Lack of Quality Evidence Around Cannabis Use Complicates Patient Management in the Health-System Setting

As the use of both medical and recreational use of cannabis become more common with increased legalization of these products across the United States, new challenges continue to emerge, including relating to use of medical marijuana within health systems.

Pharmacists at the 2019 Annual American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting & Exposition gathered for a roundtable discussion on this subject, touching on an array of issues including policy confusions, the best practices to reduce stigma, and how to have discussions with primary care providers. 

Policy Complications

One pharmacist from the University of Las Vegas Medical Center said that some confusion exists at her hospital about defining those patients who are uing products that meet standards set for legal products. Herbal medications, she said, are not allowed. 

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Another pharmacist brought up the issue of responsibility for potential interactions with cannabidiol (CBD) use. At his health system, he said patients are allowed to use CBD, but it has to be pure, 100% CBD. If the product doesn’t meet that standard and the patient tests positive for THC, the clinician can be held accountable, since CBD and THC can effect patients differently.  

Discussions About Cannabis

Stigma regarding marijuana use was one of the most prominent issues the panel discussed at the roundtable. 

A pharmacist that works in an outpatient clinic at the VA said that she, the VA’s practitioners, and pharmacists always ask about other complementary therapies that the patients may be taking. Although she noted that she couldn’t be certain that people were telling the complete truth about their marijuana use, she said patients will often be open to the discussion of their cannabis and CBD use. She noted that she doesn’t necessarily tell her patients to stop using marijuana, but she does inform them that the healthcare industry does not have enough information on the contents of the products and that patients consequently need to use caution when using the products. 

As an example of the lack of awareness of interactions, she provided a case-based experience from her medical center, specifically, a patient prescribed an opioid who had tested positive for marijuana. The patient swore he was not taking marijuana, but indicated that he was using CBD oil. “Was it possible that the patient could test positive for THC while using CBD,” the physician asked? The pharmacist responded: yes. She then advised the physician and told the patient that the opioid prescription would stop. To resume treatment, the patient would need to return in a month after suspending use of CBD. 

Educating Patients

The roundtable panel agreed that patient education was needed on this topic.

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One pharmacist said that his health system had developed an FAQ brochure that addressed basic things patients should look out for such as drug interactions and adverse events. The brochure covers pharmacist and protects patients by ensuring that pharmacists are taking care of patients as best as they can, given the little amount of information currently available. 

The ASHP moderator said that they might look into developing a similar education leaflet and will possibly work to provide something similar on their website in the future. 

References:

Controversy in Cannabis: Cannabidiol Products and Health-System Approaches. Presented at ASHP Midyear Clinical Meeting & Exposition. December 8-12, 2019. Las Vegas, Nevada.