I have received many unusual requests from patients over the years. One guy comes to the ER every couple of weeks to ask me to call his mother for him, the idea being that I could vouch that he was in the ER and not out engaged in mischief. It is the only way she will take him back into her home after his days-long wanderings. I have never actually called his mother but I am pretty sure our social worker does, because he eventually slips out of the ER, presumably bound for home.
So I shouldn’t have been surprised when an elderly patient of mine asked me to prescribe her medical marijuana for her many ailments. She had seen a headline that proclaimed that Virginia had legalized medical marijuana in April 2018 and she wanted to revisit her youth as lived out in the 1960s. As a child of the ’70s myself I actually gave this some consideration. I wasn’t too sure of the dosing anymore nor was I familiar with the many new delivery options beyond simply smoking it, so I looked into it.
Turns out prescribing medical marijuana has been legal in Virginia since 1979. Who knew? Virginia was the second state, after New Mexico to legalize medical marijuana. But there are two major problems with this law.
First, no U.S. physician can prescribe marijuana. The Federal Drug Enforcement Agency (DEA) considers marijuana a Schedule 1 drug, meaning it has no currently accepted medical use and a high potential for abuse. Other Schedule 1 drugs include heroin and LSD. Schedule 1 drugs cannot be prescribed legally.
In contrast, Schedule 2 drugs can be prescribed legally, although they have a high potential for abuse. These include cocaine, methamphetamine, methadone, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (Oxy-Contin), fentanyl, Dexedrine, Adderall, and Ritalin.
Yes, I can prescribe cocaine but not marijuana. Hmmm. That probably needs to change. I used to prescribe cocaine somewhat frequently early in my career. It is very effective at staunching vigorous and occasionally life-threatening nosebleeds (yes, you can die from a nosebleed) as it quickly constricts the nasal arteries. We did have trouble keeping it in stock, though; it always seemed to disappear from the medication drawer in the ER. We eventually stopped stocking it, and it is not in much use these days. Meanwhile our patient satisfaction scores have dropped considerably from those days.
The second problem with Virginia’s 1979 law is that physicians are licensed to prescribe only FDA approved medications. Marijuana is not FDA approved.
Surprisingly, the Virginia law is still on the books, but it has no practical application. Someone should have done his or her homework.
So, what is behind the headlines that my patient was so excited about?
In April 2018 the Virginia Senate and House unanimously passed bills allowing physicians to approve patients for medical use of two types of oils derived from cannabis (marijuana and hemp) plants for any medical condition. The oils are called CBD (cannabidiol) oil and THC-A (tetrahydrocannabinolic acid) oil. They are psychoactive meaning they have effects in the brain, but they are non-intoxicating, unlike marijuana.
I would have to take a course, pay a fee (there is always a fee) and register with the Board of Pharmacy if I wanted to provide patients with certifications for use of CBD or THC-A oils. The patient would also have to register with the Board of Pharmacy, who could issue a certification card for cannabis oils. The oils will be produced in five dispensaries located throughout the state. I still would not be prescribing them, the patients would buy them on their own initiative.
As usual, though, the devil is in the details. The DEA considers CBD and THC-A to be Schedule 1 drugs, so despite your certification card, it is illegal to possess them. The card does not change this, though it may offer some legal cover for judges to exercise some leeway.
The DEA is wrong about marijuana and is way behind the science and the other branches of the Federal government.
For example, in June of 2018 the FDA approved a prescription formulation of CBD called Epidiolex to treat two devastating forms of childhood epilepsy; Lennox Gastaut syndrome and Gravet syndrome. Well-controlled clinical trials have demonstrated CBD’s efficacy, and it is considered a lifesaving medication for these patients.
Epidiolex, which is chemically identical to CBD (Schedule 1), is classified by the DEA as a Schedule 5 controlled substance, meaning it has very low abuse potential and accepted medical use.
Another drug, Marinol, which has been FDA approved for over 30 years for the treatment of nausea related to chemotherapy, is chemically identical to THC (Schedule 1) but is a Schedule 3 (low potential for abuse and accepted medical use) drug.
It appears that if big Pharma makes a drug, it is okay with the DEA, but if you grow it in your backyard, you are a felon. Don’t grow it in your backyard.
The ancient Greeks grew cannabis in their back yards and recommended it for the spasticity associated with what was likely multiple sclerosis. Three thousand years ago the Egyptians recommended cannabis for hemorrhoidal pain.
Despite its long usage, our understanding of medical cannabis is in its infancy. It was only in 1988 that scientists identified the first cannabis receptor in humans and in 1993 a second receptor was discovered. Now an entire Endocannabinoid System (ECS) has been described in humans, a network of receptors that interact with internally produced cannabinoids to regulate multiple neurologic and immune functions. Endocannabinoids are continuously produced by our central nervous system and serve as neurotransmitters in the brain and peripheral organs.
The National Academies of Sciences, Engineering and Medicine released a 500-page report last year on the medical effects of marijuana, reviewing all known studies since 1948. The report concluded that use of marijuana for chronic pain, neuropathic pain, and spasticity due to multiple sclerosis is supported by high-quality evidence. A separate review in The Journal of the AMA in 2015 reached the same conclusions. Importantly, both studies found there is substantial evidence of a statistical association between cannabis use and the development of schizophrenia or other psychoses, with the highest risk among the most frequent users. So marijuana is not a completely benign super medicine.
Fortunately there is another safer way to get high and relieve your many afflictions. One of the body’s naturally occurring endocannabinoids, anandamide, which is structurally similar to THC, has been shown to rise in response to moderate to high aerobic activity and to cross into the brain to cause euphoria. Elite athletes refer to this as the “runner’s high.”
There was no way my patient was going to take up running at her age, but I did recommend simply getting up and moving as a way to stimulate her ECS and help her feel better. Heck, I felt better just by dispensing this sage holistic advice. She did not feel better and still wants her weed. She will have to wait until recreational marijuana becomes legal in the Old Dominion, which is inevitable, but likely still far off.
Happy New Year!