Help answering patient questions about marijuana

[deleted18755]

Hello friends,

I can't imagine that I am the only oncologist who regularly gets asked (by patients and family) about marijuana for pain control and to stimulate appetite. My opinion has always been to stay clear since it's illegal, so by definition unregulated and the patient has no way of knowing what they are actually getting and then ingesting. I obviously also don't want my patients roaming the streets looking for a drug dealer!

I had this conversation with a patient's son today but he said that he actually regularly works in a state where marijuana is totally legal for recreational use. Since that is the case, it is regulated and I assume that he therefore can know exactly what he is purchasing (purity, exact doses, and I assume he knows there are no harmful fillers or other drugs or whatever). He also doesn't have to worry about going someplace dangerous to get it and although it must be illegal to cross state lines he doesn't seem to care about that.

So my I have a few questions:
1. I'm curious how everybody else handles these situations and how one would handle this one in particular

2.For those of you in states where medical marijuana is legal, what is the additional training like? I assume it is a special license and not just any provider (but then again if any provider with a DEA can prescribe high doses of narcotics why not marijuana if it's legal?). Do you ever (or routinely?) refer patients and to whom (palliative care, pain clinic, random family medicine doctor who "specializes" in marijuana?).

3. For those of you in states where recreational marijuana is legal, when your patients ask you about it do you tell them to go ahead and see if it helps kind of like trial and error, or is there a particular "brand" and starting dose and frequency or even any kind of titration strategy?

If anybody has references to actual scientific studies/literature either in regards to the efficacy of marijuana or best practices on how to counsel patients I would appreciate if you could post a link. I feel like I should know more about this topic but I might be more clueless than the average college kid!

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[Gfunk6]

I personally feel that 99% of use will agree on the two facts below:

1. Marijuana clearly has a benefit for Oncology patients and can often do a better job than prescription narcotics and without the addictive potential.
2. Marijuana is a Schedule I drug according to the DEA and is therefore illegal at the federal level, regardless of what your state laws are.

Therefore, while I certainly do not object to my patients taking marijuana and may even suggest it in some cases, I will not prescribe it myself. Who can prescribe marijuana and how probably varies a bit by state. In California any MD/DO can prescribe marijuana; as far as I know there is no special training/licensing involved other than having an active CA medical license. These "marijuana mills" have an extremely low threshold for prescription - they just want the patients to tell them I have pain/cancer/low libido and they will prescribe without question. Given this low threshold, they certainly don't need a "prescription" or any documentation from me. Also, if the feds in their infinite wisdom decide to bust a marijuana mill, do you really want documentation with your name on it lying around?

 

[evilbooyaa]

Certainly OK to use it for cancer patients for appetite stimulation, and pain if necessary.

I don't prescribe it. Most patients seem to know ways of obtaining it already (or have already done so and are just asking me if it's OK). I do work in a recreationally legal state.

I tell them not to drive on it, ever. If they ask about how much to take, I tell them to start slow. At this point it's trial and error.

 

[Reaganite]

My state legalized it, but even prior to this there was never any formal "prescription" required. All we had to do was sign a somewhat formal-looking "recommendation" stating patient met criteria for medicinal use, and they would take that to the dispensary and get whatever product their heart desired. We gave no recommendations on starting dose, frequency, etc. Your recommendation doesn't even go on a standard prescription pad; ours was something I concocted in-house. For what it's worth, it would make no sense for me to give a starting dose anyway since most of my patients who request it have PHD's in cannabis use if you get my drift.

 

[scarbrtj]

I have been using Cesamet, a synthetic cannabinoid, in many patients for several years--it works well. I would have been using the non-synthetic real thing in patients if it were possible and available. I remember reading the warning label for Cesamet... "produces relaxation, drowsiness, and euphoria in the recommended dosage range"... and thinking that's gotta be the most seductive drug warning label of all time.

 

[medgator]

I have been using Cesamet, a synthetic cannabinoid, in many patients for several years--it works well. I would have been using the non-synthetic real thing in patients if it were possible and available. I remember reading the warning label for Cesamet... "produces relaxation, drowsiness, and euphoria in the recommended dosage range"... and thinking that's gotta be the most seductive drug warning label of all time.

It's specifically indicated for CINV per the label. Do you get it paid for outside of that indication?

 

[scarbrtj]

It's specifically indicated for CINV per the label. Do you get it paid for outside of that indication?

No I don't. But so many of the patients who need it (lung, head/neck) are getting concurrent chemoRT it's not an obstacle. What is an obstacle is the varying rates at which insurances pay (which is a total mystery to me). Some patients get it cheaply; others have to pay a lot and never get the RX filled.