Presentation Transcript

1. Eve Gilron Spinal Stenosis, Pain and Medicinal Marijuana PSP Managing Pain Cases April 30, 2014
2. Learning Objectives Explain the physician’s role in the MMPR (Marijuana for Medical Purposes Regulations). Describe a professional and responsible way to excuse yourself from that role if you are uncomfortable. List resources you can access to assist you and the patient. Provide a rationale for the exploration of cannabis as a therapeutic agent.
3. Physician’s Role in MMPR Credit: @Matt Cornock flickr.com
4. Physician’s Role in MMPR Canadian Federal Law prohibits the possession and use of cannabis, which is punishable by imprisonment. The Canadian Charter of Rights and Freedoms guarantees every citizen both liberty and security of the person. The Courts recognize that possession and use of cannabis may be pivotal for security of the person in certain medical circumstances, and therefore 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.
5. Physician’s Role in MMPR 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. Physicians have the option (according to Regulatory Authorities) personally to decline accepting that role. 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.
6. If you are uncomfortable…. How could you professionally and responsibly excuse yourself? From discussing it From supporting an exploration or application for exemption
7. Some suggestions: “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.”
8. Some suggestions “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.”
9. Some suggestions: “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. “
10. Other suggestions: ?
11. Case Description 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
12. Case Description 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
13. Case Description 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
14. Case Description 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
15. Case Description Opioid trial: Informed consent. Oxycodone 2.5-5 mg q4h prn Gradually progress to 10mg Oxycodone CR q8h Pain control 50% improvement Reports sleep improved Constipation controlled with daily laxative Overall satisfied
16. Case Description 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
17. Next Steps How would you proceed?
18. Next Steps Respectfully decline to engage in the conversation or support the patient further. Engage in discussing medicinal cannabis but decline to support an exploration of usage or application for an exemption. Engage in discussing medicinal cannabis and supporting an exploration of usage and application for exemption.
19. Resources you can access Practitioners for Medicinal Cannabis Pose a question : pmcaccess@gmail.com Join the group Look for a physician for referral Refer to the Medicinal Cannabis Resource Centre (mcrci.com) Canadian Consortium for Investigation of Cannabinoids (ccic.net) Health Canada Document on Medicinal Cannabis Resource document created by Dr. Pam Squire Sample Informed Consent Document
20. Provide a Rationale for Cannabis as Therapeutic Discussion.
21. Provide a Rationale for Cannabis as Therapeutic There is a sound scientific basis for how cannabinoids and cannabis-derived medicines might affect a number of medical conditions. There is historical evidence of a wide safety profile for cannabis, there having been no deaths attributed to overdose. 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.
22. Considerations in the “exploration” of a trial There is no standardization of the composition of plant-based cannabis products available. 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.
23. Considerations in the “exploration” of a trial 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. 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. The patient may already be well informed about the aforementioned statements, and possibly have some personal experience of the medical effects of cannabis. 
24. Moving Forward “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.”
25. Follow up 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
26. Follow up 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.
27. Learning Objectives Recap Explain the physician’s role in the MMPR (Marijuana for Medical Purposes Regulations). Describe a professional and responsible way to excuse yourself from that role if you are uncomfortable. List resources you can access to assist you and the patient. Provide a rationale for the exploration of cannabis as a therapeutic agent.