Side effects: Medical community dealing with benefits, issues surrounding cannabis
As soon as State Question 788 passed in 2018, a team from OU Medicine went to work.
"We realized that we needed to have a structure around medical marijuana to educate providers and effectively respond to patients," said Dr. Lynn Mitchell, chief medical officer of OU Physicians, the state's largest physicians group.
What should those doctors tell patients seeking advice about cannabis as a treatment?
"We want everyone to have a basic knowledge around medical marijuana — where to find out more information, who to call, those kinds of things — because we certainly owe that to our patients," she said.
A 30-member committee dived into the many issues surrounding medical marijuana — legality, provider education, research, insurance, operations, communications and more — so OU Medicine could develop a plan and a policy.
Mitchell said they started with this guiding principle: "All provider-based recommendations of medical marijuana use are based upon peer-reviewed, evidence-based medicine and to advance research related to medical marijuana."
They investigated what other states and other academic medical centers were doing.
"There is some evidence behind using marijuana for certain conditions, although it's relatively limited because of the fact that marijuana still remains a Schedule I drug and is not looked at as a legal medicine," Mitchell said.
The U.S. Drug Enforcement Administration puts marijuana in the same category as heroin, LSD and ecstasy.
"We put together a list of potential scenarios where medical marijuana might be helpful for our patient population, never initially as a first-line approach, but when other things have been tried," Mitchell said.
They came up with a limited set of diagnoses and a limited set of specialists who could recommend medical marijuana. "We started with some of our neurology specialists, some of our palliative care specialists, some things that are pretty common uses in the literature to support, like chemotherapy-induced nausea, some of those diagnoses," she said.
The policy allows the addition of diagnoses as new literature and research supports it.
To be a recommender, OU system doctors must complete two required courses — a one-hour general training about medical marijuana and its use, and a three-hour training that goes into the OU policy and the law.
"We're trying to get that general level of knowledge out to all of our physicians across the practice because there will be — and there have been — individuals come in who have had a recommendation from another physician that is seeking care from us," Mitchell said.
The policy requires a doctor who recommends medical marijuana to review potential risks with the patient. The patient must sign a form acknowledging there are certain risks and there is a lot that medical science doesn't know yet know about the drug.
"We've got a few providers who are interested in being recommenders, but very few," Mitchell said. "There was a handful of providers that really stepped up and said, 'If this is going to happen, I feel like I need to be the one that's advising my patients. I owe that to them because they've entrusted their care to me.'"
As of last week, 364 doctors completed the basic training and three have completed the additional three-hour training.
Despite the relatively few physicians from the state's largest network preparing to be recommenders, plenty are making recommendations.
Hundreds of physicians are pre-registered with the Oklahoma Medical Marijuana Authority to recommend marijuana to patients. More than 250 are listed publicly online at the OMMA website, and 170 chose to register but not be publicly listed.
'Another tool we can use'
After medical marijuana became legal in Oklahoma, some patients told Dr. Johnny McMinn they've been using it for years.
"It helped them get through their treatment," said McMinn, a medical oncologist with Integris Cancer Institute of Oklahoma.
Patients report marijuana helps them deal with pain, nausea, loss of appetite, sleeplessness and anxiety associated with their cancer and cancer treatment.
More patients are asking about it now, many in their 70s and 80s, McMinn said. Other times, he is the one to suggest it might help.
"Patients aren't offended when I bring it up, even church-going people in the Bible belt," McMinn said. "It's a big positive. It's another tool we can use."
It also is easily misused, he said.
Unlike other medications, doctors don't prescribe marijuana. They can recommend it to a patient and fill out a physician recommendation form that allows the patient to get a license from the Oklahoma Medical Marijuana Authority.
"I'm not a big fan of the form," McMinn said. It includes a place for the doctor to list the medical conditions the recommendation is based upon, but filling out that section is optional. A recommendation without a diagnosis code is just an opening to recreational marijuana, he said.
"There are places out there that give my profession a bad name ... an assembly line handing out forms for every headache or hangnail," McMinn said.
License-holders can purchase medical marijuana from any dispensary. Since they have no prescription, what they buy and how much they use is up to them.
"There are dispensaries on every corner. I'm sure there are good ones and bad ones," McMinn said.
Some of his patients are not getting good advice on dosing from knowledgeable people; they can end up "stoned" by using the suggested dose.
"I tell them to undershoot it by half and then build up if they need to," he said. "There's a lot of trial and error. That makes me uncomfortable."
Acquiring the license is a hardship for older patients who are not tech savvy, McMinn said. The application and payment must be done online. It involves uploading a photo and documents, which some patients don't have the knowledge or equipment to do.
"The state needs to assist people to make it easier," he said.
One important benefit is medical marijuana provides a way to treat pain other than opioids, McMinn said.
Patients with neuropathy — a burning sensation in hands and feet — may have to deal with pain permanently. The condition is a side effect of chemotherapy, which often continues after treatment ends and the cancer is gone, McMinn said.
Many patients can reduce the number of opioid pills they take by using medical marijuana, he said. It can pose a financial hardship, however, since marijuana is not covered by insurance.