Medical marijuana brings new uncertainties for physicians Pennsylvania fully implemented its medical marijuana law in 2018 and joined 38 states and the District of Columbia that have authorized medical or recreational marijuana at a state level. In an attempt to regulate medical marijuana as a pharmaceutical medication to the extent possible, Pennsylvania instituted a process for certification of patients by qualified physicians, and those certifications can only be honored by licensed dispensaries supplying cannabis products from approved growers within the state. Similar to other states, the requests are overwhelmingly by patients to treat chronic pain. At the University of Pittsburgh Medical Center (UPMC) where I practice, we have been inundated with such requests and physicians are scrambling to follow the guidelines in the literature and meet the patient demand for medical marijuana certification. I led the effort to author UPMC specific guidelines for medical marijuana certification and the emailed responses I received from physicians after the rollout ranged from congratulations to "horror" that we would institutionalize a process for such an evil substance outside the scope of medical practice. Every time I consider certifying a patient my brain is flooded by more questions than answers: By giving patients our "approval" to use marijuana for chronic pain are we just catering to consumer demand or are we offering them a reasonable nonopioid option? Certification In addition, "certification" is not the same as prescribing, despite the state of Pennsylvania's attempt to medicalize it as much as possible, and dispensaries are free to sell the patient any amount of different products they wish to, such as vaping oils or THC pills. The dispensaries tell me that, on average, medical marijuana costs the patient $200 per month. What is our role in protecting financially vulnerable patients from potentially wasting their money? Since medical marijuana is so expensive, do we feel comfortable if the patient admits to using recreational marijuana for pain? To what extent will we be liable if we certify a patient and they become addicted or do something terrible under the influence of marijuana, such as killing someone in an auto accident? Should we certify patients who are already prescribed opioids or should we insist that opioids be tapered if they are going to use medical marijuana? How do you determine if the patient is benefiting from medical marijuana primarily because they have improved pain or because they like getting high? Do we even care if they get high or not? I have heard an administrator ask, "What does it matter if they get high?" What percentage of patients do get high on medical marijuana, even when used at low doses? In fact, what is the right dose and how should it be delivered: vaping, oil under the tongue, or pills? How good are the data that medical marijuana is indeed helpful for chronic pain? Uncertainty Many physicians are uncomfortable with such uncertainties, and hence it is very understandable why most physicians in the states with medical marijuana laws have chosen not to participate in certification. Other physicians like myself are eager to take this journey with their patients and figure out over time what the best approaches are. I suppose that each physician's comfort with uncertainty may make them more or less likely to want to be certifying providers. In this era of healthcare reform, I see these uncertainties as no different than so many of the other uncertainties we face in our practices, such as whether even generic pain medications are going to be covered by insurances, whether we should advocate for low-dose opioids in some of our patients with chronic pain, and whether it is ethical to advise a patient who may have a marginal indication for a nerve block to get it -- knowing that it may only work for 2 weeks, and they have to pay a $1,000 deductible? Obviously, there are no answers to any of these questions, but the more uncertainty the more ethical and moral choices confront a physician. Since in most of the patients, we see there is some degree of complex decision-making, why bother taking on any more complexity? I never went to medical school to learn how to prescribe medical marijuana. Then again, I never thought that rectal exams would stop being a routine part of the complete physical. Now that I see my own doctor every year I am grateful for this evolution in practice! This is the inaugural entry of the AAPM-Pain Medicine blog and I thought that this was a poignant topic to kick it off. The medical marijuana phenomena may get at the core of what we may like or dislike about our physician responsibilities and the myriad of choices we need to make daily for our patients. For some physicians the vexing decision-making paradoxes are energizing and for others they are draining. Perhaps medical marijuana certification is also a lens into how we see ourselves as physicians. Source
