Doctors must confront the clinical, legal, and ethical implications as more states permit the use of marijuana.
As more states legalize medical marijuana, doctors increasingly find themselves serving as gatekeepers for a drug that they may not understand, and perhaps don’t condone, with clinical and legal considerations to boot.
By the fall of 2015, 23 states and the District of Columbia, had approved the use of marijuana for medical purposes, according to the National Conference of State Legislatures. While the specifics of state laws vary, typically they rely on a doctor’s involvement to refer the patient, called a certification, because the Schedule 1 substance can’t be prescribed.
This scenario presents a series of quandaries for doctors and patients alike. “People start popping up with these state forms to fill out,” says Scott Hammer, MD, a family physician in Milford, Delaware, which opened its first dispensary in June 2015. Some of the requests are clearly for recreational purposes, he says. But other patients have conditions that might benefit from marijuana, such as the man with metastatic cancer who was coping with a myriad of related symptoms, such as pain and nausea. “I looked at him and said, ‘Regardless of my personal feelings, I’m just not [personally] ready to fill these forms out yet,’” recounts Hammer, citing the drug’s Schedule 1 status among other concerns.
Debate persists among doctors and researchers regarding which symptoms marijuana can ease, and to what degree, with proponents pointing out that badly-needed research has been squelched by the drug’s illegal status.
Doctors worry about running afoul of law enforcement in some way, whether it’s federal drug officials or a police officer investigating a traffic accident. Guidance from professional organizations is primarily limited to calls for more research.
Meanwhile, primary care doctors like Hammer, who are reluctant to sign any certifications, acknowledge that patients can obtain the paperwork through another doctor, potentially leaving their regular physician in the dark.
But if patients don’t inform their
primary care provider, they can’t be monitored for any potential issues arising from marijuana use, such as interactions with other drugs or emerging addiction concerns, says Kevin Hill, MD, an assistant professor of psychiatry at Harvard Medical School. “That’s a dangerous scenario,” he says. “Whether or not they [doctors] want to write for medical marijuana certification, they need to have their eyes open to this issue.”
Another dilemma: a patient admits marijuana use during an office visit. “Then there is a decision point,” Hill says, because doctors shouldn’t be part of a treatment plan that they don’t agree with. “Ultimately the physician is left with the choice of whether or not they want to manage it, or sort of sign off on it begrudgingly, or transfer [the patient to another clinician].”
State laws vary significantly as to the types of conditions under which marijuana can be used, as well as the paperwork they require, says Karmen Hanson, marijuana legislative analyst at the National Conference of State Legislatures in Denver. The conditions listed most frequently are cancer, epilepsy, and multiple sclerosis, although some states cover a much broader spectrum of conditions or symptoms, sometimes adding them over time, she says. Some states, such as Hawaii, initially allowed patients to use marijuana grown by the patient or a close friend or relative, but are moving to permit the opening of dispensaries, she says.
Public acceptance appears to be growing, with 58% of Americans surveyed by Gallup in October 2015 supporting marijuana’s legalization, compared with 36% a decade before.
Doris Gundersen, MD, medical director of the Colorado Physician Health Program, describes increasing legalization across states as a clinical situation almost without precedent. “It’s kind of unusual to have a new treatment introduced to the public by ballot initiative,” she says. “My concern for the public is when something is legal, that might translate into an opinion or belief that it’s completely safe and that’s not necessarily the case with marijuana.”
A meta-analysis published in June 2015 in the Journal of the American Medical Association attempted to capture the research to date involving cannabinoids-which can be consumed in various ways, including orally, smoked, inhaled, or mixed with food- as well as the two prescribed pill forms: dronabinol and nabilone.
Compared with placebo, researchers found that there was moderate-quality evidence favoring cannabinoids for treating chronic neuropathic or cancer pain and spasticity due to multiple sclerosis. Researchers also noted numerous possible short-term effects, some of them serious, including balance problems, confusion, diarrhea, fatigue, hallucination and nausea, among others.
Despite legalization at the state level, there appears to be only a relative handful of doctors filling out the paperwork, and frequently it’s not the patient’s primary doctor, critics say. “What we’ve seen in Colorado at least with some practitioners is they’ve treated the patient-doctor relationship differently when recommending marijuana than they would for other treatments,” says Gundersen, noting the relative lack of physical exams and follow up appointments, among other measures.
In Arizona, where medical marijuana was legalized by a 2010 ballot initiative, just 615 physicians-2% of those eligible-had issued 51,747 certifications, according to a report by the Arizona Department of Health Services, based on data from July 2013 to June 2014. That state permits doctors of naturopathic medicine to certify, along with MDs and DOs, and the naturopathic doctors issued 40,057 of the total 51,747.
In Arizona, some naturopaths “have made this a core part of their business model in terms of seeing patients,” says Will Humble, MPH, who served as the health department’s director until early 2015 and now is division director for health policy and evaluation at the University of Arizona Health Sciences in Tucson.
While doctors in Arizona or elsewhere might prefer to bypass the entire cannabis subject, Humble says, there are risks to that approach as well. “Essentially what ends up happening is that the patient gets pushed out of their medical home,” he says. “And in our state, they get pushed into a naturopath’s office that advertises in a weekly magazine.” Hammer, the Delaware physician, recounts how a patient he turned down mentioned that a physician in another city would sign the form for $200.
Karen O’Keefe, JD, director of state policies for the Marijuana Policy Project, a Washington, D.C.-based advocacy group that supports marijuana legislation, rejects the implication that marijuana referrals are only occurring through turnstile-like clinics. “A lot of these doctors just do this as part of the practice and they don’t want to be known as the marijuana doctor,” she says.
In addition, some states have created hurdles for doctors, such as training requirements-New York State has implemented a four-hour online training course, O’Keefe notes-in which clinicians may not be willing to invest time if they anticipate recommending only a few patients.
Moreover, patients face their own hurdles, O’Keefe says. Some states require that the paperwork come only from the doctor treating the related condition, which means a cancer patient may have no options other than to change doctors, if the oncologist won’t sign off, she says.
Josiah Rich, MD, MPH, a practitioner in Providence, Rhode Island, says he’s by no means a marijuana proponent, adding that he was “outed” several years ago by a Rhode Island newspaper as among the state’s top certifiers. But if one of his patients is already using-typically someone with HIV-he’d prefer to sign the paperwork than leave the patient at risk legally for using a drug he or she believes is beneficial, even if it’s just the placebo effect.
Rich says some of his patients complain of nausea when taking their HIV medication. “They take a little toke before they take their medicines, and they take their medicines without any problem,” says Rich, an infectious disease specialist at The Miriam Hospital in Providence. “It’s allowed them to take their life-saving treatment. That’s like a no-brainer to me.”
To date, major medical groups have offered little guidance to doctors caught in the escalating clinical-legal debate. In its policy, the American Academy of Family Physicians endorses changing marijuana’s classification so that more research can be conducted. The American College of Physicians holds a similar position, and maintains that physicians and patients in states where medical marijuana is legal should be protected from criminal or civil penalties.
But doctors who are amenable to certifying have little guidance on how to assess the patient in front of them, says Scott Miscovich, MD, a family physician in Kaneohe, Hawaii. Miscovich, who estimates that he’s certified roughly 30 patients in the prior six months, also cochairs the Commission on Medical Cannabis Education, which the Hawaii Medical Association created to educate doctors and patients in light of the anticipated opening of dispensaries in the state later this year.
While medical marijuana is already legal in Hawaii, the opening of the dispensaries could result in products with higher tetrahydrocannabinol (THC) concentrations. That poses a particular risk for new users, Miscovich says. The commission’s recommendations for physicians, which were still being finalized at press time, likely will spell out the health and safety risks that doctors should convey to patients, along with suggested follow-up and related steps, such as lung screening for those who insist upon smoking.
“You must engage your patients,” says Miscovich, who suggests that doctors regularly ask about marijuana use. “We believe that there’s no one better to have this conversation than the long-term treating physician who has that relationship with the patient. Because they are going to have the best ability to influence the appropriate change, whether that’s seeking medical marijuana or perhaps seeking another alternative.”
Hill, who authored Marijuana: The Unbiased Truth about the World’s Most Popular Weed, published a 2015 article in the Journal of the American Medical American Association that attempted to provide doctors some guidance in evaluating patients requesting medical marijuana. He details a list of conditions for which randomized studies indicate some benefit: nausea and vomiting related to chemotherapy; anorexia from wasting illness like AIDS; chronic pain; neuropathic pain; or spasticity associated with multiple sclerosis.
Among other considerations when evaluating patients, Hill writes: Have they tried (and failed) first and second-line medications for the related condition? Have they tried an FDA-approved cannabinoid (dronabinol or nabilone)? Do they have an active substance use disorder, psychotic disorder, unstable mood disorder, or anxiety disorder?
Simply having that discussion, delving into why a patient wants to use marijuana, might unearth other significant issues, such as an undiagnosed psychiatric condition, Hill says. “It’s an opportunity to get people into treatment who otherwise wouldn’t get into treatment.”
As with any other medicine, doctors need to perform a risk-benefit calculus, weighing potential symptom relief against concerning factors such as a patient’s pulmonary or cognitive difficulties, says Steven Wright, MD, a family physician and addiction medicine specialist in Littleton, Colorado. That means for the snowboarder who has hurt his or her shoulder, the answer would be no, Wright says. But for someone confined to a wheelchair by multiple sclerosis, who is no longer driving and has exhausted other options, trying a cannabinoid might be the way to go, he says.
Of the roughly 30 patients that Miscovich has referred for medical marijuana use, a handful have advanced cancer, two have multiple sclerosis with related pain and muscle spasms, and the remainder have chronic pain, primarily from failed lumbar spinal fusions. They are no longer surgical candidates and have tried a battery of other treatments, including physical therapy, psychology referrals, and other medications, such as muscle relaxants. “These are patients who are well established and well worked up,” Miscovich says.
With these sorts of chronic pain patients, Miscovich believes that medical marijuana-particularly with products that have a high cannabidiol content-might be a better option than long-term opioid use. If patients are using marijuana, the goal is to cut their opioid dose by at least half, he says. Of the approximately 22 patients with chronic pain he has certified, five have eliminated their opioids and only take anti-inflammatory medications such as ibuprofen along with the marijuana, he says.
One of many outstanding questions about medical marijuana is whether it can help address the opioid crisis. An analysis by RAND Corp. researchers, published in 2015 in a National Bureau of Economic Research paper, found that states with medical marijuana laws that also operate dispensaries-not all states have such laws-had a decrease in opioid addictions and opioid overdose deaths.
But there’s no doubt that patients can run into trouble with marijuana, says Miscovich, pointing to a study in the Journal of the American Medical Association published online in October 2015, which found that reported prior-year use among American adults had increased from 4.1 % in 2001-2002 to 9.5% in 2012-2013. The prevalence of marijuana abuse or dependence also increased, from 1.5% to 2.9%, which means that by 2012-2013 nearly one-third of the 9.5% of adults reporting use had experienced such difficulties.
Hammer worries about other uncertainties, such as quality control in terms of where the marijuana is coming from, who is testing it, and where it is grown. Also, while Hammer acknowledges that federal officials under the Obama administration have discouraged prosecution of patients using medical marijuana in states that have legalized its use, he points out that such guidance can always shift with a new administration.
Wright, who now primarily consults in pain management and addiction and is writing a journal article designed to provide doctors additional clinical guidance, says that he certified patients in his own primary care practice “and nobody came knocking at the door.”
With time, he predicts more doctors will become sufficiently educated and comfortable with incorporating periodic marijuana recommendations into their practice. But, he cautions, “Even if you’re convinced that marijuana works in certain individuals, don’t recommend it until you understand how to use it. It’s not off-label prescribing. It’s off-off label.”