Thank you for registering for the CSPMR Annual Meeting to be held April 21-23, 2017 at the San Francisco Airport Marriott Waterfront hotel located at 1800 Bayshore Highway in Burlingame.

If you need hotel accommodations please click on the link below.  Note the cutoff date for our $124.00 room rate ends March 24th.
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We look forward to seeing you in April!

Robyn Sato, DO
President
Medical Marijuana:  What to Tell Our Patients
By Jan Lord, MD
 
Several years ago I began a program of office urine testing to verify narcotic compliance among my chronic pain patients and to make sure that my patients were not engaging in illegal drug use.  I signed on with one of a number of companies that offer office screening with laboratory verification as needed. 
 
Most of my patients willingly provided samples.  I was surprised, then, when I began receiving spontaneous, embarrassed confessions from a full range of patients – from young men with job-related back injuries to elderly women with rollator walkers and arthritis – that they did use marijuana, often in small quantities, to promote sleep or manage pain.  Some of these people had obtained marijuana cards and some had not.  For my very low income patients – particularly the elderly on fixed incomes – the $100 or so that a marijuana card costs could be a true hardship. 
 
I decided that I neither needed nor wanted anybody’s true confession and so asked my drug lab to remove the THC strip from my urine screening cup.  Again to my surprise, I was told that my request was common.  Many physicians choose not to know whether their patients are using marijuana or not.  Given the impossible conflict between federal and state law – as well as the reality of widespread marijuana use throughout multiple demographics – doctors simply threw up their hands and decided, “don’t ask; don’t tell.” 
 
It is my opinion that, realistically, the federal government can no more prevent marijuana use among individuals with chronic pain than the local high school can prevent sexual activity among libidinous teenagers. 
 
Given that legalization of recreational marijuana is likely to become reality here in California, I offer the following comments/suggestions when patients ask about using it (from NetCE continuing education course #95170, Medical Marijuana and Other Cannabinoids, www.NetCE.com/MD16):
 
1.  Cannabis is available as a plant extract that includes multiple chemical compounds, several of which have medicinal/psychoactive properties.  Tetrahydrocannabinol (THC) is the primary psychoactive component, but multiple other chemicals contribute to the plant’s effects.  There is no “pharmaceutical grade” cannabis in the U.S., as the drug is neither standardized nor controlled.  Thus, dosing is always uncertain and the patient needs to pay attention to drug effects and control dosing based on effect with each purchase. 
 
2.  Most patients prefer to smoke Cannabis because smoking offers rapid onset of therapeutic benefit (seconds to minutes) and, with rapid onset, patients are able to control dosing so that they derive therapeutic benefit without excessive cognitive side effects.  Duration of effects is 2-3 hours. 

3.  Cannabis can be vaporized.  Onset of effect occurs between 30 and 60 minutes post inhalation and benefit lasts about 6 hours.  Given the reasonably rapid onset of benefit, patients are able to titrate dosage to maximize benefit while limiting side effects.
 
4.  Oral ingestion of cannabis provides substantially delayed onset of benefit (2-4 hours), making dose titration difficult.  The website Vault of Erowid offers the L.E.S.S. method (start Low.  Establish potency.  go Slow.  Supplement as needed) for using oral cannabis.   (https://www.erowid.org/plants/cannabis/cannabis_article1.shtml)
 
5.  Cannabis appears to be safe, particularly when compared with side effect and risk/benefit profiles of common pain management drugs, including opiates, tricyclics, antidepressants and anticonvulsants.  There have been no reported deaths from cannabis overdose. 
 
6.  Low dose use of cannabis can be associated with mild light headedness, dizziness, dry mouth, sedation, muscle weakness and palpitations.  Usually these resolve relatively quickly as the drug is distributed out of the circulatory system. 
 
7.  Risk of addiction or “amotivational syndrome” appears to be about 9%, similar to the addiction risk for opiate users. 
 
8.  Contraindications include personal or family history of schizophrenia, history of hypersensitivity to cannabinoids, severe cardiopulmonary disease, severe liver or renal disease, pregnancy or planned pregnancy, breastfeeding.  
 
Considerations on Proposition 64:  Marijuana Legalization
By Jeff Young, MD and Jan Lord, MD
 
ITEM 1:  Proposition 64 on this year’s November ballot legalizes marijuana for use by adults 21 or older, designates state agencies to license and regulate the marijuana industry, imposes state taxes on marijuana, establishes labeling, advertising and marketing standards and prohibits marketing and advertising directly to minors. 
 
ITEM 2:  On August 11, 2016, the Drug Enforcement Administration (DEA) announced that marijuana will remain a Schedule l controlled substance, meaning it has "no currently accepted medical use and a high potential for abuse." This keeps the drug in the same category as heroin, LSD and Ecstasy.  It also continues the current disconnect between federal and state law regarding marijuana use.  Despite the federal prohibition, at least 25 states and the District of Columbia have approved the use of medical marijuana for conditions ranging from epilepsy to arthritis. 
 
Huh? 
 
Background: 
Cannabis (marijuana) has been used as a psychoactive substance, generally for spiritual purposes, for thousands of years.  In 1839, it was introduced into the United States as a medicinal substance, useful as an analgesic, appetite stimulant, antiemetic, muscle relaxant and anticonvulsant.  It was prescribed routinely for those purposes, although there were unresolved difficulties with dose standardization and variability of response.  It was heavily taxed by the Federal Marijuana Tax Act of 1937 and then removed from the U.S. Pharmacopoeia in 1942.
In 1970, Congress passed the Controlled Substance Act signed by President Richard Nixon.  Drugs were classified by their potential for abuse and accepted medical use.  Marijuana was temporarily classified as Schedule 1 and subject to review.  The National Commission on Marijuana and Drug Abuse was created to further explore the scheduling of marijuana.  The commission opined that marijuana should not be legalized and recommended changes to federal law that would permit citizens to possess a small amount at a time.  Marijuana continued as Schedule 1, in part, because of concerns of what would happen if marijuana was not regulated closely.  The sentiment was best summarized by the 1974 testimony by senate committee chair Sen. James Eastland, D-Miss., “if the cannabis epidemic continues to spread at the rate of the post-Berkeley period, we may find ourselves saddled with a large population of semi-zombies – of young people acutely afflicted by the amotivational syndrome.”
 
In 1989, President Ronald Reagan declared a war on drugs and Marijuana was included.  The “three strikes” law was created making mandatory life sentences for repeat drug offenders. 
However, starting in the 1960’s scientific research pursued further understanding of Marijuana and it effects.  In 1964, the chemical structure of THC was identified and, subsequently, endogenous cannabinoid receptors were discovered.  From the 1970’s to 1990’s clinical benefits of Marijuana, including control of nausea and vomiting from chemotherapy and relief from the wasting syndrome associated with AIDS, were verified. 
 
Given Marijuana’s medical effective medical uses, in 1996, California passed, by popular vote, Proposition 215, the Compassionate Use Act.  Legalization of marijuana was born.  The Compassionate Use act allowed the use of marijuana for any illness for which marijuana provided relief.  In the ensuing years, further laws and court decisions further defined the intent of the vaguely worded Compassionate Use Act.  As a matter of policy, the court refused to place boundaries on the medical indications appropriate for the use of marijuana.  This led to the prescription of marijuana for any condition deemed appropriate by the prescribing physician. 
 
Pain control and opiate sparing has become a significant indication for medical marijuana.  Some opioid patients benefit from using medical marijuana for pain.  Others continue to complain of 8/10 pain and also use opioids.  If medical marijuana were so effective, why are opioids needed?  Patients have now gone the next step and obtained licenses to grow marijuana for personal use.
 
In 2003, Governor Gray Davis signed SB 420, the Medical Marijuana Protection Act, establishing a card identification system for medical marijuana.  The creation of this card imbued further credibility on the use of marijuana.  The subsequent prescribing habits of physicians writing for marijuana made it so that marijuana could be used for any condition deemed medical.  This resulted in there being an estimated one million medical marijuana cards being issued by 2015.  Other states followed California’s lead and, at last count, 25 states and the District of Columbia enacted laws to legalize medical marijuana.
 
At the same time, as of August 11, 2016, the Drug Enforcement Administration (DEA) re-visted and moved to continue marijuana as a Schedule l controlled substance, maintaining the drug in the same category as heroin, LSD and Ecstasy.  The FDA did recognize in their language the need for promoting future research in the uses and effects of marijuana.  Physicians and scientist recognize the paucity of persuasive research in the long term effects and clinical efficacy of marijuana.  Numerous studies exists that are lauded by marijuana proponents as conclusive evidence of the medically beneficial effects of marijuana.  However, these studies have been criticized for lacking the appropriate powering, participants and peer review generally accepted by the medical community.  The big difference from the 70’s was that the door was opened to allow further research into possible beneficial effect of marijuana.  Proponents of marijuana see this as golden opportunity to legitimize the use of marijuana.
 
What’s next?
 
Public sentiment in California has shifted from marijuana being stigmatized as a dangerous drug to being considered an herbal remedy with numerous health benefits.   Just about anybody who wants a medical marijuana card can go to a clinic and obtain one.  The doctors who do this vary from true believers in medical marijuana to doctors on probation with restricted licenses.  In any case, medical marijuana has established a firm foothold in California. 
 
With the stigma on marijuana decreased, marijuana proponents are now pushing to legalize marijuana for recreational use, taking marijuana pretty much along the same path as alcohol. In 2010, California voters narrowly defeated the attempt to legalize recreational marijuana with Proposition 19 by a vote of 53% to 46%.  However, Colorado and Washington took California’s lead and legalized recreational marijuana in 2012.  Oregon and Alaska followed in 2014.
 
This year, Proposition 64 is on the November ballot to legalize marijuana for use by adults 21 or older.  It designates state agencies to license and regulate the marijuana industry, imposes state taxes on marijuana, establishes labeling, advertising and marketing standards and prohibits marketing and advertising directly to minors.  Unlike prior ballot measures, not only does the proposition ask for the legalization of recreational marijuana, but it attempts to attract capitalistic opponents of marijuana by imposing potentially lucrative taxes on marijuana.  An interesting caveat not know by most voters is that the Internal Revenue Code does not allow deductions for taxes relating to Schedule I controlled substances.  There is already a proposed change in the Internal Revenue code to plug this loophole and allow deductions for the sale of Schedule I substances.
 
So as always, the solution for now is to vote, and vote your conscience.  I see the legalization of marijuana in a liberal state like California as an inevitability.  What we, as doctors, should prepare to do is to update our knowledge base on upcoming research on the effects on marijuana.  We can educate our patients.  But more so, we must formulate our own opinion and develop a comfort on the use of marijuana to prevent our patient from future harm.  We will need to decide if detecting marijuana on a urine drug screen is justification to discontinuing prescribing opioids.  We will need to reconcile with our patients why a legalized substance is prohibited by a drug agreement.  Just like seat belts and alcohol, we will have to warn our patients on the detrimental effects of using anything beyond moderation.
 

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