My life changed three years ago when my sister-in-law was diagnosed with breast cancer at age 40. She had two small children the same age as my own. Of course, this diagnosis caused a tidal wave in our family.
Her oncologist recommended she smoke marijuana while she was receiving chemotherapy. She asked him for details about how, why, the frequency, and the dose, but he just said, “I don't know. Just google it.”
My mouth dropped open, and I shrugged my shoulders when she told me. I was taught, like every other emergency physician, that medical marijuana was just a way for people to get high. Sure, she wouldn't have to deal with the pain if she were high.
We spent time googling and found a “pot doc,” who confirmed our perspective of the fakeness of this “medicine.” He barely looked up, told us to circle areas of pain on a diagram, and then wrote a recommendation.
Next, we went to a dispensary, which looked like an old pager store that had been cleared out and had marijuana put in. She bought what the kid, who may have been high, recommended and went home. This whole process left me feeling disappointed and frustrated. Was this really medicine? Why is it that we value this medication but act like this is somehow worse than narcotics, benzodiazepines, and hypnosedatives? Aren't all of these classes of medications misused or abused to get high? How is this medication any different?
That set me on a quest to understand medical marijuana. I have learned a number of things that every emergency physician should know.
- Marijuana is slang. Just like we don't refer to Ativan as vitamin A in medical papers or public policy papers, we shouldn't refer to Cannabis, its biologic term, as marijuana.
- Cannabis has side effects, just like every medication. We couldn't name a single medication that doesn't.
- We are driving a wedge into the doctor-patient relationship when we alienate our patients by not addressing cannabis use.
- There are multiple modes of administration of cannabis and different onsets of action, including smokables (oil and flower), edibles (baked goods and oils), topicals (creams), suppositories, and more.
- Dosage matters, just like any other medication. THC tends to be around 1-5 mg per dose (but there is a wide margin of safety), and patients develop a tolerance, just like narcotics, benzodiazepines, and hypnosedatives.
- CBD, the non-intoxicating part of the plant, can be derived from hemp or Cannabis (think marijuana). Hemp is federally legal in all 50 states, and that means it can be bought online and shipped anywhere.
- CBD also has general dosages, typically between 10-50 mg per dose (again with a wide margin of safety).
- Dosages vary for these medications, similar to mood stabilizers, narcotics, benzodiazepines, and blood pressure medications, among others.
- There is no current lethal human dose, unlike narcotics.
Three years ago, in my own disbelief of how well Cannabis worked, I started looking up the research and discussing it with people. California was legalizing Cannabis, and I wanted to understand what the onslaught of patients were going to present with in the ED.
A strange thing happened. I not only changed my mind about Cannabis, but I also decided to open an office and start working with patients in a legitimate medical setting where they could seek sound advice on dosing their medication, titrating down or adjusting their current medications, and answering as many of their questions as I could.
My patient roster is full, and my patients are appreciative of the work I do for them. They each leave saying, “I am so glad I found you,” and “Can you teach other doctors about this?” Many people envision an office full of Cheech and Chong, which could not be further from the truth. I have children with brain tumors and adults with narcotic dependence getting off years of prescribed narcotics. My proudest accomplishment has been creating a pathway to remove narcotics for patients, which has been successful for a dozen patients, ages 30-70.
Patients come to me with insomnia, chronic pain, and fibromyalgia. Some patients are trying to get off benzodiazepines and hypnosedatives. Others want to stop taking gabapentin. Cannabis has allowed patients to have another option, another pathway out of pain. Why are we as an educated group of people so resistant to a new medication that has not been packaged with a $5,000 price tag from a pharmaceutical company when we complain about needing to get insurance approvals for our patients? Are we so masochistic that we would rather suffer the torment of health insurance denials for access and pharmaceutical company's exorbitant price tags than actually listen to what patients are telling us?
Yes, Cannabis can be abused, as can everything else we prescribe. Start talking with your patients. Don't dismiss them. Don't blow them off because they tried something new to help with their pain when no one else wanted to help them. We only have ourselves to blame when we turn a blind eye to the “medical marijuana industry.” We should demand pharmacist involvement and medication reconciliation. I challenge each of you. It is time to learn about Cannabis.Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.