According to the US Federal Controlled Substances Act, marijuana is a Schedule I illegal drug, which signifies it has no medical use and may lead to abuse.1 Despite this fact, the majority of states have passed laws to legalize or decriminalize its use for medical indications. Thirty states allow for the sale of marijuana for medical reasons, with nine of those states and the District of Columbia allowing recreational and medical sales of marijuana; sixteen states allow only the sale of cannabidiol (CBD), the non-psychoactive component of marijuana.2
Cannabis is the most popular illicit drug used in the US, followed by prescription drugs used for nonmedical purposes. Results of a 2015 nationwide survey reported 22.2 million (8.3%) Americans over the age of 11 used cannabis in the past 30 days.3 Another survey assessed reasons for cannabis use in adults and found 53.4% of people used marijuana for recreational purposes only, 10.5% for medical reasons only, and 36.1% for mixed medical/recreational use.4
As more patients use medical marijuana, health systems must develop strategies and policies for managing its use. Pharmacists, as the medication experts, are in an ideal position to take a leadership role in these pursuits. To this end, pharmacists must educate themselves on the risks and benefits of medical marijuana, its legal/regulatory status, and take an active role in educating patients.
Benefits and Risks of Medical Marijuana
In 2017, the National Academies of Sciences reviewed the literature on cannabis and cannabinoid use and published a book that reviewed over 10,000 articles published since 1999.3 There is conclusive or substantial evidence that cannabis is effective for chronic pain in adults, as an antiemetic in the treatment of chemotherapy-induced nausea and vomiting, and for improving the spasticity symptoms of multiple sclerosis. There is also substantial evidence for a statistical association between cannabis and worsening respiratory symptoms and more frequent chronic bronchitis episodes with long-term smoking, increased risk of motor vehicle crashes, lower birth weight for babies born to women who smoked cannabis while pregnant, and development of schizophrenia or other psychoses, with the highest risk among the most frequent users. TABLE 1 lists some of the benefits and harms of cannabis, as well as the supporting evidence.3
Marijuana and Opioids
As the opioid addiction crisis continues, interest in the purported pain-relieving effects of cannabis has increased. An article published this year reviewed the association between state implementation of medical cannabis laws and opioid prescribing practices under Medicare Part D.5 The authors hypothesize that medical cannabis policies may be a potential mechanism to encourage less prescription opioid abuse and positively impact the opioid crisis. They found that in states where any medical cannabis law was enacted, prescriptions filled for all opioids decreased by 2.11 million daily doses per year from an average of 23.08 million.5 When medical cannabis dispensaries opened, this number decreased by 3.742 million daily doses per year.5 Because pain is the most common indication for medical marijuana use, it may be a viable alternative to opioids and assist in managing the opioid crisis.5-8
Challenges Related to Medical Marijuana
Marijuana use has many ostensible benefits, and while it is effective for some patients, it is not appropriate for everyone and must be used cautiously. Cannabis is not regulated as an FDA-approved product; considering this lack of regulation and its classification as an illegal substance on the federal level, significant challenges must be taken into account when recommending its use.
Several barriers exist in conducting medical marijuana use research.
A Knowledge Deficit
The knowledge gap surrounding the use of cannabis and cannabinoid products remains significant. Pharmacists who work in dispensaries in some states report relying on educated guesses and advice from colleagues regarding which products, strains, and formulations to recommend to patients.11 It is challenging to locate data on cannabis within traditional pharmacy resources, which makes it difficult to characterize potential drug-drug interactions.
In addition, different strains and formulations have various side effect profiles. Certain side effects may be more common in one patient demographic than another. For example:
Without clear evidence, it is a challenge for pharmacists and providers to accurately counsel their patients and optimize therapy for safe and efficacious cannabis use.
Considering the gap in medical marijuana knowledge and the existing regulatory concerns, health care institutions should have a policy in place addressing marijuana use, especially in states where it is legal for medical indications. Essential elements of the policy should address which patients may be eligible to receive medical marijuana, where it should be stored, who is permitted to administer it, and documentation requirements.16
Hospitals are potentially at risk of being in violation of federal law if they allow medical marijuana use in their institutions. Since cannabis is illegal under federal law, hospitals accredited through the Centers for Medicare and Medicaid Services could be cited for violations, lose federal funding, and receive fines in the event of permitted cannabis use. Moreover, because marijuana is not an FDA-approved medication, providers are not permitted to prescribe or provide it to patients. The Joint Commission Medication Management Standards provide recommendations on the safety of medications brought into health care facilities by patients.17 This resource provides some guidance on treating medical marijuana as a home medication. In states without tightly regulated medical marijuana dispensaries, concern exists regarding how to accurately identify the product for labeling when it is brought into a health care facility.
If an institution decides to develop a policy regulating cannabis use within its walls, the policy should be thoroughly reviewed by a legal team familiar with federal, state, and case law.18 It is critical to develop a comprehensive policy that includes how every department may be impacted: primary care clinics, specialty clinics, the emergency department, intensive care unit, and the inpatient units.18 Examples of how some states have addressed these policy issues include:
As the medication experts, pharmacists are uniquely suited to discuss marijuana use with patients and help them navigate the complex landscape of its use. Unfortunately, most pharmacy schools do not provide formal education on this topic. Pharmacists must keep abreast of the varying state laws, as each state can dictate who is eligible to receive medical marijuana, who can recommend or dispense cannabis, and in what dosage form and quantity.
Patients should receive education on various dosage forms, anticipated side effects, possible drug interactions, safe use, and safe storage and handling. As more patients use cannabis, it is important for pharmacists to be on the forefront of patient education to ensure safe and appropriate use. Thomas Jefferson University (https://cme.jefferson.edu/lambert) and the University of Vermont (https://learn.uvm.edu/program/cannabis-science-and-medicine) offer lecture series on cannabis that can serve as a foundation to increase pharmacists’ knowledge base. TABLE 2 lists several helpful resources for health care providers.
More than half of US states have laws in place regarding medical marijuana use, and marijuana use for medical indications is increasing. Thus, it is critical that health care providers understand federal law and its implications, as well as state laws where they practice. Pharmacists are in a prime position to assume a leadership position in educating patients and other health care providers on safe, appropriate use.
Ashley E. Glode, PharmD, BCOP, graduated from Duquesne University School of Pharmacy in 2007 and is an assistant professor at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. She works in the outpatient phase of the I/GI/sarcoma/head and neck clinic, providing patient education and clinical consults for cancer patients receiving standard of care or study treatment. Ashley teaches at the School of Pharmacy, and her professional interests include the use of complementary and alternative medicine, the pharmacist’s role in optimizing supportive care, and patient education.
The Colorado Experience
In Colorado, the state constitution was amended in 2000 to allow patients with chronic, debilitating medical conditions the use of medical marijuana.1 However, medical marijuana use did not increase significantly until 2009, when the US Attorney General provided guidelines for federal prosecution of the possession and use of marijuana, relinquishing jurisdiction of marijuana law enforcement to state governments.2 In 2012, the state of Colorado legalized the retail sale, purchase, and possession of marijuana for state residents and visitors 21 and older.3 Dispensaries began selling to consumers on January 1, 2014.
Products sold in Colorado for medical and recreational use are identical, but regulations differ. For medical use, there is no minimum age, and only state residents can legally purchase medical marijuana.4 As of June 2018, 86,755 patients have an active medical marijuana registration with the state and 2221 caregivers have an active caregiver registration.5 Those who cultivate or grow marijuana, or transport it for homebound patients, are required to register as a caregiver.6 Over 450 physicians have recommended medical marijuana for one or more patients included in the registry. The most frequently reported conditions for medical marijuana use are severe pain, muscle spasm, and severe nausea.5
With the increase in marijuana use, Colorado has seen a corresponding increase in unexpected health effects, including an increase in burns, cyclic vomiting syndrome, and provider visits due to the ingestion of edible products. The majority of marijuana-related health care visits are due to intoxication from edible products. With edible products, there is a delayed onset of effect compared to inhalation. Also, there may be dose variability among products due to variations in manufacturing practices. A report in the Denver Post cited products that claimed to contain 100 mg of THC, but actually contained between 0 and 146 mg of THC. Edible products are often packaged to look like candy, and there has been an increase in unintentional ingestion by children. In response, a childproof packaging requirement was implemented for recreational and medical products. However, once a product is opened, it may be readily accessible to children.4,7