I met my first medical Cannabis patient early in my emergency medicine career. It was 2009 in Los Angeles, and I had no idea what medical Cannabis even was.
The patient was an 80ish-year-old woman who presented after a fall. I began my assessment and went through her previous medical history and medication list, and was surprised at how few medications she was using. She had severe osteoarthritis, but she was not taking any pain medications.
I diligently asked for more detail about her NSAID/APAP use, and her response was, “No, all I take is a quarter of a cookie.”
I stood there for a moment, unsure of what she meant. The thought that went through my mind was, “Man, that must be some amazing chocolate chip cookie.”
So I asked because I didn't understand. “Ma'am, what type of cookie is that? Chocolate chip?”
She laughed, and said, “No, a pot cookie.”
I stopped cold in my tracks. I didn't know what else to ask. I didn't know what else to say. So I did what every good emergency physician does: I shrugged my shoulders, rolled my eyes, and continued with my physical exam.
But she and her cookie stuck with me, and a week later I was having lunch with my grandmother, who also had arthritis, and I asked her if she had ever used a pot cookie. My grandmother, a well-respected midwife in Iran who delivered more than 10,000 babies, scoffed, so naturally I thought this was bogus, and I thought nothing more of it for a long time.
Fast forward to 2015, and I'm still in the same community ED in Los Angeles associated with multiple cancer centers. Many cancer patients present for pain management, fever, nausea, and vomiting. It is common to see a woman in her 70s with advanced metastatic cancer presenting with fever after chemotherapy. Concern for neutropenic fever prompts antibiotics, labs, cultures, imaging, and admission, a rather quick process once you have been through this drill a number of times.
But I began asking more questions about pain and nausea management in relation to chemo. The answers blew me away, like this one: “I pre-mix Cannabis with butter, and then use a slab in my scrambled eggs in the morning. That helps me with pain.”
This unusual answer kept popping up when I least expected it. The frustrating part was I didn't know what to say next. So I continued to shrug my shoulders and moved on.
Cannabis is recreationally legal in California, and there's a ton of social media advertising for it. We are seeing more Cannabis use than ever before. What do we do? Should we continue to shrug it off? I would urge you not to. Ask the deeper questions, go the extra mile because you may prevent someone from coming in with a nonlethal edible Cannabis overdose. Or you may actually help patients obtain the pain treatment they want.
Consider asking these questions of patients who use Cannabis:
- What is your mode of administration? Do you smoke it, eat it, apply it topically, or use suppositories?
When Cannabis is smoked, it has a quick onset and short duration of action, and generally poses a lower risk for overdose. Ingestible medications have a one- to two-hour delayed onset of action, but last longer and pose a higher risk for overdose. Topical medications have a quick onset of action, variable duration of action, and no risk for overdose. Suppositories' onset of action is delayed, lasts longer (similar to ingestibles), and overdoses are infrequent because usage is low.
- Where do you purchase your medication? Through a legal dispensary, from a friend, or on the internet?
It depends on where you live, but everyone in states where it is legal can access tested Cannabis products in legal dispensaries. This comes with a 30 percent tax in California.
- How frequently do you use Cannabis?
This will help you assess the condition they are treating. This may relate to Cannabis hyperemesis syndrome and addiction for younger patients. If they have a hard time estimating how much they use, ask how much they spend each week. Asking this will often give you a better idea about its average cost in your area.
- How many milligrams do you use, and what specifically do you use? Please show me a picture of the product.
Very often people tell me they are taking a CBD product when in fact they are using a THC:CBD ratio medication. This changes things. Think acetaminophen alone v. hydrocodone/acetaminophen combinations. You wouldn't think those two are the same, right? Dosing of THC can vary, but a dose is usually 0.5-5 mg. A dose of CBD is 5-50 mg.
Please feel free to email me questions, describe clinical presentations, and requests for Cannabis science through EMN at [email protected].