My practice and "Acceptable Standards"

Because medicine is a constantly evolving field, there is a wide range of acceptable standards of care for treating many specific problems. This is more noticeable in dealing with symptom management as opposed to curative therapy; it is particularly relevant in a new field such as Cannabis Therapeutics, in which research has historically  been constrained by legal considerations.

In my practice, cannabis is most frequently employed for symptom management (Larson, 1992) as well as for the reduction of what has been termed "symptom distress" -the physical or mental anguish or suffering that results from the symptoms the patient is experiencing (Rhodes & Watson, 1987).

With appropriate use of medical cannabis, many of these patients have been able to reduce or eliminate the use of opiates and other pain pills, ritalin, tranquilizers, sleeping pills, anti-depressants and other psychiatric medicines, as well as to substitute the use of medical cannabis as a harm reduction measure for specific problematic or abused substances with a much more serious risk profile (including alcohol, heroin/opiates, and cocaine). The diagnoses of my medical cannabis patients (see sidebar "USES/INDICATION") are consistent with the bulk of my medical practice diagnoses.

Symptoms are subjective phenomena by definition, and as such are difficult to evaluate. Symptoms include, but are not limited to: fatigue, insomnia, depression, anxiety, nausea, vomiting, anorexia, elimination problems, and breathing difficulty.

The control of symptoms and the alleviation of symptom distress are some of the most important therapeutic uses of cannabis. Both the alleviation and the control of symptoms remain areas in which further research is needed (Grant, 1992).

The need for additional research on symptom management is compounded by the lack of research and standards for the use of cannabis therapies. Legal disapprobation, restrictions on the opportunities for clinical research intrinsic to cannabis' status as a Federal Schedule I Controlled Substance, and a long historic gap in the accumulation of clinical writing on cannabis therapeutics since criminalization in the 1930s have resulted in there being relatively little clinical literature from which we can seek guidance.

The Medical Board of California (MBC) and the California Medical Association (CMA) have a "working group" drafting guidelines, but seven years after  the therapeutic use of cannabis was legalized, there are no practice standards other than what is usually expected of any clinician in the course of his or her practice. 

"Any physician who recommends the use of marijuana by a patient," according to the Medical Board's July 2003 Action Report,  "should have arrived at that decision in accordance with accepted standards of medical responsibility, i.e., history and physical examination of the patient; development of a treatment plan with objectives; provision of informed consent, including discussion of side effects; periodic review of the treatment's efficacy and, of critical importance, proper record keeping that supports the decision to recommend the use of marijuana.  However, the Board recognizes that these principles may require further elaboration to take into account the factors that may affect the physician-patient relationship in this context."

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