When I worked as a pain and addiction medicine specialist provider here in Utah, way before Medical Cannabis came around, I encountered many patients who were dependent on their opioids and struggling to find adequate relief for their complicated chronic pain conditions.
“If only cannabis was medically available here. I would prefer to use it over these pain pills,” one of them told me during our regular monthly visit. I believed him and felt his frustration.
Gradually I became aware of a handful of patients who were obviously turning to the occasional use of cannabis for pain relief. Some stated they were able to reduce their opioid use because of it. Generally, they had obtained this from other states where it was legally available, or via family and friends.
Unfortunately, this placed me in a difficult position as a clinician. While I was actively working to reduce patients’ reliance on opioids and find non-opioid alternatives, I was still prescribing controlled substances. I was informed that if I continued to prescribe such medications for patients that were illegally using cannabis, I could possibly put my license at risk.
These were always difficult conversations with patients and a source of great cognitive dissonance. Truth be told, I would much rather people use cannabis than opioids for obvious safety concerns. I’ve seen lives destroyed by the effects of opioid addiction. I’ve done chest compressions on patients who had overdosed on opioids when I worked in a local Emergency Department. Never have I had to worry about these things with a patient who only uses Medical Cannabis.
Yet there I was, a strong proponent of this non-opioid option to treat a variety of medical conditions, yet I was pulling away needed support for these patients. Per clinic policy, if patients continued to use cannabis, I stopped prescribing for them.
I am very pleased to see the laws in Utah changing as more patients are speaking up and being heard. Clinicians and patients will improve their therapeutic alliances as they will finally be able to utilize Medical Cannabis as an option. This makes sense not only on a scientific basis, but also upon the principles of medical ethics which are ingrained in healthcare providers; patient autonomy, beneficence, non-maleficence, justice, dignity, and fidelity.
Utah’s Medical Cannabis program has been an uphill battle. There are many reasons for this, including moral opposition, conflicts of interest, blatant lies and propaganda, dispensary issues, and a general misunderstanding of the medical science of cannabis. Having now gained this right, it is incumbent upon healthcare providers and patients alike to educate themselves about the law and the options that they now have available.
One topic which is worth mentioning is the inclusion of both oral, transdermal, and whole flower cannabis options in the law. Many patients across the country use tablets or edibles, but others prefer smoking whole flower. They have their preferences and their reasons. However, in Utah smoking Medical Cannabis is NOT permitted by the law. It may be vaporized but not smoked.
“The route of administration matters for any medication”, a professor once informed me in one of my pharmacology courses. Whenever I prescribe or administer a medication I carefully consider this truth. Medical Cannabis is not an exception.
One of the difficulties with cannabis, if we may call it that, is that the whole plant contains many more active compounds than just THC and CBD. To say otherwise is an oversimplification. The additional cannabinoids present may contribute to the varied effects of different strains as reported by patients. These may also be felt differently depending upon how the medicine is administered.
An oral or transdermal route will have a much slower onset and a prolonged duration, while an inhaled route will have a significantly more rapid onset and a shorter duration. An inhaled route may be easier to dose, while an oral route may be more difficult “to find the sweet spot”, which is also dependent on when and what the patient last ate. Obviously, this matters when we consider the nature of a patient’s symptoms. Do they need quick and on-demand relief for abrupt onset of pain, or something entirely different? Each patient should have the freedom to explore options, and providers should encourage this as well when appropriate. We need to remove any presupposed moral objections to any specific route of administration. Just as bronchodilators can be given orally or inhaled, so too can Medical Cannabis.