Integrating Cannabis Into Patient Care
By Diana Hahn and Stacey Marie Kerr MD
Cannabis is not a conventional medicine. As a result, physicians may face unique situations and challenges in making the decision whether to recommend, certify, or even condone medical cannabis use for a patient.
Lack of information about delivery methods and quality
Many doctors who have never been to a dispensary immediately think of smoking when the topic of medical cannabis comes up. While some patients still choose to smoke dried flowers, there are many other delivery choices including sublingual, topical, ingestible, and non-combustion inhalable forms of cannabis that physicians can suggest instead of smoking. Cannabis from a licensed dispensary is also exclusive in that all dispensary products have passed rigorous third party testing for active content and contaminants.
Lack of dosing standards
There are several factors that make titration vary significantly from patient to patient (and sometimes even from dose to dose for the same patient). These include variations in the strength and compound profile of medicine, variations in bioavailability related to delivery method, and a general lack of information regarding how the endocannabinoid system functions in different individuals.
The result is that titration is best left to patients, with doctors monitoring usage especially in the cases of patients who are medically fragile and/or taking other medications. While it is unusual for a patient to use a drug without a prescription outlining dosage, it is not entirely unheard of to have a patient self-titrate, especially in the context of palliative care.
If patients are instructed to begin with very low doses and increase slowly and incrementally, an effective dosage can be found with relative safety and ease. All products sold in a dispensary in the state of Hawai'i are required by law to have information about cannabinoid content for patients to gauge their doses.
Lack of FDA approval
Cannabis is not an FDA approved drug largely because the research and testing necessary for approval has been made impossible by the DEA and federal government’s policy. The FDA has approved several synthetic drugs containing cannabinoid and cannabinoid-like compounds, however these synthesized drugs tend to be less effective while producing more side effects compared to plant-based medical cannabis products.
The complexity of whole plant-based botanical medicine (e.g. cannabis) makes the quantification and regulation of content and effect very difficult, thereby making FDA approval difficult. At the same time, it is this very complexity, or “entourage effect” that very likely makes cannabis an effective treatment choice for many patients.
Perception of cannabis
The “War on Drugs” portrayed cannabis as a dangerous gateway drug with huge potential for addiction and abuse. The reality is that the potential for risk and abuse of cannabis alone is significantly lower than many other medications, specifically those prescribed for pain management.
Recently U.S. Attorney General Loretta Lynch publicly acknowledged that the consumptions of cannabis does not lead a person to harder drugs. Another common bias is that a patient just wants to get “high.” Although the DEA classifies cannabis as a Schedule 1 substance and there are many people who use cannabis recreationally, there are documented effective uses of clinical cannabis, and a patient’s treatment preferences should be respected.
Many physicians are concerned about liability related to discussing medical cannabis with patients. Under Hawai'i state law, no physician shall be subject to arrest or prosecution, penalized in any manner, or denied any right or privilege for providing written certification for the medical use of cannabis for a qualifying patient provided that the physician is in compliance with state medical cannabis law. Under federal law, physicians are legally allowed to discuss the benefits and side effects of cannabis, recommend, or approve use as long as they do not prescribe the drug.
Many physicians are concerned about their reputation among their colleagues and patients. If they recommend cannabis, will they be labeled a ‘pot doc’? Will they themselves be subject to suspicion, and will their practice be suspect? Will others assume that they are high while practicing medicine? Physicians were not taught about the endocannabinoid system in medical school, and we now know it is one of the largest receptor systems in the human body. Healthcare providers continually need to update their knowledge base to include new, relevant information. There is no shame in being knowledgeable and professional about including cannabis as just one more integral part of patient care when appropriate. Only familiarity with the science and usage of clinical cannabis will overcome societal fear.
Patients are often the catalyst for physicians to develop an interest in and learn about medical cannabis.
When a patient with a qualifying condition asks for a certification or informs a physician of medical cannabis use (certified by another physician), it is invaluable for a physician to gather evidence-based information by not only reviewing the existing research, but by listening to and taking patient questions and reports seriously. In a field of medicine with little documentation compared to claims and potential, the earnest act of being curious, open, and discerning can contribute significantly to patient care.
It behooves a physician to cultivate clear lines of communication that allow patients to be honest about their medical cannabis use. Cannabis does have interactions with some prescription drugs, most notably opioids. By getting a complete picture of a patient's medications, a physician will be able to provide safer, more effective care.