I look forward to clinic days. I thoroughly enjoy meeting with patients, hearing how they’re doing, and helping them to feel better – even if, on occasion, the only thing I can do to help is to listen.
Yesterday was a clinic day.
In the middle of the morning, I met with a medical cannabis patient treated for anxiety. As we reviewed his current symptoms, medications, and how he is benefitting from his cannabis treatment, he mentioned an experience he found very upsetting. When he went to pick up his medicine at a cannabis dispensary, this patient told me that he overheard a bud-tender giving medical advice to a cancer patient. This is akin to the checkout clerk at CVS giving medical advice to a patient. Instead, such advice should be given by a physician and reiterated, or expounded upon, by a pharmacist – both of whom have had many years of training, testing, and credentialing. And both of whose professional activities are overseen by governing boards that hold them and their practices to the highest standards. My patient was appalled that this clerk was allowed to dispense medical advice and was adamant that this should not be the case. I could not agree more.
Every patient has unique needs. Cancer patients are no different. In fact, cancer patients can have additional sets of medical issues, often as the side effect of chemotherapy, radiation, and other processes necessary to treat their disease. One such issue is that occasionally, the patient’s neutrophil count (the portion of the white blood cells that fight particular infections) becomes very low. There have been cases, albeit rare, of patients undergoing bone marrow transplantation acquiring Aspergillus pneumonia via the inhalation of cannabis. In these rare cases, the fungi were transferred via the inhalation process, and the cannabis was “street weed.” Dispensaries now test for Aspergillus, yet, the theoretical risk remains and, for that reason, Cannabis specialist physicians do not recommend the inhalation of cannabis medicine to neutropenic patients. I am fairly certain that the bud-tenders do not know this and cannot counsel patients about it. I am certain that they are not monitoring the patient’s bloodwork to look out for a low white cell count.
Unlike conventional medications, cannabis dispensaries generally are not bound to provide a patient with the medicine as written on a prescription. In fact, there is no legal requirement for a prescription at all. After the patient meets with the Cannabis Specialist physician, who determines their needs, educates them about cannabis medicine, and then certifies them to purchase cannabis medicine, the patient should receive advice from the physician about what is most beneficial to treat that person’s particular illness or symptom. Once the patient goes to the dispensary, however, all bets are off. Often patients are met with a bud-tender who says things like, “Your doctor doesn’t know what she is talking about.” or, “Why would your doctor set your limit so low? Other patients have much higher limits.”
To guard against such undermining and overselling tactics, physicians may choose to reduce the extremely high purchase limit that the state permits and to educate patients about not only about their condition and how they could best benefit from a particular mode of administration and dosing of cannabis, but we also have to warn patients to be prepared for high-pressure tactics, purchasing sales, and literal games (think roulette, for example) that occur at dispensaries. The goal here is to sell products, not to care for patients. This is, of course, absolutely not the case when patients pick up their prescriptions from the pharmacist at a traditional pharmacy.
There is a solution to this problem, and it is twofold: First, medical cannabis should be prescribed, just as any other medication is. And, second bud-tenders must be prohibited from giving medical advice. In fact, I belong to an organization, the Association of Cannabis Specialists, trying to get such laws passed to protect patients’ wellbeing and provide them the best possible care.
Coincidentally, my clinic day ended with an email exchange from a patient who requires the chronic use of blood thinners. He emailed to ask about a recommendation made to him by a clerk at the dispensary. The bud-tender suggested that the patient purchase a product with a level of CBD that could interact with his blood-thinning medication and, therefore, his INR (International Normalized Ratio: the number used to monitor how “thin” his blood is). Thankfully this patient was armed with the education provided by his physicians; he knew that the advice he gets at dispensaries is often incorrect and can actually be harmful.
It is illegal to dispense medical advice without a medical license. This leaves me wondering why is it that bud-tenders and medical cannabis dispensaries do not have to abide by this law?
Jill Becker is a physician and can be reached at her self-titled site, Jill Becker, MD.
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