By August 2015, almost half of U.S. states (plus the District of Columbia and Guam) passed legislation that allows physicians to recommend cannabis—more commonly known as marijuana—as a medical treatment.1 Even if your state has not taken this step, you may already be fielding questions from patients about medical marijuana. The answers to those inquiries are complicated by a lack of research, the variety of patient options, and legal limitations.

First and foremost among the complicating factors is that cannabis has not received approval from the U.S. Food and Drug Administration (FDA). The U.S. Drug Enforcement Administration considers marijuana a Schedule I agent (a drug with potential for abuse and no known medical use), and federal law prohibits the possession of cannabis. This classification prevents physicians from prescribing cannabis due to limited scientific research into its effects and viability.2 However, despite the legal confusion, researchers and physicians are intrigued by the drug’s potential and are calling for further large, randomized clinical trials.3,4

“We’re at the very beginning level of knowledge on this,” says Leslie Mendoza Temple, MD, chair of the Medical Cannabis Advisory Board, Illinois Department of Public Health, and medical director of the integrative medicine program at NorthShore University HealthSystem in Glenview, Illinois.

Stems and seeds

The hemp plant, Cannabis sativa, has been credited for thousands of years with treating many ailments, but its primary use has been for pain alleviation.2 More recently, the term medical marijuana has been coined for the use of the unprocessed plant or its chemical extracts to treat a disease or symptom.5 Cannabinoids, chemical components of cannabis, activate specific receptors within the body and produce pharmacologic effects, particularly in the central nervous system and the immune system.2

Two cannabinoids found in cannabis have piqued interest in its possible medical use: delta-9-tetrahydrocannabinol (delta-9-THC or THC) and cannabidiol (CBD).2 While THC is a psychoactive ingredient and therefore affects the mind, CBD does not affect the mind or behavior.2

The FDA-approved THC-based medications are used to increase appetite and reduce nausea. In addition, THC may decrease pain, inflammation, and muscle control problems. Cannabidiol also may be useful in reducing pain and inflammation. Further, CBD may be helpful in controlling epileptic seizures, and possibly even treating mental illness and addictions.6

Scientists are conducting further studies into marijuana and its extracts to treat these and other diseases and conditions, including cancer and autoimmune diseases, such as HIV and AIDS, multiple sclerosis, and Alzheimer’s disease.6

Budding confusion

Currently, individual strains are not necessarily labeled with percentages of cannabinoids (THC, CBD, or others). “They don’t do a lot to guide physicians,” says Abraham Nussbaum, MD, MTS, assistant professor of psychiatry at the University of Colorado School of Medicine, Denver. “It’s very hard to recommend it with the certainty physicians would normally have with a medication.”

“The compounds vary, from stem to leaves,” says Dr. Nussbaum. “Like chili peppers, where some are spicy and some are mild, the doses, heterogeneity, and potency are unstandardized.”

Cannabinoids can be administered in various forms, including oral capsules, vapor, smoke, oromucosal spray, and intramuscular injection. They can also be mixed with food.3 The FDA has approved two medications containing synthetic THC: dronabinol (Marinol) and nabilone (Cesamet). These are generally prescribed to treat nausea and loss of appetite in cancer and AIDS patients.4

A study of label accuracy in edible medical cannabis products found that just 17 percent were accurately labeled for THC content. The products, legally purchased from dispensaries in California and Washington, “failed to meet basic label accuracy standards for pharmaceuticals.”4 Additionally, of all evaluated products, more than 50 percent contained significantly less cannabinoid content than the label stated. Some products even contained negligible amounts of THC, which may have negated any intended medical effects.5

Healers, not dealers

Instead of prescribing medical cannabis, physicians recommend its use to patients. The exact procedures and regulations, including possession limits, vary by state.1

Patients generally fill out paperwork during each office visit, and may need to obtain an identification card, depending on the state’s program. These requirements exist for good reason, says Dr. Mendoza Temple. “They don’t want to make a joke of the process by making it too easy to get a card.”

When considering recommending cannabis to a patient, a physician can organize criteria into a decision tree to allow a step-by-step examination of the patient’s situation4:

  • Does the patient experience persistent neuropathic pain?
  • Does the patient not respond favorably to, or have an intolerance for, standard treatments?
  • Will the patient consider medical
    cannabis?
  • What are the risks vs. benefits?
  • Will the physician monitor efficacy and side effects?

A screening questionnaire, such as the Screener and Opioid Assessment for Patients with Pain, can gauge the risk of possible drug abuse or addiction.4

When patients leave their physician’s office, they purchase medical cannabis at a dispensary, where most will receive recommendations for which strain to try, says Dr. Mendoza Temple.

Dr. Nussbaum warns of the ethical danger to the physician-patient relationship when physicians recommend a substance without knowing enough about the effectiveness and safety. He suggests physicians recommend marijuana only if they have a long-term relationship with the patient, have no financial incentives, and acknowledge the limited scientific knowledge of available cannabinoids. Also, physicians should recommend marijuana only if other, more rigorously studied treatments have not been effective.7

Physicians who do recommend cannabis have one common interest: compassion for patients who are in pain and out of options. In many cases, the range of possible effects—both negative and positive—is better with cannabis than with opioids, notes Dr. Mendoza Temple. In her integrative medicine practice, she sees many patients with the conditions approved to be treated with cannabis according to Illinois guidelines. She recommends cannabis to patients “after they’ve tried other medications or even other integrative therapies. To me, medical cannabis is just one other tool.”