Portrait of a Medical Cannabis Clinical Practice: Shaping the Road Ahead

Portrait of a Medical Cannabis Clinical Practice: Shaping the Road Ahead

In May of 2018 at the top global research meeting for integrative health and medicine, two academic leaders with medical cannabis practices organized an informal breakfast round-table. One co-convenor helping guide dialogue in the overflow room was Leslie Mendoza Temple, MD. The past chair of the politically-killed Illinois Medical Cannabis Advisory Board brought more than personal reflection to the attendees. Temple had performed a comprehensive chart review on the first 166 medical cannabis patients certified in the practice. Her findings, recently published, and her reflections on now 650 patients – plus the curious politics of cannabis in her state – will be eye-opening for practitioners tracking medical cannabis developments.

On January 1, 2014, Illinois initiated the Compassionate Use of Medicinal Cannabis Pilot Program Act which, with a recent extension, will run through 2020. Roughly 40 conditions are approved. Temple’s analysis was moved by the practical mission of revealing barriers and opportunities that might shape a law that will replace the pilot. Her synopsis, published in September 2018 in open access in JACM-Paradigm, Practice and Policy Advancing Integrative Health (The Journal of Alternative and Complementary Medicine) as Barriers to Achieving Optimal Success with Medical Cannabis: Opportunity for Quality Improvement, offered five core findings:

  1. inadequate scientific knowledge [in medical marijuana retail personnel] regarding effectiveness, dosage, delivery mechanism, indications, and drug interactions in humans;
  2. lack of educational standards for dispensary and medical staff training;
  3. lack of communication and coordination of patient care;
  4. complexity and inconsistent availability of dosing options; and
  5. barriers to access for patients seeking this therapy.

Temple engages the challenges one by one, proposing solutions for each. For any clinician who is expecting to operate in a context of standards, the survey findings are an eye-popping wake-up call. For those preferring the wild-west of the medical and recreational cannabis movement, the commentary offers a sobering lesson in the roping and corralling that is likely ahead.

The findings of Mendoza-Temple and her co-authors – Sara Lampert and Bernand Ewigman, MD, MSPH – are directly reminiscent of challenges the burgeoning dietary supplement industry faced in the consumer-driven natural health movement of the 1980s and then the industry’s jet-propelled expansion following the 1994 Dietary Supplement Health and Education Act. Back then it was: What do natural foods store workers know? What about the variations in product quality from different suppliers? How was one to communicate with these untrained retailers who were effectively often medical advisers? And what, really, do most physicians know about supplements?

For challenges with dietary supplements, a key solution for interested clinicians was to create in-office pharmacies. They side-stepped the questions of retailer-as-medical-prescriber and could drive patients to suppliers they trusted – whether or not such trust was in fact evidence-based. The clinician could also control dosing.

Selling cannabis out of one’s office is not an option for medical cannabis prescribers. Clinicians must rely – as Temple found – on “dispensary workers [who] may guide patients differently regarding strain, route of delivery, dose, and frequency compared with their counterparts.” These uncertainties on the retail end are exponentially compounded by low clinician knowledge about cannabis. Of 2100 professionals in Illinois who have certified patients for medical marijuana, only 16 treated over 100 patients and thus are likely to be “cannabis-literate.” Nor does it make treatment easier that cannabis has such a rich profusion of compounds – cannabinoids, terpenes, and sesquiterpenes – adding additional complexities.

The picture sounds like a bad dream: uncertainties are compounded by ambiguities and ratcheted beyond by ignorance. This is the context for care among the estimated 42,000 adult patients and 305 pediatric patients in Illinois that were registered medical cannabis cardholders through August 2018. Meantime, a non-ambiguous driver has increasingly spiked government interest: total retail sales since November 2015 reached $196,056,866. Tax revenues could be real.

I reached Temple for follow-up. She said that as the initial panacea-like public excitement over the 2014 law settled down, her now expanded patient base has taught her where to expect value. She ticked off 4 health-related issues where she has found medical cannabis to be dependable:

  • sleep
  • disconnecting from pain
  • help reducing anxiety
  • help with digestive issues.

While this may seem a vast constriction of the 40 conditions, one or more of these issues has a good chance of percolating to the surface in patients diagnosed with any of the accepted diagnoses in Illinois – from Crohn’s disease to lupus, cancer, glaucoma, Parkinson’s, HIV and the rest.

In fact, Temple shared that she and the Medical Cannabis Advisory Board wanted more conditions listed. They got into hot-water with Republican governor Bruce Rauner when not once but three times the board’s investigation and hearing processes produced recommendations for expanding the list. As Chicago Magazine reported, Rauner – who was not friendly toward this inherited legislation on assuming office – demanded disbanding of the board in late 2017 as a condition of extending the life of the pilot.

Temple believes the board could have provided useful service this past year as the legislature debated then passed a major opioid-related bill that is expected to significantly expand the rolls of medical marijuana users. Patients prescribed medical marijuana as alternatives to opioids will be able to bypass formal certification. Temple shared that she was able to quietly have some say via her connections with the organization for primary care doctors that helped shape shaping the bill. Rauner’s antagonism was just resolved by Illinois voters who turned him out. They elected a Democrat, J.B. Pritzker. Pritzger is on the record supporting recreational marijuana. Temple believes he is likely to bring back an advisory board in some form.

As use ramps up, Temple hasn’t seen much movement toward solutions, either in Illinois or elsewhere. She mentions a freely-available “Physician Education and Training” modules for clinicians in the District of Columbia. When I noted the dietary supplement industry’s efforts 25 years ago to rapidly create certification programs of retail workers, Temple noted that she believes private educational companies have major opportunities to serve both retailers and clinicians with medical marijuana courses. And while some states are requiring a pharmacist or physician to be onsite in medical cannabis shops, such a direction will be certain to run up the costs that are already creating access problems for many patients.

Temple takes a long view of the changing relationship with what was once the subversive pot: “In 20 years, we are going to be looking at marijuana as we do alcohol now.” Yet at the same time, while alcohol may be widely used medicinally by self-prescribing individuals, it is not in the tool box of medical prescribers. Temple hopes the directions set by the commentary will give guidance “to the liassez-faire free-for-all” that characterizes medical marijuana delivery today. She shares two guiding lights for work that she hopes she will be able to engage under Illinois’ incoming governor Pritzger: “It’s critical to keep patients safe. And we want to give patients the best care we can.” The commentary makes clear that present practice is falling short on each.



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