Physicians are held in very high esteem in our society thanks to their dedication to ensuring the health of our population. They show their dedication through completing a rigorous education and taking the Hippocratic Oath to do no harm. The minimum educational requirement for a general practitioner involves 4 years to obtain a bachelor’s degree, followed by 4 years of medical school. Upon graduation physicians are required to complete a 3-year residency. If the physician would like to be a specialist, they will also complete 1 year of internship prior to their residency. During this training, physicians finely tune their skills for using their medical expertise to treat a wide range of disease conditions. Realizing their medical decision making will have a direct impact on numerous people’s lives, physicians are dedicated to continually achieving advanced comprehension regarding how the human body optimally functions. Suffice it to say that physicians are extremely well educated & have a thorough understanding of disease conditions and their treatments. We place our lives and the lives of our loved ones directly into their hands as we trust the system that has been put in place for developing their expertise.
Medications traditionally go through the FDA approval process for specific conditions and uses. However, after a medication’s introduction to market physicians often use their training to determine that the medication may also effectively treat another condition or symptom. This practice is known as “off-label” utilization. Once this approach has been successful and is able to be duplicated the physician will consult with their peers and share information regarding the potential for treating the condition or symptom. As physicians continually seek to educate themselves this information is readily disseminated within their network. Over time if this use continues to be successful, the off-label use of that medication becomes standard medical practice. This does not change or effect the original FDA approved use the medication has been assigned, unless the FDA is further petitioned. Regardless, it is routine for healthcare providers to prescribe a medication for an unapproved use so long as during their medical decision making they have determined that the medication is appropriate for their patient.
Many of these medications may have a very low therapeutic index (TI). Therapeutic index is a numeral rating system that translates to the relative safety margin of a medication. It refers to the range between therapeutic effect and toxicity. This ratio is calculated by comparing the median lethal or toxic dose to the median effective dose. The lower the TI, the closer the effective dose is to also being a toxic or lethal dose. This information allows us to understand the safety margins of medications. Ideally a wide safety margin is desirable and will often prompt a physician to utilize one medication over another.
Armed with this information, it would be prudent to examine the medicinal applications of cannabis. The TI for cannabis is extremely high; or in other words, cannabis has a very wide margin of safety. Comparing the TI of common over the counter medications with cannabis is very insightful when determining if cannabis should be considered a viable treatment option for a range of disease conditions. Acetaminophen, otherwise known as Tylenol is commonly used, and has a low therapeutic index of (less than) <3 due to the increased risk it presents for severe liver damage and various other gastrointestinal issues even when taken in amounts near the recommended dosage. In contrast, the therapeutic index of cannabis has been determined to be (greater than) >1,000. This is a stark contrast in terms of relative safety.
After examining the off-label usage of medications and the wide margin of safety of cannabis it is appropriate to examine the regulations concerning disease conditions that qualify a patient for medical cannabis treatment. In every aspect of our medical treatment we differ to a physician’s expertise and we trust them to make sound decisions for our individual healthcare needs. However, the regulations concerning medical cannabis prohibit a physician from exercising their medical decision making and limit them to recommending cannabis only for approved disease conditions.
The FDA allows a physician to utilize medications that are potentially far more harmful than cannabis for conditions those medications were not approved for through off-label use. It seems intrusive into the practice of medicine, and counterintuitive to prohibit a physician from including cannabis in their plan of care for a patient when the benefits of cannabis therapy appear to outweigh the risks. This is especially so when considering that these condition lists were arrived at through regulation and not through the course of clinical decision making. It is reasonable and helpful to have a specific condition list to help guide physicians as to which conditions cannabis is known to successfully treat. It is equally reasonable to allow physicians to recommend cannabis as a treatment option for any condition they determine cannabis may help improve, much like off-label use of other medications. Simply put; let physicians decide.
Maggie Fauver, RHIT