The times (and laws) have changed when it comes to marijuana use, leaving many doctors with a big question: “What do we tell our patients?”
Recently, the editors of the Annals of Internal Medicine asked readers to share their perspectives on prescribing or recommending marijuana to patients. From 100 submissions, the editors chose to publish six essays that they say touch on some of the most important issues that clinicians face when discussing marijuana with their patients.
The essays, published in a special section of the new issue of the medical journal, touch on questions from the safety of marijuana use by pregnant and breastfeeding women, to its use in treating pain, to the problem of hard scientific evidence to back claims about its benefits.
So what’s the current state of marijuana legalization? “States are passing marijuana laws at blistering speed,” writes Jan K. Carney, M.D., of the Larner College of Medicine at the University of Vermont in Burlington, as she called for more research. Medical marijuana is now legal in more than half of the states in the U.S. and the District of Columbia, and a few states have legalized recreational use for adults. Cannabis use is increasing and the perception of its risk is declining, Carney says. However, the federal government still classifies marijuana as a Schedule I drug, in the same category as heroin and LSD—drugs with “no currently accepted medical use.”
Research into the benefits and risks of marijuana use has been limited, leaving most doctors with more questions than answers. “Widespread use of medical cannabis is straining medicine's conventional boundaries, as patients venture without guidance into the unknown and return bearing strange medicines that seem strikingly nonmedical. As physicians and scientists, we must be willing to do our part by listening, showing compassion and using the best available knowledge to support patients and keep them safe on their journey,” write pain researchers Kevin F. Boehnke, Ph.D., and Daniel J. Clauw, M.D., of the University of Michigan Medical School in Ann Arbor.
So as many doctors, who never learned about the once-illegal drug in medical school and find limited scientific studies, struggle to advise patients, here are six takeaways from the commentaries:
Doctors need more scientific evidence about the benefits and risks of marijuana use. “Would I recommend marijuana to patients? Not yet,” writes Carney in her commentary. “Evidence is growing but still inadequate, and marijuana use is associated with risk for harm to pregnant women, adolescents and young adults.”
Doctors must advocate together to remove barriers to marijuana research, create a national strategy and fund those efforts, she says. Researchers need to track the benefits and harms through public health surveillance methods and educate the public to eliminate the differences between what patients believe and what physicians know about the drug.
Doctors should consider marijuana use harmful to pregnant and breastfeeding patients until there is evidence that proves it is safe. Marijuana is the most commonly used illicit substance during pregnancy and has gone mainstream, writes Eli Y. Adashi, M.D., of Warren Alpert Medical School at Brown University in Rhode Island. Without data and approval for a marijuana-based drug from the Food and Drug Administration, physicians should discourage its use by pregnant and lactating patients, he says.
Erring on the side of caution, several professional associations strongly discourage marijuana use in the period immediately before and after birth, he notes. With patients who use marijuana for therapeutic reasons, doctors should replace it with a drug with a pregnancy-specific safety record, he recommends. “Doing no harm requires that uncompromising vigilance not be allowed to lapse. Doing anything less is to ignore the well-being of would-be progeny,” he writes.
Doctors should take a “start-low, go-slow” philosophy when it comes to cannabinoid dosing for managing patients’ chronic pain. Researchers Boehnke and Clauw say they are “underwhelmed” by systematic reviews of clinical trials of cannabinoids but say doctors cannot ignore the reality of its use as a medicine to treat chronic pain. It’s “uncertain territory” for physicians and patients.
The two pain researchers say they do not view cannabinoids as first-line treatments for pain but as adjuvant therapies to be used before opioids if other options fail to control chronic noncancer pain. As with any pain medication, they say marijuana should be used as part of an integrated, patient-centric management program, with emphasis on appropriate nonpharmacologic treatment options such as exercise, cognitive behavioral therapy and mindfulness. They recommend that patients select products verified for safety and potency by third-party testing and propose that patients use oral formulations, such as capsules, for long-term relief, with tinctures for breakthrough pain. Patients who prefer to inhale cannabinoids should try vaping because it probably has fewer adverse effects than smoking, they suggest. “We advocate a “start-low, go-slow” dosing philosophy, applied to both quantity and adverse effect profiles,” they write.
Greater availability of marijuana has unintended consequences for emergency departments, which provide some red flags for doctors and patients. That’s been the case in Colorado, where marijuana for medical use has been available since 2000 and was legalized for recreational use by adults in 2014. Nearly 90,000 Colorado residents have medical cannabis cards and about one-third report daily consumption, write Kennon Heard, M.D., Ph.D., Andrew A. Monte, M.D., Ph.D., and Christopher O. Hoyte, M.D., of the University of Colorado School of Medicine in Aurora.
While the benefits of marijuana for medical conditions continue to be debated, there has been an impact in Colorado emergency departments, the doctors say. One is the increase in hospitalizations of children from exposure to marijuana, often by an ingestible cannabis product such as candy or baked goods. The doctors say they see several cases each month. They’ve also seen a dramatic increase in ED visits for cannaboid hyperemesis, a condition that leads to repeated and severe bouts of vomiting. The hospital sees more than 100 patients for the condition each year, they say, and patients who use cannabis as daily therapy are at risk. Evidence has also linked marijuana use to mental health disorders, and ED visits because of cannabis use were five times more likely to be coded as related to a mental health disorder.
“In summary, as emergency medicine providers in a state with a high level of cannabis use, we have observed a substantial increase in acute medical conditions associated with this substance,” the doctors write. “Providers considering recommending medical cannabis should counsel patients on safe storage, inform them of the symptoms of cannabinoid hyperemesis, and warn them that cannabis use may precipitate mental health crises,” they said.
Evidence is growing that marijuana use is not without risks, including those for patients with cardiovascular disease. Preventive cardiologists are faced with the challenge of properly counseling patients about marijuana use, write Tina M. Kaufman, Ph.D., Sergio Fazio, M.D., Ph.D., and Michael D. Shapiro, D.O., from the Center for Preventive Cardiology at the Knight Cardiovascular Institute at the Oregon Health & Science University in Portland.
They advise doctors to ask patients about their marijuana use in a nonjudgmental way, discussing specific methods for how they use the drug and the reasons why. They say they inform patients about the potential adverse effects of smoking marijuana and let them know more research is needed before they can make definitive recommendations. The method of use probably matters, they say, and from a practical standpoint, smoked marijuana probably carries the greatest cardiovascular risk.
“Until more definitive data are available to guide recommendations, it is incumbent on clinicians to engage in shared decision making, encompassing a thoughtful, open discussion with patients about marijuana use and potentially guiding them to safer alternatives,” they conclude.
As they look for alternatives to opioids, doctors and health insurers face a “cannabis conundrum.” The use of medical marijuana is complicated by the fact that there is no standardization of products from pills to oils and a lack of robust evidence for its use, write Pennsylvania researchers Chester B. Good, M.D., Natasha Parekh, M.D., Kavita Fischer, M.D., James Schuster, M.D.; Chronis Manolis, R.Ph., and William Shrank, M.D.
“The need for adequate clinical substitutes for opioids has never been greater, and optimizing symptom relief for persons with debilitating diseases is a core function of the healthcare system. However, creating policies and providing insurance coverage when high-quality evidence is lacking and products are not standardized runs counter to the responsibilities of health insurers, who are prohibited by federal law from covering these products,” they say.
What’s the solution? They suggest that insurers partner with providers and academics to develop evidence and pave the way for safer patient management and evidence-based decisions about coverage of medical marijuana.