The Case for Cannabis

FigureFigureCannabis is seeing a huge financial boom because of recreational Cannabis legalization across the United States, Canada, and other countries. But in its wake, medical Cannabis (formerly known as marijuana) is being left in the shadows. Why would an industry that has been built on its medical benefits and that advertises them routinely suddenly forget the shoulders of the giants it stands on? Simple: Money. Most people I meet in the recreational industry started for a noble cause: Cannabis helped them with skin cancer, get off opioids after a motorcycle accident, deal with anxiety, etc. Yet none of these individuals took the Hippocratic Oath to do no harm. None of them cares what happens to your mom, dad, spouse, friend, kid, or loved one simply because Cannabis won't kill you. Is everything else fair game? There are no real limits on usage, purchase, or dosage; you can get 90% THC in a single vape oil, dab, or shatter v. the three to seven percent THC flower you could get in the 1970s. The recreational limits in place in California are laughable. “Research” is done by leaders in the field on products that would make any “Cannabis connoisseur” (AKA lifetime user) in a recreationally legal state scoff at the dosage used in research. This is akin to doing research on Tylenol with codeine while hydromorphone is being sold in the marketplace and then making claims that Tylenol with codeine research is applicable to hydromorphone. That being said, there is still more ongoing research on Cannabis than on widely sold products such as Ambien and Lunesta. But let's not stop there. A physician's recommendation in California now doesn't mean a thing (except in pediatric cases where it is imperative). Patients are taxed at the same rate as a recreational user, which harms our most vulnerable patients: those with chronic illness, including the elderly, children, and disabled patients, placing an additional financial burden on them month after month to get their medication. Insurance doesn't cover these medications either, except in extreme cases like Dravet syndrome and Lennox-Gastaut syndrome. Patients get no protection under the law, including employee and driving protections. Please note that benzodiazepines, hypnosedatives, and opioids when taken appropriately on a doctor's recommendation are protected, but in this instance, a patient who is not intoxicated and using medication appropriately is not protected under the law. The only thing a physician can currently provide a patient is actual medical advice. And physicians using “marijuana” as medicine risk losing their medical license. (Vice. Oct. 16, 2018; https://bit.ly/3yznlxT.) We physicians aren't even very good at protecting ourselves. Think it's a great way to make some side income? It is, but if you live in certain states (like California), you cannot even hint at profiting or investing in a Cannabis company if you recommend Cannabis because you can lose your license. On the other hand, if you don't write recommendations for Cannabis, feel free to invest in a pot farm, like one of our California Medical Board Representatives! The Art of Medicine Emergency physicians have an amazing foundation for understanding patients, understand a huge variety of medical pathologies, and have the capacity to see the bigger picture, which includes speaking with the families of patients who die in the ED (young and old, expected and unexpected), manually disimpacting an opioid-induced constipation patient and hearing them scream from pain and embarrassment (all while discussing opioid reduction strategies and improved bowel habits), and hearing about the anxiety of a parent who has a child with chronic seizures in the ED for an abnormally long seizure, etc. The focus of medicine now is not just on diagnosis and treatment, but also the social and behavioral sciences that we started learning about in medical school and that should be a part of all medical practices. Patients are happy to Google on their own to identify and read up on a diagnosis or medication, but that's not what they need us for anymore. They need us to orchestrate their care and anticipate their questions. Consider a patient with a UTI. Here is a quick script that embodies the art of medicine: “Ms. X, you have a UTI. Feel free to Google it. Here is an antibiotic that should make it better quickly, and this is an additional prescription for the pain (or burning or urgency) that you may experience; use it if you need it. Some patients don't like that it can stain their underwear due to the color it makes your urine, so use a panty liner to prevent staining. You may develop a yeast infection from using the antibiotic. Has that ever happened to you before? Yes? Here is a vaginal suppository prescription, so that your next week or two doesn't have to be consumed with doctor's appointments, fear, vaginal irritation, and frustration for a normal anticipated side effect. Probiotics should be considered anytime you are taking an antibiotic to help prevent other antibiotic side effects. Also, I don't mean to be intrusive, but consider using vaginal lubricant when you engage in sexual activity to help prevent further UTIs.” That advice to a patient is simple, quick, and effective, and it prevents follow-up visits to the doctor's office and normalizes the experience for your patient. There should be four prescriptions on your EMR note standard for a UTI. None of this is available on Google. And that's what Cannabis medicine is. It is not just “take a toke, and call me if you still aren't stoned.” It is assessing the totality of a patient's medical experience. Take, for instance, a 14-year-old boy I treated in my Cannabis practice, who has been living with a seizure disorder his entire life. He was taking an antiseizure medication as well as three or four other prescription medications for depression, sleep, and ADHD, and he still experienced breakthrough seizures, one of which landed him in the ED with his mother. The mother told me the EP berated her about her son not taking his seizure medications (which was not true; the child is under the care of a neurologist and on antiepileptic medication). Because of the breakthrough seizure, the EP and neurologist added a medication, but it caused the child to be hyperaggressive, angry, and violent, and the mother stopped this medication. All of these aspects are evaluated in Cannabis medicine. Antiseizure medications with unwanted side effects would be slowly titrated off (with approval from the neurologist) and CBD slowly added. The result was this patient's aggression improved after the offending pharmaceutical was removed and CBD was started, and there was improvement in his family relationships, his caretaker's mental health, seizures, and sleep. Oil tincture was administered by a parent using BID-TID dosing and adjusted based on the results of treatment, yielding whole patient care and a positive ripple effect for the whole family. EPs talking about mental health is something we should all be doing more, not compartmentalizing that into something that doesn't affect us. This mother's comment at the end of our last visit was perhaps the most impactful: “We have a different life, a better life. My son is able to complete 51 tasks instead of three. School is happy with his progress, and so are we. He has a life of enjoyment now, instead of being a zombie. This is the first time in 13 years that a doctor has helped change our quality of life.” Every person reading this article can provide this care to patients. If you do not feel you can do this directly, then refer to a Cannabis physician who can.

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