April 20, 2018 By Fred Gardner.  The Medical Board of California (MBC) is meeting at the LAX Hilton today. There are two agenda items of special interest to cannabis clinicians and patients:

The board meeting starts at 9 a.m. and will be streamed live. Here’s the link to watch (and comment, if you are so moved). Igor Grant’s presentation  probably won’t start till 10 a.m.  It’s hard to predict how much time will be devoted to the preceding agenda items.

Grant and his colleagues at the Center for Medicinal Cannabis Research were the med board’s go-to experts when they were drafting their “Guidelines for Recommendation of Cannabis for Medical Purposes” last summer. The Guidelines were adopted by a unanimous vote of the board six months ago.

On April 6 the board posted a redline edit of the Guidelinesm which will almost certainly be approved at today’s meeting. The most significant change is a warning against marijuana use during pregnancy that will have real ramifications for countless thousands of pregnant women. (See note at bottom of article.)

The Guidelines effectively script what the doctor should tell the patient about cannabis. A  physician “should document a written treatment plan that includes

  • Advice about other options for managing the terminal or debilitating medical condition (pursuant to the Act conditions include cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis, migraine, or any other illness for which cannabis provides relief).
  • Determination that the patient with a terminal or debilitating medical condition may benefit from the recommendation of cannabis.
  • Advice about the potential risks of the medical use of cannabis and reminders to safeguard the cannabis, including but not limited to, the following:

•  The variability of quality and concentration of cannabis;

•  Cannabis use disorder (previously “The risk of Cannabis use disorder.”)

• Potential adverse events, such as exacerbation of psychotic disorder, adverse cognitive effects for children and young adults, falls or fractures, and other risks.

• Using cannabis during pregnancy or breast feeding (previously “The risk of using cannabis during pregnancy…”)  Please be aware that risks of cannabis use on a fetus or breast-feeding infant are unknown. The American College of Obstetricians and Gynecologists (ACOG) Committee Opinion (Number 722 – October 2017) states physicians should be discouraged from recommending cannabis for medicinal purposes during pregnancy and lactation.

•  The need to safeguard all cannabis and cannabis-infused products from children, pets, or domestic animals; and

• The reminder that the cannabis is for the patient’s use only and the cannabis must not be sold, donated, or otherwise supplied to another individual.”

Why the emphasis on harm?

Note that the doctor is not required to discuss dosing and the different effects of delivery methods —essential subjects that patients, especially new cannabis users, need to learn about. Thousands of California doctors are just beginning to approve cannabis use and will carefully adhere to the medical board Guidelines. They will tailor their interaction with patients to conform to the requirements of the treatment plan.

How much time will be left for useful information after the doctor has gone over the potential risks, variable quality and potency, cannabis use disorder, adverse events, no diversion, and most of all we’ve got to hide it from the kids?

The MBC Guidelines will guide the doctor-patient interaction away from the useful and towards the fearful.

Restoring the “Parental” Role

“Successful doctor-patient relationships are characterized by candor and trust,” Tod Mikuriya, MD, wrote soon after California voters legalized cannabis for medical use in 1996. “Removing the stigma of criminality promotes candor and trust.”

Mikuriya decried what he called the doctor’s “parental role” in the traditional doctor-patient relationship. The treatment plan  that the California medical board is pushing on cannabis-approving doctors re-establishes their “parental role.”  Mikuriya was writing in reference to patients substituting cannabis for alcohol, but his approach applies to pain patients seeking to reduce opiate use:

“Treating alcoholism by cannabis substitution creates a different doctor-patient relationship. Patients seek out the physician to confer legitimacy on what they are doing or are about to do. My most important service is to end their criminal status —Aeschlapian protection from the criminal justice system— which often brings an expression of relief. An alliance is created that promotes candor and trust. The physician is permitted to act as a coach —an enabler in a positive sense.”

The med board’s fear-inducing treatment plan re-enforces the notion of cannabis as a dangerous drug, easily abused. This inflated dangerousness is what “justifies” the complex, onerous regulations that politicians at the state and local levels have been enacting in California. The bureaucrats and law enforcers would not have been able to turn legal marijuana into a job creator and moneymaker for themselves if the medical establishment characterized its safety profile as relatively benign, akin to that of coffee.

The whole complex structure of marijuana regulation and taxation rests on its characterization as a dangerous drug by the medical establishment.

PS:  On March 2 the Journal of Drug and Alcohol Dependence published a study by researchers at the Centers for Disease Control and Prevention showing that marijuana use during pregnancy does  not lead to lower birth weight!