Cannabis and the doctor-patient relationship

One night while working in the emergency department, I treated 2 young men presenting with lacerations. They gave me dubious explanations for how their injuries had occurred. I quickly ascertained they had addiction issues. They did not have family physicians, so I offered to see them at my office. The first patient visited my office and seemed genuinely interested in changing his life. The second patient came much later asking for a prescription for medical cannabinoids.

He used every excuse in the book to justify his need and refused any suggestion of alternative solutions. I proposed further investigations and other solutions to his problems, offering him a follow-up appointment. He left my office saying that he would find another physician to prescribe him smoked marijuana.

Situations like these often cause us to question ourselves as physicians.

On the one hand, I asked myself whether I had used the proper approach. Could I have managed the situation differently to better establish a relationship with him? Was my knowledge up to date enough to make this decision? Had I been too rigid?

On the other hand, I had taken more time than scheduled with this patient to manage his request for a medical prescription that would support what appeared to be the recreational consumption of an illegal substance. I was late for my appointments with other patients as a result.

In this case, the situation was fairly simple, given that the request was coming from a patient without any chronic diseases and with whom I had no previous longstanding relationship. The situation is far more complicated when such requests come from those who have been my patients for a long time and who I have been treating for chronic conditions, particularly for mental health problems. Refusing a request for a medical cannabinoid prescription from these types of patients can affect doctor-patient relationships that we have spent years establishing and can negate the work we have done.

We could discuss at length the benefits and risks of legalizing marijuana from a social perspective, but from a medical perspective legalization could at least reduce the effect of refusing medical cannabinoid prescription requests on our doctor-patient relationships. There are still benefits for people who have prescriptions, but it will ease the pressure on us as physicians. We no longer need to consider the legality of our patients’ recreational cannabis use.

Over the past few years, the lack of credible information, free of conflicts of interest, available to physicians facing this new challenge has been a problem. Furthermore, the information given to the public by promoters and investors in this emerging industry has made the situation even more difficult inside the offices of family physicians.

Luckily, thanks to the leadership of Dr Mike Allan, Acting Director of the CFPC’s Programs and Practice Support department, we now have a credible tool to support us. Alongside a group of fellow family physicians and health care professionals, he has produced a simplified guideline for prescribing medical cannabinoids in primary care.¹

Despite the many virtues associated with medical cannabinoids, there is very little evidence of its benefits, and the only consistency across these studies has been the presence of adverse effects. The practice guidelines do not recommend its use for most patients and conditions. In the few situations where it can be considered, it should be limited to patients whose symptoms are not responding to standard medical therapies. When used, it is preferable to use pharmaceutical cannabinoids rather than medical marijuana.

Not all practice guidelines are helpful for use in primary care. The CFPC promotes those guidelines developed in close collaboration with family physicians and that are without conflicts of interest. In this case, the authors clearly declared their objective to support primary care applications. If I had had access to this resource 2 years ago when I met this patient, I would have certainly felt much more supported in making my decision.

Only time will tell whether the legalization of cannabis will present more benefits than risks to society. However, I believe that, from a medical perspective, it has the potential to decrease the number of requests for prescription medical cannabinoids that are difficult to justify scientifically. This would at least benefit our doctor-physician relationships and our punctuality!

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