Applied Evidence

Medical Cannabis: A guide to the clinical and legal landscapes

J Fam Pract. 2019 September;68(7):390-394,396-399

References

1. College of Family Physicians of Canada. Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance from the College of Family Physicians of Canada. Mississauga, Ontario: College of Family Physicians of Canada; 2014. www.cfpc.ca/uploadedFiles/Resources/_PDFs/Authorizing%20Dried%20Cannabis%20for%20Chronic%20Pain%20or%20Anxiety.pdf. Accessed July 10, 2019.

2. Hartig H, Geiger AW. About six-in-ten Americans support marijuana legalization. Pew Research Center Web site. www.pewresearch.org/fact-tank/2018/10/08/americans-support-marijuana-legalization/. Published October 8, 2018. Accessed July 10, 2019.

3. Li H-L. An archaeological and historical account of cannabis in China. Econ Bot. 1974:28:437-448.

4. Zuardi AW. History of cannabis as a medicine: a review. Braz J Psychiatry. 2006;28:153-157.

5. Marijuana strains and infused products. Leafly Web site. www.leafly.com/start-exploring. Accessed July 10, 2019.

6. Fraguas-Sánchez AI, Torres-Suárez AI. Medical use of cannabinoids. Drugs. 2018;78:1665-1703.

7. Maurya N, Velmurugan BK. Therapeutic applications of cannabinoids. Chem Biol Interact. 2018;293:77-88.

8. Kelkar AH, Smith NA, Martial A, et al. An outbreak of synthetic cannabinoid-associated coagulopathy in Illinois. N Engl J Med. 2018;379:1216-1223.

9. Pertwee RG. The diverse CB1 and CB2 receptor pharmacology of three plant cannabinoids: Δ⁹-tetrahydrocannabinol, cannabidiol and Δ⁹-tetrahydrocannabivarin. Br J Pharmacol. 2008;153:199-215.

10. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015;313:2456-2473.

11. Ellis RJ, Toperoff W, Vaida F, et al. Smoked medicinal cannabis for neuropathic pain in HIV: a randomized, crossover clinical trial. Neuropsychopharmacology. 2008;34:672-680.

12. US Department of Justice, Drug Enforcement Administration, Diversion Control Division. Title 21 United States Code (USC) Controlled Substances Act. Subchapter I—Control and Enforcement. Part A—Introductory Provisions. §801. Congressional findings and declarations: controlled substances. www.deadiversion.usdoj.gov/21cfr/21usc/801.htm. Accessed July 10, 2019.

13. Yeh BT. The Controlled Substances Act: regulatory requirements. Congressional Research Service 7-5700. https://fas.org/sgp/crs/misc/RL34635.pdf. Published December 13, 2012. Accessed July 10, 2019.

14. US Department of Justice, Drug Enforcement Administration, Diversion Control Division. Title 21 United States Code (USC) Controlled Substances Act. Subchapter I—Control and Enforcement. Part B—Authority to Control; Standards and Schedules. §812. Schedules of controlled substances. www.deadiversion.usdoj.gov/21cfr/21usc/812.htm. Accessed July 10, 2019.

15. United States Senate. The STATES Act. Senator Elizabeth Warren and Senator Cory Gardner. 2018. www.warren.senate.gov/imo/media/doc/STATES%20Act%20One%20Pager.pdf. Accessed July 10, 2019.

16. Strengthening the Tenth Amendment Through Entrusting States (STATES) Act of 2019, HR 2093. 116th Cong, 1st Session (2019). www.congress.gov/bill/116th-congress/house-bill/2093/text. Accessed July 20, 2019.

17. Strengthening the Tenth Amendment Through Entrusting States (STATES) Act of 2019, S 1028. 116th Cong, 1st Session (2019). www.congress.gov/bill/116th-congress/senate-bill/1028/all-info?r=3&s=6. Accessed August 8, 2019.

18. State medical marijuana laws. National Conference of State Legislatures Web site. www.ncsl.org/research/health/state-medical-marijuana-laws.aspx#3. Published July 2, 2019. Accessed July 10, 2019.

19. Conant v Walters. 309 F.3d 629 (9th cir. 2002).

20. American Society of Addiction Medicine. The role of the physician in “medical” marijuana. www.asam.org/docs/publicy-policy-statements/1role_of_phys_in_med_mj_9-10.pdf?sfvrsn=0. Published September 2010. Accessed July 12, 2019.

21. What are marijuana’s effects on lung health? National Institute on Drug Abuse Web site. www.drugabuse.gov/publications/research-reports/marijuana/what-are-marijuanas-effects-lung-health. Updated July 2019. Accessed July 10, 2019.

22. Tashkin DP. Effects of marijuana smoking on the lung. Ann Am Thorac Soc. 2013;10:239-247.

23. Zhang LR, Morgenstern H, Greenland S, et al. Cannabis smoking and lung cancer risk: pooled analysis in the International Lung Cancer Consortium. Int J Cancer. 2015;136:894-903.

24. Getting medical marijuana. Commonwealth of Pennsylvania Web site. www.pa.gov/guides/pennsylvania-medical-marijuana-program/. Accessed July 20, 2019.

25. Kosiba JD, Maisto SA, Ditre JW. Patient-reported use of medical cannabis for pain, anxiety, and depression symptoms: systematic review and meta-analysis. Soc Sci Med. 2019;233:181-192.

26. Crippa JA, Zuardi AW, Martín-Santos R, et al. Cannabis and anxiety: a critical review of the evidence. Hum Psychopharmacol. 2009;24:515-523.

27. Moore TH, Zammit S, Lingford-Hughes A, et al. Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. Lancet. 2007;370:319-328.

28. Barrus DG, Capogrossi KL, Cates S, et al. Tasty THC: Promises and Challenges of Cannabis Edibles. Publication No. OP-0035-1611. Research Triangle Park, NC: RTI Press; 2016. www.rti.org/sites/default/files/resources/rti-publication-file-6ff047d7-3fa4-41ad-90ed-9fb11663bc89.pdf. Accessed July 10, 2019.

29. MacCallum CA, Russo EB. Practical considerations in medical cannabis administration and dosing. Eur J Intern Med. 2018;49:12-19.

30. MacCoun RJ, Mello MM. Half-baked—the retail promotion of marijuana edibles. N Engl J Med. 2015;372:989-991.

31. Cannabis use disorder [305.20, 304.30]. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association; 2013:509-516.

32. Williams AR, Santaella-Tenorio J, Mauro CM, et al. Loose regulation of medical marijuana programs associated with higher rates of adult marijuana use but not cannabis use disorder. Addiction. 2017;112:1985-1991.

33. American Academy of Pediatrics Committee on Substance Abuse, American Academy of Pediatrics Committee on Adolescents. The impact of marijuana policies on youth: clinical, research, and legal update. Pediatrics. 2015;135:584-587.

34. Wong SS, Wilens TE. Medical cannabinoids in children and adolescents: a systematic review. Pediatrics. 2017;140. pii: e20171818.

35. Drug Enforcement Administration. Drugs of abuse: a DEA resource guide. www.dea.gov/sites/default/files/drug_of_abuse.pdf. Published 2017. Accessed July 10, 2019.

36. National Academies of Science, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press; 2017. www.nap.edu/read/24625/chapter/12017:2017-2019. Published 2017. Accessed July 10, 2019.

37. Emerging trend and alerts. National Institute on Drug Abuse Web site. www.drugabuse.gov/drugs-abuse/emerging-trends-alerts. Accessed July 10, 2019.

38. Drug Policy Alliance. From prohibition to progress: a status report on marijuana legalization. www.drugpolicy.org/sites/default/files/dpa_marijuana_legalization_report_feb14_2018_0.pdf. Published January 2018. Accessed July 10, 2019.

Physician shield. Despite inconsistent and evolving state and federal laws, physicians are protected, based on the Conant v Walters decision, from prosecution or revocation of their prescriptive authority for the professional “recommendation” of the use of medical marijuana.¹⁹ In 2002, the US Ninth Circuit Court of Appeals upheld the permanent injunction, based on a physician’s First Amendment right to discuss medical marijuana with patients.

CASE

Mr. S is amenable to trial of Cannabis to relieve nausea and anorexia. He asks you if he is allowed to use Cannabis at work, were he to return to an office-based desk job—even part-time—during treatment for cancer.

How would you answer Mr. S? Patients are legally protected from workplace penalties and dismissal for using and consuming Cannabis in states with a medical Cannabis law (including the state in which Mr. S resides). However, all employers have some variability in corporate policy, especially if a person works in a federally supported or regulated occupation. It’s always helpful to advise patients who will be using medical Cannabis to be proactive and speak with a human resources or employee health department staff member before beginning a course of medical Cannabis. Additionally, Cannabis with any amount of THC has the ability to alter focus, concentration, and perceptions of time. Thus, if a patient using medical Cannabis with THC asks about driving to work, he should be given the same advice one would offer about driving after consuming alcohol or ingesting opioids.

Common concerns

Ignorance of legal status. Theoretically, the Conant v Walters decision protects physicians from investigation for recommending medical Cannabis even in states where it is illegal. However, you should adhere closely to procedures set out by your state. The National Council of State Legislatures provides up-to-date information on each state’s procedures and programs,¹⁸ and the American Society of Addiction Medicine (www.asam.org) has established standards of professionalism for physicians who discuss medical Cannabis with patients (TABLE).²⁰

Exposure to smoke. Cannabis smoke carries many of the same carcinogens found in tobacco smoke; furthermore, use of Cannabis and tobacco are highly correlated, confounding many population-based studies. The manner of inhalation of Cannabis can result in significantly higher levels of tar and carbon dioxide than with tobacco smoking. Because the effects of Cannabis last longer, however, people who smoke Cannabis may smoke it less often than tobacco smokers smoke tobacco.²¹

Continue to: Large cross-sectional...