Imagine that you are suffering from chronic pain.
The pain keeps you awake at night so you don’t get much sleep. Lack of sleep most nights and the ensuing chronic fatigue causes you some anxiety during the day. Your primary care physician suggests that she is concerned with the increasing amount of aspirin and ibuprofen you are consuming to manage the pain. She can prescribe opioids to help with the pain, a benzodiazepine to manage the anxiety, and a sleeping pill (such as zolpidem) for insomnia. Of course (she warns you), opioids, benzodiazepines, and sedatives all have admittedly alarming (and common) side effects, including constipation, panic attacks, anxiety, depression, seizures, addiction, aggression, agitation, confusion, hallucinations, memory issues, changes in personality, risk-taking behavior, decreased inhibitions, suicidal thoughts, and death. Furthermore, none of these prescription medications are intended for long-term use. They are, however, covered by your insurance. And, you can receive from your primary care physician and the pharmacist reams of instructions and documentation to help mitigate the risks of these drugs.
Alternatively, you can try a single medication—cannabis—that might effectively control your pain, insomnia, and anxiety. Compared to other commonly used and FDA-approved medications, the three most common adverse effects of cannabis seem quite benign. The most widely reported side effect is dry mouth. A second side effect is drowsiness. The third most-reported side effect seems curious—it’s euphoria (patients reported feeling better). Of course, there exist other adverse effects that can occur from cannabis exposure. These effects tend to be dose-dependent—larger doses of cannabis increase your risk—including things like rapid heartbeat, panic attacks, and dysphoria. These effects are more common in more cannabis-naïve consumers, and again, they are more likely to occur at higher concentrations. The dose-dependent side effects can be easily mitigated with some education and a good treatment plan.
Now imagine that your primary care physician refuses to discuss cannabis with you, or simply states that she cannot give you any information about what type of cannabis you should use or product to buy, how much of that product to take, when to take the product, how frequently to take the product, for what duration, what the expected side effects might be and how to address them, and whether you should take other medications with the cannabis product. You are on your own. And by the way, cannabis isn’t covered by your medical insurance.
For many patients, this is a very real scenario, and a growing problem as more states legalize cannabis and more patients consider it to help treat conditions and disease. Patients are attempting to treat severe medical conditions using cannabis, and without the guidance of medical professionals.
Given the legal ambiguity of cannabis, it’s no surprise that health care professionals are reticent to discuss cannabis with their patients. Cannabis remains a Schedule I substance at the federal level—which is defined as a drug with no accepted medical use, with a high potential for abuse, and with a lack of accepted safety even under clinical supervision. In addition to cannabis, Schedule I drugs include heroin, LSD, ecstasy, and mescaline.
In 2002, a federal court case ruled that health care professionals can speak openly to patients about cannabis and the court ruled that some health care professionals can recommend cannabis. A cannabis recommendation enables a health care professional to discuss with patients the benefits and detriments of consuming cannabis, if that patient is considering cannabis as an option. However, cannabis recommendations have limitations. For example, it remains a violation of federal law for a health care professional to aid or abet the purchase, cultivation, or possession of any Schedule I drug, including cannabis. Clinicians who help patients identify specific cannabis product types or provide patients with specific dosing instructions—information critical to the safe use of any prescribed medication—risk losing professional licenses and even facing federal prosecution. Given the uncertainty, health care professionals are, understandably, reticent to embrace cannabis as a therapeutic option.
However, the ubiquity of cannabis legalization and cannabis popularity requires that we rethink the practice of sending patients to cannabis dispensaries for medical advice. Patients who are encouraged to try cannabis without any further clinical guidance face a number of unreasonable challenges. There are hundreds of cannabis products with varying potencies, multiple cannabinoid combinations, varying terpene profiles, and multiple routes of administration.
When a patient elects to consider cannabis as a medicine, their clinician should approach its use no differently than they would with other medications. Of course, all clinicians should perform only those duties that are well-defined by their scope of practice. When appropriate, it is the clinician’s responsibility to develop a treatment plan for their patient, and that plan should include:
- The appropriate cannabinoids for the patient’s condition or disease
- A specific product or product profile to consider
- The route of administration that will likely be most effective
- The appropriate starting dose (which can depend on multiple factors, including the potency of the product, the consumer’s experience with cannabinoids, the condition that they’re attempting to help treat, their age, their health and health history, and other factors)
- How to titrate the dose if the starting dose isn’t effective
- When and how frequently to take the medication
- How long to take the medication
- Potential benefits of using the medication
- Potential risks and drug interactions, and how to mitigate adverse effects
Patients need licensed health care professionals to help guide them through this process. Of course, no clinician wants to deny a patient a safe option to achieve efficacy and relief. To help guide patients, clinicians will require education, resources, and the support of their health care organizations to adequately address the cannabis education gap. A standard system of cannabis education is necessary and guidelines established by a national health care association or medical board can help clinicians discuss and recommend cannabis properly. Health care professionals should demand that the standards of care for patients include cannabis as an option. Furthermore, medical schools and hospitals must adopt cannabis standards for clinical competencies that are similar to other areas of expertise.
Timothy Byars is a medical cannabis educator and consultant.