Many physicians feel they are not well informed about the indications, risks, benefits, and side effects of medical cannabis. Considering the inconsistency with federal and state laws and the mixed messages between legislation and government action, it is easy to see why most physicians have opted to avoid the issue until the confusion clears. However, as medical cannabis is being accepted and used by more patients, physicians have a responsibility to expand their current knowledge on the topic.
As humans, we all have biases. However, it is vital that bias not interfere with patient care. Physicians should be able to discuss the warnings of using medical cannabis and recognize the side effects. The reality is, although the stereotypical “stoner” will likely always exist, individuals between the ages of 55 to 65 are the fastest growing demographic starting to use medical cannabis. Technology allows for patients to have access to more information and many individuals are now using medical cannabis for wellness — not to get high. In other words, lumping all cannabis patients together is a disservice to your patients and their care.
While cannabis contains at least 113 cannabinoids, there is only one that gets you high, tetrahydrocannabidiol (THC). Because THC is the psychoactive component in cannabis, patients that use cannabis products with THC may exhibit different and more severe side effects than those individuals using cannabis products without THC.
In contrast, cannabidiol (CBD) is the primary non-psychoactive cannabinoid. Often, cannabis products contain a combination of THC and CBD. However, for wellness, many are choosing products that are solely CBD. Therefore, patients using these products are likely to have minimal to no side effects and they are not getting high.
Under the Federal Controlled Substances Act of 1970, cannabis is classified as a Schedule I drug — which means it has a high potential for abuse, there is a lack of accepted safety, and there is no medically accepted use in the United States. Therefore, physicians who intentionally make certain oral or written statements, or take other actions, for the purpose of assisting patients to obtain cannabis in violation of federal law, may be subject to serious liability. Even in states that have legalized the medical use of cannabis, such as California, providers are subject to federal law prohibiting physicians from recommending it to patients. The Ninth Circuit in 2002 ruled (Conant) that physicians have a right to discuss medical cannabis with their patients under the First Amendment as long as they are not aiding and abetting their patients to violate federal drug laws. Therefore, physicians should be cautious if advising patients on medical cannabis. This prohibition should aim the physician away from advising patients as to where they can purchase cannabis and from discussing dispensary options or dosing of products. It is wiser to refer patients to the Internet so they can conduct their own research.
The current recommendations may change in the near future as more research continues, professional organizations recommend the rescheduling of cannabis, patients increasingly demand access to the product, and the recent FDA-approval of Epidiolex, the first plant-based cannabis (CBD only) pharmaceutical in the U.S. in approximately 80 years. However, at least for now, the uncertainty continues. The FDA-approval of Epidiolex does not make all forms of cannabis legal. Each potential cannabis medication would have to go through the same process and become FDA-approved for physicians to prescribe the drug without fear of violating federal drug laws.
Patients who admit to using cannabis should be provided the warnings listed below and all warnings given should be well documented in the medical record:
- Keep cannabis secure and away from children
- If using products with THC, warn against driving under the influence
- Warn high-risk patients, such as minors, those with kidney and liver disease, women who are pregnant or breastfeeding, and those with certain psychiatric diagnoses, that they may be at higher risk for side effects and other complications
- The potential dangers from long-term smoking for those that use this route
- Advise patients to avoid synthetic cannabis products – these can be dangerous, even deadly
In addition to the warnings listed above, patients should be told of the possible side effects of using cannabis.
The majority of side effects are associated with products that contain THC. Side effects associated with cannabis use include:
- Cannabinoid hyperemesis syndrome
- Tachycardia
- Hallucinations, paranoia, anxiety, depression
- Dizziness, decreased balance, coordination, and reaction time
- Hypotension
- Dry mouth, red eyes, hunger
Until the path on medical cannabis becomes clearer, we encourage physicians to continue to enhance their knowledge on this commonly used drug. Since violating federal law could subject a physician to sanctions, it is vital you understand the rules. Please follow the guidelines provided by the Department of Justice, state medical board, and professional organizations. The following resources can assist you in learning more about medical cannabis:
- Stay up to date with federal law by looking at the DOJ’s website at www.justice.gov
- Review CMA guidelines at www.cmanet.org
- The California Medical Board’s statement on the medical use of cannabis can be found at https://www.mbc.ca.gov/Publications/guidelines_cannabis_recommendation.pdf
- Stay on top of current research by reviewing the Center for Medicinal Cannabis Research at UCSD at www.cmcr.ucsd.edu
- Review and warn your patients against the use of synthetic products https://www.cdc.gov/mmwr/volumes/67/wr/mm6720a5.htm
Members of the Cooperative of American Physicians should be aware that under the terms of the Mutual Protection Trust Agreement, members will not be covered for claims arising out of the prescription, use, or administration of medications that are not FDA-approved.
The information in this publication should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.
Kimberly Danebrock is Director of Risk Management for CAPAssurance. Questions or comments related to this article should be directed to kdanebrock@CAPphysicians.com.