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Limitations
Significant limitations
on my discussions with medical cannabis patients are imposed by federal government requirements or
threats. Experienced medical users will know how to titrate their dosage to achieve the desired effect. For example, I don't
suggest an amount of cannabis to use unless it's to suggest "less" or a safer
method of ingestion for harm reduction/risk minimization purposes. In my experience, medical
cannabis users consume widely varying amounts. (The handful of patients who remain in
the Federal IND program, which supplies cannabis to patients, receive six pounds
per year in tinned, pre-rolled cigarette form.) Nor do I discuss the
locations of dispensaries or how to obtain cannabis. If asked, I explain that
federal law prohibits my doing so. Because accurate
information is vital to health and patients should always have access to
accurate information, I make available a list of resources other than
dispensaries through which they can learn more. These include:
I don't sign any forms
from dispensaries, and I don't sign caregiver forms. The designation of a
caregiver is not a medical decision, but is determined by agreement between the
patient and the caregiver, in accordance with California law. Documentation - Pros and Cons
There is a wide range of
acceptable standards in medicine. Some doctors have been criticized for not
requiring documentation of diagnosis when they approve cannabis use. Others feel
that the requirement creates unnecessary barriers for patients. My arguments for
requiring documentation include:
The following arguments
have been made against requiring documentation:
Notes on Confidentiality
Many patients seek out
cannabis consultants because they don't feel comfortable disclosing to their
primary care providers doctors that they have been self-medicating with
cannabis. Although I do require
that the patient's primary provider or other appropriate practitioner be aware
of, and follow, the serious illness for which cannabis is used, I do not require
that the patient disclose his or her medical cannabis use to these providers in
all cases. The wording I generally use in
explaining this is: "In a perfect world, you should be able to tell your
physician everything. But unless, and until the federal government, employers
and insurance companies no longer discriminate against medical cannabis users,
there is valid reason not to have cannabis mentioned in your medical records." I ask the patient to
assess whether he or she feels safe in telling their doctor "off the record"
that they're using cannabis medicinally. If the answer is yes, I encourage them
to do so. Your own doctor knows you best, and in a perfect world, one should be
able to tell his or her doctor everything. I don't accept insurance
for medical cannabis consultations, nor do I recommend that the patient bill the
insurance company, unless the patient is willing to have his/her insurance
company see these records. Special circumstances
Some patient-care
situations deserve special mention, as they present unusual complexities or
problems. Should a patient's
medical cannabis use be questioned, some presentations or diagnoses are
particularly likely to be challenged by school, probation or law enforcement
authorities. Psychiatric Patients
Psychiatric diagnoses,
particularly if unstable, are likely to raise this kind of "red flag." In such cases, it is important to have a good history of the efficacy of
cannabis for the patient. Approval of the therapist is desirable; next best is a
significant other who can attest to the patient's condition being improved by medical cannabis use. Minors
The recommendation of
medical cannabis use to minors is an area of controversy. As in all of medicine,
one must make a risk/benefit assessment. The developmental needs
of adolescents and children suggest that cannabis use should be discouraged,
unless, as would be true in a person of any age, the medical benefit obtained
outweighs the risk. Recommendations
for medical cannabis for minors should be issued conservatively, and evidence of
effectiveness should be well-documented, as should be parental consent. Elders and/or naïve users
Many elders have never
been exposed to a social environment in which cannabis is used recreationally.
For these patients, as well as for any naïve or first-time user, the
psychological effects may be disturbing. The extensive report on medical
cannabis prepared by the National Academy of Sciences Institute of Medicine in
1999 suggests that "for some patients-particularly older patients with no
previous marijuana experience-the psychological effects are disturbing (p. 4)." In the years following
the legalization of cannabis for medical use, only a small fraction of patients
seeking physician approval have been cannabis-naive. At least 90 percent
of those seeking approval from CCRMG-affiliated physicians already know that,
for them, the benefits outweigh any adverse effects. More naive patients can be
expected to inquire about cannabis as a treatment option as favorable research
results from Europe are reported in the literature. How will the naive patient learn to use
cannabis?
Conclusions
Physicians who are
considering whether to approve cannabis use by their patients must first educate
themselves on the subject. Cannabis has a long, impressive history as a safe and
effective medicine. Although the United States has limited studies on the
benefits of cannabis, the National Institute on Drug Abuse has funded
significant research into its mechanism of action. Universities and major
pharmaceutical companies are conducting groundbreaking studies. Much of this
research is available in:
Cannabis and Cannabinoids: Pharmacology, Toxicology, and Therapeutic Potential. My advice to
colleagues, in brief:
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