Cannabis and Patient Care in A Rapidly Changing Environment
Patients increasingly ask doctors for guidance in using cannabis. This article, originally published in the American Journal of Endocannabinoid Medicine (AJEM) on July 12, 2023 and reprinted here by permission, discusses the current rules, regulations, and considerations for doctors when discussing or recommending cannabis to patients and removing the barriers for physicians to communicate openly with their patients about cannabis.1,2
As a cannabis lawyer, I am often asked, “When will cannabis finally be legalized?” My typical response is, “Cannabis is already legal.” Even from the standpoint of a lawyer advising cannabis companies daily, however, it can be tricky to keep up. The rules regarding cannabis vary considerably from state to state and from product to product.2,3 To complicate matters further, we have 2 parallel cannabis legal regimes in the forms of “marijuana” and “hemp,” each of which is governed by entirely different rules. Marijuana remains illegal at the federal level, whereas hemp is lawful.4
Despite the thicket of overlapping, confusing, and conflicting state and federal laws regarding cannabis, an adult consumer can easily and legally purchase a wide array of cannabis products—from cannabidiol (CBD) cosmetic creams to delta-9-tetrahydrocannabinol (THC) gummies to high-potency cannabis flower—online and in shops in almost every city in the country. The only difference is that cannabis consumers in North Carolina (where medical marijuana remains illegal) purchase “hemp” THC gummies, whereas consumers in California (where adult-use marijuana is lawful) purchase “marijuana” THC gummies.5 Although this provides legal fodder for lawyers, the reality is that these 2 products are similar, and usually identical, in their physical characteristics. The cannabis market is open for business throughout the United States.
The recent and widespread availability of a vast array of cannabis goods poses a unique challenge to physicians, whose patients are consuming these products at an accelerating rate. Patients often seek advice and recommendations from a trusted source intimately familiar with their medical history.1,6 In addition to keeping up with a rapidly evolving market and the numerous scientific studies regarding cannabis compounds that inform their health recommendations, physicians must also navigate both federal and state regulations and understand the legal distinction between “marijuana” and “hemp” to best advise their patients and stay within the bounds of the law. To add to their responsibility, medical providers must respond to patients’ requests for “quality” products. The task can be daunting in an atmosphere of rapid change, novel discoveries, and creative product development.6
Although the cannabis legal landscape is complex and evolving, there are some general principles physicians should consider when considering how to address patient questions about cannabis.
Increase Physician Patient Communication
First, removing the barriers for physicians to have an open line of communication with their patients about cannabis is essential. Physicians must create an atmosphere where patients can be open and honest about their cannabis use. Many patients already use cannabis products but may not disclose this information to their health care providers because they are concerned about their physicians’ reactions. By establishing an open line of communication, physicians can ensure their patients are using cannabis safely and effectively, and they can also identify potential adverse effects or drug interactions.1,6
Once the conversation is started, physicians need to be knowledgeable about the latest research on cannabis and its medical uses. Physicians should also be prepared to discuss the potential risks and benefits of cannabis use with their patients and make recommendations based on their patients’ medical histories and conditions.
Physicians May Not Prescribe Cannabis, But Can Recommend
Although 38 states have legalized marijuana for medical use, and 21 states and the District of Columbia have legalized marijuana for recreational use, it remains a Schedule 1 drug under federal law. For this reason, physicians are prohibited from prescribing marijuana.3,4 However, physicians may recommend marijuana to patients in states where it is legal for medical use. Specific guidelines must be followed. Typically, the recommending physician must have a bona fide doctor–patient relationship with the patient, which means that the physician has examined and is treating the patient for a medical condition. The physician’s recommendation must be in writing. The physician must specify the amount of marijuana that the patient may possess and any limitations on use related to the patient’s medical needs. Physicians must also keep thorough records of interactions with patients regarding cannabis.6
It is important to note that products containing hemp, which includes CBD, cannabinol (CBN), delta-8 THC, tetrahydrocannabinolic acid (THCA), and numerous other cannabinoids, are widely and legally available in most states. This is because hemp, which is legally defined as cannabis with no more than 0.3% delta-9 THC by dry weight, is lawful under federal and state law.4 Although patients do not need prescriptions, or even recommendations, to access hemp products, they often want advice from their physicians about them.
Physicians must also consider ethical considerations when discussing cannabis with their patients. They must ensure their recommendations are in the patient’s best interest based on their medical history and current condition. Physicians should also be aware of potential drug interactions and side effects of cannabis use.7
Although many studies have shown promising results for the use of cannabis in treating certain medical conditions, there is still much that is unknown about the effects of cannabis on the body, particularly when it comes to long-term use.8 This means physicians must exercise caution when recommending cannabis products to their patients and should be clear about the limitations of the current scientific research.
Despite these challenges, a growing number of resources are available to physicians interested in providing their patients with guidance on cannabis use.
- American Journal of Endocannabinoid Medicine (AJEM)
- American Medical Association
- Imperial College of London, Medical Cannabis Research Group
- Journal of Cannabis Research
- Mayo Clinic
- FDA
The widespread availability of cannabis products has created new challenges for already heavily taxed medical providers, who must navigate a complex legal and ethical landscape when discussing cannabis with their patients. However, by establishing an open line of communication and staying informed of current cannabis research and the available products in their state, physicians can ensure that their patients are using cannabis safely and effectively and can identify potential adverse effects or drug interactions. The key is to balance the potential benefits of cannabis use with the potential risks and make recommendations that are in the patient’s best interest. As the legal and scientific landscape regarding cannabis continues to evolve, physicians must stay informed and approach the topic of cannabis use with an open mind and a commitment to the well-being of their patients.
References:
- Sabatier J. New website aims to help doctors talk with patients about cannabis. Accessed June 7, 2023. https://www.opb.org/article/2022/01/18/new-website-aims-to-help-doctors-talk-with-patients-about-cannabis/
- Hasin D, Walsh C. Trends over time in adult cannabis use: a review of recent findings. Curr Opin Psychol. 2021;38:80-85. doi:10.1016/j.copsyc.2021.03.005
- National Conference of State Legislatures. State medical cannabis laws. Accessed June 7, 2023. https://www.ncsl.org/health/state-medical-cannabis-laws
- US Food and Drug Administration. FDA regulation of cannabis and cannabis-derived products, including cannabidiol (CBD). Accessed June 7, 2023. https://www.fda.gov/news-events/public-health-focus/fda-regulation-cannabis-and-cannabis-derived-products-including-cannabidiol-cbd#farmbill
- An act to conform the hemp laws with federal law by permanently excluding hemp from the state controlled substances act, senate bill 455, Session law 2022-32 ( 2022). Accessed June 7, 2023. https://www.ncleg.gov/Sessions/2021/Bills/Senate/PDF/S455v5.pdf
- Federation of State Medical Boards. Model guidelines for the recommendation of marijuana in patient care. Accessed June 7, 2023. https://www.fsmb.org/siteassets/advocacy/policies/model-guidelines-for-the-recommendation-of-marijuana-in-patient-care.pdf.
- Antoniou T, Bodkin J, Ho JMW. Drug interactions with cannabinoids. CMAJ. 2020;192(9):E206. doi:10.1503/cmaj.191097
- McDonagh MS, Morasco BJ, Wagner J, et al. Cannabis-based products for chronic pain: a systematic review. Ann Intern Med. 2022;175(8):1142-1153. doi:10.7326/M21-4520
August 8, 2023
Rod Kight is an international cannabis lawyer. He represents businesses throughout the cannabis industry. Additionally, Rod speaks at cannabis conferences, drafts and presents legislation to foreign governments, is regularly quoted on cannabis matters in the media, and is the editor of the Kight on Cannabis legal blog, which discusses legal issues affecting the cannabis industry. You can contact him by clicking here.
Great article, Rod! One comment I’d like to add is that many folks don’t discuss their cannabis use with their physician out of fear that their medical record will include information about their cannabis consumption. This “black mark” on their record (similar to tobacco usage) can affect their ability to secure health insurance, life insurance, airman medical certificate (for flying), and so on. Until the negative stigma surrounding cannabis use is removed, these concerns will remain, and patients may fear speaking about their cannabis use openly with their physicians. You can’t have an open dialog when the topic is taboo…
Good point, Christian. I think some people are definitely worried about getting a “black mark” on their medical record. Education and advocacy are key.
Rod