“Would you authorize its use for a 22-year-old patient with treatment-resistant epilepsy who is not a candidate for epilepsy surgery, is having two complex partial seizures a week and one tonic-clonic seizure per month, and is currently on three antiepileptic drugs [AEDs] at high doses,” asked Dr. Friedman. “How about for a 63-year-old woman with focal motor seizures following a meningioma resection who has not been able to tolerate adequate doses of four prior AEDs?”
The answer depends on myriad factors, not the least of which is the legal status of medical marijuana in the neurologist’s state. Although “23 states and the District of Columbia have approved medical marijuana for certain conditions, including epilepsy,” the US Drug Enforcement Administration still considers cannabis and its derivatives schedule I compounds, which means that they have “no accepted medical use in the US,” a high abuse potential, and cannot be prescribed—only “recommended”—by a physician, saidDr. Friedman.
Patients should be evaluated at a comprehensive epilepsy center to determine whether they have been unable to achieve control with conventional therapies due to lack of efficacy or side effects, and whether other proven effective therapies, such as vagus nerve stimulation, a ketogenic diet, or surgery, have been considered, he added.
For patients who do initiate treatment with medical marijuana, the risks and benefits should be carefully weighed, and a treatment plan that includes a timeline for discontinuation should be developed. Laboratory values and clinical status should be monitored regularly.
“Perhaps one day we’ll have [cannabis] in the pharmacy,” Dr. Freidman concluded. Until then, patients should be cautioned against buying cannabinoids on the Internet because, as one FDA study showed, products bought from such sources may have no detectable cannabinoid levels.
—Debra Hughes
