First Do No Harm – A Commentary on Medical Cannabis Use in Canada

Working in ER I am blown away by many things. The number of Tylenol, NSAID, Opiod and Benzo overdoses have been skyrocketing year after year. The amount of overdoses in seniors over 60 and teens from age 10 – 18 is heartbreaking. None of these medications have the packaging, warnings and restrictions that cannabis does. Further, we give amphetamines to kids (for ADHD) and wonder why the rate of amphetamine abuse has skyrocketing. II understand there’s no research to confirm this, but clinically I see it. Cannabis use recreationally has never been a problem in ER. No one dies from cannabis overdose unless it is laced with something else such as fentanyl. In fact cannabis is one of the safest recreational products especially when compared to alcohol. It was used prior to the 20th century “war on drugs” for many medical indications such as epilepsy, menstrual cramps and chronic pain.

Chronic pain is probably one of the main reasons patients come in ER. Patients of all ages have chronic pain caused by previous injuries, spinal stenosis, fibromyalgia, arthritis, diabetic neuropathy, chronic abdominal pain due to IBS and other unknown causes. These can be the most difficult things to treat in medicine. Often these patients are on multiple medications including opiods, SSRIs, gabapentin, pregabalin in addition to NSAIDs and tylenol. Despite these combinations, they are a revolving door in the ER, often on disability or welfare non functioning with decreased quality of life unable to participate in what is important to them. They are often hesitant to ask about cannabis. Some of them even use it unofficially. In my ER we are “cannabis friendly”. I ask about it’s use and if patients are interested in exploring it. The response is overwhelmingly positive. When patients have tried every option available in traditional medicine, it is unethical in my opinion to withhold cannabis. Often these patients start cannabis and all the other meds including opioids fall off one by one and they become functional both in their families and communities again. It’s rewarding to watch.

Over the last 2 yrs my hospital has been open to me offering cannabis consultations in hospital and often I will offer a trial of medical cannabis to chronic pain patients who come through the ER multiple times. Most of these patients are blown away that I would offer them a trial of cannabis and once I start to work with them, inevitably they go off all of their pain medications (even though I specifically tell them not to) and manage their pain with some form of oral cannabis. I literally see their ER visits drop to almost zero. What is more important is that I see people go back to functioning. They go back to work and are able to attend family functions and their kids football games. I have never seen anything more rewarding. When people find out that our hospital is “cannabis friendly” they are blown away and it changes the whole physician/patient relationship. What’s more is that I work in a very conservative mennonite community. THe results of cannabinoid medicine in my community in all ages have been amazing and this has paved the way in decreasing the stigma and allowing us to authorize in hospital. We even have local pharmacies that facilitate deliveries to the hospital for admitted patients. Amazing.

In searching for position/guiding statements related to cannabis in Canada, I found this quote by the CMA in January 2018 prior to recreational legalization. “The CMA believes that once the Act (Cannabis Act) and regulations are in force, there will be no need for two systems. Cannabis will be available for those who wish to use it for medicinal purposes, either with or without medical authorization, and for those who wish to use it for other purposes. The medical profession does not need to authorize use once cannabis is legalized, especially given that cannabis has not undergone Health Canada’s usual pharmaceutical regulatory approval process, and its anticipated removal as a controlled substance from the Controlled Drug and Substances Act” (CMA position statement, January 2018).

Although this is an old statement now, it has not been revised and I can say confidently that the statements here were not accurate. Medical cannabis in Canada needs to have a place for many reasons. We now know that there are many dangerous drug interactions when one combines cannabinoids with benzos, blood thinners and other medications that go through the P450 cytochrome system of the liver. Since recreational legalization, I have seen patients go to their family physician or specialist requesting a trial of CBD/cannabinoids and refused. Often they are told to “go down the street to the dispensary”. This in my opinion is unsafe and due to the knowledge available now, it is a huge mistake and can be a huge source of litigation for physicians given the fact that patients are asking to access cannabis safely with a physician who knows their medications and history. Cannabis is also more complex than that. They need help to navigate it for medical purposes and there is a need for physicians in this space who can help.

In my practice, I have provided a consult service for other physicians to help bridge the gap between medical cannabis and physicians who prefer not to authorize. In my opinion, medical cannabis has become complex as we learn about the entourage effect provided by the accessory terpenes, cannabinoids and flavonoids in each product. Personally I had to learn this first hand. My son was on a full spectrum product that brought his seizures to an abrupt halt. He went from seizing 3-5x/hr despite multiple hospital visits per week, often not leaving and multiple anti epileptic medications. I then tried to find a Canadian product but every isolate I tried resulted in him seizing day 3-5 and back to square 1. I then connected with a group in BC and went to visit. They took me through the plant growing, extraction and everything involved in making cannabis oils. I was amazed. It was the terpenes and accessory cannabinoids that made the difference. Each time I switched back to the full spectrum product the seizures stopped. This experience was the first step in my educational journey and influences my practice with the patients I see of all ages. Cannabis has become a specialty. It is a powerful medication and if used appropriately can have astounding effects in treating many conditions traditional medicine has failed to do. Because of this it is unethical to withhold cannabis to a patient who wants to explore it for medical purposes. As a physician I am to “do no harm”. Witholding a potentially life saving treatment especially in epilepsy is doing harm. That’s the bottom line.

Bill C-45: The cannabis act:

Proposed approach to the Regulation of Cannabis