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Cannabis is not for everyone

Cannabis is not for everyone

The Canadian Medical Association has suggested the following general guidelines for prescribing medical cannabis:

  • Medical cannabis should be prescribed with caution.
  • Patients should be selected carefully.
  • Patients with medical cannabis prescriptions should be monitored.
  • If patients cause concern they should be discontinued.

Recommendations for Prescribing Cannabis for Chronic Pain or Anxiety

Research Evidence

No research evidence exists to support medical cannabis as a treatment option for the pain conditions seen in primary care (e.g. conditions like lower back pain, level III). The CMA recommends that dried medical cannabis should be considered only for patients with neuropathic pain which has persisted through standard level I treatments.

Considerations Before Prescribing Cannabis

Doctors who are considering authorizing medical cannabis for neuropathic pain might consider:

  • Trying other nonpharmacologic and/or pharmacologic therapies first.
  • Trying other nonpharmacologic and/or pharmacologic therapies first.

Not Appropriate For All Conditions

Some doctors have found that dried cannabis therapy isn’t appropriate as a treatment for anxiety or insomnia, level II. It has also been found to not be appropriate for patients who:

  • Are under 25 years of age.
  • Have strong family history or personal history of psychosis.
  • Currently have or have had a history of cannabis use disorder.
  • Currently have an active substance use disorder.
  • Suffer from a cardiovascular disease or condition like peripheral vascular disease, angina, cerebrovascular disease, and/or arrhythmias).
  • Currently have a respiratory disease or have had one.
  • Are breastfeeding, planning to become pregnant, or are currently pregnant.

Authorizing Cannabis with Caution

Some doctors agree that authorizing patients to use dried medical cannabis should be done with caution for patients who:

  • Currently have a concurrent anxiety disorder or active mood disorder.
  • Currently smoke tobacco regularly.
  • Exhibit cardiovascular disease risk factors.
  • Abuse alcohol heavily in a regular manner or consume high doses of opioids and/or benzodiazepines or other medications which create sedating effects.

Following Regulations

The CMA urges doctors to follow the regulations laid out by their governing provincial medical regulators and always refer to these regulations when considering prescribing medical cannabis.

Monitoring Patients

It is recommended that doctors assess and monitor all patients using medical cannabis for signs of potential abuse or misuse of the medicine.

Monitoring a patient can involved examining a patient’s response to medical cannabis treatment while considering if and how the patient’s quality of life and ability to function are affected and whether the treatment provides pain relief. Some doctors have chosen to discontinue their authorization to use medical cannabis if the therapy is not effective or if they suspect it is causing the patient harm.

Before Signing the Medical Document

Many doctors go through the following procedures before signing a medical document and authorizing a patient to use medical cannabis:

  • Conducting a pain assessment on the patient.
  • Conducting a assessment for anxiety and mood disorders.
  • Conducting a screening and assessment for substance use disorders.

Patients on Cannabis Shouldn’t Drive

Patients should not drive after using medical cannabis. Some doctors advise patients not to drive after using medical cannabis for different intervals depending on the means of ingestion:

  • If the patient smokes, don’t drive for four hours after inhalation.
  • If ingesting orally, don’t drive for six hours after oral ingestion.
  • If the patient experiences euphoria following inhalation or oral ingestion, don’t drive for eight hours.

Disagreeing with Patients

Some patients disagree with their doctors about authorization to use medical cannabis, dosing, or other medical-cannabis-related issues. In such cases, doctors might find it practical to manage the disagreement using evidence-based statements presented unambiguously.

Harm Reduction

Many doctors find it practical to advise the patients they have authorized for medical cannabis about harm reduction strategies.

Doctor Responsibility

According to regulations, the doctor who authorizes a patient to use medical cannabis for a given condition must be primarily responsible for following up the patient regularly and managing the treatment of the condition for which medical cannabis was prescribed. A doctor who seeks second opinions regarding medical cannabis as a treatment for one of his or her patients should only refer to facilities which meet or exceed the standards for quality of care applied to specialized pain clinics. In either case, regulations indicate that the authorizing doctor should communicate with the family doctor in order to provide comprehensive patient care.

Dosing: Start Low, Go Slow

Many doctors who authorize patients to use medical cannabis find the best practice for dosing is to “Start low and go slow,” meaning the patient should start with a low dosage and only increase it gradually.

Recommending THC Content

Some doctors choose to specify the percentage of THC on the medical documents they fill out even though it is not required by the ACMPR. They choose to specify THC content because it allows them to indicate the dosage they want for their patients just as they would do with other analgesics.

Recommendations for Prescribing Cannabis for Chronic Pain or Anxiety

Misuse of Cannabis

Visit our Doctor’s Resources page to the find resources like:

  • Sample Treatment Agreement
  • Cage aid tool

Advice for patients about safety and harm reduction

Some doctors provide patients with the following advice to promote responsible use and effective medical cannabis treatment.

  • Always use the lowest dose which is still effective.
  • Don’t take a higher dosage than a doctor has specific.
  • Don’t “breath hold” when using medical cannabis.
  • Avoid smoking to take your medical cannabis to reduce your risk of exposure to toxins created when you inhale combusted plant matter. Instead, eat cannabis in one of its edible forms or use a vaporizer.
  • Never mix using medical cannabis with sedating drugs or alcohol.
  • Never mix tobacco into your medical cannabis if you are smoking it.
  • Never sell or give medical cannabis to anyone.
  • Always store your medical cannabis securely in a locked, air-tight container where it is hidden and inaccessible to visitors, children, and pets.
  • Limit exposing others to second hand cannabis smoke by only smoking alone outdoors.
  • Do not drive immediately after taking a dose of medical cannabis. Refer to the above section titled “Patients on Cannabis Shouldn’t Drive” for more information about when it is acceptable for patients to drive following a dose of medical cannabis.
  • Never use medical cannabis in any form if you are breastfeeding, pregnant, or trying to become pregnant.

Clinical features of cannabis use disorder in patients with chronic pain

The following tendencies have been observed in patients who exhibit symptoms of cannabis use disorder. The patient may have cannabis use disorder if he or she:

  • Insists on a medical document for dried cannabis instead of trying alternative treatments which are known to be effective for his or her condition.
  • Spends considerable time using cannabis on a daily or almost-daily basis.
  • Does not function well socially and/or has poor performance at work or school.
  • Is abusing or addicted to other substances other than alcohol or tobacco.
  • Exhibits risk factors for cannabis use disorder.
  • Admits to having difficulty reducing cannabis consumption or stopping altogether.
  • Reports symptoms of cannabis withdrawal including fatigue or intense anxiety.
  • Has people (friends/family) concerned about his or her cannabis consumption.

The authorization for cannabis should be discontinued if the patient

Doctors commonly discontinue authorization for a patient to use medical cannabis if the patient:

  • Seeks out cannabis from other sources or finishes prescriptions early.
  • Abuses other drugs (opioids, alcohol, etc.).
  • Shows any signs of cannabis use disorder.

Side effects

The side effects of medical cannabis can include:

  • clumsiness
  • hypotension
  • Tachycardia
  • dizziness
  • sedation
  • impairment of sensory and/or perceptual functions
  • dry mouth

Long Term Use

The long term use of medical cannabis in implicated in causing the following conditions:

  • Fertility problems (in the form of decreased sperm count in males and menstrual dysfunction in females).
  • Issues with memory.
  • Problems with motivation.
  • Hyperemesis.

Symptoms of Tolerance, dependence, and withdrawal

Symptoms of cannabis withdrawal

  • The most common symptoms identified as cannabis withdrawal include irritability, anxiety, nightmares/strange dreams, insomnia/sleep difficulties, craving, headache, restlessness, anger or aggression, and decreased appetite and/or weight loss.
  • Symptoms could also potentially include chills, shakiness, depressed mood, stomach pain, and sweating.

Cannabis Treatment for Specific Conditions

Medical cannabis in palliative care

Many doctors give the following considerations priority when medical cannabis is used in palliative care treatment:

  • quality of life
  • empowerment
  • individual choice
  • patient autonomy
  • comfort

The role of medical cannabis in palliative care

Historically, doctors have chosen to use medical cannabis treatment to address the following aspects of palliative care:

  • The nausea, vomiting, and/or anorexia/cachexia associated with chemotherapy or radiotherapy treatment.
  • Severe depressed mood, severe pain, and/or insomnia.

Using medical cannabis may provide a measure of relief in both cases listed above. However, medical cannabis has not been shown to control anticipatory nausea as effectively as the symptoms listed above.

Considerations regarding medical cannabis and anorexia/cachexia

The effectiveness of medical cannabis in stimulating appetite and promoting weight gain in patients with cancer cachexia have not be studied conclusively. It has only been shown anecdotally that smoking cannabis can stimulate appetite in such cases.

The Access to Cannabis for Medical Purposes Regulations (ACMPR) allow medical cannabis to be used to address weight loss, anorexia, and cachexia associated with cancer found in patients who have not responded to conventional treatments or who would not be considered to benefit from conventional treatments.

The ACMPR also authorizes medical cannabis to be used by HIV/AIDS patients suffering from weight loss, anorexia, and/or cachexia which is associated with their illness if the patient has not responded well to conventional treatments or would not be considered to benefit from conventional treatments.

Cancer Pain

Medical cannabis may be of benefit in the advanced forms of pain associated with cancer.

Nabiximols (brand name Sativex® ) is conditionally approved as an adjunctive analgesic during the highest tolerated dose of strong opioid therapy for persistent background pain in adults who are experiencing moderate to severe pain caused by advanced cancer.

Multiple Sclerosis

The ACMPR allows the use of medical cannabis in the context of the following MS-related symptoms in patients who have not benefited from conventional treatments or would not be considered to benefit from conventional treatments:

  • Persistent muscle spasms associated with MS
  • Severe pain

ALS

Select studies have shown medical cannabis may have the following effects in patients with ALS:

  • Decreased muscle cramps
  • Decreased fasciculations

Spinal Cord Injury

Select studies have found that medical cannabis may alleviate neuropathic pain associated with injury of the spinal cord.

About Medical Cannabis Medicine

Safety and Testing of Medical Cannabis

Medical cannabis must be treated and tested to ensure it is a safe, consistent treatment for patients. The following considerations must be taken by LPs:

  • No un-authorized pesticides must be used.
  • The level of moisture in the medical cannabis must be at the proper level to ensure it is stable and usable.
  • The cannabis must have microbial purity to ensure the final product is free of E. coli, Salmonella, and S. aureus.
  • Medical cannabis must be tested for the presence of any metals and mycotoxins.
  • Medical cannabis must be thoroughly tested for cannabinoid concentration (e.g. THC and CBD) and must be meet the requirements of the Food and Drugs Act.

Dosing

  • Start Low and go slow. For more information refer to the “Dosing: Start Low, Go Slow” section above.
  • Typical doses are between .5 to 3 grams of dried medical cannabis flowers per day.

Dosage in Joints

  • The typical joint contains between .5 and 1 gram of medical cannabis.
  • A patient with a daily dosage of 3 grams will use approximately 3 to 6 joints or equivalent.

Too much

5 grams of medical cannabis per day may have negative effects on a patient’s cardiovascular, pulmonary, and immune systems as well as psychomotor performance. It could also potentially lead to a dependency.

CFPC Recommendations

The College of Family Physicians of Canada indicate that physicians should note on the medical document that patients should use strains containing 9% THC or less. The CFPC also indicates that doctors should request information regarding the % THC composition should be sent directly to the doctor’s practice and that the doctor should be notified of any change in the % THC concentration of a product given to a patient.

Cost

The cost of medical cannabis for a patient is between $5.00-$40 per day + shipping. Shipping typically takes 2-5 days.

Prescribing Tips

The CMA provides the following recommendations to doctors for prescribing medical cannabis:

  • Prescribe 1-3 grams per day
  • Start a patient with a 3-month trial then monitor the patient’s progress
  • If the treatment is beneficial prescribe for 1 year
  • The prescription must be renewed each year

Consumption

CMA does not recommend any form of smoking any plant. Vaporizing is suggested over other forms of ingestion.

About Medical Cannabis Medicine
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