What Considerations Are There in Prescribing a Medical Cannabis Card?

Patient Presentation
A 19-year-old male came to clinic to request a medical cannabis card to help manage his pain from Crohn’s disease. He had not seen his regular physician in the past 2 years and was being managed by a gastroenterologist. He said his pain was not being controlled but had also not contacted his gastroenterologist about it. He used marijuana at least 2-3 times a week to help manage his pain and was unsure how long he had been using it. He was evasive about other medications he had tried or was currently using to manage his pain. He was not interested in talking about other aspects of his health. The pediatrician, who was not his regular pediatrician, tried to engage him in conversation about what he knew about the overall effects and potential side effects of marijuana and he became angry. “If you’re not going to give me the card, then I can just leave,” he said. She tried again to engage him in a discussion about the options for better pain management, he grumbled that he didn’t want to talk to a pain specialist and would bring it up with his gastroenterologist at his followup appointment within the month. He then got up and left.

Cannabis is a plant which has many pharmacologically active compounds with THC or tetrahydrocannabinol and cannabidiol (CBD) being the most studied. For this case, medical cannabis will be used to describe different forms of the plant used to pharmacologically treat a variety of medical conditions.

Medical cannabis has been proposed and mainly studied in adult populations. Qualifying conditions for use of medical cannabis in this author’s US state currently include: ”

  • Cancer – if the illness or its treatment produces one or more of the following: severe or chronic pain, nausea or severe vomiting, cachexia or severe wasting.
  • Seizures
  • Crohn’s disease
  • Chronic pain
  • Multiple [s]clerosis with severe and persistent muscle spasms
  • AIDS or HIV ….
  • Amyotrophic lateral sclerosis (ALS)
  • Parkinson’s disease
  • Post-Traumatic Stress Disorder (PTSD)
  • Any terminal illness with a probable life expectancy of under one year – if the illness or its treatment produces one or more of the following: severe or chronic pain, nausea or severe vomiting, cachexia or severe wasting
  • Ulcerative colitis
  • Severe, intractable pediatric autism with self-injurious or aggressive behaviors
  • Severe, intractable autism with self-injurious or aggressive behaviors
  • Corticobasal Degeneration

    Requirements are different depending on the state and jurisdiction. Generally to use medical cannabis a person must be certified by a healthcare provider as having a qualifying condition and need for the medical cannabis. This certification can be in the form of a medical cannabis card which allows the person to legally obtain and use cannabis for a period of time within a prescribed jurisdiction.

    Main adverse effects of medical cannabis include:

    • Addiction
    • Dizziness
    • Impaired judgement, memory, motor skills
    • Mental status changes – confusion, disorientation, hallucinations, sedation
    • Psychiatric conditions
    • Nausea and emesis

    Studies in the pediatric population are confounded by small participant numbers, lack of control groups, different cannabis forms and dosages and different ages studied. In pediatrics some of the most common use is for seizures, but also chronic pain and muscle spasms. CBD is the more common form of cannabis used for seizures. Epidiolex® is a liquid cannabis-derived medication that is FDA approved in the United States for the treatment of patients 2 years and older with Lennox-Gastaut syndrome seizures or Dravot Syndrome. During childhood, adolescence and young adulthood, the brain continues to grow and develop. In the pediatric population, studies have shown changes in brain volume, cognition, memory, and depression for adolescents who use cannabis. Therefore the American Academy of Pediatrics does not recommend using cannabis in the pediatric population.

    Learning Point
    Some considerations for a health care provider when providing a medical cannabis card include:

    • Local, state and federal laws need to be followed along with appropriate medical licensing.
      • Cannabis is a schedule I drug from the US Drug Enforcement Agency. Some laws may be legal in one location or venue but not another. Similarly, certain professionals may be allowed to complete the forms and others cannot.
      • Some health care providers may also be in the position to be asked to directly administer or oversee the administration of cannabis as well (e.g. a school physician or nurse).
    • Initial patient and family counseling and education, and administrative processes and procedures need to be complied with.
    • Ongoing monitoring and appropriate review and renewal of the medical cannabis card need to be complied with.
    • Determination if the patient has a qualifying condition and/or severity, etc.
    • Consideration of who is the appropriate professional to provide medical cannabis card? Who has the appropriate expertise and experience?
      • Most of the qualifying conditions are complex or a patient has a particularly intense disease course where specialty care and monitoring are necessary. Medical cannabis is not a first or second-line treatment generally.
        This does not mean that the primary care provider cannot provide the medical cannabis card for the patient, but often it would be the specialist who will have the most current knowledge about the specific condition and the patient’s clinical status regarding the condition.
        A primary care provider often will partner with the specialist and patient and family to identify who can/should provide the card for the family.
        This may be the condition specialist or it could also be another specialist such as a pain or palliative care specialist who can help provide overall care to the patient.
    • How many patients within the practice will want or need such a medical card? The administrative overhead for a single patient within a primary care practice may be resource prohibitive but an appropriate specialist likely will have more patients and it may not be resource prohibitive.
    • Is this an opportunity for the health care provider to expand their knowledge, expertise and scope of practice in this area and to effectively offer this service to this patient and potentially others as well?
      • What training would be required or wanted to provide this service?

    Questions for Further Discussion
    1. What laws affect medical cannabis use in your location?
    2. Why or why do you not prescribe medical cannabis cards for patients?
    3. What is the dose of CBD oil? A review can be found here

    Related Cases

      Symptom/Presentation: Pain

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Marijuana

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Academy of Pediatrics. Accessed October 19, 2021. https://pediatrics.aappublications.org/content/135/3/584

    Wong SS, Wilens TE. Medical Cannabinoids in Children and Adolescents: A Systematic Review. Pediatrics. 2017;140(5):e20171818. doi:10.1542/peds.2017-1818

    Russell K, Cahill M, Duderstadt KG. Medical Marijuana Guidelines for Practice: Health Policy Implications. J Pediatr Health Care. 2019;33(6):722-726. doi:10.1016/j.pedhc.2019.07.010

    Marijuana and the Pediatric Population. American Academy of Pediatrics. Accessed October 14, 2021. https://pediatrics.aappublications.org/content/146/2/e20192629.long

    The Office of Medical Cannabidiol – For Patients and Caregivers. Accessed October 19, 2021. https://idph.iowa.gov/omc/For-Patients-and-Caregivers

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa