Doctors shouldn't be scrutinized

Here's another excellent article from Jenna, posted on Huff...
The last paragraph is a beauty.
I hope Conroy reads Huffington Post

http://www.huffingtonpost.ca/jenna-valleriani/marijuana-prescribing-doctors_b_5511692.html

Health Canada has recently announced a proposed amendment that will require licensed producers (LPs) under the Marijuana for Medical Purposes Regulations (MMPR) to submit information about doctors who are prescribing cannabis to provincial medical licensing authorities on a semi-annual basis. It costs the industry an estimated $400,000 to prepare and send the records annually. This also includes information about dosage and period of use. Each province has their own regulatory body, such as The College of Physicians and Surgeons of Ontario, which has the power to issue certificates of registration to doctors, allowing them to practice medicine, as well as conduct discipline hearings when doctors have committed an act deemed as "professional misconduct".

Although The Canadian Medical Association (CMA) is not a governing body, it does advocate on behalf of its members, as well as provide 'leadership and guidance' to physicians. The CMA has been upfront about their lack of support for cannabis as a medicine, cautioning doctors about prescribing until proper clinical trials have been conducted. Health Canada have themselves often referred to cannabis as a drug without proper scientific evidence or trials, yet has done little to assist this research over the last decade. If it was difficult for patients to find a signing doctor under the old regulations, you can bet this new amendment, if implemented, will effectively discourage a large number of doctors from prescribing cannabis.

I suspect this is most likely an attempt by Health Canada to get itself out of hot water with the CMA. As the largest professional organization of doctors in Canada, it has been upfront about its disapproval concerning their new role as the sole gatekeepers to medical cannabis access in Canada under the MMPR. Rather than patient applications for federal authorization being processed through Health Canada, the patient now brings their one page medical document directly to a licensed producer -- an aspect of the MMPR praised for easing up an onerous application process. Although the CMA has been rather relentless in their rigid (and frankly outdated) view of cannabis as a medicine, it also points to the fact that it's not just the patients who are unhappy with the new regulations. The proposed amendment is most certainly one step backwards for the MMPR, furthering the difficulty of access and the stigmatization of not only cannabis as a medicine, but the patients themselves.

The emerging industry is doing a lot to move medical cannabis towards normalization and professionalization, while simultaneously working to push forward education, research and development. These proposed amendments will place the few signing doctors under close scrutiny, and, I suspect, discourage others all together. Many industry stakeholders' recent comments have highlighted the notion that doctors should have nothing to hide, supporting this more rigorous regime. Nevertheless, we would be delusional to believe that these doctors will not face additional scrutiny, and possibility disciplinary action if it crosses the arbitrary threshold of what the provincial bodies may consider "too much" in both numbers of prescriptions or individual dosages. Even if regulatory bodies do nothing to follow up with doctors on prescriptions, the mere fact this proposed amendment exists is enough for many doctors to close their doors on the idea entirely.

In my opinion, this isn't about the "integrity" of the program, but rather another backhanded attempt to further de-legitimize the traction cannabis has been gaining in Canada and to appease the powerful institutions that surround federally authorized access. Although Health Canada projects growth from 40,000 to 400,000 legally authorized patients, now seems like a right time to ask if the MMPR actually does anything for the "illusion of access" cited as a major problem under the old regime.

This blog previously appeared on Lift.

I hate this new requirement. but, umm, $400k annually to submit patient records?

More like $500 worth of programming for each LP. The data is already in their system. If this feature cannot be added EASILY, then the LP is using the wrong software...

Not to mention that...

DOCTORS WERE THE "GATEKEEPERS" UNDER MMAR TOO!!!

DOCTORS WERE THE "GATEKEEPERS" UNDER MMAR TOO!!!

DOCTORS WERE THE "GATEKEEPERS" UNDER MMAR TOO!!!

But of course, the Doctors wouldn't just hand over patient information for free all willy nilly. But for a price......................... Good post leaf, glad to see some people in the media are expressing legitimate concerns and not just continuing to write LP porn articles which verbally felate and massage the ego's of LP's which frankly, have had a ABYSMAL results thus far in terms of product they deliver. Makes me wonder if any of these news outlets are aware of offerings from places like Tweed so far. I bet if they Saw what was sent to Johny not ONCE but TWICE they may chime up a bit more.

The fact of the matter is that nobody can get a prescription for anything without a doctor signing for it. The CMA told HC that they wanted nothing to do with this program. I guess they didn't believe them. It is bullshit though. Unless a doctor is doing harm they should be able to do right by their patients without fear of repercussions.

Did anyone look at the pics at the bottom? Notice the girl with the beautiful long hair and her head in the garden? And is Tweed being across the street from the cops supposed to be intimidating?

imo all these fucks need to pull there heads out there assholes and stop thinking like harper or that they are gods. they neeed to grow some balls and do what is right.

rnr said:

imo all these fucks need to pull there heads out there assholes and stop thinking like harper or that they are gods. they neeed to grow some balls and do what is right.

Click to expand...

Unfortunately that's the hardest thing to do for some folks, usually due to how people will perceive them for choosing to do so.

The Canadian Consortium for the Investigation of Cannabinoids (CCIC) has so much information. How can other doctors not be on board?

http://www.ccic.net/index.php?home&lng=en

Found this last night, shows how much homework has been done to be published.

Early release, published at www.cmaj.ca on June 23, 2014. Subject to revision.

Meldon Kahan MD, Anita Srivastava MD


Health Canada’s Marijuana for Medical Purposes Regulations took effect Apr. 1, 2014. Patients are now able to purchase dried cannabis from a licensed distributer if they have a physician’s prescription specifying the daily dose and monthly quantity. Although cannabis may be prescribed for any condition, we have focused our comments on chronic pain, which is the most common reason for medical marijuana use.

The Canadian Medical Association, the Col- lege of Family Physicians of Canada and the Federation of Medical Regulatory Authorities of Canada have all opposed the new regulations because of the lack of evidence on the safety and efficacy of smoked cannabis. Their concerns are justified: only five randomized controlled trials of smoked cannabis have been conducted, rang- ing in duration from 1 to 15 days, with a com- bined total of 182 participants.1 Smoked canna- bis was compared with placebo rather than other treatment modalities. The trials found that it was superior to placebo in the management of neuro- pathic pain associated with HIV infection, multi- ple sclerosis and surgery.1

Smoked cannabis has short- and long-term safety risks. Smoking is an uncontrolled delivery system that rapidly produces high plasma levels of delta-9-tetrahydrocannabinol (THC), the pri- mary psychoactive ingredient of cannabis. A sys- tematic review of controlled trials of cannabis preparations, including synthetic oral formula- tions, reported increased rates of altered percep- tion, motor function and cognition,2 which could cause functional impairment with long-term use. Smoking cannabis has been associated with an increased risk of motor vehicle crashes, schizo- phrenia, mood disorders and addiction.3,4 Obser- vational studies have shown that the risk of these outcomes is higher among those under 25 years old and those who have a current or past history of psychosis or substance use disorder.3

Moreover, combustion of dried cannabis pro- duces hundreds of toxic products, some of which

are carcinogenic. Although previous studies have had conflicting results, a recent large, long-term retrospective cohort study has shown that smok- ing cannabis is associated with an increased risk of lung cancer.5 There have been case reports of younger adults experiencing acute coronary events shortly after smoking cannabis.6 Vaporiz- ing produces much lower concentrations of exhaled carbon monoxide than smoking, but smoking remains the most popular delivery route.

Canadian physicians will be asked by patients to prescribe dried cannabis for chronic pain, despite its safety risks and weak evidence of effi- cacy. We therefore urgently need prescribing guidelines to help us understand the evidence, to counsel our patients and to know when and how to prescribe cannabis.

The guidelines will need to define the indi- cations, precautions and contraindications for smoked cannabis. Based on the limited controlled trials, the only clear indications for its use are neu- ropathic pain conditions and spasticity associated with multiple sclerosis.1 It might also be consid- ered for palliative care and for severe biomedical pain conditions such as rheumatoid arthritis.1 In all cases, smoked cannabis should be reserved for

Key points

Competing interests:

The authors have received honoraria from Reckitt Benckiser, makers of Suboxone (buprenorphine– naloxone).

This article has been peer reviewed.

Correspondence to:

Meldon Kahan, [email protected]

CMAJ 2014. DOI:10.1503 /cmaj.131821


2 CMAJ

And

Commentary

CMAJ

Debate: On the one hand ...

New medical marijuana regulations: the coming storm

• The only clear indications for medical marijuana are neuropathic pain conditions and spasticity from multiple sclerosis.

• Before smoked cannabis is prescribed, all patients should have an adequate trial of standard analgesics and synthetic oral or buccal cannabinoids such as nabilone.

• Smoked cannabis is not indicated for common pain conditions such as fibromyalgia and low-back pain and is contraindicated in patients under 25 years of age and those with a current substance use disorder.

• Physicians should review strategies for harm reduction with patients who currently smoke marijuana, such as not smoking daily, not mixing with alcohol or sedating drugs and not driving after smoking.

• Dried cannabis should be titrated to a dose that is effective for pain while minimizing intoxication and cognitive impairment. We suggest a maximum daily dose of 400 mg of dried cannabis; the prescription should specify that the producer supply a strain with no more than 9% THC.

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.

© 2014 Canadian Medical Association or its licensors CMAJ 1

Commentary

patients whose pain does not respond to standard analgesics or pharmaceutical cannabinoids. Two pharmaceutical cannabinoids available in Canada are nabilone, an oral product, and nabixamols, an oral–buccal preparation. Both are safer and have greater evidence of efficacy than smoked cannabis. For example, in an experimental study, dronabinol (an oral cannabinoid not available in Canada) had an equal intensity and longer duration of analgesia than smoked cannabis for cold-induced pain in healthy volunteers.7 Contraindications to and pre- cautions for smoked cannabis would likely include young age, a history of psychosis or substance abuse, and a history of poorly controlled mood or anxiety disorder.

These indications and contraindications will exclude many people who are current medical marijuana users. Most of them have common pain conditions such as fibromyalgia and back pain,8 for which there is little evidence of benefit from smoked cannabis. One study found that patients with fibromyalgia who used medical marijuana were more likely than others with fibromyalgia to have current unstable mental ill- ness and substance use disorders.9

The guidelines will also need to recommend a dose that has been shown to be effective for neu- ropathic pain but does not cause cannabis intoxi- cation. One controlled trial found that 25 mg (roughly equivalent to one inhalation) of 9% THC relieved neuropathic pain and caused minimal intoxication.1,10 The duration of analgesic action of smoked cannabis is probably about three to four hours. In our view, the maximum safe dose, there- fore, would be about one inhalation of 9% THC four times daily, or 400 mg of dried cannabis per day. (Health Canada allows prescriptions of up to 5 g/d.) Physicians should specify on the prescrip- tion that the THC concentration not exceed 9%. Licensed producers are marketing strains contain- ing 15%–25% THC or higher. Such potent strains are neither necessary nor safe; acute cognitive effects of cannabis are related to the THC dose.

Patients who request cannabis should be assessed for problematic use of cannabis and other substances. Cannabis use disorder should be suspected in patients who are heavy daily smokers, who spend large amounts of time and money on smoking, and who have impaired work or school performance or dysfunctional social relationships. Other features of cannabis use disorder include repeated attempts to quit or reduce use, and risk factors (young age, concur- rent anxiety or mood disorder and misuse of other substances).

Patients who use cannabis recreationally should be advised of strategies to reduce exposure to cannabis smoke and to reduce the harms of cannabis intoxication.3 Strategies include not smoking daily, not holding one’s breath when inhaling, using a vaporizer rather than smoking, not adding tobacco to cannabis cigarettes, not mix- ing cannabis with alcohol or sedating drugs and not driving for at least six hours after use. High- risk groups, such as adolescents and patients with substance use or psychiatric disorders, should be advised to smoke only occasionally or not at all.

Some current medical marijuana smokers will be dissatisfied with the physician’s decision not to prescribe cannabis if it is contraindicated or not indicated. The best strategy for dealing with patient disagreements is to stick to unambiguous and hon- est messaging: “I am not comfortable prescribing smoked cannabis because it has little evidence of efficacy for your condition and considerable evi- dence of harm.” Physicians should advise patients with a suspected cannabis use disorder to abstain from cannabis and should refer them for treatment.

References

1. Controlled Substances and Tobacco Directorate. Information for health care professionals: cannabis (marihuana, marijuana) and the cannabinoids. Ottawa (ON): Health Canada; 2013.

2. Martín-Sánchez E, Furukawa TA, Taylor J. et al. Systematic review and meta-analysis of cannabis treatment for chronic pain. Pain Med 2009;10:1353-68.

3. Fischer B, Jeffries V, Hall W. et al. Lower risk cannabis use guidelines for Canada (LRCUG): a narrative review of evidence and recommendations. Can J Public Health 2011;102:324-7.

4. Kalant H. Adverse effects of cannabis on health: an update of the literature since 1996. Prog Neuropsychopharmacol Biol Psychiatry 2004;28:849-63.

5. Callaghan RC, Allebeck P, Sidorchuk A. Marijuana use and risk of lung cancer: a 40-year cohort study. Cancer Causes Control 2013;24:1811-20.

6. Singla S, Sachdeva R, Mehta J L. Cannabinoids and atheroscle- rotic coronary heart disease. Clin Cardiol 2012;35:329-35.

7. Cooper ZD, Comer SD, Haney M. Comparison of the analgesic effects of dronabinol and smoked marijuana in daily marijuana smokers. Neuropsychopharmacology 2013;38:1984-92

8. Aggarwal SK, Carter GT, Sullivan MD, et al. Characteristics of patients with chronic pain accessing treatment with medical cannabis in Washington State. J Opioid Manag 2009;5:257-86.

9. Ste-Marie PA, Fitzcharles MA, Gamsa A, et al. Association of herbal cannabis use with negative psychosocial parameters in patients with fibromyalgia. Arthritis Care Res (Hoboken) 2012; 64:1202-8.

10. Ware MA, Wang T, Shapiro S, et al. Smoked cannabis for chronic neuropathic pain: a randomized controlled trial. CMAJ 2010; 182:E694-701.

Affiliations: Department of Family Medicine (Kahan), Univer- sity of Toronto; Substance Use Service (Kahan), Women’s Col- lege Hospital; Department of Family and Community Medicine (Srivastava), University of Toronto; Urban Family Health Team (Srivastava), St. Joseph’s Health Centre, Toronto, Ont.

Contributors: Both authors contributed equally to the con- ception, writing and revising of the manuscript. They both approved the final version submitted for publication and have agreed to act as guarantors of the work.

1 hit, 4 times daily, of 9% THC cannabis is their recommended dose? hahahahahahahahahahahahahahahahahaha

Thank you for posting this.
So fucking pathetic!

Who writes this shit? Oh the makers of Suboxone! This is the kind crap that will set us back decades. Can you imagine...9% limit? Feed them bullshit and keep them in the dark! I defy them to prove to me that med mari doesn't allow me to get out of bed everyday. I defy them to prove that muscle spasms don't essentially disappear when I use med mar. Is it surprising that it is recommended that Suboxone. Sounds like big pharma may be a weeeeee bit concerned with the direction this thing may go. Good, they should be.

It is fucking amazing that cigarettes are still legal given ALL THE EVIDENCE TO PROVE THAT THEY KILL PEOPLE . They should be talking to all of us who have been using for a long time. Depending who you ask, I don't think I'm showing signs is psychosis or mood disorder, I'm really trying hard to spend as little money on this as possible, but the MMPR will make that near impossible, I've not been in a car crash even though I drive after using my meds....gee, I just don't get it.

cigrits(thanks pug1 now you have me sayin it ...beg ma pard) should be place in the pharmacy and should be by prescription only....
to those who are addicted, there is zero reason to allow the sale of cigarette products to even 18 or 19 year old 's,
why make it available for anyone else to start....highly addictive and definitely will kill.......
so what evidence of efficacy does tobacco have????

As someone who only tried smoking cigarettes once is middle school I SERIOUSLY just don't get it. WTF does it do that makes people want to do it? Does NOTHING for you except kill ya. Because in my case I didn't puff once and go " wow this is fucking horrible, maybe if i give it time it gets better?" I threw that shit out and moved on.

I've been a cigarette smoker for longer than I care to admit. It truly is a filthy, disgusting, self destructive habit I've struggled with for a long time. It was mostly peer pressure and the feeling of being "cool" that got me started and turned into a straight addiction from there. Tobacco itself isn't all that harmful in moderation, it's all the chemicals and carcinogens and poisons the tobacco companies process it with that kills people. Pretty sad they don't offer organic/natural tobacco cigarettes without the poison.

It works like this...

someone has a smoke...in grade school. Looks interesting. Can I have one. Sure.
Next day. etc same shit for a month.
Then...Hey can I have a smoke...NO buy your own. fuckkk that...
That night....how come I feel anxious....maybe I need a joint....maybe Ill grab a smoke off the parents.

That worked but you don't even realize.
Until the day you quit, how controlled your life has been by this stinking, friggin, federally supplied, cancer causing, poison!



Now you're buying them because.... you don't even know why other than you THINK you want one.
Addiction sucks eh.
Simple.

I quit....I used champix.....easiest thing I've done.

That's awesome!
We're not all addicts after all.

after a 30 year plus smoking addiction.of 2 to 3 packs a day.....I quit cold turkey on the morning of my heart attack.
and have never looked back....the incentive here was to still be alive and getting a second chance....its been 8 years and I have not
smoked tobacco even once....its funny how easy it was to actually quit...when scared to death
Plus before they would do open heart surgery on me ...had to be checked for cancer....and was cancer free...(felt like I dodged a bullet)
that being said ....my recommendation to anyone trying to quit....just go for it....it will probably suck for the first while...
there are some prescription things if its too too hard....
but its better than open heart surgery with an 10" scar to remind you ... or even worse death
herb is sooooo much better than cigarettes....take up herb....and lose the smokes....
even a doctor would have to agree.....

I've switched to e-cigs lately and have been cutting down on actual cigarettes (5-6 a day instead of a pack). I've tried almost everything in the past (patches, gum, zyban etc) and nothing worked. I like the e-cig for my oral fixation and cravings, the actions and sensation of still smoking seems to be working pretty good. Eventually I should be able to cut actual cigarettes out completely.