Medical Marijuana: Consider the ''Whole Patient'' in Deciding Whether to Certify

Marijuana Is Not a First-Line Therapy, Physician-Experts Say

The legalization of medical marijuana in Massachusetts is no longer just a ballot question; it’s reality. But physicians who are willing to certify patients for medical marijuana will find little research about its indications, contraindications, risks and benefits — especially in comparison to conventional pharmaceutical therapies.

For that reason, the MMS held a first-of-its kind CME event in June, in which more than 100 physicians gathered to learn how to navigate these new regulations using currently available medical science.

Throughout the half-day event, Medical Marijuana: Regulations, Responsibilities, and Communication, physician panelists presented various clinical scenarios in which marijuana certification could be considered.

Patients who had been using marijuana to alleviate disease symptoms before the passage of the referendum may use the law as an opportunity to become certified, legal users, noted Alan Ehrlich, M.D., an assistant professor of family medicine at University of Massachusetts Medical School.

“We as physicians are now the gatekeepers of deciding this is a legitimate use or not a legitimate use, but the agent is the same,” Ehrlich said.

Thus far, the research available on the medical effects of smoked cannabis is limited, but data does exist demonstrating some positive results. “When I went to medical school, this was information that was not available,” he noted. “The endocannabinoid system really has been elucidated over the las 20 years or so. What we’ve learned is that this is a system, just like the adrenonergic system or the dopaminergic system.”

Medical Marijuana Is Not a First-Line Therapy

Nonetheless, in order for a patient to be eligible for medical marijuana certification in Massachusetts, he or she must suffer from a debilitating medical condition, such as cancer, glaucoma, HIV, or other diseases that can cause weakness, intractable pain, or otherwise substantially limit a patient’s quality of life.

During the presentations, panelists frequently cited multiple sclerosis (MS), which is a listed certifiable disease afflicting most of its sufferers in their 20s and 30s, as an example illustrating physicians’ complex decision-making process of whether to certify.

“Your task is to first understand that marijuana does not fix MS,” emphasized Dr. Ehrlich. “If you have a patient with MS, you’d better make sure they’re on disease-modifying therapy.”

The distinction between disease-modifying therapy and treating symptoms is an important one, agreed Riley M. Bove, M.D., a neurologist with Partners Multiple Sclerosis Center at Brigham and Women’s Hospital. “We have no data on marijuana as a disease-modifying therapy in MS — whether it influences immune system, relapse rate, or ­disability progression — things that are really well targeted by disease-modifying therapies that do exist,” she said.

But if the patient is receiving adequate treatment for MS and still having symptoms, Dr. Ehrlich continued, certification may be a consideration.

Is Marijuana Medicine?

What patients should know about the use of medical marijuana is the topic of the latest episode of Physician Focus with the Massachusetts Medical Society. Watch it online here. More online resources on medical marijuana are available here


Importantly, before certifying a patient with a complicated disease, be sure to coordinate care with the physician primarily responsible for treating that condition, Dr. Ehrlich noted. Using the MS example, that would mean initiating a dialogue with the patient’s neurologist to determine how well the underlying disease is already being managed.

Multiple sclerosis is not the only qualifying condition in which this notion applies. Whether a patient is suffering from cancer, glaucoma, ALS, MS, or chronic pain, physicians must determine whether patients are undergoing treatments to manage their disease before turning to marijuana to help manage symptoms of their disease, or in some cases side effects of other treatments.

Risk Is Relative

When it comes to marijuana, people often hold biases at extreme ends of a spectrum, noted Kevin P. Hill, M.D., MHS, director of Substance Abuse Consultation Service, Division of Alcohol and Drug Abuse at McLean Hospital and an assistant professor of psychiatry at Harvard Medical School. “We have people who believe that any marijuana use will lead you on the road to ruin. We have people who believe that it’s harmless. The answer is really somewhere in the middle,” ­according to Dr. Hill.

Nonetheless, Hill presented several risks about marijuana that he recommended physicians keep in mind:

  1. Addiction.An estimated 9 percent of adults who use ­marijuana become addicted, which translates to about 2.7 million people out of current users.
  2. Cognitive decline.“Imaging studies show that people using marijuana regularly are working at a much higher pace, recruiting different parts of the brain, to get the same amount of work done as someone who is not using it,” Dr. Hill said. Research has shown that regular marijuana users may experience up to an eight-point decline in IQ, he added.
  3. Worsening anxiety.“A lot of people talk about using marijuana to treat their anxiety,” Dr. Hill said. “While acutely your anxiety level is going to go down , ultimately you’re raising your baseline anxiety level.”
  4. Psychosis.“We have strong data showing that if you have a family history or risk [of schizophrenia or other psychiatric disorders] that you increase the likelihood that you’re going to express that risk if you use marijuana,” he said.
  5. Withdrawal.People who use marijuana daily and stop abruptly often experience withdrawal symptoms similar to nicotine withdrawal, Dr. Hill said.
  6. Driving impairment.Patients should not drive while under the influence of cannabis.

Ultimately, the question isn’t whether marijuana use is risky, noted Dr. Ehrlich, but how dangerous it may be when compared to other risks, such as a patient not being able to stick with therapy due to intolerable side effects. “If it helps you complete therapy and you can get your hepatitis C virus properly treated,” he said,” well then it may be less risky than not being able to tolerate therapy.”

Similarly, medical marijuana may offer some patients a helpful alternative to long-term steroid or narcotic use. “Overall, the side effects of medical marijuana compare favorably with many of your standard medicines,” noted J. Mark Sloan, M.D., hematologist/oncologist at Boston Medical Center.

As with recommending any treatment for patients, physicians have to look at it in the full context of patients’ lives, noted Dr. Bove. “We always have to look at the patient as a whole person,” she said.

— Debra Beaulieu-Volk
Vital Signs Staff Writer

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