Medical Marijuana: Take Two Puffs and Call Me in the Morning
Robin Young • Wed, June 28th, 2017
In the United States, 1.2 million people have a medical marijuana card.
Since 1996, when California approved the use of medical marijuana, 28 other states also legalized medical marijuana.
A handful of states, notably Colorado, legalized recreational use of marijuana. With recreational use many patients threw their medical marijuana card away.
But not all.
In fact, a core group of medical marijuana users have emerged in those states.
Medical use of marijuana is both a fact and increasingly part of the overall continuum of care for certain patients.
The most common medical indications for which marijuana has been legalized are:
|Medical Marijuana Indication||To Treat:||Clinical Studies (We Found Several Hundred)|
|Cancer||Nausea, vomiting, loss of appetite from chemotherapy, neuropathic pain.||Marta Duran, M.D., Clinical Pharmacologist, Fundació Institut Català de Farmacologia, Universitat Autònoma de Barcelona, et al., Nov 2010: "Preliminary Efficacy and Safety of an Oromucosal Standardized Cannabis Extract in Chemotherapy-Induced Nausea and Vomiting," British Journal of Clinical Pharmacology.|
|Glaucoma||Intraocular pressure (IOP).||Ileana Tomida, M.D., Oct 2006: "Effect of Sublingual Application of Cannabinoids on Intraocular Pressure: A Pilot Study" Journal of Glaucoma: Assessed the effect on IOP and the safety and tolerability of low dose of delta-9-tetrahydrocannabinol and cannabidiol.
CONCLUSIONS: A single 5 mg dose of Delta-9-THC reduced IOP temporarily and was well tolerated by most patients.
|HIV/AIDS||Neuropathic pain||Ronald J. Ellis, M.D., Ph.D., Aug 2008: "Smoked Medicinal Cannabis for Neuropathic Pain in HIV: A Randomized, Crossover Clinical Trial," Neuropsychopharmacology: Double-blind, randomized, clinical trial of short term adjunctive treatment of neuropathic pain in HIV associated distal sensory polyneuropathy. Pain relief was significantly greater with cannabis than placebo. Smoked cannabis was generally well tolerated and effective.|
|Parkinson’s Disease||Insomnia, pain, tremors, rigidity||Itay Lotan, M.D., Mar/Apr 2014; "Cannabis (Medical Marijuana) Treatment for Motor and Non–Motor Symptoms of Parkinson Disease: An Open-Label Observational Study," Clinical Neuropharmacology. 22 Parkinson’s patients assessed via Unified Parkinson Disease Rating Scale, visual analog scale, present pain intensity scale, Short-Form McGill Pain Questionnaire.
RESULTS: Unified Parkinson Disease Rating Scale score improved significantly; specific motor symptoms had significant improvement after treatment in tremor, rigidity and bradykinesia. No significant adverse events.
|Multiple Sclerosis||Spasticity||Peter Flachenecker, M.D., Jun 2014: "Long-Term Effectiveness and Safety of Nabiximols (Tetrahydrocannabinol/Cannabidiol Oromucosal Spray) in Clinical Practice," European Neurology.
RESULTS: 52 patients, 12-month follow up. Mean spasticity rating scale (NRS, 0-10) decreased significantly. 84% of patients did not report adverse events.
|Epilepsy||Seizures||Hess EJ, Moody KA, Geffrey AL, Pollack SF, Skirvin LA, Bruno PL, Paolini JL, Thiele EA., Oct 2016: “Cannabidiol as a new treatment for drug-resistant epilepsy in tuberous sclerosis complex,” Epilepsia. 56 patients were treated with 5 mg/kg/day with cannabidiol (CBD), increased each day to 50 mg/kg/day.
RESULTS: Seizure frequency decreased from 22.0 to 13.3 after 3 months. Well tolerated.
|Wasting Syndrome||Appetite, insomnia||Bedi G, Foltin RW, Gunderson EW, Rabkin J, Hart CL, Comer SD, Vosburg SK, Haney M., Dec 2010: “Efficacy and tolerability of high-dose dronabinol maintenance in HIV-positive marijuana smokers: a controlled laboratory study”, Psychopharmacology. 7 patients, double blind study.
RESULTS: Increased caloric intake for first 8 days and improved sleep quality for first 8 days. Well tolerated by patients.
|Crohn’s Disease||Appetite, sleep, abdominal pain, joint pain, abdominal cramping and diarrhea.||Timna Naftali, M.D., Oct 2013; "Cannabis Induces a Clinical Response in Patients with Crohn's Disease: A Prospective Placebo-Controlled Study," Clinical Gastroenterology and Hepatology. 21 patients with Crohn’s Disease Activity Index greater than 200 who failed steroid, immunomodulatory or anti-tumor necrosis factor-alpha treatment. Patients treated with 115 mg of delta 9-tetrahydrocannabinaol or placebo.
RESULTS: Complete remission by 5 of 11 in treatment group, 1 of 10 in placebo group. No significant side effects.
|Post-Traumatic Stress Syndrome||Anxiety, insomnia, appetite, depression||George R. Greer, M.D., Charles S. Grob, M.D., Adam L. Halberstadt, Ph.D., Mar 2014:"PTSD Symptom Reports of Patients Evaluated for the New Mexico Medical Cannabis Program," Journal of Psychoactive Drugs. 80 patients assessed using Clinician Administered Posttraumatic Scale for DSM-IV (CAPS).
RESULTS: 75% reduction in CAPS symptom scores were reported when patients were using cannabis compared to when they were not.
It’s a cash business and legal sales of marijuana reached $6.7 billion in 2016—up from essentially $0 in 1995.
Tax revenues have also soared.
Is marijuana ready to become part of every physician’s armamentarium?
In Colorado, patients may not have access to medical marijuana without a doctor’s examination and continuous care. The specific language from the Colorado statute is:
“Physician and patient have a treatment or counseling relationship, in the course of which the physician has completed a full assessment of the patient’s medical history and current medical condition, including a personal physical examination; the physician has consulted with the patient with respect to the patient’s debilitating medical condition before the patient applies for a registry identification card; and the physician provides follow-up care and treatment to the patient, including but not limited to 1 patient examination to determine the efficacy of the use of medical marijuana as a treatment of the patient’s debilitating medical condition.”
We were in Denver attending the American College of Sports Medicine conference this past May and took the opportunity to visit a number of medical marijuana dispensaries to ask about the role of physicians in the medical marijuana business.
We learned that while the doctor is the source of the registry ID card and therefore the gatekeeper to medical marijuana, they are otherwise irrelevant to the sale, dosing and use of medical marijuana.
Barely a handful of physicians, 3 to 5 per dispensary we visited, refer patients for medical marijuana.
When patients enter a medical marijuana dispensary, they do not come with specific instructions from their doctor as to dosing, adverse events or which specific strain of marijuana might best suit for their condition.
That information typically comes from the clerk behind the counter. Or the chart on the wall from Leafly (see image to the right).
Interview With a Medical Marijuana Dispensary
One of the most successful medical marijuana dispensaries in Colorado is Strainwise, which owns and operates nine stores in and around Denver. We spoke with Ashleigh Langford, retail sales director for Strainwise and asked her about their relationship with the physician.
Orthopedics This Week: How many patients do you treat annually?
Strainwise: Between all medical stores we see approx. 5,300 annually.
OTW: How often do individual patients come into the dispensary?
SW: Most patients will visit 2 times per week.
OTW: Patients obtain a card from their doctor, but after that, what is the doctor’s role?
SW: None. Only see them again upon renewal.
OTW: Do doctors ever specify which strain or type of marijuana they would like their patient to use?
SW: No. Our bystanders do that based on speaking with the patients and trying to understand their malady.
OTW: What is your interaction with doctors?
SW: Per state law, we cannot have any. It is viewed as a conflict of interest.
OTW: Do they contact you regarding certain patients?
OTW: Do you hold regular seminars?
OTW: What kind of questions / concerns do doctor’s express to you and how do you answer them?
SW: Most doctors and clinics are concerned about patient benefits. If they recommend our dispensary to a patient they want to make sure the patient is treated well.
OTW: How do you determine the right dose?
SW: Speaking with them about why they need it and when they are using it—i.e., night time for sleep vs. day time.
OTW: Do you have dose guidelines?
SW: Only those provided by the state regulations.
OTW: Do you have a specific form of marijuana for each indication?
OTW: Do you have an instructions for use for each indication?
SW: We have instructions for each strain we carry and what they can be used for.
OTW: What is your outlook for medical marijuana in terms of its incorporation into the main stream medical community?
SW: As more clinical trials are approved the outlook is good. Unfortunately with the massive advancements being made on the research front in Israel and Canada, the United States may be left out if the federal government does not get behind a program.
Finding Where Medical Marijuana Fits
There is no shortage of studies regarding marijuana for medical use. We easily found several hundred which range from case studies to double-blinded, placebo based trials at major academic institutions.
The accumulated information shows that marijuana has a place in the continuum of care for several medical complaints.
But physicians, despite the explosion of medical marijuana use, remain largely absent. Patients are, essentially, self-medicating.
It appears to this writer that medical marijuana is at a key inflection point.
Recreational marijuana use is legal (in Colorado) so medical marijuana is no longer a back door to recreational use. What now?
The logical answer is that medical marijuana needs to grow up and become something other than “blueberry kush.”
Can medical marijuana suppliers change and thereby earn a place in today’s evidence-based medicine, cost constrained medical marketplace? Conversely, what will it take for doctors to add marijuana to the continuum of care for their patients?