Talking to Patients about Medical Cannabis

With David Bearman, MD

Physicians and patients alike may be unsure how to approach the subject of medical cannabis as part of a pain management strategy during a clinical encounter. While many clinicians consider cannabis to be a legitimate medical therapy, one-half of primary care physicians surveyed in a new study either were not ready to or did not want to answer questions from patients on this subject.¹ However, others reported that they did want to learn more about the potential of medical cannabis (see PPM's online poll results on the cannabis conversation below).

One thing is clear—there are many knowledge gaps, including:

• the workings of the endocannabinoid system
• the efficacy of cannabis, versus hemp, versus marijuana, for a range of conditions
• dosing and delivery methods—there is no official consensus on starting strains or doses but “low and slow” seems to be commonly advised
• potential side effects, interactions, and toxicities.

These questions were urgent enough that the National Academies of Sciences, Engineering and Medicine (NAM) undertook a priority comprehensive review of medical literature on the health effects of cannabis and cannabinoids and issued a 2017 report.² The report focused on 11 areas, among them therapeutic effects, cancer incidence, cardiometabolic risk, respiratory disease, injury and death, and problematic use. The committee identified and prioritized a number of barriers to research.

Add to this the fact that clinicians simply are not taught about cannabinoids such as cannabidiol (CBD) and tetrahdydocannibinol (THC) for medical use. “Physicians need to be aware that their medical schools have not served them well,” said David Bearman, MD, a physician in private practice who specializes in pain management and has more than 50 years of experience in the substance abuse treatment and prevention field. He serves as vice president of quality assurance and credentials at the American Academy of Cannabinoid Medicine.

Two-thirds of medical school deans surveyed reported that their graduates were not at all prepared to prescribe medical cannabis or marijuana and one-quarter reported that their graduates were not at all prepared to answer questions about the substances.³ “Physicians ought to at least understand the endocannabinoid system and have a passing familiarity with it,” said Dr. Bearman.

Despite the lack of training, clinicians should expect to get questions from their patients about cannabinoids, especially as more states are legalizing its medical and recreational use. “It’s important for doctors to realize that there is a reason that their patients are asking them about this. They have friends or relatives who are using cannabis medically and who are getting benefit from it,” he said.

At the very least, those who feel unprepared to answer patient questions should become familiar with the clinicians or practices in their area who are knowledgeable about cannabinoid medicine, he recommended. “It’s OK to say, ‘I don’t know but I can recommend someone who does.’” In fact, Dr. Bearman gets referrals from other physicians with patients interested in medical cannabis.

“My best advice to clinicians is that you don’t have to do anything special with regard to cannabis. Just practice medicine and provide good documentation,” said Dr. Bearman. If you do not have them, get their medical records. Take a history and do a physical. “Handle this the same way you have always handled your prescriptions for oxycodone and other opioids or Schedule II medications,” he advised.

When your patient asks about trying medical marijuana for pain being open and honest about what the medical community knows about cannabis can ease the conversation. (Source: 123RF)

Medical Cannabis Education Resources

While medical schools have been slow to add cannabinoid medicine to their curricula, there are organizations that offer continuing medical education (CME) and other resources for clinicians seeking to learn about medical cannabis, marijuana, and hemp. These include the International Cannabinoid Research Society, the Society of Cannabis Clinicians, the International Association for Cannabis as Medicine, and the American Academy of Cannabinoid Medicine.

Medical schools with cannabis medicine programs or centers — such as the Universities of Washington, Vermont, Colorado, and California at San Diego, Irvine, or Los Angeles — are also good sources, as are professional health organizations such as the American Academy of Pain Medicine, American Cannabis Nurses Association, the American Pharmacists Association, and the American Public Health Association. In addition, state health departments where the substance has been legalized should be helpful.

For a sample Cannabis Patient Agreement template, refer to Wilsey B, et al’s “Medicinal Cannabis Treatment Agreement,” which appeared in the December 2015 Clinical Journal of Pain.

See prescribing considerations with Drs. Mark A. Ware and David J. Casarett