New data from each of the 23 states which have legalized medical marijuana use indicates that as of March 2016, more than 1, 246, 170 medical marijuana identification cards have been issued.
That averages out to more than 8 patients per 1, 000 residents. The state with the largest per capita use of medical marijuana is Colorado at 19.8/1, 000 residents, followed by California at 19.4/1, 000, then by Oregon and Washington at 19.2/1, 000 and Michigan at 18.4/1, 000.
Impact on Orthopedic Care Givers
Proponents of medical marijuana have touted it for an extraordinarily wide range of maladies including certain types of cancer, multiple sclerosis, Alzheimer disease, posttraumatic stress disorder (PTSD), epilepsy, Crohn’s disease, glaucoma, chronic pain, sleep disorders and much more.
But data shows that the vast majority of patients seek medical marijuana cards because of chronic back or large joint arthritis pain.
For physicians who specialize in treating orthopedic or spine conditions, the fact remains that “prescribing” marijuana is illegal under federal law. The federal government considers marijuana a substance with a high potential for dependency or addiction, with no accepted medical use in treatment.
In 2013, the U.S. Department of Justice (DOJ) updated its marijuana enforcement policy. While reiterating marijuana’s classification as an illegal substance, the DOJ opened the door for medical marijuana use by advising states and local governments (that authorize marijuana related conduct) to implement strong and effective regulatory and enforcement systems. The intent of the new systems would be to address any threat that new medical marijuana laws could pose to public safety, public health, and other interests.
Through all of this, the one group that has found itself in the middle of this rush to legitimize marijuana is the orthopedic physician. When asked, what do they offer patients in terms of an evidence based opinion regarding marijuana use for chronic pain or other musculoskeletal problems?
Federation of State Medical Board (FSMB) Steps Up
In 2015, FSMB Chair J. Daniel Gifford, M.D., appointed a work group to develop policy recommendations for state medical boards regarding marijuana in patient care. The work group also worked up a position statement regarding the regulation of licensees who wish to prescribe marijuana.
The FSMB represents 70 state and territorial medical licensing boards in the United States.
Both the recommendations for marijuana in patient care and the board’s statement about physician personal use of marijuana involved a systematic review of more than 40 peer-reviewed articles from the medical literature by the task force members.
State medical board members and members of the American Society of Addiction Medicine also weighed-in and added further commentary and feedback about draft language.
The FSMB policy recommendations were unanimously adopted by state medical boards on April 30, 2016.
The FSMB 10 Medical Marijuana Policy Recommendations:
- Patient-Physician Relationship. Because the patient-physician relationship is fundamental to the provision of acceptable medical care, physicians must document details of the patient encounter to reflect that such a relationship was established and in place before providing a recommendation, attestation, or authorization of marijuana for the patient. Consistent with prevailing standards of care, physicians should not recommend, attest, or otherwise authorize marijuana for themselves or a family member.
- Patient Evaluation. A documented, in-person medical evaluation and collection of relevant clinical history commensurate with the presentation of the patient must be obtained before a decision is made to recommend marijuana for medical use. At a minimum, the evaluation should include the patient’s history of present illness, social history, past medical and surgical history, alcohol and substance use history, family history (with emphasis on addiction or mental illness and psychotic disorders), physical examination, documentation of therapies with inadequate response, and a diagnosis requiring the marijuana recommendation.
- Informed and Shared Decision Making. The physician should discuss the risks and benefits of marijuana use with the patient, and patients should be advised of the variability and lack of standardization of marijuana preparations and the effect of marijuana. Patients should be reminded not to drive or operate heavy machinery while under the influence of marijuana. If the patient is a minor or without decision-making capacity, the physician should ensure that the patient’s parent, guardian, or surrogate is involved in the treatment plan and consents to the patient’s use of marijuana.
- Treatment Agreement. The health care professional should document a written treatment plan that includes a review of other measures attempted to ease a patient’s symptoms that do not involve the recommendation of marijuana, and a specific duration for the authorization to obtain marijuana for a period no longer than 12 months.
- Qualifying Conditions. Recommending marijuana for certain medical conditions is at the professional discretion of the physician. The indication, appropriateness, and safety of the recommendation should be evaluated in accordance with current standards of practice and in compliance with state laws, rules, and regulations, which may specify conditions for which a patient may qualify.
- Ongoing Monitoring. The physician should regularly assess the patient’s response to the use of marijuana and overall health and level of function. This assessment should include the efficacy of the treatment to the patient, the goals of the treatment, and the progress of those goals. Where available, the physician recommending marijuana should check the state’s prescription drug monitoring program, register with the appropriate oversight agency (such as a marijuana registry, as exists in Colorado and Minnesota), and provide the registry with information each time a recommendation, attestation, authorization, or reauthorization is issued.
- Consultation and Referral. A patient who has a known or suspected history of substance use disorder or a co-occurring mental health disorder may require specialized assessment and treatment. The physician should seek a consultation with, or refer the patient to, a pain management, psychiatric, addiction, or mental health specialist, as needed.
- Medical Records. The physician should keep accurate and complete medical records. Information that should appear in the record includes the patient’s history; results of the physical examination; patient evaluation; other treatments and prescribed medications; authorization, attestation, or recommendation for marijuana (including the date, expiration, and any additional information required by state statute); instructions to the patient (including discussions of the risk and benefits, adverse effects, and variable effects); results of ongoing assessment and monitoring; and a copy of a signed treatment agreement (including instructions on safekeeping and instructions on not sharing marijuana with others).
- Physician Conflicts of Interest. A physician who recommends marijuana should not have a professional office located at a dispensary or cultivation center or receive financial compensation from, or hold a financial interest in, a dispensary or cultivation center. The physician should not be associated in anyway with a dispensary or cultivation center.
- Physician Use of Marijuana. State medical and osteopathic boards advise their licensees to abstain from the use of marijuana for medical or recreational purposes while actively engaged in the practice of medicine. Practicing medicine under the influence of marijuana may constitute unprofessional conduct or incompetence.
So, What, Precisely, Is Medical Marijuana?
First, it is not your freshman dorm version of pot. Medical marijuana today is the product of advanced ag-engineering and is, in effect, a deconstructed then re-engineered blend of marijuana’s active components.
According to medical marijuana industry group United Patients Group (https://unitedpatientsgroup.com/about/), there are over 400 natural compounds in medical marijuana and, of these, 80 are only found in cannabis plants. These 80 compounds are known as cannabinoids. Cannabinoids have the ability to stimulate receptors in the brain that look for similar compounds that occur in the human body, such as dopamine.
There are five major cannabinoids in medical marijuana: THC, CBD, CBN, CBC and CBG.
Delta-9-Tetrahydrocannibinol (THC)
THC is probably the best known cannabinoid present in medical marijuana and is typically prescribed as a muscle relaxant and anti-inflammatory. Psychologically it can act as a stimulant. It also stimulates appetite and lowers blood pressure.
Cannabidiol (CBD)
CBD actually reduces the psychological effects of medical marijuana. Marijuana strains that are high in both THC and CBD will tend to have fewer “mental” effects and more physical ones. Users tend to use high CBD strains to reduce pain, nausea or anxiety. Cancer patients can respond well to a high CBD marijuana strain.
Cannabinol (CBN)
Not to be confused with CBD, CBN is very similar to THC, but has fewer psychological effects. It is produced as THC breaks down within the medical marijuana plant. High THC will make CBN’s effects stronger, and very high CBN concentrations can produce undesirably strong head highs. CBN is often associated with lowering pressure in the eye (glaucoma, for example) or for use as an anti-seizure drug.
Cannabichromene
Cannabichromene’s main action is to enhance the effects of THC. High cannabichromene levels will make a high-THC medical marijuana strain much more potent as a possible sedative, analgesic or anti-inflammatory.
Cannabigerol (CBG)
CBG has no psychological effects on its own, and is not usually found in high amounts in most medical marijuana. Scientists believe that CBG is actually one of the oldest forms of cannabinoids, meaning it is essentially a “parent” to the other cannabinoids found in medical marijuana. Some of the medical claims made regarding CBG are that it will help lower eye pressure and can be a sedative.
Combining Strains
The five major cannabinoids are considered to be more “effective” (depending on what “effect” is desired) when they work together. That may be one reason that medical marijuana replacements like Marinol do not work very well.
Professional medical marijuana growers increasingly differentiate their products by dialing in different recipes of these five major cannabinoids to find the right combination for patients to treat specific conditions.
Final Word
Joe D. Goldstrich, M.D., FACC, a cardiologist who became a cannabinologist has the following advice for physicians who are thinking of prescribing marijuana.
“Most patients are seeking to avoid the psychoactivity associated with THC, and for that reason it is of paramount importance to start with extremely low doses (i.e., 1 to 5 mg) of THC and build up slowly, taking advantage of the known tolerance that develops with continued THC use. CBD, having little psychoactivity, can usually be advanced more quickly. That’s what I have learned so far. My experience convinces me that cannabis should be removed from its schedule 1 status so placebo controlled, double-blind studies can be carried out. Only then will we realize the full potential of this remarkable medicine.”
