Medical Marijuana – It’s Complicated

Recent approval of marijuana for medical use has brought up more questions than it has answered. The main conundrum is how this substance can be legal in various states – in 29 for medical use and in 7 for recreational use – but still be illegal in the eyes of the federal government.

How does that affect us as physicians who could potentially be asked to ‘prescribe’ marijuana? My license to practice medicine is issued by the state of Maryland. Here, recreational marijuana has been decriminalized and use of marijuana for medical purposes is legal. BUT even if I wanted to, I can not prescribe it.

In order to prescribe medications, I have a state-issued Controlled Drug Substance number and a federally-issued Drug Enforcement Agency (DEA) number. In all matters, when there is disagreement between state law and federal law, the latter rules. Clearly, I cannot prescribe marijuana – no matter what Maryland law states – it is illegal on the federal level. It continues to be a Schedule I drug, meaning that according to the government, it has no medical use and has a high potential for abuse.

So what can physicians do? We can only document that a patient has a qualifying diagnosis and that they may acquire a supply of marijuana that was grown by a certified grower, processed by a certified processor and sold through a certified dispensary. The qualifying diagnoses can vary from state to state. In Maryland, they include cachexia, anorexia, wasting syndrome, chronic or severe pain, severe nausea, seizures, severe or persistent muscle spasms, glaucoma, and post-traumatic stress disorder. The first few listed refer to loss of appetite and extreme weight loss which are often treated as they relate to HIV/AIDS and cancer.

In 2013, a Cole memorandum (James Cole was Deputy Attorney General under Obama at the time) stated that in states in which the voters chose to legalize marijuana, there would not be the usual federal-state partnership in law enforcement. The federal government’s priorities in this area, given their limited resources, would be in prohibiting distribution to minors and prohibiting possession on federal property (e.g., airports, banks, government buildings, …). They trusted that state and local law enforcement would take care of the details according to the state provisions. In other words, if you’re in a state where marijuana is legal, “Stay under the radar and you’ll be OK.”

On January 4th, 2018, however, Attorney General Jeff Sessions declared that the Cole directive was not in accordance with the principle that federal law overrides state law; going forward, the states’ choice to legalize marijuana will not be recognized. He said that the Senate can declare it a legal substance if they chose. Right now, it’s illegal and it isn’t his place to decide which laws to enforce. It is not clear yet what the implications of this declaration will be.

Physicians interested in recommending marijuana online and all patients interested in medical marijuana need to register with the Maryland Medical Cannabis Commission (MMCC). The commission has broad representation, including 3 physicians, a pharmacist, a scientist with experience in the field, a patient or other person representing the public, law enforcement, the legal community, Office of the Comptroller, and a horticulturist.

According to the MMCC website, there are about 20 physicians registered, 20 certified growers, 20 processors and over 100 dispensaries. Physicians are prohibited from profiting in any way from the growth or distribution of marijuana – they may not be owners or receive any benefit from the dispensing of these products. Since banks are federally regulated, they are prohibited from doing business with any marijuana-related entities. Likewise, these businesses cannot be insured, so during the California wildfires, many businesses literally went up in smoke without any coverage.

Unlike medications that we prescribe, we have no control over what is actually dispensed. The two major components of marijuana are THC – the primary psychoactive ingredient – and cannabidiol (CBD), which exists in inverse proportion to THC and moderates its effect. As reviewed in a prior article, over the years THC has increased from an average of 3% of content years ago to newer strains that have as much as 20%, making it much more potent. Due to its long half life, THC has been shown to affect a pilot’s response in a flight simulator 24 hours after a single dose.

There are many varieties of marijuana, each with different percentages of THC and CBD, so each batch will be different. A staff member of the dispensary decides which product to recommend based on the patient’s symptoms. The illegal status and large variety of species affects research in the field as well. Most labs are unable to obtain sizeable quantities of specific strains to determine their efficacy, and in turn, that specific strain won’t necessarily be available at a particular dispensary. Species that show benefit in seizure control in studies, for instance, may not be what is dispensed to a seizure patient.

What does our state medical society say about the issue:
Disclaimer – We recognize that cannabis is a complex and contentious issue and we make no assurances or warranties regarding the practices of cannabis as a medical tool.

Based on how few doctors have registered with MMCC, my guess is that given all of the concerns regarding the federal status, lack of uniformity of plants, and lack of controlled studies, many physicians will watch from the sidelines for a while. We’ll see how things play out.