Is medical marijuana a good idea?
Twenty-one states and the District of Columbia have legalized medical cannabis, which remains illegal under federal law. (Photo by iStockphoto)
Dustin Sulak, DO, who practices integrative medicine in Falmouth, Maine, considers himself fortunate. Two months after he launched his practice four years ago, Maine expanded its 1999 medical marijuana law to cover chronic pain and a number of other conditions—on top of the originally included diseases of glaucoma, epilepsy, multiple sclerosis, AIDS and cancer. Already interested in the medicinal effects of cannabis, he saw an opportunity to help many more patients and grow his practice.
Since then, Dr. Sulak has become one of Maine’s leading advocates and recommenders of medical marijuana.
“People are hardwired to respond to cannabinoids for a number of different healing purposes and for a variety of conditions,” says Dr. Sulak, a diplomate and soon-to-be governing board member of the American Academy of Cannabinoid Medicine.
This view is becoming increasingly mainstream. To date, 21 states and the District of Columbia have legalized medical cannabis. And in August, CNN’s chief medical correspondent Sanjay Gupta, MD, admitted that he had been wrong about his previous dismissal of medical marijuana, stressing that it does have therapeutic value for certain conditions.
Nevertheless, medical marijuana remains highly controversial. The U.S. Drug Enforcement Administration still classifies cannabis as a Schedule I controlled substance, which means it can’t legally be prescribed by physicians, nor can it be legally cultivated, manufactured, distributed, possessed or consumed.
A handful of federal agencies remain “rabidly against marijuana,” says medical cannabis activist Phillip Leveque, DO, PhD, of Molalla, Ore., who no longer practices medicine. He notes that the DEA still conducts raids on dispensaries in states that have legalized medical marijuana.
In addition to worrying about its illegality under federal law, some physicians are concerned about marijuana’s potential for abuse, variability and lack of regulatory oversight.
Although he believes cannabis does have medicinal value, pain management specialist Douglas Jorgensen, DO, of Manchester, Maine, contends that some patients who seek marijuana certification do so deceptively so they can smoke pot recreationally to get high. In addition, he says, some physicians will qualify anyone for marijuana who pays the certification fee.
“In some practices in Maine, if you have $300 and walk in the door, you are getting certified for medical marijuana,” Dr. Jorgensen says. “Some of these doctors are even certifying teenagers who have substance abuse probems.”
Major medical associations, such as the AOA and the American Medical Association, have emphasized the need for more research on the therapeutic effects of cannabis. In 2011, the AOA House of Delegates passed a resolution calling on the National Institutes of Health to fund well-designed clinical trials to investigate marijuana’s medicinal properties. Most U.S. government-funded research on marijuana has focused on adverse effects of recreational use.
But a number of DOs like Dr. Sulak are already convinced of medical marijuana’s benefits. They stress strict adherence to state laws and careful screening and monitoring of patients to ensure appropriate and safe use of cannabis.
Caution plus compassion
Family physician Douglas G. Ballaine, DO, who runs a combination primary care and medical cannabis consulting practice in Santa Rosa, Calif., became seriously interested in the therapeutic effects of marijuana a few years ago while working at a community health center in Lakeport, Calif., a community where medical cannabis usage is prevalent.
“I was getting a lot of letters from a physician in the area who was recommending medical marijuana for some of the center’s patients,” remembers Dr. Ballaine, who once trained to be a chemist. “I decided then that because a large number of my patients were using medical cannabis, I needed to learn something about its pharmacology.” He began reading numerous journal articles, some of which were published in the United Kingdom, Canada, Israel and Brazil.
Dr. Ballaine soon concluded that cannabis could be an effective, safer alternative to more traditional medications, such as nonsteroidal anti-inflammatory drugs, various muscle relaxers, antiseizure medications and acetaminophen-based pain medications.
“When a patient has a chronic pain problem and will need medications long term, there are safety considerations with NSAIDs and acetaminophen, which are now known to increase the risk of heart disease and stroke, liver disease and kidney disease,” Dr. Ballaine says. “There is no evidence that cannabis leads to any of these problems.
“What’s more, research has shown that medical cannabis can significantly lower the amount of opiate medications needed to control pain.”
Dr. Ballaine views himself as a primary care physician first and foremost. Consequently, while building the medical cannabis side of his practice, he made a conscious decision not to imitate the consultation-only practice model used by many medical marijuana specialists in California.
“People are hardwired to respond to cannabinoids for a number of different healing purposes and for a variety of conditions.”
“It is my belief that every medical cannabis encounter should adhere to an acceptable standard of care,” Dr. Ballaine says. “This involves obtaining an adequate history, including a history of the present illness and lists of all comorbidities and current medications.
“The physician must perform an adequate physical examination and, if justified, a mental status examination. An assessment and treatment plan must be completed, and treatment goals must be defined.”
Dr. Ballaine also encourages his medical marijuana patients to return for follow-up care, noting that more than 60% of his primary care patients originally came to him for a cannabis recommendation. “I tell my medical cannabis patients that they can come back and talk to me for free if they have any questions,” he says.
In California, registered patients and caregivers can grow marijuana or buy it from dispensaries, which are not regulated by the state. The lack of quality control means that physicians must become as educated as they can about cannabis and share what they learn with patients, Dr. Ballaine says.
While it is impossible to become an expert on the more than 1,000 different strains of marijuana, medical marijuana specialists advise physicians to learn the differences between the two main classifications: Cannabis sativa and Cannabis indica. In a nutshell, sativa strains are more uplifting and energizing, while indicas are more sedating, but the pharmacology of cannabis is complex.
The two classes of cannabis have varied properties outside of the effects associated with delta-9 tetrahydrocannabinol (THC), marijuana’s main psychoactive ingredient, and cannabidiol (CBD), the cannabinoid responsible for helping many people with seizure disorders, according to Dr. Ballaine.
THC binds to the CB1 receptor, while CBD binds to the TRPV-1 receptor, known to mediate inflammation, pain perception and body temperature. “These receptors are tied to many physiological functions,” Dr. Ballaine says. “I feel all physicians should be educated on the pharmacological properties of THC and CBD and the other chemicals found in marijuana.”
Physicians who recommend medical cannabis to patients cannot provide informational handouts or recommend particular dispensaries.
“We doctors have to be very careful not to aid and abet at all,” Dr. Ballaine says. In 2002, the 9th U.S. Circuit Court of Appeals held that physicians cannot be punished for recommending marijuana to a patient but they cannot assist patients in obtaining it.
Patients can be advised to seek dispensaries that laboratory-test their products, however. For one thing, these dispensaries are less likely to sell mold-contaminated marijuana, which can harm immunocompromised patients. Mold tends to develop when growers add water to dry product so that it weighs more and, thus, commands a higher price.
Indeed, the high price of medical cannabis is one of Dr. Jorgensen’s main concerns. Because it is illegal at the federal level, medical cannabis is not covered by any health insurance plans. He notes that many patients in Maine pay the $300 certification fee for medical cannabis only to discover that they can’t afford to spend hundreds of dollars a month to purchase the drug at a dispensary. In contrast, patients with health insurance typically pay a modest co-pay of $10 to $40 to purchase opiate medication from a pharmacy.
Botanical versus pharmaceutical
The complexity of cannabis, which has more than 80 cannabinoids and hundreds of other compounds, causes some physicians to shy away from recommending it. But the fact that cannabis is a natural botanical rather than a pharmaceutical product explains why it provides relief for so many different conditions, Dr. Sulak says.
He points out the irony in the federal government’s outlawing of marijuana, when its most psychoactive and dangerous cannabinoid has been isolated and approved by the U.S. Food and Drug Administration as a Schedule III controlled substance. Derived from THC, dronabinol (better known by the trade name Marinol) has been available since the mid-1980s, approved as an anti-nausea drug and appetite stimulant for AIDS and cancer patients.
“The argument that medical marijuana isn’t necessary because Marinol is available is invalid and quite backwards,” Dr. Sulak says. “Of all the cannabinoids to isolate, THC should have been the last one, but it happened to be the first one to be researched.
“Most herbal cannabis is more effective and safer than Marinol,” Dr. Sulak says.
Another synthetic cannabinoid medication, nabiximols (known by the trade name Sativex), combines THC and CBD. Developed for MS patients by a pharmaceutical company in the United Kingdom, Sativex is a mouth spray that has been approved by several European countries and Canada but not yet by the FDA.
“As with Marinol, people are asking, ‘If Sativex is approved by the FDA, why would we need herbal cannabis?’ But within this plant, cannabis, there are so many different medicines,” Dr. Sulak says. “Some strains of cannabis don’t cause psychoactive effects. Some are better for pain, while others are better for digestion and still others are better for spasticity.”
What’s more, says Dr. Sulak, the compounds in cannabis work synergistically to treat the whole patient, not just isolated symptoms. “Take ulcerative colitis and cyclic vomiting syndrome. These conditions are notoriously hard to treat with traditional approaches, but they respond very well to cannabis,” he says. “Not only are patients not in the bathroom all day long, but they also have better appetite, they sleep better and their inflammation is reduced.”
“Every medical cannabis encounter should adhere to an acceptable standard of care.”
Patients with chronic pain also see many benefits from cannabis, according to Dr. Sulak. “It’s more than the treatment of the pain,” he says. “The cannabis also helps the patient sleep, and it reduces stress and anxiety.”
Dr. Jorgensen agrees that cannabis reduces anxiety and promotes sleep, but he says that these calming effects are the reason marijuana provides relief for some pain patients. Marijuana is not a panacea for pain, he stresses, even though it may help lessen the need for opiate medication in some patients.
Dosing and delivery
Although some medical marijuana patients smoke joints, other delivery methods are preferred by physicians to prevent bronchial irritation.
Dr. Ballaine suggests that patients use a small, fast-acting vaporizing device for inhalation. “Patients who take one or two hits off that vaporizer are going to get the effects they need,” he says.
Glycerin-based tinctures of cannabis are another safe, effective option for patients, according to Joseph J. Starkman, DO, a family physician in Highland Park, Ill., who has experience certifying Maine patients for medical marijuana. “Patients learn how to dose it by testing it one drop at a time under the tongue,” he says.
“Because the potency of herbal cannabis and preparations of cannabis are so variable, we educate patients to titrate the optimal dosage within a given range,” Dr. Sulak says. “Since there is no risk of lethal overdose, in contrast to conventional pain medications, and even modest overdoses are at worst unpleasant but not dangerous, it is safe and effective for patients to do some educated trial-and-error dosing.”
Complement to OMT?
Cannabis works so well as a medication because it reinforces the body’s natural endocannabinoid system, says Dr. Sulak, who as a medical student served a rotation under cannabis researcher John M. McPartland, DO, of Middlebury, Vt., the author of a 2008 article in The Journal of the American Osteopathic Association (JAOA) that discussed endocannabinoids in detail.
“The cannabinoid receptor is the most abundant G-protein receptor found in the brain, and the endocannabinoid system is found in tissues throughout the body,” Dr. Sulak says. “This system is intimately involved in homeostasis and healing, yet it is not being taught in our schools.
“Osteopathic medical students should demand that their physiology classes include this important information vital to a complete understanding of self-healing.”
Indeed, the effects of cannabis and osteopathic manipulative treatment are similar, Dr. McPartland pointed out in a 2005 article in the JAOA. Thus, it is not surprising that DOs who recommend medical cannabis also often perform OMT, Dr. Sulak observes.
Dr. Starkman, who finished his residency a couple of years ago, is happy that Illinois has legalized medical cannabis, effective Jan. 1, 2014, even though the law is more restrictive than the medical marijuana laws in most other states. The Illinois law, which has a sunset provision, is a four-year pilot program that will need to be renewed by the state legislature.
Illinois will not allow patients or their caregivers to grow their own marijuana, and the list of more than 30 covered conditions has some glaring gaps, according to Dr. Starkman. For example, while complex regional pain syndrome is considered a cannabis-qualifying ailment, chronic back pain and chronic neck pain are not listed, he says.
“But patients who don’t have a qualifying diagnosis can petition the state, and I’ll be able to help them do this,” Dr. Starkman says. “I can write a letter for them and send over their records.”
The Illinois law also requires physicians to have an established relationship with their cannabis patients, but the details of this provision have not yet been worked out.
Despite having many questions, Dr. Starkman is grateful that he’ll be able to incorporate medical marijuana into his practice. “It’s very exciting because medical cannabis helps so many patients who aren’t getting help from conventional medicine,” he says. “It’s a medicine that has broad applications. It doesn’t fit the conventional medical paradigm of one drug for one symptom.
“Cannabis is something patients can use that affects their total health. It fits perfectly with a whole-patient, integrative approach to care.”
Dr. Jorgensen, however, has some reservations. Many champions of medical marijuana have an ulterior motive, he says. He believes that they use medical advocacy as a bridge to what happened in Colorado earlier this year: legalization of the drug for recreational use.
“I have seen evidence that marijuana helps some folks and can improve the functionality of patients with chronic pain,” Dr. Jorgensen says, acknowledging that some of his patients are on medical cannabis but he does not certify them himself. “But from what I’ve seen, the vast majority of people on cannabis are not necessarily using it for medicinal purposes.”
This article has been modified to correct an error related to the properties of cannabidiol.