Where are we with medical marijuana?

medical-marijuanaLegalization of Medical Marijuana

Medical marijuana is legal in 20 states and the District of Columbia, with pending legislation to legalize the drug for medical purposes in 4 others.[1] Although still illegal in 30 states, millions of patients are undoubtably using marijuana for medicinal purposes in these jurisdictions.

Much has been written about politics trumping science with respect to rescheduling marijuana from a Schedule I drug,[2-5] as its medical benefits become progressively more accepted by the mainstream medical community as well as the general public.[6] The Veterans Administration, which is becoming a leader in pain care in the United States, has even approved of its physicians authorizing medical marijuana in states in which it is legal.

Earlier this year, Kondrad and Reid[8]published a large-scale survey-based study of family physicians’ attitudes toward medical marijuana in Colorado — a state in which medical marijuana has been legal since 2000. The results of their investigation were both startling and disturbing. They found that only 19% of respondents believed that physicians should recommend medical marijuana to their patients. However, they also found that 80% of respondents believed that education about medical marijuana should be incorporated into medical school curricula, 82% believed that such education should be included in family practice residency training, and 92% agreed that continuing medical education on medical marijuana should be made available to them. Opposition to recommending medical marijuana as a result of concerns about legal liability or licensure was reported by 23% of respondents, whereas only 13% cited a lack of medical evidence as their reason for opposition. These figures indicate that science is clearly not the primary issue of concern.

These intriguing data tell us that a lack of education is the primary cause of physicians’ discomfort in recommending medical marijuana. Schatman recently addressed the ethical imperative for physicians to consider medical marijuana as a part of their pain management armamentaria. This is particularly important, given the lack of an evidence base for chronic opioid therapy and physicians’ reluctance to prescribe opioids in this era of fear of legal and regulatory sanction.

Why So Reluctant?

In clinical practice, physicians have been found to refuse to authorize medical marijuana out of concern that doing so will place their controlled substances licenses in jeopardy. Although 20 states have “legalized” medical marijuana, it remains a violation of the federal Controlled Substances Act, and the reality of the license to prescribe controlled substances being issued by the US Department of Justice’s Drug Enforcement Administration (DEA) clearly has served, for many physicians, as a deterrent to the authorization of medical marijuana.[10] Physicians who treat patients with chronic pain rely on their abilities to prescribe controlled substances, and fear of losing the privilege to do so has resulted in an unfortunate reluctance to authorize what can be an extremely effective and relatively safe alternative to opioid analgesics.[9]

An unintended consequence of this fear has been naturopathic doctors (NDs) developing “doc-in-the-box” medical marijuana authorization practices in states in which NDs are permitted to authorize medical marijuana. These practices are often cash-only entities; this is particularly troubling in such states as Washington, in which health insurers are required to compensate NDs. Given the financial incentives, these naturopathic providers have loose and easy criteria for authorization of medical marijuana, because they have no controlled substance registrations to lose.[11]

The result is that many recreational users are obtaining legal access to high-tetrahydrocannabinol (THC) “medical marijuana” at a relatively low price from dispensaries. However, a small number of allopathic and osteopathic physicians have overcome their fears of legal and regulatory sanction and have brazenly developed specialized practices consisting primarily of medical marijuana authorization, without expertise in the treatment of the conditions for which they are authorizing its use.