Cannabis as Medicine
In this article, we will use the term cannabis, since marijuana is a term which is considered racist and derogatory to many international readers. Cannabis has achieved semi-legal status in the United States for use as a medicine in 14 states,1 although its status by federal classification remains Schedule I under the Controlled Substances Act:
A) A drug or other substance that has a high potential for abuse.
B) A drug or other substance that has no currently accepted medical use in treatment in the United States.
C) There is a lack of accepted safety for use of the drug or other substance under medical supervision.”2
Therefore, prescribing cannabis is impossible under present DEA regulations and knowingly prescribing controlled substances to a person who is using cannabis—regardless of whether for medicinal or discretionary purposes—will potentially violate DEA licensure for the provider. Two synthetic prescription medications currently exist in the U.S. that can be prescribed. This conflict in its legal status between state and federal regulation remains a gray area and will be discussed in this article. The author lives in Montana, which legalized the medical use of cannabis in 2004. We will discuss how its use in pain medicine might be approached without forfeiting DEA licensure.
The Montana Experience
Presently, there are more than 14,000 registrants in Montana with more than 11,000 giving ‘chronic pain’ or ‘chronic pain and muscle spasms’ as the reason for registration.3 There are more than 2,500 “medical caregivers” who are registered to grow and provide cannabis to the patients. Montana law also allows for a registered caregiver to grow and provide cannabis to the registered user.
At the time of publication, no providers in Montana have had to either forfeit their DEA license or been subjected to state licensing board discipline for prescribing controlled substances with cannabis use. One provider has been censured for inappropriately providing registration in a series of clinics held on weekends with hundreds of registrations in each clinic. One provider in Montana has provided more than 3,000 registrants with certification to use medical cannabis. In most cases, after registration is obtained, the “patient” has no formal followup with the provider until the next year for renewal. Cities and counties in Montana have varied widely in their approach to the issue of medical cannabis. Some have local laws banning its use. Others have formal regulation of the provider storefronts. An informal survey by local journalists has not revealed a significant difference in criminal activity in the municipalities with a high tolerance for use. The overarching concern has been the bogus acquisition and use of cannabis by young persons, some of who are still in high school.
Online Survey of Cannabis Users
The author performed an open-ended online survey of cannabis users in Montana. The survey was advertised by giving an interview which was published in the five largest newspapers in Montana and spread to the internet news sources for medical cannabis and cannabis reform. There were 360 participants, with 292 of them being Montana medical cannabis registrants. Of the 292 responding as Montana registrants, only 13% were between the age of 21 and 30 years while actual MT registration statistics indicate that more than 25% of the registrants are in that age range. Because of the methods used, and comparison to the known registrants from Montana state sources, the survey may not be representative of the actual registrant population. 79% of the respondents have a caregiver but 48% also grow their own cannabis.
Background of Cannabinoids
A synthetic form of the main psychoactive ingredient of cannabis—tetrahydrocan-nabinol-delta-9 (THC)—has been available by prescription in the USA since 1986 (dronabinol, marketed as Marinol®) and was downgraded from Schedule II to Schedule III in 19994 when it was noted that it has little street value because its cost exceeds the cannabis available.5It is listed for use in nausea and vomiting associated with cancer chemotherapy and appetite improvement for patients with AIDS. An additional synthetic cannabinoid, race-mic-nabilone (marketed in the USA as Cesamet®), has approval for chemotherapy-related symptoms. Some providers have used both medications for chronic pain. In Canada and Europe, a cannabis-based medical extract is approved for use as an oromucosal (mouth) spray (Sativex®). This product is entirely derived from the cannabis plant itself—with specially grown cannabis plants—and an extensive quality control process involved in production. A book was written about the development of this product,6 which has entered Phase 3 drug testing in the USA.