Medical Marijuana

In this post I will be discussing another therapy used for chronic pain: medical marijuana. Since I practice in NY, and the state laws vary so much, I will only be discussing the program in NY. I’ll give a brief overview of how the program is set up here and the different types of medical marijuana products used. Then, I’ll talk about the evidence to support the use of medical marijuana for pain.

New York State currently has what is called a certificate program, meaning that physicians who undergo additional training in medical marijuana use are able to certify that patients under their care have qualifying conditions which allow them to enroll in the program. There is no prescription issued per se, which is important, because federally, marijuana is still considered illegal. The qualifying conditions in NY are similar to many other state programs, and importantly for my practice, include chronic pain and cancer. This past year, New York also added opioid replacement therapy as a qualifying condition, which is relevant to my practice as well.

Once a patient is enrolled in the program, they have access to specialized pharmacies called dispensaries, which sell medical grade marijuana products. Although there are many ways to utilize medical marijuana, in New York, all that is available currently are oils that are vaporized, liquid that goes under the tongue called a tincture, and capsules. Smoking and edibles are not approved in NY at this time. There is no insurance coverage for medical marijuana products.

There are two major chemicals in marijuana that are used for medical purposes: THC and CBD. They each have their own effect profile that makes them suitable for certain treatment goals. THC is a chemical that in high doses can have psychoactive effects (making people feel “high” or altered), but in low doses is a very powerful pain reliever, especially for nerve type pain. CBD is a different chemical with limited psychoactive effects, but appears to be a weaker pain medication and may have some benefits for anxiety.

Companies that prepare medical grade marijuana products are able to provide different blends or ratios of the two chemicals leading to different side effect profiles.  Many of my patients wind up using two different types of products: a high CBD or pure CBD product during the daytime, and a higher THC or 50/50 ratio product at night.

I most often recommend to patients that they use vaporized products, as the onset of action is the most fast and reliable. Tinctures take slightly longer to kick in, but are also a good option. I rarely recommend capsules with any THC in them because the oral absorption is pretty unpredictable, meaning that patients cannot depend on reliable effects in a certain time frame.

There are multiple studies looking at and demonstrating the efficacy of medical marijuana. Associated pain conditions that can be treated by medical marijuana include neuropathic (nerve pain), cancer related pain and fibromyalgia. It can be tricky to study medical marijuana for many reasons. First, the illegal federal status can make it difficult to obtain for studies and also makes many researchers wary of conducting trials. Additionally, there is significant variation in CBD and THC levels depending on which strain of marijuana is used. More high quality research would greatly benefit the field.

I talk to my patients about the risks of medical marijuana, including small chance of addiction, potential to worsen mood issues, and the fact that we are not sure of the long term health issues relating to chronic vaporizing/use, although we believe it is safer than smoking the plant. The decision to certify someone is made after a thorough review of their medical history, physical examination and discussion of all of these factors. I also have my patients sign a controlled substance agreement, similar to my practice for opioids, and complete a urine drug screen. Patients remain actively under my medical care, and may be receiving other complementary pain therapies as well from me.

Medical marijuana can be a politically and socially fraught therapy, but as someone practicing on the frontlines of the opioid epidemic, I am grateful to have another tool in my toolbox to help patients with chronic pain.