Cannabis Patient Care - November 2021

Cannabis Patient Care November Issue

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31 october/november 2021 | cannabis patient care advocate focus in 1996 in California, threatened to revoke the prescribing privileg- es of any physicians who recommended cannabis to their patients for medical use. Conant contended that such a policy would violate the First Amendment, and the federal courts agreed (8). In that case (Conant v. Walters [8]) the Ninth Circuit Court of Appeals held that the federal government could neither punish nor threaten a doctor merely for recommending the use of cannabis to a patient. "But it re- mains illegal for a doctor to 'aid and abet' a patient in obtaining can- nabis," according to court documents. While it appears that doctors can legally discuss cannabis with their cancer patients in states where medical cannabis has been le- galized, there are still concerns about how such phrases as "aid and abet" might be interpreted. Before that ruling, doctors had their hands tied when it came to discussing cannabis with their patients. One example: Dr. Milton N. Estes, associate clinical professor in the Department of Obstetrics, Gynecology and Reproductive Medicine at the University of Califor- nia-San Francisco (UCSF), reported his feelings as a result of the gov- ernment's public threats (8): "I do not feel comfortable even dis- cussing the subject of medical marijuana with my patients. I feel vulnerable to federal sanctions that could strip me of my license to prescribe the treatments my patients depend upon, or even land me behind bars. . . . Because of these fears, the discourse about medi- cal marijuana has all but ceased at my medical office. . . . My patients bear the brunt of this loss in communication." The Cannabis Medical Treatment Narrative Nearly every story about a breast cancer patient getting access to cannabis treatment follows a sort of four-part narrative: dealing with the adverse effects of prescribed pharmaceuticals for treatment; asking their doctor for a better way of dealing with side effects from the cancer drug therapy; hearing about the benefits of cannabis from other cancer patients; then trying cannabis and experiencing better, drug-free relief—all as their doctor approves by not tacitly disap- proving of their use of cannabis. That is, if the cancer patient even discloses their cannabis use. Dr. Danielle Noreika is the medical director of palliative services and an associate professor of medicine in Virginia Commonwealth Univer- sity's (VCU) Division of Hematology, Oncology and Palliative Care. She works with other doctors in the VCU Massey Cancer Center, which is one of only two cancer centers in Virginia designated by National Can- cer Institute, and one of only 71 cancer centers in the United States. Virginia legalized medical marijuana in July 2020 (9), one of the more recent states to do so. Doctors in Virginia can recommend can- nabis and issue written certifications , but not prescriptions. Dr. Noreika is one of 24 medical marijuana licensing doctors in the Richmond, Virginia area (10). As much as she appears to be an ad- vocate for cannabis, she is careful in her explanation about what that means. "I will say in general, as a way of not directly answering that question about being an advocate, is that I'm an advocate for things that are going to improve the quality of life of my patients," Dr. Noreika said. "Because I think we still need to know more for me to say that I know exactly where this fits into the treatment plans for my patients at this point." She added that she is very open to seeing more research done over time, where cannabis could be integrated into patient care. "Ab- solutely. I am always wanting to see something else that we can kind of add to what we do that will make patient's lives better," she said. "As far as the health care institutions and my talking to colleagues about marijuana—not only here, but also in other places—there's still a lot discussion about not knowing how to integrate (cannabis therapy), and they are not sure what to do with it. They say that they are just going to watch it for awhile," said Dr. Noreika. "Our practice in the state at the moment is that the Board of Pharmacy has to sort of agree that you're not prescribing it, but you're sort of writing a certi- fication for a patient to use. And you have to be registered for that. I think there's patients who may benefit from cannabis therapy. But in real life, at this point, we haven't gotten to a place where we're able to see kind of an uptake on that, at least sort of globally, in a lot of the different institutions." Until there is more evidence to go on, it's hard to tell any individ- ual patient about the benefits and side effects. "There's always both whenever you're considering any sort of substance," Dr. Noreika said. The other challenge for patients right now, she said, is when pa- tients have an interest in pursuing cannabis treatment, but find out that many providers are not listed with the state yet. "There's this sort of thinking that 'OK, if this is really what I want for my care, I have to sort of go out and find the providers that are willing to kind of make this certification.' But there's not as many of them right now. And many of them are not able to accommodate new patients." In sharp contrast to Virginia, Colorado legalized medical marijua- na more than 10 years ago (11). Dr. Virginia Borges, medical oncology professor at the University of Colorado School of Medicine, said that medical cannabis is something that she has had a fair amount of ex- perience with by virtue of how her patients choose to support them- selves during their cancer care. "So it kind of behooved me to get as educated as I could, based on the data that I've been able to find or others have been able to help find for me, or in the field," Dr. Borges said. "My viewpoint is that cannabinoid containing products are use- ful as a supportive care measure in cancer treatment, not as a direct cancer targeted therapy, because we don't have data for that in the clinical setting at this point in time." There is some interesting preclinical evidence about the effec- tiveness of cannabis for real anti-cancer treatment. "But the prob- lem is that there's a lot of things that look interesting when they're in the lab," Dr. Borges said. "But whether that would ever pass mus- ter and get to the level of a clinical trial where we could prove that it could be an actual therapy, an anti-cancer directed therapy, we're just not there yet." Dr. Borges said that some of the work being done in oncology is evidence-based, where there have been randomized clinical trials done. "Some of that is practical evidence gained over time by vir- tue of either what our patients choose to do, or just what we gain experience with," she said.

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