Expect Questions About Medical Marijuana



“Whether or not individual professionals support the clinical use of herbal cannabis, all clinicians will encounter patients who elect to use it and therefore need to be prepared to advise them on cannabis-related clinical issues despite limited evidence to guide care,” according to a recently published article in the Journal of Pain.1 The article included American Pain Society Clinical Practice Recommendations for Care of Patients Using Cannabis as Therapy, and the first two recommendations are to be aware of federal and state laws governing the use of medical marijuana.

There is great variability among my physician colleagues in their comfort level with [medical marijuana]. We have a lot to learn about the introduction of this compound into our armamentarium of pain control.
— Judith A. Paice, PhD, RN

ASCO’s recently released practice guideline, Management of Chronic Pain in Survivors of Adult Cancers,2 includes this statement: “Clinicians may follow specific state regulations that allow access to medical cannabis or cannabinoids for patients with chronic pain after a consideration of the potential benefits and risks of the available formulations.” Judith A. Paice, PhD, RN, who was the lead author of the ASCO practice guidelines, told The ASCO Post: “It is a pretty broad statement because we didn’t want to overtake the entire focus of this clinical practice guideline, which was on pain management in survivors. But we do make a statement that medical marijuana may be useful in some individuals and that prescribers need to be aware of the state laws.”

For clinicians, that means knowing “what is allowable, what is your role, and what is your responsibility if you are certifying patients to be able to receive medical marijuana,” Dr. Paice explained to oncologists and other health-care professionals attending the 18th Annual Lynn Sage Breast Cancer Symposium in Chicago.3 Dr. Paice is Director of the Cancer Pain Program in the Division of Hematology-Oncology at Northwestern University, Feinberg School of Medicine, Chicago.

She reminded physicians that in the states where medical marijuana has been approved, they do not prescribe marijuana, but rather, they can certify patients who meet state criteria for the use of medical marijuana. “Remember that marijuana is still a Schedule I controlled substance, along with phencyclidine (PCP) and heroin. Federally it is still illegal.”

Maintain Open Dialogue

Echoing another of the other Pain Society recommendations, Dr. Paice also advised: “You need to review the patient’s condition at various intervals. Most important is to maintain an open dialogue, to be nonjudgmental. Are patients trying to use marijuana to treat symptoms for which we might have better agents? Is the use becoming troublesome? Is it causing them to have aberrant behaviors? Are they ignoring family and other social responsibilities?”

Both the ASCO and American Pain Society clinical practice guidelines were just published this summer, and Dr. Paice said it is too early to tell whether these guidelines have had any effect on clinicians. In addition, “there is great variability among my physician colleagues in their comfort level with this,” Dr. Paice said. “We have a lot to learn about the introduction of this compound into our armamentarium of pain control.”

Dr. Paice also noted the need for educating patients, not only about the potential benefits and downsides of medical marijuana, but also on the certification process and the risks of crossing state lines with marijuana. Each state makes its own rules, and if patients are caught with marijuana in a state where it is not approved, it is still a federal offense.

People are also asking if insurance would pay for medical marijuana. It won’t.

Additional Resources

Dr. Paice listed several additional resources for physicians, other health-care professionals, and patients interested in learning more about medical marijuana:

  • The National Cancer Institute PDQ statements, both patient and professional versions, on cannabis and cannabinoids, are available at www.cancer.gov/publications/pdq.
  • Stoned: A Doctor’s Case for Medical Marijuana, a book by David ­Casarett, MD, maintains objectivity about marijuana but “describes some interesting, sometimes humorous, experiences,” Dr. Paice commented.
  • The Erowid website, which describes its mission as “a member-supported organization providing access to reliable, nonjudgmental information about psychoactive plants, chemicals, and related issues,” is available at www.erowid.org. ■

Disclosure: Dr. Paice reported no potential conflicts of interest.

References

1. Savage SR, Romero-Sandoval A, Schatman M, et al: Cannabis in pain treatment: Clinical and research considerations. J Pain 17:654-668, 2016.

2. Paice JA, Portenoy R, Lacchetti C, et al: Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guidelines. J Clin Oncol 34:3325-3345, 2016.

3. Paice J: Medical marijuana: Pros and cons. 2016 Annual Lynn Sage Breast Cancer Symposium. Presented September 22, 2016.


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