Jonathan Kaplan, MD, MPH, makes a serious error when he states that “marijuana use for medicinal purposes is now legal in 29 states plus the District of Columbia, (MedicalEconomics.com, September 20, 2017), ignoring the fact that state laws legalizing marijuana do not in any way affect federal laws making marijuana illegal and subject to federal prosecution. President Obama instructed his federal prosecutors not to enforce federal anti-cannabis laws, but Attorney General Jeff Sessions is planning to enforce them aggressively. Those of us who disagree with the illegal status of cannabis have only two choices: Either obey the nationwide federal ban on medical marijuana, or risk becoming a test-case, and, most likely, a “marijuana martyr.”
Under federal law, marijuana is illegal to use, possess, cultivate or distribute. Sentencing guidelines for possessing even the smallest amounts range from up to one year incarceration and a 1,000 fine to up to three years in jail and a $5,000 fine.
Federal law always preempts and overrides state laws. This means that even if your state allows you to grow or sell marijuana, federal agents can still arrest you. And, if you are found guilty, you will be sentenced under the federal guidelines.
Kaplan advocates prescribing marijuana for post-op pain instead of opiates as a way to reduce opioid addiction and overdoses. However, marijuana is not indicated for post-surgical pain, and the evidence Kaplan cites of its efficacy compares marijuana to placebo, not to the potent pain relief afforded by opioid analgesics, such as hydrocodone, oxycodone or morphine. A surgeon who routinely prescribes marijuana for post-op pain instead of an opioid will quickly be sued for failing to control post-op pain with a proven-effective, FDA-approved opioid medication. In addition to civil lawsuits, physicians who fail to prescribe strong enough opioid doses to treat a patient’s pain can even face criminal prosecution. While it is true that opioid-related addiction and overdoses can be avoided by not prescribing opioids, this is analogous to avoiding hypoglycemia by not prescribing insulin when it is indicated, or avoiding bleeding complications by not prescribing blood thinners when they are indicated. Our job as physicians is to manage the risks of potentially dangerous medications when they are indicated. Even a patient with a known history of opioid abuse should not be denied treatment with opioid pain medication, when it is required, as noted in a 2014 Population Health Management study.
Kaplan also emphasizes that THC is approved by the FDA for the treatment of nausea, and its use increases appetite and weight gain. That is an argument for prescribing THC for nausea, appetite stimulation and anorexia, but it in no way excuses a physician from treating pain with an opioid, when required. Cannabis and its components, such as THC and CBD, may reduce pain when compared to placebo, but they do not achieve anywhere near the efficacy of opioid analgesics, and Kaplan could not cite any studies even comparing cannabis or its derivatives with opioids specifically for the treatment of pain.