Despite a lack of regulatory and legal clarity, significant numbers of patients use medical cannabis, thus clinicians and pharmacists should be educated on these products. During a presentation at AMCP eLearning Days, Sean Chitwood, PharmD, MBA, director of clinical services at KeyScripts, and Eric Hauser, RPh, presidentofOrganic Remedies,discussed cannabis terminology, legislative and regulatory considerations, and how to optimize and manage the treatment of patients using medical marijuana.
Following a century of slow change related to medical cannabis, the last five years have seen rapid movement related to medical marijuana. There are some commercially available cannabinoids, including dronabinol, nabilone, nabiximols, and cannabidiol, and there are three general strain types: sativas, indicas, and hybrids.
State medical marijuana programs are highly regulated, with very specific rules and regulations surrounding patient certifications, dispensary operations, safety and security procedures, product labeling, inventory control, and mandatory reporting processes. There is limited research available for specific product recommendations, and physicians and patients rely on pharmacists for guidance on appropriate strain, mode of delivery, and dosage.
The goals of therapy should be to reduce or eliminate symptoms and polypharmacy. Patient history of marijuana use should be taken into consideration to direct starting dose for medical marijuana products. It may take several weeks for the full effects of medical marijuana to be realized, so start with a low dose and titrate up slowly to minimize adverse events and monitor concurrent prescription and over-the-counter drug use.
Pharmacists should educate patients about the risks and benefits of marijuana. New patients should receive 30- to 60-minute consultations with the pharmacist before purchasing the product. The pharmacist should review the patient’s medical history, medication list, symptoms, and goals of therapy, and based on this information, the pharmacist should select the most appropriate product. The patient should be entered into a research database to track progress and aid in future research of medical marijuana. Patient check-ins should occur every week to see how products are working.
The pharmacist should also review each dosage form with patients to help decide the best product. It is important to consider the following:
- Inhaled products have an onset of one to five minutes and a duration of two to six hours.
- Sublingual products have an onset of 15 to 60 minutes and a duration of two to 12 hours.
- Topical products have an onset of 15 minutes to two hours and a duration of one to eight hours.
- Oral products have an onset of 30 minutes to four hours and a duration of four to 24 hours.
The speakers then discussed the research on efficacy of cannabinoids to treat various conditions. There is conclusive or substantial evidence for efficacy to treat chronic pain, nausea/vomiting, and multiple sclerosis (MS) spasticity symptoms. There is moderate evidence for efficacy to treat sleep issues associated with obstructive sleep apnea, fibromyalgia, chronic pain, and MS. There is limited evidence for efficacy for appetite/weight loss in HIV/AIDs, Tourette syndrome, anxiety, and post-traumatic stress disorder. There is limited evidence for ineffective use for dementia, glaucoma, depressive symptoms in chronic pain, or MS. There is insufficient evidence to support or refute use for cancer, anorexia, irritable bowel syndrome, epilepsy, spinal cord injury spasticity, amyotrophic lateral sclerosis, Huntington’s and Parkinson’s disease symptoms, dystonia, and schizophrenia.
States allowing medical cannabis have seen a decrease in prescription medications, and an increasing number of animal and in vitro studies have indicated potential for anti-cancer effects of cannabinoids.
Still, concerns remain, with clinician fears stemming from poorly designed or low-quality studies, biased populations, wide-ranging or inconsistent dosing, varying formulations and delivery routes, and lack of meaningful sobriety tests available.
Presentation: Cannabis Use in Health Care: What Payers Need to Know. AMCP eLearning Days, April 20-24.