Marijuana in Your Clinic

Ready or not, here it comes.

By Anthony Sinacore, PT, DPT

October 2018

Marijuana. Cannabis. Weed. Grass. Whatever names are being used these days, these terms by themselves spark debate, and you have more than likely already made up your mind on where you stand on the topic.

In health care, the discussion regarding the benefits and harmful effects of marijuana-and-its-like substances (MLS) has lately come under the political spotlight, bringing a lot of controversy. Some of this controversy is founded on its limited evidence, while other arguments focus on its long-lasting “Schedule I” federal drug classification (i.e., high potential for abuse with no medical benefits). Sitting alongside cocaine, LSD, and heroin, a Schedule I label comes with a pretty daunting stigma. So with that I’ll ask, does it have any place in your physical therapy clinic? Maybe. Maybe not. But currently with over 30 U.S. states having legalized marijuana in some form, it’s probably going to show up whether you like it or not.¹ This article will discuss how you can be prepared for it when it does and why that might not be a bad thing after all.

First, let’s all get on the same page. I say “like substances” because there are hundreds of known compounds, called cannabinoids, in any given cannabis product, most of which have an array of effects on the body. For instance, THC (trans-delta-9-tetrahydrocannabinol), is the most widely known cannabinoid as it provides the psychoactive effects attributed to being “high.” But most plants also contain CBD (cannabidiol), a compound that has no psychoactive effects and interacts in other ways in the human body, such as in the stomach and intestinal tracts. CBD has been shown to counteract the psychoactive effects from THC. Hemp, for example, is a substance with such high CBD levels and low THC levels, that it provides no euphoric or psychoactive properties and instead is used for a variety of commercial and industrial products including rope, clothes, food, paper, and textiles.

Depending on what state you live in, some or all of these substances may be available for you or your patients to obtain legally. Some states have chosen to legalize MLS products for recreational use, with regulations similar to picking up alcohol from a liquor store. As it is still considered an illegal drug on the federal level, states have more commonly pardoned these products strictly for medicinal use, which requires a prescription by a physician for an approved condition. Other states have chosen to decriminalize but not legalize MLS to lessen the penalties associated with harsh drug and criminal justice policies.

Considering how slowly legislative changes occur on Capitol Hill, it is shocking to note that most of these laws have been made within the past 10 years. So for the majority of those reading this, that past decade marks only a fraction of your career, and I can see why some of the past generations continue with judgmental stereotypes, labeling users as stoners, potheads, dopers, and the like. Just realize, with added legalization comes more transparency. In legalized states, manufacturers, cultivators, and businesses are required to label the potency of each cannabinoid in every product. This helps reduce the risk of unnecessary and blatantly harmful chemicals, thus allowing the consumer to make a more educated decision on which to buy. This safety net is far different than how users in unregulated states must procure MLS (read: via the illegal market), relenting to the consequences of a product with unknown potencies and potentially harmful substances.

TIME FOR A CHANGE?

Every clinic I have ever worked in has handled MLS users the same way. They screen for illegal drug usage on the medical history questionnaire and when reviewing it with the patient, simply tag the drug of choice as marijuana. The therapist moves on to the next checked box on the questionnaire, as if this answer was dull and required no follow-up. Does this sound familiar from your experiences? As a student and then a clinician I witnessed how the information then became a topic of conversation with coworkers affirming why a patient wasn’t compliant with their home exercise program or why they were late to their appointment every week. The judging and the stigma continued, and it didn’t take long before I realized this labeling made me feel uncomfortable. I wanted to change this mindset and help destigmatize the drug that I had only heard positive anecdotes about.

So rather than trying to change the minds of all of my colleagues and clinic owners, likely resulting in some shaming directed toward myself, I started with the patient. I knew the best way to do this was to dive a little deeper during the intake questionnaire. Almost immediately I was second-guessing myself and moving out of my comfort zone. Was any additional information even necessary? Would they even tell me the truth? Then I realized that if they have already disclosed they use it, they are probably open for a light discussion regarding why. Plus we can’t help the individuals who choose not to divulge their medical/social history to us. So I came up with a list and started asking some intuitive questions: How frequently do you take marijuana? Do you use it for a specific medicinal or psychological reason or only for recreation? If just for recreation, what do you like about it? What is your typical medium of delivery (inhalation, ingestion, topical absorption)? The response was overwhelmingly positive. I quickly learned some simple truths that allowed me to gain a much higher level of appreciation for my patients, and just as I had expected, many of these people weren’t the so-called stoners we naively assumed. I learned that most MLS users have done their own research—obviously some more than others. For instance, I had a patient describe the differences between THC and CBD (before I even knew them myself) and recite why he chose a specific strain to help with his irritable bowel syndrome, which had minor psychoactive side effects that would affect his performance at work. Another told me that she “saw everyone and tried everything,” but MLS was the only drug that consistently helped her manage her anxiety and depression without ever having to worry about an unexpected episode or breakdown.

So let me ask you . . . since both of these examples were set in states that didn’t have legal medicinal marijuana at the time, should I have immediately told them that the law prohibits them from using this substance and they should find something legal to help them cope? Should I have told them that my clinic has a strict “no illicit drug use” policy and we will not be able to treat them? Well, yes, I probably should have, and it is our right to refuse services to anyone who doesn’t comply with our policies and procedures. Not to mention that along with holding a doctorate in physical therapy, we also have the knowledge to provide recommendations of a multitude of drugs that are relatively safe and FDA approved. But after learning all of that information about the patient, I had a tougher time showing them the door than empathizing with their situation. This not only helped build my rapport with these patients who could have easily written me off, as I once did to them, but soon our client–patient relationship grew. Believe it or not, they also began referring friends and family to me— individuals who didn’t necessarily use marijuana personally, but understood that I cared for their overall well-being and came “highly recommended.” That was a win-win and a terrific confidence boost.

Even a little extra questioning on the topic can have several benefits:

1. It helps you understand your patients better and why they might be using these substances. Not everyone wants to get high and sit on the couch eating potato chips and watching TV.
2. It helps reinforce that your clinic is nonjudgmental. This can help foster a relationship and help your patients and your employees have those harder conversations regarding drug use.
3. It helps facilitate destigmatization of marijuana within your community as its popularity steadily increases.

EDUCATE YOURSELF

Asking a few extra questions and treating a marijuana user with respect is a perfect way for you to start change within your clinic (it seems like common sense when I put it like that, eh?). But stopping there isn’t going to alter your clinical practice much. As its use and availability become more widespread, you will also need to familiarize yourself with MLS so you don’t get yourself into any trouble down the road.

For example, if a physician medically prescribes a beta-blocker to a patient of yours for the first time, you probably have a good understanding of how this medication could potentially change their hemodynamics and produce an altered heart rate. Knowing this, during exercise you may choose to closely monitor their nonverbal signs or use a self-reported rated perceived exertion (RPE) checklist to help oversee their cardiovascular response. Your patient education might consist of what to expect and how these measures will be used in conjunction with therapy to provide a maximal therapeutic benefit. Pretty common, right? So how would it change if the same physician prescribes MLS to a patient for his lumbar pain and then refers them to you? Our confidence in the reasoning for the prescribed drug shouldn’t change. A licensed physician is well trained and understands the physiological responses and side effects that are likely to occur based on this drug and their other medications.

But do you know how this substance might affect your treatment approach, as the beta-blockers did? Remember, we aren’t pharmacologists; we don’t need to know more than the basics of physiology and pharmacokinetics. But a simple literature search on PubMed can inform you that a natural biological system, called the endocannabinoid system, exists in the body which contains receptors for endogenous and exogenous cannabinoids to bond with. Yes, you read that correctly; aside from the exogenous plant-based compounds, the human body creates cannabinoids naturally, and the most famous is probably anandamide, a mimetic twin to THC, which is linked to that physiologic response known as the “runner’s high.”² Further, scientists have discovered two main receptors: CB1 receptors, which are found mostly in the central nervous system (CNS) and largely contribute to the psychoactive side effects when stimulated, and CB2 receptors, which are rarely within the CNS but exist in abundance within the gastrointestinal systems. CBD has been shown to bond to CB2 receptors, which is why studies have shown therapeutic benefits for systemic conditions.^3,4,5

In order to know how these substances will affect your treatment plan, it is imperative that you become familiar with the potency within MLS products. If you are unsure, have your patient bring in the label of the product or just call the referring physician and ask, as you would with any other medication. You’d be surprised how this simple phone conversation can help build an interdisciplinary relationship that can only benefit your patient and your base of knowledge.

LEGALIZED MEDICINAL USE

The list of qualifying health conditions for medical cannabis is steadily increasing depending on the state. These include, but are not limited to, conditions such as: epileptic disorders, cancer, HIV/AIDS, multiple sclerosis, amyotrophic lateral sclerosis, Crohn’s disease, Alzheimer’s disease, posttraumatic stress disorder, fibromyalgia, chronic pain, Parkinson’s, lupus, rheumatoid and psoriatic arthritis, and traumatic brain injuries.6 Notice anything about that list? Physical therapists either treat all of these conditions or the associated symptoms that result from them. However, this is almost always in conjunction with other health care practitioners or medications. It shouldn’t be far-fetched to believe that if you live in a state that has or is about to approve marijuana for medicinal use, that you’ll see MLS on your patients’ medication list in upcoming years. Like any other new treatment moving into popularity, that can have good and bad implications.

THE BAD

Let’s start with the bad and just get the facts out in the open. The federal government has banned any research on MLS from all institutions, private or public; limiting support from the National Institutes of Health or any other national funding source. While there is budding evidence about how MLS reacts via the endocannabinoid system, there is very little evidence supporting how these interactions affect our health, which leaves a lot of unanswered questions. What are the long-term implications of cannabis use? Does it affect infants, children, and adults in the same way? What about younger versus older adults? Should it be used regularly or in moderation? What balance, or potency, of cannabinoids provides patients with the optimal therapeutic benefit? As physical therapists, our profession prides itself on maintaining a high standard for keeping our treatments and recommendations evidence based. Unfortunately, until the federal government allows for institutionalized and government-backed research, this line of inquiry will be left under-explored.

THE GOOD

Migraines, nausea, psychosis, lethargy, irritable bowels, muscle spasms, spasticity, and (obviously) pain can really throw a wrench into your treatment plan and pose a challenge to participation in home exercise programs. MLS is often prescribed to counteract specific symptoms or side effects from other drugs, while producing minimal side effects of its own and offering fewer withdrawal symptoms.⁷ If MLS is used to lessen these effects, maybe your patient will tolerate treatment better, since the risk of negative effects from multiple medications will be minimized.

Another key distinction of marijuana is its potential for treating chronic pain. With the current opioid epidemic and drug-related overdoses at an all-time high, this issue has rapidly become the largest elephant in the largest room of health care, and the facts are hard to hide from. Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them and about 80 percent of people who use heroin first misused prescription opioids.^8,9 This is a key factor as to why every day more than 115 people in the United States die after overdosing on opioids.¹⁰

MLS may provide an answer to this problem. Between 2010 and 2013, physicians in states with medical marijuana laws prescribed 1,826 fewer doses of drugs per year to treat pain than in states without medical marijuana. There was also a drop in prescriptions for antidepressants, seizure medication, sleeping pills, anxiety medication, and anti-nausea drugs.11 Considering there has been no evidence of a single toxic overdose from marijuana, a case can be made for MLS to hit the medicinal mainstream.

References

¹ State Marijuana Laws in 2018 Map. Governing: The States and Localities; Data. www.governing.com/gov-data/state-marijuana-laws-map-medical-recreational.html. Published March 30, 2018. Accessed June 2018.

² Raichlen DA, Foster AD, Gerdeman GL, et al. Wired to run: exercise-induced endocannabinoid signaling in humans and cursorial mammals with implications for the ‘runner’s high.’ J Exp Biol. 2012 Apr 15;215(Pt 8):1331-1336. doi 10.1242/jeb.063677.

³ Lim MP, Devi LA, and Rozenfeld R. Cannabidiol causes activated hepatic stellate cell death through a mechanism of endoplasmic reticulum stress-induced apoptosis. Cell Death Dis 2011;. Accessed July 2018.

⁴ Naftali T, Mechulam R, Lev LB, Konikoff FM. Cannabis for inflammatory bowel disease. Dig Dis 2014;32:468-474.

⁵ Penner ElA et al. The impact of marijuana use on glucose, insulin, and insulin resistance among US adults. Am J Med 126 (7):583-589.

⁶ Qualifying Conditions for a Medical Marijuana Card by State. Leafly. https://www.leafly.com/news/health/qualifying-conditions-for-medical-marijuana-by-state. Published Oct 30, 2017. Accessed June 2018.

⁷ Reiman A. Cannabis as a substitute for alcohol and other drugs. Harm Reduct J. 2009;6:35. doi:10.1186/1477-7517-6-35.

⁸ Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569-576. doi:10.1097/01.j.pain.0000460357.01998.f1.

⁹ Muhuri PK, Gfroerer JC, Davies MC. Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Rev. August 2013.

¹⁰ CDC/NCHS, National Vital Statistics System, Mortality. CDC Wonder. Atlanta, GA: US Department of Health and Human Services, CDC; 2017. https://wonder.cdc.gov.

¹¹ Fewer annual drug doses in U.S. states with medical marijuana laws between 2010 and 2013, by drug category (prescribed per physician). Statista. 2018. https://www.statista.com/statistics/585119/fewer-annual-drug-doses-in-medical-marijuana-states/. Accessed June 2018.

Anthony Sinacore, PT, DPT, is a physical therapist at Action Potential in Glen Mills, Pennsylvania. He can be reached at jsinacor@gmail.com.