Medical Marijuana

General Overview

  • Access to Cannabis for Medical Purposes Regulations (ACMPR) can access fresh or dried marijuana or cannabis oil
    • Requires healthcare practictioners to indicate the quantity (grams) of dried marijuana that they authorize for the patient and period of use
    • The licensed producer will then provide that quantity of fresh or dried marijuana or cannabis oil that is equivalent
  • Each provincial College has suggested guidelines and policies
    • Quebec CMQ physicians should not provide patients with a medical document to access medical marijuana unless part of a research project.
  • Sign a declaration rather than write a prescription
    • State that the patient meets Health Canada criteria allowing access to marijuana
    • Physicians cannot prescribe a drug without safeguards in place (evidence on effectiveness, safety, indications, dosing and precautions)

Factors to Consider

  • Evidence supporting analgesic effect of cannabis is weak
    • Trials of short duration, small sample sizes, incomplete outcome measures
    • Higher evidence for harm than for benefit
      • Adverse events include: CNS effects/confusion/sedation/"high"/dysphoria, speech disorders, dizziness, ataxia, numbness, impaired concentration or memory, hypotension, psychiatric, hallucination, psychosis
    • Smoked cannabis was compared against placebo (not other cannabis formulations or standard analgesics)
  • Smoke is a hazardous delivery system
    • Smoke contains chemicals potentially carcinogenic or harmful to heart or other organs
  • Cannabis can already be prescribed as
    • Oral capsule (Nabilone) - indicated for chemotherapy induced N/V
    • Inhaled spray (Sativex) - spasticity or neuropathic pain from MS or cancer

CFPC Recommendations

  • Some evidence are for refractory (third/fourth-line) chemotherapy induced N/V, spasticity due to MS or spinal cord injury, neuropathic or palliative cancer pain
  • No evidence for pain conditions such as fibromyalgia or low back pain
    • May only consider in neuropathic pain if failed to respond to standard treatments (adequate trial of pharmacologic, nonpharmacologic, and pharmaceutic cannabinoids)
  • Dried cannabis is NOT appropriate for
    • Anxiety/insomnia
    • Age <25yo
    • Personal or strong family history of psychosis
    • Active substance use disorder
    • Cardiovascular disease (angina, peripheral vascular disease, cerebrovascular disease, arrhythmias)
    • Respiratory disease
    • Pregnant, planning pregnancy, breastfeeding
  • Caution in patients with
    • Concurrent active mood/anxiety disorder
    • Smoke tobacco
    • Risk factors for cardiovascular disease
    • Heavy use of alcohol, opioids, benzodiazepines, or other sedative medications
  • Prior to signing a medical document authorizing dried cannabis for pain
    • Conduct a pain assessment
    • Assess for anxiety/mood disorders
    • Assess for substance use disorder
    • Inform of harm reduction startegies
  • Regularly monitor
    • Function, quality of life, pain relief
    • Misuse, abuse
  • Discontinue therapy if not effective or causing harm
  • Not be allowed to drive for at least 4 hours after inhalation, 6 hours after oral ingestion, 8 hours if experiences euphoria