Pubdate: Tue, 24 Jun 2014
Source: Toronto Star (CN ON)
Copyright: 2014 The Toronto Star
Contact:  http://www.thestar.com/
Details: http://www.mapinc.org/media/456
Author: Isabel Teotonio
Page: E1
Bookmark: http://www.mapinc.org/mmjcn.htm (Cannabis - Medicinal - Canada)

JOURNAL LIGHTS UP DEBATE ON POT PRESCRIPTIONS

It was a discussion with a patient, who attempted suicide after 
failing to respond to antidepressants, which recently prompted Dr. 
David Juurlink of Sunnybrook Health Sciences Centre to do something 
he had never done. The man explained how after years of suffering 
anxiety and work-related stress, and not responding to psychotropic 
drugs, he only felt at peace when smoking a joint during his evening 
walk with the dog. For the first time in his 20-year career, 
Juurlink, an internist and head of the Division of Clinical 
Pharmacology and Toxicology, suggested the patient talk to his family 
doctor about medical marijuana. "This was a revelatory clinical 
encounter for me," recalls Juurlink in a commentary published Monday 
in the Canadian Medical Association Journal. "Endorsing the use of 
medicinal cannabis for this patient was the right thing to do." He 
wasn't the only one weighing in on the issue.

So too did Dr. Meldon Kahan, medical director of Substance Use 
Service at Women's College Hospital, and Dr. Anita Srivastava, a 
family physician at St. Joseph's Health Centre, who also co-authored 
a commentary. The two opinion pieces are part of a new debate format 
in the CMAJ that will feature experts with opposing views.

Kahan and Srivastava argue that when it comes to chronic pain - the 
most common reason for prescribing pot - there is "weak evidence" 
that it's effective. And, they note, there are "short- and long-term 
safety risks." "Smoking cannabis has been associated with an 
increased risk of motor vehicle crashes, schizophrenia, mood 
disorders and addiction," they write, adding risk is higher among 
those under age 25.

The issue is timely given Health Canada's introduction in April of 
new rules around medicinal marijuana, which have garnered criticism 
from groups such as the Canadian Medical Association and the College 
of Family Physicians of Canada. The government used to license 
medical marijuana users, but it's now up to doctors and nurse 
practitioners to prescribe pot, which must be purchased from approved 
commercial producers.

Dr. David Juurlink says doctors should not dismiss medical marijuana 
just because it makes them uncomfortable Kahan and Srivastava say 
physicians "urgently need prescribing guidelines to help us 
understand the evidence, to counsel our patients and know when and 
how to prescribe cannabis."

Guidelines, they note, should include indications, precautions, 
contraindications and recommended doses. They argue the only clear 
indications, or valid reason to use marijuana medicinally, is for 
neuropathic pain and spasticity from multiple sclerosis. (This means 
patients currently smoking pot for common pain conditions, such as 
fibromyalgia and lower back pain, would be excluded.) And, they 
suggest reasons for not prescribing pot would likely include a 
history of psychosis, substance abuse, mood disorders and anxiety.

Although Health Canada permits prescriptions of up to 5 grams of weed 
a day, they argue a maximum safe dose is 400 mg of cannabis that 
contains less than 9 per cent THC, the main psychoactive ingredient. 
Licensed producers, however, are selling strains with up to 25 per 
cent THC, so they suggest that any physician prescribing pot specify 
that the THC content not exceed 9 per cent.

Juurlink urges doctors not to reject marijuana as a medicine simply 
because it makes them uncomfortable. Nor should physicians "invoke 
concerns about effectiveness and safety without acknowledging that 
the other drugs we might prescribe carry similar and often much 
heavier baggage."

When it comes to treating chronic pain, says Juurlink, "many 
analgesics we might prescribe instead of cannabis are themselves not 
supported by robust evidence." And with regards to safety, "the 
direct toxic effects of cannabinoids are simply dwarfed by those of 
opioids and non-steroidal anti-inflammatory drugs."

"Many patients are injured or die every year from the medications we 
prescribe for pain," writes Juurlink. "A case can be made for the 
judicious prescribing of cannabis, particularly for patients who have 
previously experienced meaningful symptomatic improvement with its 
use, and for those who have not benefited from or are intolerant of 
conventional medications."
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