funded indication is narrow, so confirm eligibility with the prescriber.

Appetite stimulation

THC-dominant formulations show mixed findings and have not been studied in palliative cohorts. Set a weight or intake target with the prescriber and stop if there is no change at 4 weeks.

Anxiety

CBD-dominant formulations have low-quality data. Use only if other interventions have failed and a mental health clinician is involved in the monitoring.

Sleep disturbance

THC or balanced THC:CBD may improve sleep, but the improvement is often secondary to pain relief. Try a pain-targeted formulation first and track sleep quality separately.

Safety, adverse effects and daily life

Do not drive or operate machinery after taking any THC-containing formulation. THC impairs coordination, reaction time and judgement. The impairment can last for hours after dosing and varies by formulation.

Common adverse effects include dizziness, sedation, dry mouth, and cognitive clouding. Older adults and people with cardiac conditions are at higher risk of hypotension and falls. THC can worsen anxiety, paranoia and psychosis in susceptible people. CBD is generally better tolerated but can cause diarrhoea, fatigue and appetite changes. Report any new or worsening confusion, chest pain, or fainting to the prescriber immediately.

The prescriber must document the indication, baseline measures and planned review date. The pharmacist checks for interactions with existing medicines, especially anticoagulants, anticonvulsants and CNS depressants. The NZ Formulary (2024) lists cannabis formulations as a specialist recommendation, meaning they are not first-line. The New Zealand Medical Association (2021) advises that cannabis should be considered only after conventional treatments have failed.

When the findings do not apply

The data described here come from controlled trials in defined populations. They do not apply to recreational use, wellness or self-medication with unregulated products. CBD sold as a dietary supplement under the Dietary Supplements Regulations 1985 is not registered as a medicine in New Zealand (Healthify, 2023) and has not been evaluated for palliative outcomes.

Checklist for a palliative care consultation

• Bring a list of all current medicines, including over-the-counter and supplements.
• Write down the one symptom you most want to address.
• Note what conventional treatments you have already tried and why they stopped.
• Ask the doctor: “Which formulation matches this symptom, and what should I expect in the first two weeks?”
• Agree on a stop date if there is no meaningful improvement.
• Confirm who will monitor you and how often.
• Ask about cost; a month’s supply can range from $100 to over $500 depending on the formulation.

Common questions

Can I use raw cannabis flower from a dispensary? No. The legal pathway requires a manufactured pharmaceutical dispensed by a pharmacy. Raw plant material is not an approved product under the Medicinal Cannabis Scheme.

Is medicinal cannabis funded? No. Pharmac does not fund cannabis formulations. You pay the full cost.

Can a nurse practitioner prescribe it? Not under the current scheme. Only a medical practitioner can prescribe.

Will it help with my appetite? The findings are mixed and come mostly from HIV studies, not palliative care. Set a clear target with your doctor and stop if there is no change within four weeks.

Can I drive while taking CBD? Pure CBD is not considered impairing, but many formulations contain some THC. Do not drive unless your doctor has specifically cleared you and you know exactly what is in your formulation.

Where to get help

• Healthify: plain-language overview of medicinal cannabis in New Zealand.
• NZ Formulary: prescribing information for health professionals.
• Medicinal Cannabis Agency: official regulatory body for the Medicinal Cannabis Scheme.

This is general information, not medical advice. Consult a qualified prescriber to discuss your own situation.