Tackling the Tough Questions of Medical Marijuana
Many of you need no introduction to Aaron Boster, MD, because he makes his rounds outside of the clinic on social media via Twitter and Facebook, and has an amazing YouTube channel of over 100 easy to digest videos explaining multiple sclerosis and its symptoms. He is recognized among his peers as one of those young, up and coming neurologists who is making an impact on their field through his advocacy work in patient-centered care and his research. If you don’t already follow this approachable doctor, you should consider it.
As full disclosure up front, Dr. Boster is also my first and only MS neurologist. He was the person who gave me the official news I have MS; he is my go to person for personal care, and he also makes himself available when I want to discuss issues that affect the MS community and get accurate answers.
Straight talk about prescribing medical marijuana
Recently, I dropped him a text asking how he and his practice are going to handle the change to the cannabis laws in Ohio; after a two-year implementation period, medical marijuana becomes ‘legal’ in September 2018. Not surprisingly, instead of texting a reply, he immediately called me so we could talk in depth. It seems this is a topic he is passionate about, yet he remains conflicted on how to best handle requests for medical cannabis in his practice.
With his permission, I share keys parts of our conversation about this topic. There are multiple points he thinks must be considered, and he began with the topic of employment.
Employment and cannabis use
“If they had written the law differently, the human being would be protected,” said Dr. Boster, “but as it is the Ohio law gives no protection to people who are working and also use medical cannabis.” Employers have the right to hire, fire and deny benefits if injured on the job to anyone who has a legal prescription for cannabis, as clearly outlined in Medical Marijuana and its Impact on BWC, an advisory notice from the Ohio Bureau of Workers Compensation.
“It has been proven that cannabis can help with pain and spasticity, but cognition is an invisible symptom of MS, and we have proven that cannabis worsens cognition. By someone using medical marijuana to manage pain and spasticity, we might hurt their cognition without it being overtly obvious. They could lose their job because we contributed to them not thinking clearly. Studies show if you smoke a joint there is a lasting residual effect and you don’t think as clearly two weeks later,” said Dr. Boster.
What is in that cannabis?
He also raised the question of the safety profile of cannabis.
“If I prescribe you Lyrica, I know the pharmacological compounds. I know how it works. I know its interactions with other drugs, and I know the safety profile. There is a lot of reassurance how that medicine plays out in your body. This is not the same for cannabis, and is why I say it is not a medicine,” said Dr. Boster. He pointed out that there is no way to study a plant that is grown in non-controlled conditions and processing for medical cannabis is not overseen by any agency such as the Food and Drug Administration.
It is hard to understand or rationalize why state and federal laws don’t align and are in such conflict, even after cannabis has been legalized in so many states. Dr. Boster said this fact is not lost on providers, either.
On a professional note, Dr. Boster worried aloud about physicians who prescribe cannabis and what that might mean for their practice and their medical license. “Cannabis is not federally legal, the clinician might risk his license because in the current political climate, if the winds change the recommender might face a lot of uncertainty. Even in a stable political climate, the provider could risk his medical license if there are changes to the laws that place the responsibility of using marijuana on the prescriber and something goes dramatically wrong with the patient user.”
All of this, said Dr. Boster, “puts the provider in a precarious position and inadvertently the patient in a precarious position. Knowing there is some benefit but also risk in many areas, the default is to not participate (as a cannabis prescriber). We are still literally grappling with this in our practice. Maybe if, you have refractory neuropathic pain that hasn’t responded to other drugs, and you are not working and you are not driving… then maybe cannabis is the right choice. But that’s not the life of the majority of the patients we see in the clinic.”
I commented that most people with MS want to be out in the world, working and functioning like other people.
Issues of liability
“Let’s say I give you a medical cannabis prescription card and then something went wrong while you were driving, or you lost your job due to cognitive decline or worse, I would feel horrible,” continued Dr. Boster, “and the liability laws could hold me responsible. When I write that prescription for the cannabis card, I have no control of what you buy and how you use it.”
Dr. Boster noted they believe about 25% of the patients seen in his clinic use marijuana in some form to help with their MS. “Am I critical of them? No. I am also not comfortable with giving everyone a medical card to buy cannabis.” He said each request for a cannabis card will be handled individually and will include some serious conversations between himself and the requester.
More complicated than it seems
“At first, it is easy to be excited about the prospect of prescribing medical cannabis because we know there can be benefits, but all of these concerns take the wind out of your sail quite a bit,” said Dr. Boster. “As your doctor, I assume a degree of responsibility for your wellbeing. That can’t be glossed over. There is an oath to protect my patients associated with this profession that I take seriously.”
The issues around medical cannabis for the prescribers are more complicated than I initially thought, and all that I have learned as Ohio enters this next step of legalized medical marijuana brings many more questions than answers.
Wishing you well,