With more than half the states currently allowing the use of medical marijuana, rheumatologists increasingly see patients who have questions about whether marijuana might help in the management of their rheumatic diseases.
Two experts on the subject will consider the pros and the cons of marijuana as a therapeutic agent in an interactive session titled, Clinical Cannabinoids Debate: Safety, Dosing & Accessibility from 4:30–6:00 pm on Tuesday in Room W471b.
Arguing in favor of the use of cannabinoids in medicine will be Alvin F. Wells, MD, PhD, Director of the Rheumatology and Immunotherapy Center in Franklin, WI. His position is that whether clinicians are for or against medical marijuana, societal norms are moving toward its nationwide acceptance, and therefore it’s important for providers to get up to speed on the subject.
“Regardless of the specialty, physicians will increasingly see patients who have questions about medical marijuana use,” said Dr. Wells, who is also medical director of a medical cannabis evaluation clinic with locations in the Chicago area. “I want to arm clinicians with the data and give them the best information we have so they can counsel their patients to make educated decisions about their care.”
Dr. Wells said that 30 states have approved use of cannabinoids in medicine, and the number is expanding. He will share data on the evolution of marijuana for medical use, looking at where the field has been and where it is going.
“Clinicians need to learn the standard of care,” he said. “This information is especially important for rheumatologists, who see a lot of patients who experience chronic pain. We have a big issue in this country with treating pain and the resulting opioid epidemic.”
Dr. Wells says some data point to cannabinoids as a possible solution to the management of chronic pain
“There’s data from a state where marijuana has been approved for medical use that show that deaths from overdose of opioids and heroin have gone down,” he said. “That’s a positive of this trend, and we need more research in this area.”
Dr. Wells will also discuss how providers can familiarize themselves with existing laws, which vary from state to state.
“Before considering incorporating medical marijuana into a practice, providers need to review the regulations in their state,” he said. “Individual state regulatory agencies can help providers understand the approved indications in their state and how to write prescriptions.”
Dr. Wells said he hopes clinicians come away with enough guidance to be able to confidently answer patients when questions arise.
“It’s time to have the conversation,” he said. “It’s no longer taboo. Doctors should not be afraid to talk about it. Whether you’re for it or against it, this is where societal norms are headed.”
On the other side of the issue is Duane Pearson, MD, Associate Professor of Medicine at the University of Colorado School of Medicine, Aurora, CO, who thinks there isn’t enough data to support the use of clinical cannabinoids to treat rheumatologic diseases.
“What’s happening with cannabinoids is really unprecedented,” he said. “We have a national grassroots movement that has identified a compound — the cannabinoid — as a therapeutic agent. Patients now wonder if cannabinoids are appropriate to treat their rheumatologic disease. Unfortunately, the data to support it as a therapeutic modality is scarce.”
Dr. Pearson said that while cannabinoids are potentially therapeutic molecules, the data to guide discussions with patients regarding risks and benefits and drug interactions is only slowly emerging.
“Until we have a better sense of these things, caution is the better part of valor,” he said. “We do know there are potential interactions with other sedative hypnotics as well as with pain medication. Having that frank discussion with patients about the risks and the unknowns is important.”
Dr. Pearson pointed to a lack of regulation regarding the use of medical cannabis as one of the risks for patients.
“This is a little-regulated space,” he said. “There’s no federal guidance. All regulations are based on state guidance, with few rules regarding the distribution and use of these medications. For example, how do patients know how much THC is really in a compound? Currently, there’s no standard regulation that ensures product packaging accurately reflects the contents.”
Dr. Pearson said the marketing and distribution of many medical cannabinoid products also put people at risk for inappropriate use more so than other drug classes. He points to the marketing of edible cannabinoid products in Colorado, which was among the first states to legalize the use of marijuana.
“The pharmaceutical industry, after years of issues with inappropriate use, adopted child-resistant caps on pill bottles,” he said. “Compare that to the 180-degree difference we have in the medical and recreational marijuana industry. Not only is nothing tamper resistant, they’re actually putting these molecules in delivery vehicles attractive to children — gummy bears, brownies, cookies. Clinicians and patients alike need to be aware of these risks. The same way I would tell people to wear their seatbelts or get their vaccinations, we need to have frank conversations about unintended ingestion of cannabis.”
Dr. Pearson will also warn of the risk of running afoul of federal law.
“The distinction between state and federal government needs to be understood,” he said. “Even if medical marijuana has been legalized in your state, if you maintain a DEA license, you are bound by federal law not to prescribe class 1 drugs. If you do so, you’re violating the terms of your DEA license.”
Dr. Pearson said despite these warnings, he doesn’t necessarily dissuade patients who are interested in exploring cannabidiol or other medical marijuana modalities. He said he doesn’t prescribe them because, in addition to having a DEA license, he doesn’t have enough data to prescribe them.
“We just don’t know enough to counsel patients on what to use,” he said. “Which means the counseling patients do receive is coming from individuals who are not medically trained. As physicians, we have essentially abdicated our role in counseling our patients on medical marijuana, unfortunately. Until we have more data and federal regulations, the best we can do is to tell patients the limits of our knowledge and share our concerns.”