Medicinal Cannabis Case

Mrs. M.P.
Spinal Stenosis, Pain and Medicinal Marijuana
PSP Managing Pain Cases
Learning Objectives
1. Explain the physician’s role in the MMPR (Marijuana for Medical
Purposes Regulations).
2. Describe a professional and responsible way to excuse yourself
from that role if you are uncomfortable.
3. List resources you can access to assist you and the patient.
4. Provide a rationale for the exploration of cannabis as a
therapeutic agent.
Physician’s Role in MMPR
1. Canadian Federal Law prohibits the possession and use of
cannabis, which is punishable by imprisonment.
2. The Canadian Charter of Rights and Freedoms guarantees
every citizen both liberty and security of the person.
3. The Courts recognize that possession and use of cannabis
may be pivotal for security of the person in certain medical
circumstances, and therefore
4. For Canadians in those circumstances, prohibition is
contrary to their Charter Rights, and the Government is
required to provide a process to exempt them from
Physician’s Role in MMPR
5. The ensuing Government Regulations (Marijuana for
Medical Purposes Regulations (MMPR) place responsibility
for deciding which patients are medically qualified to be
exempt from prohibition in the hands of Health Care
6. Physicians have the option (according to Regulatory
Authorities) personally to decline accepting that role.
7. A physician who supports a patient's qualifying to use
cannabis for medical purposes must specify "the daily
quantity of dried marihuana to be used by the patient” in
If you are uncomfortable….
 How could you professionally and responsibly excuse yourself?
› From discussing it
› From supporting an exploration or application for exemption
Some suggestions:
 “Physicians are advised by the College of Physicians and
Surgeons that they should not prescribe any substance for their
patients without knowing the risks, benefits, potential
complications and drug interactions associated with the use of
that agent. Currently, that caution includes marijuana in its
smoked form. Because I am not versed in the evidence related to
marijuana use, I do not feel comfortable supporting your use of it.”
Some suggestions
 “According to Health Canada, dried marijuana is not an approved
drug or medicine in Canada, and the Government of Canada
does not endorse the use of marijuana.”
 “I respect the Government’s position on this, and am
professionally not comfortable to discuss this with you.”
Some suggestions:
 “If you still feel it may help you, I can assist you to find a physician
who is more conversant with the issues related to medicinal
marijuana. “
Other suggestions:
Case Description
 83 yr. old widow in assisted living
 Has close relationship with daughter nearby who comes to
medical appointments
 Spinal stenosis – clinical and imaging
 Constant pain in both legs / some back pain
 Sleep disturbed – wakes q2h with pain
 Mood low
 Mild Cognitive Impairment
Case Description
PHQ-9: 13 (moderate depressive symptoms)
GAD-7: 9 (mild anxiety symptoms)
Opioid Risk Tool: 1 (low risk)
Brief Pain Inventory:
› Pain Scores: low 4, high 7
› Pain Interference from BPI: 44/70
Case Description
Referred to spinal surgeon – non operative
Tried epidural steroid – did not help
Tylenol – 1000mg TID – modest benefit of back pain
Gabapentin titration to 300 mg bid – modest benefit
 Remains moderate – severe pain, with poor sleep
Case Description
 Medical history:
› Right THR 2009 – status good
› Partial Colectomy 2012 for cancer – no recurrence
› Hypertension
› Mild cognitive impairment
 Medications:
› HCTZ 25 mg od
› Atenolol 50 mg od
› Gabapentin 300 bid
› Metoclopramide 10mg od
Case Description
Opioid trial: Informed consent.
Oxycodone 2.5-5 mg q4h prn
Gradually progress to 10mg Oxycodone CR q8h
Pain control 50% improvement
Reports sleep improved
Constipation controlled with daily laxative
Overall satisfied
Case Description
One year later returns
Opioid still working but feels overall pain control diminished.
Sleep deteriorating again
Worried about being on opioids
Brings up query regarding medical cannabis instead of opioid
Next Steps
 How would you proceed?
Next Steps
1. Respectfully decline to engage in the conversation or support
the patient further.
2. Engage in discussing medicinal cannabis but decline to support
an exploration of usage or application for an exemption.
3. Engage in discussing medicinal cannabis and supporting an
exploration of usage and application for exemption.
Learning Objectives Recap
1. Explain the physician’s role in the MMPR (Marijuana for Medical
Purposes Regulations).
2. Describe a professional and responsible way to excuse yourself
from that role if you are uncomfortable.
3. List resources you can access to assist you and the patient.
4. Provide a rationale for the exploration of cannabis as a
therapeutic agent.
Resources you can access
1. Practitioners for Medicinal Cannabis
1. Pose a question :
2. Join the group
3. Look for a physician for referral
Refer to the Medicinal Cannabis Resource Centre (
Canadian Consortium for Investigation of Cannabinoids
Health Canada Document on Medicinal Cannabis
College of Family Physicians of Canada
Resource document created by Dr. Pam Squire
Sample Informed Consent Document
Provide a Rationale for Cannabis as Therapeutic
1. There is a sound scientific basis for how cannabinoids and
cannabis-derived medicines might affect a number of medical
2. There is historical evidence of a wide safety profile for cannabis,
there having been no deaths attributed to overdose.
3. There are convincing anecdotal reports of medical benefit, but
limited high quality clinical data to assess benefits and risks of
cannabis used for medical purposes.
Considerations in the “exploration” of a trial
1. There is no standardization of the composition of plant-based
cannabis products available.
2. Cannabis contains 60+ cannabinoids
THC (delta-9 tetrahydrocannabinol)
CBD (cannabidiol)
Are two important ones, with different medical effects
The “entourage effect” of the components acting in concert is
postulated as an explanation for why the plant appears to be
more effective than single components or pharmaceutical
Considerations in the “exploration” of a trial
3. Response to medicinal cannabis is unique to the individual and
will vary with the patient’s sensitivity, tolerance to side effects,
medical condition, severity of symptoms, cannabis strain used,
and route of administration.
4. Possession and use of cannabis remains prohibited for
Canadians in general. The exemption for medical purposes is
the only avenue of access to a legal supply of cannabis. Many
Canadians use it for other than medical purposes.
5. The patient may already be well informed about the
aforementioned statements, and possibly have some personal
experience of the medical effects of cannabis.
Moving Forward
 “I feel that medicinal cannabis may be an option in your
treatment. I’d like to discuss with you some of the risks and side
effects so that you and I can explore whether this is a good option
for you.”
 “If it appears to be a good option for treatment, we’ll set functional
goals for you, ensure that there are no drug interactions to be
concerned about with your other medications, and explore how
we might introduce a trial of cannabis.”
Follow up
 Mrs. Gilron started with cannabis capsules from compassion club
at dose of 0.25 grams q8h – a “low” THC variety
 She reported improved sleep with 7 hours continuous
 Pain subjectively better
 No side effects so far
 No feeling ‘high” or distorted reality
 Saw cardiologist pre trial – who was unconcerned
 BP and HR remained stable
Follow up
 Continued use of oxycodone CR 10 mg q8h
 Advised to reduce to 10 mg bid
 Increase cannabis to 0.33 mg q8h
 Contracted flu, hospitalized, vomiting.
 No cannabis for a week
 Restarted with cannabis lozenges (0.25 grams, q8h)
 Stabilizing after flu
 Evaluation of the “exploration” is ongoing.