State medical cannabis programs are slowly failing.  They are failing largely because they don’t support patient care, neither from the patients’ perspective nor from the practitioners’. 

Consequences

The consequences of this failure can be seen in two ways: the failure to provide care to the vast majority of patients for whom cannabis could be helpful but is not on their or their PCP’s radar; and the failure to provide adequate care to those who are using, or want to use, cannabis for health benefit.

Recently US News and World Report ran an article “Many Americans Are Using Marijuana to Manage Health Issues” in response to the publication of a scientific paper, “Cannabis Use Reported by Patients Receiving Primary Care in a Large Health System” by Gelberg et al at UCLA. The scientific report looked at how many people use cannabis and their reasons for use. 

They found that in California, arguably one of the most cannabis-friendly states, only 17% of respondents used cannabis.  However, of those 17%, a large majority (76%) said they used it to help manage health issues. At the same time, respondents rarely identified themselves as a “medical marijuana patient”.  Additionally, almost 35% of cannabis users met criteria for Cannabis Use Disorder.

What we must conclude is that:

• A very small percentage of the patients who would likely benefit from cannabinoid treatment are getting it. On the national level, there are ~180 million Americans over the age of 50, all of whom will develop one or more conditions that respond to cannabinoid treatment (anxiety, depression, pain, and insomnia, for examples). Clearly 17% found in this study does not represent the percentage who need this treatment.

• The vast majority of those who are using for health reasons are doing so without guidance from their physician.

• As a result, many are at risk from misuse and downstream consequences that could be avoided with proper guidance.

• Our overall approach to providing medical cannabis care to patients who need it is failing both from insufficient recommending of cannabis and insufficient guidance of those who are using it.

Why are we failing our patients so badly?

“Not asking patients about their cannabis use results in a missed opportunity for opening up doctor-patient communication regarding use of cannabis generally and for management of their symptoms," Gelberg added in a UCLA news release.

This is absolutely correct.  Primary care must engage in these discussions to identify both those who may be misusing and at risk, and also those for whom cannabis could be a viable treatment for their symptoms. 

However, it is unreasonable, given all that primary care is already tasked with, to expect them to have the time and knowledge to respond to the answers their patients provide.  It is this time and knowledge gap that led Association of Cannabinoid Specialists (ACS) to provide a specialist model for this type of care, as well as CME education for specialists and generalists alike.

Even more importantly, the current systems do not allow practitioners to effectively guide their patients.  The “recommendation” built into these systems does not specify the type, brand, dose, or manner of use of the medicine leaving patients to figure it out from other users or from the seller (with all their conflict of interest).  Even when the practitioner does give explicit instructions, these are often overlooked when faced with the sales tactics at the dispensary counter or are directly contradicted by the sales agent.

Doctors are naturally skeptical of a system this loose.  If you can’t give specific guidance and expect that it will be carried out, or at least honored at the point of sale, how can you care for and be responsible for your patient?  This leads to practitioners resisting providing this care for their patients.  Many providers are keenly aware of the lessons from the Opioid Crisis and are twice-shy of other potentially addictive substance, especially with this lack of control. 

Let’s Not Reinvent the Wheel

The solutions are remarkably easy to find (and perhaps not as simple to implement).  We need look no further than the pharmacy systems that have evolved to be quite effective over the past 100 years.  A prescription that is specific and immutable will solve problems with patients not getting the medication that they need.  It also safeguards against the conflict of interest at the point of sale. 

A feedback loop, like the already existing Prescription Drug Monitoring Program (PDMP), is also necessary.  Almost all states collect data on what patients are buying, but rather few states provide that feedback to practitioners.  These data are crucial to being sure that the patient is getting what they need, not getting things that would be harmful, and for engaging the patient in discussion about what they are actually taking. 

A prescription and feedback loop would go a long way to inspiring confidence among practitioners that their patients will get the care offered.  This will get more practitioners to engage with this medicine and, in turn, offer it to their patients who need it.  Further, it will facilitate communication between patient and clinician to help identify patients who need more guidance, either to avoid misuse or to respond to it. 

It is ACS’s position that this is the role for the Federal government in the medium-term future.  Harmonizing state medical programs to include a prescription and PDMP feedback link will facilitate patient care, public safety, and bring disparate state programs into a cohesive whole that provides proper medical care across the nation.

Watch the Casual Conversations episode on Prescriptions vs Recommendations here.