"I’d like to start helping people get their mind wrapped around what are we talking about today with a case," Dr. Alan Ehrlich said, looking out over an auditorium packed with doctors, lobbyists and advocates for medical marijuana. They'd gathered for the Massachusetts Medical Society's first continuing education course on the use of marijuana to treat medical issues.
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What should a doctor consider when a patient asks for a medical marijuana certificate?
Dr. Alan Ehrlich, assistant professor of family medicine at UMass Medical School, offered these recommendations based on reviewing available scientific evidence.
- Marijuana is not first‐line treatment for any medical condition
- Best evidence for efficacy is for HIV, Crohns disease,MS, neuropathic pain and Hepatitis C
- May be helpful with some other painful conditions suchas fibromyalgia
- Little benefit for glaucoma, ALS, Parkinson's disease
- All else is anecdotal
"Marilyn is a 68-year-old woman with breast cancer," said Ehrlich, the senior deputy editor at DynaMed, a website that reviews medical research for doctors.
Marilyn's cancer had spread and she was undergoing chemotherapy. She did not have any energy, she’d lost her appetite and she was having a lot of back pain.
"So she comes in to a visit with you as a primary care physician," Ehrlich continued, and "wants to talk about the possibility of using marijuana to alleviate the symptoms of nausea, pain and fatigue. How many people think this is a good woman to certify for the use of marijuana?"
About three-quarters of the audience raised a hand. Well, Ehrlich said, let's look at the evidence.
For this course, Ehrlich gathered studies on the benefits and risks of marijuana for medical treatment. The U.S. government controls the use of medical marijuana for medical research. There are more studies on the risks than on the benefits.
For Marilyn, who wants to relieve nausea and vomiting, two effects of chemotherapy, there are "no randomized trials of smoked cannabis versus placebo," Ehrlich said. "So everything I’m going to present from now on, if you’re thinking about using smoked marijuana for this, you’re talking about extrapolations."
In other words, tests the FDA would require before approving a drug to treat Marilyn's nausea have not been done for marijuana. Doctors may hear stories from patients who find that marijuana helps, Ehrlich said, but there is almost no scientific proof.
Ehrlich described one 30-year-old study of 20 patients that compared the effects of smoking marijuana to swallowing a synthetic pill. It shows mixed results, with less vomiting among patients who smoked pot but more adverse effects. The pill seemed to work a little better.
There are two medications, each based on one compound found in marijuana, that are approved by the FDA to treat chemotherapy-induced nausea and vomiting. Pharmaceutical firms are testing other compounds and applications.
What about the intense pain in Marilyn’s middle and lower back? Might marijuana help that? Yes, Ehrlich said, but the research is extremely limited.
Of the eight debilitating conditions named in the Massachusetts law, Ehrlich told these doctors that the best evidence for relief of symptoms with marijuana is with HIV, Crohn’s disease, multiple sclerosis, hepatitis C and pain tied to nerve damage. The research shows little benefit for glaucoma, ALS and Parkinson’s disease.
The possible benefits of marijuana are not a doctor's only concern, Ehrlich cautioned.
"Anytime you are certifying [a patient], you have to assess risks and benefits," he said. "It’s not just, do you qualify? [It's also] what are the risks?"
The course touched on possible side effects of marijuana including dizziness, vomiting and psychosis for patients who have some personal or family history with this problem.
Dr. Kevin Hill, director of the substance abuse consultation service at McLean Hospital, said 9 percent of adults become addicted to marijuana, long-term use may lower a patient’s IQ and some patients experience withdrawal when they stop the drug.
"The problem," Hill said, "is that the majority of people out there believe marijuana is harmless. Unfortunately that’s not the case."
Hill said patients who use marijuana should seek strains with balanced amounts of THC, the compound that typically produces a high, and CBD, a compound that offsets the effects of THC.
The Massachusetts Medical Society opposed the statewide ballot question that made marijuana legal for medical purposes. But the society offered this course because the drug is legal now for some medical treatment and doctors are seeing patients who want a marijuana certificate. Doctors do not prescribe marijuana under the Massachusetts law; they only certify that their patient has an illness for which marijuana might provide relief.
"Given the state of the science on [marijuana's] effects and side effects, many of these physicians have turned to us to help them sort out the evidence," said Dr. Richard Pieters, MMS president.
But some doctors in the audience said the society's bias against medical marijuana was evident in the course.
"It was a little skewed," said Dr. Susan Lucas, who has epilepsy and uses marijuana to help control her seizures.
"Many of these physicians or many people here are of the sort of Reefer-Madness era," Lucas said. "I agree that [marijuana] should be in addition to regular medications, but I don’t think it should be written off as just THC and people sitting around with their kids getting high."
Dr. Karen Munkacy, who has applied to open a dispensary in Newton, said she was "just very happy that the Massachusetts Medical Society was putting on this conference."
Munkacy, who is on the board of the medical marijuana advocacy group Americans for Safe Access, said the course concluded "that for some very serious medical conditions [marijuana] can be very useful. I'm very happy that [MMS is] getting this message out to their members. It's going to help a lot of very sick patients."
The course included a review of state regulations that apply to "qualifying physicians." MMS attorney Bill Ryder said it's not clear yet if nurse practitioners will be authorized to sign marijuana certificates.
Some of the roughly 80 physicians at this course came because, as of July 1, they will need to complete a continuing education course in marijuana for medical purposes if they want the option of certifying patients. Others came because they’ve already been asked to sign the forms and don’t feel prepared.
"It’s very frightening as a physician," said Dr. Marisa Bochman, who practices family medicine in Hamilton. "You know a lot of us have been put in the position where we had to kind of swim on our own, and I wish we had a lot of this information a long time ago."
Bochman has certified two patients with chronic pain to get the maximum amount of the drug, 10 ounces for 60 days. She was stunned to realize how much marijuana she had authorized.
"I’ve never used marijuana," Bochman said. "I have no idea what an ounce or 10 ounces mean. Now I know. Ten ounces is about 600 joints.That’s 10 joints a day. Sounds like a lot to me."
Her voice trailed into nervous laughter.
Many doctors worry about how a marijuana certificate will translate into treatment for their patients.
"When I prescribe [the patient] a medication that is FDA approved, I'm telling you to get a specific medication with specific doses: how many times to take a day and for how long," Hill said.
There are no universal, approved recommendations in place for marijuana.
"When you don't have those safeguards in place, that's when things can go quite badly," Hill warned.
In addition, doctors don’t know whether to suggest that patients smoke marijuana, vaporize it, eat products infused with pot or take a pill. For the moment, it may be trial and error for patients and doctors testing this treatment option.