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Why Cannabis Medicine Might Be Right for Your Practice

By Stephanie Stephens On Jan 19, 2021

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For a plant-based, botanical product that’s been used for approximately 5,000 years—probably before recorded history—cannabis is still an outlier in most medical circles. And yes, it’s a Schedule 1 drug as classified by the federal government.

Cannabis medicine is a field that’s garnering its share of attention—and rightfully so, say the four multi-faceted physicians you’ll meet here.

The nonprofit Americans for Safe Access, founded in 2002, says:

  • 47 states have medical cannabis laws
  • 4.4 million patients use medical cannabis
  • 30,000 studies have been published on the endocannabinoid system
  • 93 percent of Americans support medical cannabis
  • 100+ known cannabinoids

Additionally, right now, 15 states, two territories and Washington, D.C., say marijuana may be used legally for recreational use; 34 states and two more territories permit medical marijuana.

Laws aside, when it comes to your peers, a March 2020 study in Preventive Medicine found 762 provider responses regarding medical cannabis use were coded for sentiment as 59.6 percent negative, 28.6 percent mixed, and 11.8 percent positive. Anonymous responses were gathered between March 2011 through January 2017, from a total of 1,439 United States licensed clinicians.

Your ‘Ethical Responsibility’

Maybe it’s time to get to know medical cannabis, says Larry A. Bedard, MD, of San Rafael, California. He’s currently the chairman of Marin Healthcare District, and a representative on the American Medical Association (AMA) Cannabis Task Force, via the California Medical Association. He was instrumental in legalizing cannabis in California, and has been a national influencer on this topic.

"I like to think of myself as a medical politician," says Bedard, who is also a past president of the American College of Emergency Physicians—he’s credited with helping make emergency medicine a specialty.

[ Read: How Ambulatory Physicians Are Moving to the Front Lines ]

"And I believe that even if you think cannabis medicine is a hoax, you have an ethical responsibility to learn about it because patients are using it," he says. "People who use medical cannabis know a lot more than their personal physician in most cases."

The 25-member AMA Task Force was approved in November 2019, after being established in October to ensure that medical students, interns, residents, and physicians already in practice have some kind of education about cannabis, he says. Ten state medical associations are members, and Bedard sees this long overdue collaboration as a good sign.

Consider a landmark report from the National Academies of Sciences, Engineering, and Medicine, compiled by top academicians who looked at more than 10,000 studies.

"It found conclusive evidence for the use of medical cannabis for PTSD, anxiety, sleep support, nausea due to chemotherapy, muscle spasms for people with multiple sclerosis, and for chronic pain," Bedard says.

"The horse is out of the barn, with the cows and chickens," he says, referring to the burgeoning cannabis industry in this country.  He predicts that in 5 years, marijuana will be legalized for recreational use nationally, but will need national standards for labeling the product.

Cannabis Lowers Costs

"For doctors interested in complementary and integrative modalities, cannabis can be used in lieu of more modern pharmaceuticals that may carry more side effects and more costs," says Sunil Kumar Aggarwal, MD, PhD, an integrative pain, palliative care, and rehabilitation physician—with a special interest in geography—who says he blends different forms of therapies. He is also an assistant professor at the University of Washington School of Medicine.

His comment is backed by a 2017 Health Affairs study that said "If all states had had a medical marijuana law in 2014, we estimated that total savings for fee-for-service Medicaid could have been $1.01 billion."

"You want to have natural alternatives for patients, that cover a lot of bases," Aggarwal says. "Cannabis may have therapeutic potential in almost all diseases affecting humans and is widely utilizable in multiple areas of medicine."

He says cannabis medicine is a "core part" of the way he practices, but that doctors "still need to know other types of medicine."

What Physicians Do and How

Remember that physicians do not prescribe or dispense cannabis—it’s not a pharmaceutical medicine. They do write recommendations or certifications for a patient’s medical condition that warrants medical marijuana.

And no, medical marijuana is generally not covered by insurance—the federal government considers it "illegal," remember? The Food and Drug Administration must also approve a drug before insurance can cover it. New York State does require insurers to cover office visits.

The need for accurate information about medical cannabis is a big one, depending upon the state and its laws, Aggarwal says, and that’s where you come in. Where clinics are being set up, a medical professional must complete medical authorization paperwork. Patients need guidance to buy at the cannabis shop, or even if they grow the plant themselves. They may need help coming off other medicines, with a de-prescribing plan.

[ Read: Physician CV Builder ]

In Aggarwal’s office, a health educator, like a health coach who doesn’t work under the physician’s license, helps provide their own educational service.

Medical cannabis can be ideal for doctors coming back from retirement, or as an add-on to a solid practice, he says.

"You need to consider how you’ll be compensated and consider the pluses and minuses of money you can make," he says. "Be familiar with local and state regulations, especially for off-label use. Often boards have something to say about how they want you to practice, and you must also respect federal issues."

It’s the physician’s job to help patients understand risks and how to mitigate them, he says, even though "these plants have been here a long time."

Research Part of Complex Circle

Emergency physician Leigh Vinocur, MD, of the Baltimore area, says that in 2008, a colleague’s research project caught her eye—a study on endocannabinoid levels in stressed rats. Vinocur thought, "I’ve been practicing for 20 years. Why does nobody talk about this in medical school?"

She started reading and was fascinated by the science, even as she was disillusioned at how physicians "got pulled into the opioid crisis," when they were trained that patients could not get addicted in the short term. It affected her opinion of pharmaceuticals.

"I felt that maybe the agencies supposed to protect us and patients were protecting the big pharma industry," she says, admitting some guilt fostered by training in Detroit’s inner city. She was taught back then that marijuana was a gateway drug and that "drugs were bad."

Now a champion of medical cannabis, with what she calls a "small medical cannabis practice," she’s contemplating career entrees way that interface with the cannabis industry, including developing training programs.

Vinocur is already a physician executive leader, industry executive and consultant as well as a national media medical expert. She’s also a member of the nonprofit Society of Cannabis Clinicians.

She says she still maintains "a healthy dose of skepticism because there are not a lot of clinical trials—the data is not there, and it hasn’t tapped into every way this is helpful. I want to see medical cannabis legitimized."

Here’s the hitch, says the AMA: "Marijuana’s schedule 1 status makes it difficult to conduct research because any cultivation, clinical testing, or research on it must attain the extremely rare approval of the federal government."

It is an adjunct to therapy, she says, to help with pain, vomiting and yes, anxiety. "But are you going to stop regular treatment? No," she says. "Everything you do has a risk/benefit ratio."

She’s not a fan of all the medical marijuana clinics that have "sprung up and spend only 10 to 15 minutes with patients to certify them—those feel like money mills," she says. "I spend more than an hour educating patients on the endocannabinoid system, about CB1 and CB2 receptors and how those intersect with disease, and I use the most up-to-date research and data."

Vinocur says the average age of her patient is 80, and that they use cannabis tinctures. They’re on a fixed income, and pay out-of-pocket.

"I don’t charge an exorbitant amount, and they can call me any time," she says. Pre-COVID, she did first visits in person, and now does virtual visits. "This is very personalized medicine, and you have to wade your way through. It’s complicated and patients really need a partner in their physician to help them manage it, especially seniors. It’s time-consuming and it’s not a windfall, but it is fascinating."

"People are tired of pharmaceuticals and they’re still in pain, and they want more control over their health," she says. "Be smart about this, because it’s one extra thing you can offer patients—that’s not just for cancer. It’s another tool in the tool box."

Patients for Life

As Executive Vice President of the American Academy of Cannabinoid Medicine (AACM), comprised of clinicians and researchers, David Bearman, MD, of Goleta, California, is also an author, public speaker, and expert witness with an extensive background in public health.

He authored "Cannabis Medicine: A Guide to the Practice of Cannabinoid Medicine." He says approximately 100 local physicians have referred patients to him because for most physicians, "their knowledge base is very shallow."

His organization has established high standards to become a certified cannabis medicine specialist, and he invites family physicians, geriatricians, anesthesiologists, and psychiatrists to consider it.

"This is a legal practice of medicine, and people should know what they’re talking about," he says. "You must have two years’ experience practicing cannabis medicine, be in good standing with your state medical board, practicing according to accepted medical standards and ethics, and pass our certification exam. We certify people as knowing their stuff."

The recreational use of cannabis has undermined its credibility as medicine, he says. The endocannabinoid system should be discussed in medical school, as "the largest neurotransmitter system in the human body." Bearman would like the National Board of Medical Examiners to "include a question or two, because they don’t do that now."

Many medical students, however, have had recreational experience with cannabis, which he says is in much the same position as acupuncture was 20 to 30 years ago in medicine.

[ Read: How to Make Yourself Stand Out as a Medical School Student ]

Higher education is taking note of cannabis medicine, with a number of universities doing research in the area, he says. It is being taught at the Lambert Center for the Study of Medicinal Cannabis & Hemp at Thomas Jefferson University, which offers a certificate.  Among those with graduate degree offerings are the University of Maryland, Baltimore with its Master of Science in Medical Cannabis Science and Therapeutics and the University of Colorado with a Master’s Degree in Pharmaceutical Sciences: Cannabis Science and Medicine Specialty Track.

Bearman says that cannabis medicine patients "can be patients for life. Treat them with respect, listen to them when they tell you something works. You’ll have a better doctor-patient relationship, and word of mouth will bring more patients."

He reiterates that cannabis can be safe, that "any kind of therapeutic substance can have side effects, but cannabis’s are extraordinarily mild—safer than eating 10 potatoes!"

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