Last week, I received a call from a patient I had seen for a medical cannabis consultation to use it in the treatment of his chronic pain issues. He did meet qualifying conditions in Arkansas and I provided his certification and advice on beginning medical cannabis, strain selection, routes of administration, etc. I returned his call with the hopes he had found my advice helpful and was on his way to improving his quality of life. Instead, it was yet another story of the stigma of medical cannabis affecting yet another pain patient.
This patient had been prescribed narcotics (opioids) from his pain doctor for his condition for some time. This was entirely appropriate for his diagnoses and with the other medications he was prescribed, a fairly standard treatment. After years of treatment and little new progress, the patient was wanting an alternative to narcotics that may be safer and possibly more effective. The new to Arkansas medication of cannabis seemed his best option. I advised him to continue his current medications and as he found the most effective strains and routes of administration to begin weening himself off the opioids slowly. This would allow him good pain control and minimize symptoms of abstinence syndrome, which are the symptoms resulting from the abrupt discontinuation of chronically administered opioids. His transition to medical cannabis could be smooth and not disruptive to his life and activities.
His pain doctor saw things differently. He was told that he would no longer be attended to by his physician because he was using medical cannabis to treat his pain and would not be prescribed medications. There would be no slow ween off opioids for this gentleman. Instead they were discontinued immediately.
Now, many will say that this doctor was out of line, that he can’t just refuse to treat his patient, that this patient should sue him for abandonment... Well, not so fast. Doctors can refuse service to patients except in emergency situations. With the doctor prescribing care, it is his responsibility to chose the most appropriate care for the patients seeking his consul. If he feels medical cannabis is a poor choice for his patient then he is under no obligation to participate in the treatment of this "noncompliant" individual. Ethically, doctors should try to ensure continuity of care by referring the patient to another physician, offering other treatment options to the patient or otherwise attempt to accommodate a conflict between the doctor and patient. Perhaps this patient's physician did just that.
The negative stigmas associated with cannabis run wide and deep in law enforcement, government, employers, society at large (though less so over the last decade) and unfortunately the medical profession. At one time, we were taught that patients who test positive for THC in drug screens were probably selling prescribed narcotics to obtain "marihuana." Many of us have not progressed past the idea that cannabis is only a drug of abuse or bother to learn about how this complicated substance can be effectively used to help our patients, of the safety of cannabis compared to commonly prescribed medications or that even the CDC, in their terribly flawed and disruptive 2016 "CDC Guideline for Prescribing Opioids for Chronic Pain," recommended not testing patients for THC as its presence did not really affect patient management.It is my hope that through patient education the demand for advice in and accommodation for patients using medical cannabis will change the attitudes of physicians. Patients have the power. Such demands from patients can force their doctors to become educated themselves about the medical use of cannabis. It is an ancient plant with millennia of human experience that has been stigmatized politically and too long forgotten by Western medicine, much to the detriment of those to which we all once swore an oath to serve.
Cannabis as a medicine seems quite new. With a majority of states now allowing its use, patients, many of their doctors, society at large and certainly to law enforcement and government are searching for information. The information available online is vast and often confusing. Much of it is incomplete, far too detailed and technical for most people to sort through, clever marketing or just plain wrong.
Medical cannabis patients are certified by a physician as having a qualifying condition. The patient is issued a card and then, too often is left to decide for themselves as to the best treatment. Dispensary employees are usually the cornerstone of giving patients advice on strains and how to use cannabis. Sometimes they are very good at giving recommendations. Sometimes, not so much.
Modern medicine treats disease with the drugs that are effective for the majority of patients, forgetting that we are all very different individuals. What is a good choice for one patient may be ineffective or cause side effects in another. Although most patients see some improvement in using cannabis, getting the best result is a bit more complicated...
I have seen patients without much knowledge or direction experience lukewarm results of medical marijuana. I have also seen those so-so results turn into remarkable improvement under the knowledgeable direction of a doctor that treats the individual patient using the correct combination/forms/amount of cannabis.
It is my hope to sift through all the noise, marketing, agenda driven studies, politics and stigmas encountered when one tries to be an informed medical cannabis patient. I want you to get the best result from medical cannabis you can.
Brian Nichol MD