New & Improved!

Approaches to Managing Medical Marijuana
November 2018 - Vol. 15 No. 11 - Page #16

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

Click here to view a larger version of this Table

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.

Insufficient Research

Several barriers exist in conducting medical marijuana use research.

  • Regulatory Challenges. As a Schedule I substance, regulatory hurdles make it difficult to study marijuana. The University of Mississippi is federally allowed to cultivate cannabis, and this is the only source of product the federal government will approve for research purposes.3,9,10
  • Product Standardization. The marijuana strains and types of products that patients receive from dispensaries are not the same as the federally approved product, making research using the University of Mississippi product potentially inapplicable. To truly understand the short- and long-term effects of cannabis, large controlled trials and observational studies are needed on the products that patients are actually using.3
  • Variation in Administration. A variety of options for cannabis administration are available, which makes research difficult. Patients often smoke marijuana or use a vaporizer as their preferred administration method. However, significant interindividual variations in inhalation technique complicate the study of this delivery method. Alternate dosage forms, including extracts, tinctures, candies, and lotions, add further complexity to this issue.3
  • Limited Funding. Adequate funding is not available for marijuana research. Without sufficient financial support, research will not be able to inform health care, public health practice, or keep pace with changes in cannabis policy and patterns of use.3

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:

  • Cognitive impairment and altered brain development are more common with long-term or heavy use early in adolescence.12
  • Because marijuana use raises the heart rate, it may be more problematic in older adults with cardiovascular disease.13
  • Cannabis hyperemesis syndrome—characterized by chronic cannabis use, cyclic episodes of nausea and vomiting, and the learned behavior of hot bathing14—is more common in young adults with a long history of marijuana use.15

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.

Institutional Policies

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:

  • The Minnesota Hospital Association developed sample policies for three different approaches hospitals may choose (ie, medical cannabis not allowed in the hospital, medical cannabis allowed and administered by patients, medical cannabis allowed and administered by nurses). Sample templates for each of these three approaches are available at: http://www.mnhospitals.org/Portals/0/Documents/patientsafety/
    Medical_Cannabis_Template_Policy.doc
    .
    The association involved physicians, nurses, pharmacists, representatives from external agencies, and legal counsel to create the policy templates. In addition, they involved individuals from the state’s medical cannabis manufacturers.16
  • The Washington Health Care Association released a hospital policy template that supports its state laws regarding cannabis use.18
  • Rochester, Minnesota’s Mayo Clinic hospitals have a policy in place allowing continued use of medical cannabis (capsules and oral liquid only), pursuant to a doctor’s order, for patients registered with the state’s program. Users must keep the product in its original container as obtained from the state’s approved dispensing centers.16
  • In Maine, many hospitals do not allow the use of cannabis in their facilities. Commonly cited concerns include fear of violating federal laws and patient safety, as it is not an FDA-regulated medication.16
  • In order to provide clinicians with state-level legal protection, some states have passed laws to permit the use of marijuana by hospitalized patients.16

Patient Education

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.

Conclusion

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.


References

  1. Krenzelok EP. Marijuana legalization: a continuing conundrum. Am J Health-Syst Pharm. 2017;74(22):1843-1844.
  2. Struyk R. Marijuana legalization by the numbers. CNN Politics (March 30, 2018). www.cnn.com/2018/01/04/politics/marijuana-legalization-by-the-numbers/index.html. Accessed September 10, 2018.
  3. National Academies of Sciences, Engineering and Medicine. The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. Washington, DC: The National Academies Press; 2017.
  4. Schauer GL, King BA, Bunnell RE, et al. Toking, vaping, and eating for health and fun: Marijuana Use Patterns in Adults, U.S. 2014. Am J Prevent Med. 2016;50(1):1-8.
  5. Bradford AC, Bradford WD, Abraham A, et al. Association between US state medical cannabis laws and opioid prescribing in the Medicare Part D population. J Am Med Assoc Intern Med. 2018;178(5):667-672.
  6. Boehnke KF, Litinas E, Clauw DJ. Medical cannabis use is associated with decreased opiate medication use in a retrospective cross-sectional survey of patients with chronic pain. J Pain. 2016;17(6):739-744.
  7. Lucas P. Rationale for cannabis-based interventions in the opioid overdose crisis. Harm Reduct J. 2017;14(1):58. doi: 10.1186/s12954-017-0183-9.
  8. Vyas MB, LeBaron VT, Gilson AM. The use of cannabis in response to the opioid crisis: A review of the literature. Nurs Outlook. 2018;66(1):56-65.
  9. The University of Mississippi. Marijuana Research. National Institute of Drug Abuse (NIDA) Contract. https://pharmacy.olemiss.edu/marijuana/nida-contract/ Accessed September 11, 2018.
  10. Winningham J, Testaberg A, Long J. The pharmacist’s role in emerging medical cannabis science: integrating medical cannabis into standard counseling protocol. America’s Pharmacist (November 1, 2017). NCPA Learning Center.
  11. Balick R. Pharmacists tread carefully into the world of medical cannabis. Pharmacy Today. January 2018;28-31.
  12. Volkow ND, Baler RD, Compton WM, et al. Adverse health effects of marijuana use. N Engl J Med. 2014;370(23):2219-2227.
  13. National Institute on Drug Abuse. Marijuana. https://www.drugabuse.gov/publications/drugfacts/marijuana. Accessed October 12, 2018.
  14. Allen JH, de Moore GM, Heddle R, et al. Cannabinoid hyperemesis: clinical hyperemesis in association with chronic cannabis use. Gut. 2004;53:1566-1570.
  15. Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid hyperemesis syndrome. Curr Drug Abuse Rev. 2011;4(4):241-249.
  16. Durkin M. Medical marijuana . . . in the hospital? As states legalize marijuana, hospitals develop policies on inpatient use. ACP Hospitalist. January 2017. https://acphospitalist.org/archives/2017/01/marijuana-policies-hospital.htm. Accessed September 10, 2018.
  17. The Joint Commission. Medication Management presentation by Valerie Henriques, MA, Med, RN, Joint Commission Clinical Surveyor (April 5, 2018). https://www.jointcommission.org/assets/1/6/Medication_Management_Presentation.pdf. Accessed October 12, 2018.
  18. Borgelt LM, Franson KL. Considerations for hospital policies regarding medical cannabis use. Hosp Pharm. 2017;52(2):89-90.

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.


Sidebar

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

Sidebar References

  1. Colorado Ballot History, Ballot Number 20: Medical Use of Marijuana (2000). http://www.leg.state.co.us/lcs/ballothistory.nsf/835d2ada8de735e787256ffe007
    4333d/64ac641c3db0a94f87256ffd006a49b5?OpenDocument. Accessed September 11, 2018.
  2. US Department of Justice, Office of Public Affairs. Attorney General Announces Formal Medical Marijuana Guidelines (October 19, 2009). www.justice.gov/opa/pr/attorney-general-announces-formal-medical-marijuana-guidelines. Accessed September 11, 2018.
  3. Colorado Amendment 64: Use and Regulation of Marijuana.www.fcgov.com/mmj/pdf/amendment64.pdf. Accessed September 11, 2018.
  4. Monte AA, Zane RD, Heard KJ. The implications of marijuana legalization in Colorado. J Am Med Assoc. 2015;313(3):241-242.
  5. Colorado Department of Public Health and Environment (CDPHE). Medical Marijuana Registry Program Statistics (June 2018). https://www.colorado.gov/pacific/sites/default/files/CHED_MMR_Monthly_
    Report_June_2018.pdf. Accessed September 10, 2018.
  6. Colorado Department of Public Health and Environment (CDPHE). Medical Marijuana Registry Caregivers. https://www.colorado.gov/pacific/cdphe/medical-marijuana-registry-caregivers. Accessed September 10, 2018.
  7. Monte; Baca R. Tests show THC content in marijuana edibles is inconsistent. Denver Post. March 8, 2014. www.denverpost.com/2014/03/08/tests-show-thc-content-in-marijuana-edibles-is-inconsistent/. Accessed September 11, 2018.

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