Applied Evidence

Medical Cannabis: A guide to the clinical and legal landscapes

J Fam Pract. 2019 September;68(7):390-394,396-399

References

1. College of Family Physicians of Canada. Authorizing Dried Cannabis for Chronic Pain or Anxiety: Preliminary Guidance from the College of Family Physicians of Canada. Mississauga, Ontario: College of Family Physicians of Canada; 2014. www.cfpc.ca/uploadedFiles/Resources/_PDFs/Authorizing%20Dried%20Cannabis%20for%20Chronic%20Pain%20or%20Anxiety.pdf. Accessed July 10, 2019.

2. Hartig H, Geiger AW. About six-in-ten Americans support marijuana legalization. Pew Research Center Web site. www.pewresearch.org/fact-tank/2018/10/08/americans-support-marijuana-legalization/. Published October 8, 2018. Accessed July 10, 2019.

3. Li H-L. An archaeological and historical account of cannabis in China. Econ Bot. 1974:28:437-448.

4. Zuardi AW. History of cannabis as a medicine: a review. Braz J Psychiatry. 2006;28:153-157.

5. Marijuana strains and infused products. Leafly Web site. www.leafly.com/start-exploring. Accessed July 10, 2019.

6. Fraguas-Sánchez AI, Torres-Suárez AI. Medical use of cannabinoids. Drugs. 2018;78:1665-1703.

7. Maurya N, Velmurugan BK. Therapeutic applications of cannabinoids. Chem Biol Interact. 2018;293:77-88.

8. Kelkar AH, Smith NA, Martial A, et al. An outbreak of synthetic cannabinoid-associated coagulopathy in Illinois. N Engl J Med. 2018;379:1216-1223.

9. Pertwee RG. The diverse CB1 and CB2 receptor pharmacology of three plant cannabinoids: Δ⁹-tetrahydrocannabinol, cannabidiol and Δ⁹-tetrahydrocannabivarin. Br J Pharmacol. 2008;153:199-215.

10. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015;313:2456-2473.

11. Ellis RJ, Toperoff W, Vaida F, et al. Smoked medicinal cannabis for neuropathic pain in HIV: a randomized, crossover clinical trial. Neuropsychopharmacology. 2008;34:672-680.

12. US Department of Justice, Drug Enforcement Administration, Diversion Control Division. Title 21 United States Code (USC) Controlled Substances Act. Subchapter I—Control and Enforcement. Part A—Introductory Provisions. §801. Congressional findings and declarations: controlled substances. www.deadiversion.usdoj.gov/21cfr/21usc/801.htm. Accessed July 10, 2019.

13. Yeh BT. The Controlled Substances Act: regulatory requirements. Congressional Research Service 7-5700. https://fas.org/sgp/crs/misc/RL34635.pdf. Published December 13, 2012. Accessed July 10, 2019.

14. US Department of Justice, Drug Enforcement Administration, Diversion Control Division. Title 21 United States Code (USC) Controlled Substances Act. Subchapter I—Control and Enforcement. Part B—Authority to Control; Standards and Schedules. §812. Schedules of controlled substances. www.deadiversion.usdoj.gov/21cfr/21usc/812.htm. Accessed July 10, 2019.

15. United States Senate. The STATES Act. Senator Elizabeth Warren and Senator Cory Gardner. 2018. www.warren.senate.gov/imo/media/doc/STATES%20Act%20One%20Pager.pdf. Accessed July 10, 2019.

16. Strengthening the Tenth Amendment Through Entrusting States (STATES) Act of 2019, HR 2093. 116th Cong, 1st Session (2019). www.congress.gov/bill/116th-congress/house-bill/2093/text. Accessed July 20, 2019.

17. Strengthening the Tenth Amendment Through Entrusting States (STATES) Act of 2019, S 1028. 116th Cong, 1st Session (2019). www.congress.gov/bill/116th-congress/senate-bill/1028/all-info?r=3&s=6. Accessed August 8, 2019.

18. State medical marijuana laws. National Conference of State Legislatures Web site. www.ncsl.org/research/health/state-medical-marijuana-laws.aspx#3. Published July 2, 2019. Accessed July 10, 2019.

19. Conant v Walters. 309 F.3d 629 (9th cir. 2002).

20. American Society of Addiction Medicine. The role of the physician in “medical” marijuana. www.asam.org/docs/publicy-policy-statements/1role_of_phys_in_med_mj_9-10.pdf?sfvrsn=0. Published September 2010. Accessed July 12, 2019.

21. What are marijuana’s effects on lung health? National Institute on Drug Abuse Web site. www.drugabuse.gov/publications/research-reports/marijuana/what-are-marijuanas-effects-lung-health. Updated July 2019. Accessed July 10, 2019.

22. Tashkin DP. Effects of marijuana smoking on the lung. Ann Am Thorac Soc. 2013;10:239-247.

23. Zhang LR, Morgenstern H, Greenland S, et al. Cannabis smoking and lung cancer risk: pooled analysis in the International Lung Cancer Consortium. Int J Cancer. 2015;136:894-903.

24. Getting medical marijuana. Commonwealth of Pennsylvania Web site. www.pa.gov/guides/pennsylvania-medical-marijuana-program/. Accessed July 20, 2019.

25. Kosiba JD, Maisto SA, Ditre JW. Patient-reported use of medical cannabis for pain, anxiety, and depression symptoms: systematic review and meta-analysis. Soc Sci Med. 2019;233:181-192.

26. Crippa JA, Zuardi AW, Martín-Santos R, et al. Cannabis and anxiety: a critical review of the evidence. Hum Psychopharmacol. 2009;24:515-523.

27. Moore TH, Zammit S, Lingford-Hughes A, et al. Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. Lancet. 2007;370:319-328.

28. Barrus DG, Capogrossi KL, Cates S, et al. Tasty THC: Promises and Challenges of Cannabis Edibles. Publication No. OP-0035-1611. Research Triangle Park, NC: RTI Press; 2016. www.rti.org/sites/default/files/resources/rti-publication-file-6ff047d7-3fa4-41ad-90ed-9fb11663bc89.pdf. Accessed July 10, 2019.

29. MacCallum CA, Russo EB. Practical considerations in medical cannabis administration and dosing. Eur J Intern Med. 2018;49:12-19.

30. MacCoun RJ, Mello MM. Half-baked—the retail promotion of marijuana edibles. N Engl J Med. 2015;372:989-991.

31. Cannabis use disorder [305.20, 304.30]. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association; 2013:509-516.

32. Williams AR, Santaella-Tenorio J, Mauro CM, et al. Loose regulation of medical marijuana programs associated with higher rates of adult marijuana use but not cannabis use disorder. Addiction. 2017;112:1985-1991.

33. American Academy of Pediatrics Committee on Substance Abuse, American Academy of Pediatrics Committee on Adolescents. The impact of marijuana policies on youth: clinical, research, and legal update. Pediatrics. 2015;135:584-587.

34. Wong SS, Wilens TE. Medical cannabinoids in children and adolescents: a systematic review. Pediatrics. 2017;140. pii: e20171818.

35. Drug Enforcement Administration. Drugs of abuse: a DEA resource guide. www.dea.gov/sites/default/files/drug_of_abuse.pdf. Published 2017. Accessed July 10, 2019.

36. National Academies of Science, 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. www.nap.edu/read/24625/chapter/12017:2017-2019. Published 2017. Accessed July 10, 2019.

37. Emerging trend and alerts. National Institute on Drug Abuse Web site. www.drugabuse.gov/drugs-abuse/emerging-trends-alerts. Accessed July 10, 2019.

38. Drug Policy Alliance. From prohibition to progress: a status report on marijuana legalization. www.drugpolicy.org/sites/default/files/dpa_marijuana_legalization_report_feb14_2018_0.pdf. Published January 2018. Accessed July 10, 2019.

A recent study considered nationwide cross-sectional survey data from the US National Survey of Drug Use and Health to examine the relationship between medical marijuana laws and CUD.³² Study findings did not show an increase in the prevalence of CUD or marijuana use among adults in states with a legalized medical marijuana program. Importantly, when researchers looked at marijuana use among adolescents and young adults, they found no increase in measured outcomes (eg, active [ie, past-month] marijuana use, heavy [> 300 d/yr] use, and a diagnosis of CUD) after medical marijuana laws were passed.³²

A paucity of pediatric data

Cannabis smoke carries many of the same carcinogens found in tobacco smoke.

The adolescent brain might be more vulnerable to the adverse long-term effects of Cannabis; there is potential significant harm associated with Cannabis in children and adolescence. However, accurate data concerning risk and benefit are limited.

The most recent policy statement of the American Academy of Pediatrics (AAP) reflects this paucity of data.³³ The AAP opposes the use of medical Cannabis outside regulation by the FDA, although the organization allows for consideration of compassionate use of medical Cannabis for children who have life-threatening or severely disabling conditions. The AAP does support (1) additional research into pharmaceutical cannabinoids and (2) changing Cannabis from Schedule I to Schedule II to facilitate this process. Since the publication of the policy statement, Pediatrics, the official journal of the AAP, has published a review of medical cannabinoids and found (1) strong evidence for benefit in chemotherapy-induced nausea and vomiting and (2) accumulating evidence of benefit in epilepsy.³⁴

Recognized risk: Not supporting medical Cannabis

At press time, the CDC issued a statement on respiratory illnesses reported after use of e-cigarette products. To learn more, go to www.cdc.gov/media/releases/2019/s0830-statement-e-cigarette.html.

As with all medical decisions, the risks and benefits of certifying patients for medical Cannabis must be balanced against the risks and benefits of not doing so. The risks that accompany failure to certify a patient for medical marijuana fall into 3 categories:

Blocking access to a substance that has potential therapeutic benefit. More data regarding the potential benefits and risks of medical Cannabis will, undoubtedly, dispel some of the uncertainty regarding the decision to certify a patient for medical Cannabis. When you recommend medical Cannabis and certify patients for its use, you do so with the certainty that the Cannabis safety index (ie, risk of overdose or serious adverse effects) is exceedingly low.³⁵

Continue to: Limiting patients to other medications