03/13/2021
Medical cannabis – what are our responsibilities as health care professional?
In recent years, medical and recreational cannabis has widely grown in popularity across the US with 36 states and the District of Columbia have legalized medical ma*****na use, and 11 states have allowed adult recreational use as well.1 Even though, many advancement have been accomplished on state level on this bipartisan issue federal legislation remains unchanged which limits research and accessibility to cannabis.2 On top of the research hurdle that has been created by the Controlled Substances Act (CSA) in 1970, a recent study by Evanoff et al.3 found that 85% of medical students receive no education on medical cannabis and its use.
The CSA classified cannabis as a schedule I drug which is the most restrictive stating ‘no currently accepted medical use and a high potential of abuse’.5 Schedule I drugs, cannot be prescribed for medical use and researched unless many obstacles are passed. Although, recreational cannabis is on the rise, sound evidence is often lacking leaving the consumers and patients to ‘do their own research’. It has become evident over the past decades that the DEA’s failure to reschedule cannabis does not reflect medical literature.6 Therapeutic benefits have been found for patients with chronic pain, chemotherapy-induced nausea and vomiting, and multiple sclerosis symptoms through randomized control trials, systematic reviews and meta-analyses.
In a world of legal recreational cannabis access, medical expertise are vital. The psychoactive effects of tetrahydrocannabinol (THC) play an important role and may increase incidences of psychosis in a dose- dependent manner. The risk of self medicating and abuse becomes therefore more and more evident with the rise in legal recreational use across the US.7 Educating medical professional of the possible benefits and risks of THC and CBD would decrease those risks and reestablish trust.
As always in medical practice, ethical considerations for treatment use should be carefully assessed in a benefit to risk ratio with a fully informed consent, careful monitoring for safety and side effects. This should include limiting recommendations for the use of cannabis for conditions with well-establish evidence only. Glickman et al.10 states that even though it may be illegal to recommend cannabis for conditions other than those
specified by state law, an ethical justifiability is present as long as available evidence supports the use of cannabis for a particular patient’s condition.
Once cannabis the health care provider has decided the use of cannabis may be beneficial for a given patient, Glickman et al.10 lays out the ethical principles that should follow the treatment course. First, previous cannabis use should not be used to determine a new treatment course given the significant changes in purity and potency of ma*****na. Second, young adults (under the age of 25 years) should undergo a more thorough investigation for potential harm. Third, the general philosophy of ‘start low, go slow’ should be adapted in all cases, especially while using edibles and highly synthesized products. Forth, under most circumstances smoking cannabis should not be recommended due to the commonly used mix of to***co and THC. Fifth, providers must take into account different ways of acquiring the product and counsel against seeking unregulated supply. Sixth, the CBD/THC ratio should always be taken into consideration, whereas higher CBD contents are generally preferred due to the protective function of CBD against psychosis and cognitive impairment. Seventh, it is imperative to understand various modalities of cannabis consumption, it seems therefore reasonable to suggest providers to advise against smoking cannabis of highly concentrated tinctures, waxes and “shatter” (except in patients with significant experience or serious chronic pain). Eighth, medical providers should be aware of the recently documented va**ng illness which was linked to unregulated THC cartridges and appeared to be connected to a vitamin E acetated.11 Ninth, like any other medical decision, cannabis should not be subject to provider’s social or political biases or anecdotal evidence.10
In conclusion, it is the authors opinion that every primary care provider has the ethical obligation to develop the requisite expertise to provide cannabis to patients who may benefit from it.
Original article from Glickman et al. used for this summary:
Glickman A, Sisti D. Prescribing medical cannabis: Ethical considerations for primary care providers. J Med Ethics. 2020;46(4):227–30.
