The Dilemmas Facing Medical Cannabis Prescribers

Medical cannabis has created a dilemma for medical providers who care for people who might benefit from its use. I’ve been thinking more about this lately because my home state of Ohio will have legal medical marijuana dispensaries starting on Sept. 8. The law passed in 2016, and it has taken almost two years for the rules of how cannabis will be supplied in Ohio to resolve.

In a recent column titled “Using Medical Marijuana for MS Symptoms Could Effect Employment,” I shared the pitfalls of employment and cannabis in the Ohio system.

My focus here is what doctors must consider when they are asked to provide a prescription for cannabis. At the 2018 Consortium of Multiple Sclerosis Centers Annual Meeting, I attended a lecture by Allen Bowling, MD, PhD, an expert in alternative and complementary medicines for MS. It was a standing-room-only crowd, which showed how many healthcare providers seek more information about cannabis and its use by patients.

A large part of Dr. Bowling’s talk was about the challenges prescribers face when asked to write a cannabis prescription while honoring the profession’s oath of “first, do no harm.” He raised concerns during the talk, including the following points:

• Cannabis is a plant crop, not a drug produced in a stable environment. Prescribers have no control over which cannabis products are bought.
• There are no quality control measures regarding strains of marijuana, growing conditions, or even which fertilizers and pesticides might be used for a mature crop.
• The people in dispensaries selling medical marijuana are not trained medical consultants.
• State laws that allow medical cannabis are not in line with U.S. law, which lists cannabis as a Schedule 1 drug. It is illegal at the federal level.
• Clinicians could face medical malpractice claims when cannabis use doesn’t work out well.
• Clinicians could lose their medical licenses for prescribing cannabis if a shift in current laws occurs or if they are found guilty of malpractice.

Dr, Bowling’s practice is in Colorado, a state that has legalized all marijuana use, so many of his concerns about prescribing cannabis are no longer an issue. But for doctors in states like Ohio that only permit medical marijuana, valid worries remain.

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Despite these questions, studies have proven that cannabis does help some people with MS pain and spasticity, but it also has been shown to increase cognitive decline. In the video “Cannabis & Multiple Sclerosis: 3 Things Science has Taught us,” my neurologist, Aaron Boster, MD, tackles this topic. I encourage you to take a few minutes to view the pros and cons of medical marijuana for MS.

I asked Dr. Boster to share his thoughts on what he will do come September when his patients ask for prescriptions for medical cannabis. In a very somber and reflective conversation, he said his practice is still wrestling with this question because there are so many variables to consider.

He said his practice estimates about 25 percent of patients seen use cannabis as part of their MS symptom management and “at first flush, it is very attractive to think I can just give my patient access to a medical marijuana card. But then when you consider all the details involved, the attractiveness fades,” Dr. Boster said. “We know cannabis works for some people for spasticity and pain reduction, but we also know it can impact cognition. Studies show that two weeks after using marijuana, we don’t think as clearly. There are lingering effects which we still don’t fully understand or appreciate.”

Dr. Boster continued by saying, “Cognition is an invisible symptom of MS and the leading cause of the loss of employment for people. If I prescribe cannabis and eventually the person can no longer work because of cognitive decline, I have to wonder what role I had in that. With all the employment and federal laws that say cannabis is not a recognized legal drug, even with a prescription, I could set patients up to lose their jobs or worse by giving them a cannabis prescription. The new medical cannabis laws put the provider in a precarious position and inadvertently could also put the patient in a precarious position.”

He also has concerns about the quality of cannabis his patients will get at state-licensed dispensaries. “If I prescribe a drug like Lyrica, I know its safety profile, and there are lots of reassurances as to how it works. If I prescribe medical cannabis for a patient, and they take their paycheck and buy assorted vapors and edibles, I have no control over what that might be. That is not how prescribing a medicine with specific medical goals and restraints works,” he said.

Dr. Boster left open the possibility of prescribing medical cannabis on an individual basis and doesn’t disagree with the benefits of cannabis for people with multiple sclerosis. He also makes it clear that providers are not comfortable with the position they are left in with the new laws. Clearly, it’s a dilemma he and other providers in Ohio will continue to wrestle with as they engage with their patients about prescribing medical cannabis.

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Note: Multiple Sclerosis News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. The opinions expressed in this column are not those of Multiple Sclerosis News Today or its parent company, Bionews Services, and are intended to spark discussion about issues pertaining to multiple sclerosis.