Although medical marijuana has been legal in the Twin States for several years, physicians and other medical providers are still figuring out how best to counsel patients who are using cannabis products to treat a wide variety of symptoms, ranging from anxiety to chronic pain.
And the questions from patients are increasing as CBD — shorthand for cannabidiol, a substance derived from cannabis for medicinal treatment — can be readily found on store shelves and online, and as recreational marijuana use was recently legalized in Vermont. But because marijuana is a Schedule I substance at the federal level, it has no currently accepted medical use, and the Federal Drug Administration has not approved it for use under medical supervision.
Medical providers in both Vermont and New Hampshire are left to answer patients’ questions about cannabis products without guidance from the FDA. They also are doing so in an ever-changing market and regulatory environment.
This dearth of information means people like Patricia Eames, who sells CBD products at her Clover Gift Shop in Woodstock, are fielding phone calls from people seeking advice about the various forms of CBD — which include oils, gummies, salves, creams and drinks — as well as how much to take and when to take it.
“I think it would be helpful for doctors to at least learn a little bit about it,” said Eames, who takes CBD to help manage her anxiety.
Though people frequently ask her how to use CBD, Eames said she cannot provide that advice. Instead, people have to try the products to find out what works or doesn’t work for them, she said.
“I’m not a doctor,” she said. “I’m not a nurse. I’m a gift shop owner with an interest in CBD.”
Because patients are using cannabis and its derivatives as medicine and recreationally, providers from the academic medical centers in both states are seeking to help other providers understand what is and isn’t known about cannabis, its risks and its medicinal uses.
In a grand rounds presentation at Dartmouth-Hitchcock Medical Center in Lebanon in January, “Cannabis and Opioids in Pain Management: Alternatives? Complements? Pipe Dream?,” Kathleen Broglio, a palliative care nurse practitioner, and Dr. Seddon Savage, who specializes in anesthesiology and pain medicine, provided clinicians with an overview of what is known and not yet known about how cannabis can be used to help manage pain.
Similarly in response to demand from providers, the Vermont Academic Detailing Program is launching a session on cannabinoids this summer. The academic detailing program, based at the University of Vermont, brings physicians and pharmacists to primary care practices throughout the state for small group sessions to discuss the state of the science on various topics. Though still under development, this session will include information about medical marijuana and CBD, and cover the risks and benefits of various options.
Though more research is needed to better understand how chemicals — including THC, which has psychotropic effects, and CBD, which does not — from cannabis plants might be used for medicine and what the risks of that use might be, the current state of the evidence, as outlined in a 2017 report by the National Academies of Sciences, Engineering and Medicine, indicate that cannabis products can be helpful with chemotherapy-induced nausea and vomiting, chronic pain and multiple sclerosis-related spasticity, which is feelings of stiffness and involuntary muscle spasms.
“For these conditions, the effects of cannabinoids are modest; for all other conditions evaluated, there is inadequate information to assess their effects,” the report said.
Negative effects of smoking cannabis include chronic cough and phlegm production, according to the National Academies report.
Smoking cannabis during pregnancy is linked to lower birth weight babies and may contribute to an increased cancer risk for children of women who smoke marijuana while pregnant, according to the report. The Centers for Disease Control and Prevention recommends that pregnant women avoid cannabis during pregnancy.
In addition, frequent cannabis use can increase the risk of developing a substance use disorder, the report said. Cannabis use affects people’s ability to operate motor vehicles and can cause memory impairment for the 24 hours following use. It can increase the risk of developing schizophrenia and other psychoses, and it may worsen the symptoms of bipolar disorder. It may be associated with one type of testicular cancer.
Given what limited information is available about benefits, risks and proper dosing, Broglio said in a recent phone interview that she first works with her patients to find drugs that have been approved by the FDA.
But sometimes that fails, Broglio said, pointing to examples such as patients struggling with cancer-related anorexia. In those cases, Broglio counsels patients who ask about medical marijuana and have the money to try it — which can run up to $500 per month — to be very clear with the people at the dispensary about which symptoms they are trying to treat.
In both states, medical providers do not prescribe medical marijuana. Instead, they sign off saying that a patient has a condition that qualifies them to carry a card allowing them to purchase marijuana from a licensed dispensary. When patients come to her asking about medical marijuana, Broglio said she feels it is her responsibility to counsel them in how to describe their symptoms to dispensary operators so they have the best chance of finding a suitable product.
She guides her patients through safe use strategies, and warns them not to drive while using medical marijuana, or to share it with others, especially children. Sharing medical marijuana with others is illegal.
She urges her patients to avoid edibles — food or candy made with marijuana — because they’re slower to take effect and may cause patients to take more than intended.
She counsels them not to purchase marijuana on the black market because it can be difficult to know the source and may be laced with other drugs, including methamphetamine.
Some providers, however, say that trying out different strains and dosages of a medication until patients find something that works for them isn’t so new.
“People tend to think the medical field is an exact science, and it’s not,” said Lisa Withrow, a palliative care nurse practitioner based in Bedford, N.H.
If, for example, Withrow prescribes oxycodone to a patient who has never had it before and that patient vomits, Withrow would switch the prescription to something else.
“(You’re) still going to go through that guinea-pig phase to try it and see what works,” Withrow said.
Other medications also come with warnings. If Withrow prescribes a patient a muscle relaxant, she warns them that it might make them sleepy and that they should keep it away from children.
Withrow advises her patients to read labels and trust the source of their product, whether it’s medical marijuana, which is state-regulated, or CBD, which is not state- or FDA-regulated and can be readily purchased over store counters or online.
“You need to get it from a reliable source,” she said.
But what is a reliable source of CBD?
“Huh, that’s the tough part,” Withrow said. “They have to research (it) themselves. I’ve researched some brands. I certainly can’t research them all.”
One happy CBD user — and retailer — is Rachael Hene, of Sharon. She has post-traumatic stress disorder and fibromyalgia, and finds that taking a tincture of CBD under her tongue twice a day alleviates symptoms such as anxiety and pain. It also helps her sleep. If she has flare-ups of pain in her hands, she applies a CBD salve that relieves the pain in about 15 minutes, she said.
“I can’t believe how much this helps,” Hene said.
She has found so much relief using CBD that she and her partner Andrew Switz have founded a CBD company, RopaNa. They sell their products, which include CBD from Colorado, at 30 retail locations and online.
Hene said it took some trial and error to find a dose and form of CBD that works for her, and she and Switz regularly field calls from people asking about dosage. She said they suggest people start with a low dose first.
Cannabis doesn’t work for everyone, however. Cheryl Hodgdon, of Croydon, obtained a medical marijuana card in hopes that it would give her relief from pain stemming from arthritis and Crohn’s disease.
She found the people at the dispensary helpful in sorting out what strains of marijuana might help with her pain, but found that it compromised her ability to operate her sheep farm and train dogs.
The marijuana “numbed me out to the point I couldn’t work,” she said.
She called it a “$400 boondoggle.”
Broglio and some of her colleagues recently reviewed their clinic’s records and found that more than one-quarter of the patients treated in the ambulatory palliative care clinic at Dartmouth-Hitchcock Medical Center in Lebanon are using either medical or recreational marijuana, and they are often doing so without medical oversight, according to an article published in the Journal of Palliative Medicine last month.
“Our patients are using cannabis,” said Broglio, one of the paper’s authors. “If we didn’t think they were using cannabis, now we really know they’re using cannabis.”
But, they said in the paper, “further research into its efficacy, side effects, and safety is needed.”
Nora Doyle-Burr can be reached at firstname.lastname@example.org or 603-727-3213.