Medical marijuana
This topic, sort of like euthanasia, has developed and been produced by popular or judicial fiat, rather than technical/scientific consensus. The 2011 legislative session has taken it upon themselves to essentially repeal the law-by-referendum rather than take a middle ground.
The problem is MT is that >30,000 persons have obtained registration for "medical marijuana". My reasonable estimates, which may be low, would place the legitimate figure at around 3,000. If cannabis was to be used like a medication, it would require the usual followup and monitoring, which mostly was never done. Therefore, there does need to be a rethink on this. That said, if compared to the real dangerous drugs, prescription narcotics, there has been no move at all to stem the tide of diversion, overprescription and abuse. That is the what the website was made to do, in some respects.
The only significant medical analysis that I know about was done by a neurologist that was working in Missoula, Ethan Russo MD. His article is actually a fascinating, anecdotal look at the issues which I recommend that you review if interested. That said, with less than 10 subjects, more people, more biopsychosocial data and more time is needed to obtain an accurate read on this.
There are reasons to believe that the drug culture seen in illicit drug trafficking has established a significant presence in the medical marijuana "culture", leading to a continuing danger to our patients. While marijuana doesn't usually cause dangerous interactions, this environment may lead to inappropriate (and fatal) drug use. A link for an excerpt follows:
http://www.cannabismd.org/reports/russo2.php
1. Prescribing opioids with marijuana. Our clinic actually believes what the medical marijuana providers tell us, that being that MM is about as good as opioids. Therefore, although we don't give our patients the documentation for the MT medical marijuana registration, we do tell them it is a "this or that" arrangement, possibly with the exception of multiple sclerosis or end-of-life pain (cancer/ HIV polyneuropathy).
2. Concurrent psych illness with pain. We feel that individuals between the ages of 19 and 65 that are "disabled" from non-traumatic or psychiatric causes should not be given controlled substances with medical marijuana. Expert opinion includes pain workers, law enforcement observation and psychatrists/ chemical dependency workers. We don't have enough experience at this point, but would greatly discourage marijuana use in folks who have either bipolar or thought disorders.
3. Arguments about freedom to use medical marijuana do not displace your medical opinion about polypharmacy. Make no mistake, marijuana contains not one but many psychotropic substances, and should as such be considered as a substance with estimable effects in the context of overall patient treatment. While most medication interactions may be mild, this is not a totally benign substance.
4. PAIN CONTRACTS We are recommending that the pain contract be re-written to reflect the medical marijuana, with the explicit concept that in the case of chronic pain that the issues are as yet unresolved. I don't question that marijuana is effective for some types of pain. I do question about the safety issues. Until these issues are resolved in a scientific sense, safety probably needs to be the prevailing theme.
5. Alternatives Although off-label for this purpose, dronabinol (Marinol) is actually activated THC. If your patient has cachexia, adult failure to thrive or chemo-related nausea, this C-III med works well. I would advise staring low (2.5 mg daily) and working up. Another alternative, according to some European physicians, is the endogenous endocannabinoid palmitoyl ethanolamide (PEA). This is a non-psychoactive supplement sold in some EU countries, notably Netherlands, and used for all manner of neuropathic pain. It is supposedly packaged for the USA as a supplement, and made available at:
ergomax.nl
The website has a translator if you right-click the mouse.
The bottom line at this point is that we really don't have compelling evidence to support the amount of marijuana being used for the diagnoses (which can include almost anything). Also, there is no molecular explanation for the different strains having more effects for spasticity, seizures or pain. There are more than 8000 registrants (as of Feb 2010) in MT at last count. MOST OF THESE CARDS WERE ISSUED IN 2009, AND AT THE RATE IT IS GOING THIS YEAR, MORE WILL BE ISSUED IN 2010 THAN 2009:
http://www.dphhs.mt.gov/medicalmarijuana/mmpregistryinformation.pdf
As of May 2011, the issues of cannabis in MT are up in the air. I attended the legislative session, and was extended the chance to see and hear an amazing blizzard of misinformation. It would appear that legitimate cannabis use will for the present, be suspended in Montana. I am sorry for this in the case of my elderly and suffering patients. I can see the reasons, though.
The problem is MT is that >30,000 persons have obtained registration for "medical marijuana". My reasonable estimates, which may be low, would place the legitimate figure at around 3,000. If cannabis was to be used like a medication, it would require the usual followup and monitoring, which mostly was never done. Therefore, there does need to be a rethink on this. That said, if compared to the real dangerous drugs, prescription narcotics, there has been no move at all to stem the tide of diversion, overprescription and abuse. That is the what the website was made to do, in some respects.
The only significant medical analysis that I know about was done by a neurologist that was working in Missoula, Ethan Russo MD. His article is actually a fascinating, anecdotal look at the issues which I recommend that you review if interested. That said, with less than 10 subjects, more people, more biopsychosocial data and more time is needed to obtain an accurate read on this.
There are reasons to believe that the drug culture seen in illicit drug trafficking has established a significant presence in the medical marijuana "culture", leading to a continuing danger to our patients. While marijuana doesn't usually cause dangerous interactions, this environment may lead to inappropriate (and fatal) drug use. A link for an excerpt follows:
http://www.cannabismd.org/reports/russo2.php
1. Prescribing opioids with marijuana. Our clinic actually believes what the medical marijuana providers tell us, that being that MM is about as good as opioids. Therefore, although we don't give our patients the documentation for the MT medical marijuana registration, we do tell them it is a "this or that" arrangement, possibly with the exception of multiple sclerosis or end-of-life pain (cancer/ HIV polyneuropathy).
2. Concurrent psych illness with pain. We feel that individuals between the ages of 19 and 65 that are "disabled" from non-traumatic or psychiatric causes should not be given controlled substances with medical marijuana. Expert opinion includes pain workers, law enforcement observation and psychatrists/ chemical dependency workers. We don't have enough experience at this point, but would greatly discourage marijuana use in folks who have either bipolar or thought disorders.
3. Arguments about freedom to use medical marijuana do not displace your medical opinion about polypharmacy. Make no mistake, marijuana contains not one but many psychotropic substances, and should as such be considered as a substance with estimable effects in the context of overall patient treatment. While most medication interactions may be mild, this is not a totally benign substance.
4. PAIN CONTRACTS We are recommending that the pain contract be re-written to reflect the medical marijuana, with the explicit concept that in the case of chronic pain that the issues are as yet unresolved. I don't question that marijuana is effective for some types of pain. I do question about the safety issues. Until these issues are resolved in a scientific sense, safety probably needs to be the prevailing theme.
5. Alternatives Although off-label for this purpose, dronabinol (Marinol) is actually activated THC. If your patient has cachexia, adult failure to thrive or chemo-related nausea, this C-III med works well. I would advise staring low (2.5 mg daily) and working up. Another alternative, according to some European physicians, is the endogenous endocannabinoid palmitoyl ethanolamide (PEA). This is a non-psychoactive supplement sold in some EU countries, notably Netherlands, and used for all manner of neuropathic pain. It is supposedly packaged for the USA as a supplement, and made available at:
ergomax.nl
The website has a translator if you right-click the mouse.
The bottom line at this point is that we really don't have compelling evidence to support the amount of marijuana being used for the diagnoses (which can include almost anything). Also, there is no molecular explanation for the different strains having more effects for spasticity, seizures or pain. There are more than 8000 registrants (as of Feb 2010) in MT at last count. MOST OF THESE CARDS WERE ISSUED IN 2009, AND AT THE RATE IT IS GOING THIS YEAR, MORE WILL BE ISSUED IN 2010 THAN 2009:
http://www.dphhs.mt.gov/medicalmarijuana/mmpregistryinformation.pdf
As of May 2011, the issues of cannabis in MT are up in the air. I attended the legislative session, and was extended the chance to see and hear an amazing blizzard of misinformation. It would appear that legitimate cannabis use will for the present, be suspended in Montana. I am sorry for this in the case of my elderly and suffering patients. I can see the reasons, though.
