Judith Paice, an expert on cancer-related pain. discusses what can go into obtaining medical marijuana.
Judith Paice, PhD, RN
Judith Paice, PhD, RN
Although medical marijuana is now available in states across America, the environment surrounding its use to treat pain and other symptoms continues to be associated with misconceptions—even stigma—making the process difficult to navigate for both healthcare practitioners and their patients
In this interview, Judith Paice, PhD, RN, an expert on treating cancer-related pain, discusses the process of obtaining cannabis for medical use, as well as its cost and benefits for patients with cancer. She is currently a research professor of medicine (hematology/oncology) at the Feinberg School of Medicine at Northwestern University. Paice co-chaired an expert panel of the American Society of Clinical Oncology which recently released a new clinical practice guideline for adult cancer survivors living with chronic pain.
What are some of the common misconceptions that people have around medical marijuana?
Paice: There is often an assumption that this is somehow more potent than what is available on the streets or somehow more effective than what is available through other, illicit means. In actuality, it is fairly similar to what is obtained on the street. The advantage is clearly that this would be unadulterated, and so it is definitely a preferred method of obtaining the product if people think that this is something that might benefit them.
It's also amazing how many people think that medical marijuana is covered by insurance. They make that assumption because it's medical, but it's actually not covered.
What is the cost like for these patients?
It varies from state to state. As you know, this is still a schedule 1 narcotic, and so federally, it's still illegal. That's important for people to know. People can't take it across state lines. If they were found to have the drug in 1 of those states where it's not legal, it is a federal offense. People don't understand that because they think, "Gee! I got it from a medical dispensary!" It doesn't matter.
The cost is somewhat comparable to what people would be paying for the illicit marijuana. It's generally a couple hundred dollars a month.
What is the process like to get the prescription and then the actual product?
Since it is a federal offense, the doctors don't actually prescribe it. In states where it is “legal,” if you will, the physician typically certifies the patient. What that means is they're certifying that the patient has one of the diagnoses approved in that state. Cancer is clearly at the top of the list. Physicians certify that the patient has that disease and, in their best judgement, could benefit from the palliative use of marijuana and also that the provider has a sustained relationship with that patient. This is not someone who just set up a booth somewhere and is signing off for people they don't know.
Once certified, the patient fills out a form, the doctor has to fill out a form, and all of that information goes to the state. In different states there are different requirements. For instance, some states require a patient to get fingerprinted or have a passport photo. The patient also has to identify a dispensary, and they have to keep going to that same dispensary. I'm often telling people, "Check out the dispensaries. Which ones are easily accessible you, and which ones have the products that you think may be more useful to you."
Then patients get a card from the state and that card has the dispensary listed on it. That serves as their "prescription," though technically, they don't actually have a prescription. Patients can then go to the dispensary with this card and get their supply of marijuana.
There's so much fear and concern right now. With the opioid epidemic receiving so much media attention, people are worried that if we make these compounds more accessible, we're going to have the same diversions as with opioids. It's hard to predict what's going to happen.
With all of the red tape involved to obtain this product medically and legally, do you see many people just going on the streets to illegally buy marijuana?
Yes. They're either buying it themselves or borrowing it from friends to determine if it is really helpful before they go through the time and expense. There is a delay. In Illinois, it's taking about 4 to 8 weeks to get the authorization card.
What are the different forms in which you could get medical marijuana, and what are the adverse effects?
What about the patient who has lung cancer and says, "Oh my gosh, I never thought I would smoke?” Well, once you do get the phytocannabinoids, the plant product, here's the deal: you can either smoke it, you can ingest it, and then there are the oils. Some people rub the oils on the skin, but there's no data whatsoever about that. And, with ingesting it, again, no data.
Let's focus on smoking and eating. As an oncology nurse, I never thought I would encourage someone to smoke, so I get where that patient is coming from, but when you smoke marijuana, you get a much more rapid response. People get plasma levels in 2 to 10 minutes. What patients tell me is that they'll smoke and then after just 1 or 2 puffs, they feel better. Their anxiety is reduced, maybe they can relax and sleep a little bit, and some people may even get a little pain control. It happens quickly, and they don't even have to smoke the entire joint or whatever they're smoking.
But when you eat the product, like a brownie or candy bar, for example, the time to get that response is 1 to 6 hours. There have been some very kind of amusing, but also cautionary editorials. One was in the New York Times, where a columnist went to Colorado, 1 of the 4 US states where it's [legal for] recreational use. She had a bite of a candy bar and didn't feel anything, so she took another bite, and after about an hour she could barely walk, started to pant, feel paranoid, and hallucinate. This had been reported, in Colorado, in particular. With ingestion, in particular, the onset is so delayed that it's difficult to titrate the dose. So with adverse effects, that's where we're seeing them.
What is medical marijuana currently being used to treat?
My general perception in talking with patients who are using it is that it does help with anxiety, mood, sleep, and relaxation. For others it helps with pain and even appetite. Those are the 2 side effects I most commonly see people using medical marijuana for.
I think what's most intriguing, and this is in the laboratory only, it's not really moved into whole human models yet, is that it does look like it alters inflammation and immune responses. This means it might be helpful for people with autoimmune disorders. Future research will help clarify that for us.
What tips or advice would you give to someone considering medical marijuana?
When you are inhaling a joint, for example, you are getting a whole lot of other products. We don't know their mechanism of action. What I do recommend for folks who are thinking of using this product and inhaling is that they use a vaporizer, which will significantly help reduce the amount of other unknown substances entering the body. Patients can find those on the internet.
For a clinical review of marijuana for oncology patients, click here.