Mrs. M.P. Spinal Stenosis, Pain and Medicinal Marijuana PSP Managing Pain Cases

2 1.Explain the physician’s role in the MMPR (Marijuana for Medical Purposes Regulations). 2.Describe a professional and responsible way to excuse yourself from that role if you are uncomfortable. 3.List resources you can access to assist you and the patient. 4.Provide a rationale for the exploration of cannabis as a therapeutic agent. Learning Objectives

3 1.Canadian Federal Law prohibits the possession and use of cannabis, which is punishable by imprisonment. 2.The Canadian Charter of Rights and Freedoms guarantees every citizen both liberty and security of the person. 3.The Courts recognize that possession and use of cannabis may be pivotal for security of the person in certain medical circumstances, and therefore 4.For Canadians in those circumstances, prohibition is contrary to their Charter Rights, and the Government is required to provide a process to exempt them from prohibition. Physician’s Role in MMPR

4 5.The ensuing Government Regulations (Marijuana for Medical Purposes Regulations (MMPR) place responsibility for deciding which patients are medically qualified to be exempt from prohibition in the hands of Health Care Practitioners. 6.Physicians have the option (according to Regulatory Authorities) personally to decline accepting that role. 7.A physician who supports a patient's qualifying to use cannabis for medical purposes must specify "the daily quantity of dried marihuana to be used by the patient” in g/day. Physician’s Role in MMPR

5  How could you professionally and responsibly excuse yourself? › From discussing it › From supporting an exploration or application for exemption If you are uncomfortable….

6  “Physicians are advised by the College of Physicians and Surgeons that they should not prescribe any substance for their patients without knowing the risks, benefits, potential complications and drug interactions associated with the use of that agent. Currently, that caution includes marijuana in its smoked form. Because I am not versed in the evidence related to marijuana use, I do not feel comfortable supporting your use of it.” Some suggestions:

7  “According to Health Canada, dried marijuana is not an approved drug or medicine in Canada, and the Government of Canada does not endorse the use of marijuana.”  “I respect the Government’s position on this, and am professionally not comfortable to discuss this with you.” Some suggestions

8  “If you still feel it may help you, I can assist you to find a physician who is more conversant with the issues related to medicinal marijuana. “ Some suggestions:

9 Other suggestions:

10  83 yr. old widow in assisted living  Has close relationship with daughter nearby who comes to medical appointments  Spinal stenosis – clinical and imaging  Constant pain in both legs / some back pain  Sleep disturbed – wakes q2h with pain  Mood low  Mild Cognitive Impairment Case Description

11  PHQ-9: 13 (moderate depressive symptoms)  GAD-7: 9 (mild anxiety symptoms)  Opioid Risk Tool: 1 (low risk)  Brief Pain Inventory: › Pain Scores: low 4, high 7 › Pain Interference from BPI: 44/70 Case Description

12  Referred to spinal surgeon – non operative  Tried epidural steroid – did not help  Tylenol – 1000mg TID – modest benefit of back pain  Gabapentin titration to 300 mg bid – modest benefit  Remains moderate – severe pain, with poor sleep Case Description

13  Medical history: › Right THR 2009 – status good › Partial Colectomy 2012 for cancer – no recurrence › Hypertension › Mild cognitive impairment  Medications: › HCTZ 25 mg od › Atenolol 50 mg od › Gabapentin 300 bid › Metoclopramide 10mg od Case Description

14  Opioid trial: Informed consent.  Oxycodone mg q4h prn  Gradually progress to 10mg Oxycodone CR q8h  Pain control 50% improvement  Reports sleep improved  Constipation controlled with daily laxative  Overall satisfied Case Description

15  One year later returns  Opioid still working but feels overall pain control diminished.  Sleep deteriorating again  Worried about being on opioids  Brings up query regarding medical cannabis instead of opioid Case Description

16  How would you proceed? Next Steps

17 1.Respectfully decline to engage in the conversation or support the patient further. 2.Engage in discussing medicinal cannabis but decline to support an exploration of usage or application for an exemption. 3.Engage in discussing medicinal cannabis and supporting an exploration of usage and application for exemption. Next Steps

18 1.Explain the physician’s role in the MMPR (Marijuana for Medical Purposes Regulations). 2.Describe a professional and responsible way to excuse yourself from that role if you are uncomfortable. 3.List resources you can access to assist you and the patient. 4.Provide a rationale for the exploration of cannabis as a therapeutic agent. Learning Objectives Recap

19 1.Practitioners for Medicinal Cannabis 1.Pose a question : 2.Join the group 3.Look for a physician for referral 2.Refer to the Medicinal Cannabis Resource Centre (mcrci.com) 3.Canadian Consortium for Investigation of Cannabinoids (ccic.net) 4.Health Canada Document on Medicinal Cannabis 5.College of Family Physicians of Canada 6.Resource document created by Dr. Pam Squire 7.Sample Informed Consent Document Resources you can access

20 Questions

21 1.There is a sound scientific basis for how cannabinoids and cannabis-derived medicines might affect a number of medical conditions. 2.There is historical evidence of a wide safety profile for cannabis, there having been no deaths attributed to overdose. 3.There are convincing anecdotal reports of medical benefit, but limited high quality clinical data to assess benefits and risks of cannabis used for medical purposes. Provide a Rationale for Cannabis as Therapeutic

22 1.There is no standardization of the composition of plant-based cannabis products available. 2.Cannabis contains 60+ cannabinoids › THC (delta-9 tetrahydrocannabinol) › CBD (cannabidiol) › Are two important ones, with different medical effects › The “entourage effect” of the components acting in concert is postulated as an explanation for why the plant appears to be more effective than single components or pharmaceutical derivatives. Considerations in the “exploration” of a trial

23 3.Response to medicinal cannabis is unique to the individual and will vary with the patient’s sensitivity, tolerance to side effects, medical condition, severity of symptoms, cannabis strain used, and route of administration. 4.Possession and use of cannabis remains prohibited for Canadians in general. The exemption for medical purposes is the only avenue of access to a legal supply of cannabis. Many Canadians use it for other than medical purposes. 5.The patient may already be well informed about the aforementioned statements, and possibly have some personal experience of the medical effects of cannabis. Considerations in the “exploration” of a trial

24  “I feel that medicinal cannabis may be an option in your treatment. I’d like to discuss with you some of the risks and side effects so that you and I can explore whether this is a good option for you.”  “If it appears to be a good option for treatment, we’ll set functional goals for you, ensure that there are no drug interactions to be concerned about with your other medications, and explore how we might introduce a trial of cannabis.” Moving Forward

25  Mrs. Gilron started with cannabis capsules from compassion club at dose of 0.25 grams q8h – a “low” THC variety  She reported improved sleep with 7 hours continuous  Pain subjectively better  No side effects so far  No feeling ‘high” or distorted reality  Saw cardiologist pre trial – who was unconcerned  BP and HR remained stable Follow up

26  Continued use of oxycodone CR 10 mg q8h  Advised to reduce to 10 mg bid  Increase cannabis to 0.33 mg q8h  Contracted flu, hospitalized, vomiting.  No cannabis for a week  Restarted with cannabis lozenges (0.25 grams, q8h)  Stabilizing after flu  Evaluation of the “exploration” is ongoing. Follow up