Medical Cannabis

Welcome to our new residents and new subscribers–our tiny community grew by 3 people this past week–a record!

Medical cannabis1I use the term “cannabis” instead of “marijuana” because of the latter’s xenophobic and racist associations. might seem to be an odd choice of topic with which to lead off the year, but the above Fresh Air segment is a great interview by the great Terry Gross and packed with issues relevant to neurology. The interview is with Dr. David Casarett, director of hospice and palliative care at Penn. He recently published a book arguing in favor of cannabis’s legitimacy as a medicine, particularly for neuropathic pain.

The discussion of the current evidence (and lack thereof) supporting the use of cannabis for various conditions is informative. One detail of interest to neurologists is the fact that cannabis actually contains many different cannabanoids, of which tetrahydrocannabinol (THC) is only the best-known. Another one, cannabadiol (CBD), may actually be the more medicinal chemical, and one not encumbered by psychotropic properties. CBD has been in the news lately because of anecdotal reports that it has greatly helped some children with Dravet syndrome, a devastating epileptic encephalopathy. Here in Wisconsin, and some other states as well I believe, the legislature recently amended the law to specifically exclude CBD from the class of banned cannabanoids and allow its prescription for the treatment of epilepsy. Other states have approached the issue more broadly, passing “Right to Try” laws to make it easier for terminally ill patients to access non-FDA-approved drugs; see here and here.

About 20 minutes in, the interview turns to a discussion of the ethical decisions facing the physician whose patient asks for advice about cannabis. Excepting the non-psychoactive CBD for the treatment of epilepsy, cannabis remains illegal in Wisconsin and illegal at the federal level as well–the DEA classifies it as a schedule 1 substance, meaning that it is dangerous and has no medical use whatsoever. Assuming for the moment that you find the evidence supporting cannabis’s efficacy for, say, neuropathic pain convincing, would you be willing to counsel a patient about that evidence? Would you countenance his use of the drug? It can’t be prescribed in the usual sense of that term, but would you be willing to write a letter for the patient, attesting that the drug is medically indicated? And perhaps most vexing of all, suppose medicinal cannabis were legal in your state of practice but still illegal at the federal level–would you be willing to prescribe it then?

There are other such dilemmas facing the contemporary neurologist. It is legal in five states for physicians to aid their terminally ill patients in suicide2Here I stick with the familiar term, which I think accurately describes the act and does not connote any moral valence. In my view, “Aid in dying” is what we neurologists do for our terminally ill patients quite regularly and doesn’t capture the intent of the act the way “suicide” does. “Death with dignity” is just a euphemism. but the official American Academy of Neurology position is that member neurologists are ethically prohibited from participating in such. If you lived in Oregon and a patient, terminally ill with glioblastoma, requested your aid in suicide, would you offer it? Another example: Wakefulness-promoting drugs such as modafinil are FDA-approved for narcolepsy. If a healthy person were to consult you out of a desire to improve his work or school performance, would you prescribe it if asked?

Finally, I thought that the discussion of hospice and palliative care is quite germane to the neurologist, especially the incoming resident. What I didn’t appreciate until I actually entered practice is that in a sense, all neurologists are palliative care physicians. Think about how many conditions we treat that are frequently fatal:

  • Malignant brain infarction
  • Intracranial hemorrhage
  • Brain tumors
  • Refractory status epilepticus
  • Encephalitis
  • ALS
  • Alzheimer’s disease
  • Traumatic brain injury

And that’s just the primary neurological diagnoses–we consult on many other patients with a wide range of terminal illnesses from cardiac arrest to metastatic cancer to malignant edema from acetaminophen overdose. I went into vascular neurology because of my preference for acute care and the satisfaction that comes from (occasionally) effecting with thrombolytic therapy an amazing turnaround in someone’s neurological condition. But what I’ve learned is that the most important thing that a vascular neurologist does–the most important thing that any neurologist does–is to help patients and families not cure but rather manage their neurological conditions in such a way as to preserve, to the greatest extent possible, the quality of their lives. Not infrequently, this means (and here I think the term is apt) aid in dying. To the new physician, it may be puzzling that aiding our patients in the dying process is not only a major, but also a potentially rewarding, aspect of neurology for patient, family, and physician. But it is, and Dr. Casarett makes the case well.

Notes / References   [ + ]

1. I use the term “cannabis” instead of “marijuana” because of the latter’s xenophobic and racist associations.
2. Here I stick with the familiar term, which I think accurately describes the act and does not connote any moral valence. In my view, “Aid in dying” is what we neurologists do for our terminally ill patients quite regularly and doesn’t capture the intent of the act the way “suicide” does. “Death with dignity” is just a euphemism.

About Justin A. Sattin

I'm a vascular neurologist and residency program director. I created this blog in order to share some thoughts with my resident and other colleagues, and to foster my own learning as well.
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