Cannabis: Getting into the Weeds

October 15, 2018 9:53 AM | Sally Winkelman (Administrator)

WACEP President's Message, October 2018
Lisa Mauer, MD

Emergency physicians do not typically think of cannabis as pertinent to our typical clinical practice.  This is demonstrated by the fact that ACEP has not adopted any of 14 resolutions (both in favor of and in opposition to recreational marijuana) that have been proposed in the last 10 years.  On the other hand, our practice is, in some ways, is defined by the failures of the healthcare system, from chronic intractable conditions in need of a novel treatment to the unanticipated side effects of increasing exposure to a recreational substance.  We may get pulled into this debate on the national level.  

But what about at the state level?  Marquette Law School poll done in August showed that 61 percent of Wisconsinites say marijuana should be fully legalized and regulated like alcohol while 36 percent oppose legalization.  Advisory referendum questions on marijuana will be included on ballots in 16 different counties and 2 cities next month.  With all of this local action, I was recently faced with the question of “What would you say to a reporter who asked what emergency physicians of Wisconsin think about marijuana?”  While our state chapter of ACEP does not form individual policy apart from our national organization, it is important that our chapter reflects our local environment.  I believe there are likely low-hanging fruit that would reflect commonalities among WI emergency physicians’ opinions on how we could best represent our patients in this public debate.  Read below for background information on what pertinent policy exists, and then email me with how you think emergency physicians in Wisconsin should publicly regard marijuana for recreational use, medical use, research, or other!  

Recreational use: Nine states and the District of Columbia have legalized recreational use of marijuana for adults over the age of 21.  Twenty-two states and the District of Columbia have decriminalized small amounts of marijuana.  AMA has policy on recreational use or legalization of marijuana:

  • Initially established in 1997 and modified several times until it was reaffirmed last year, the AMA urges legislatures to delay initiating the legalization of cannabis for recreational use until further research is completed on its consequences.
  • Advocates for point of sale warnings and product labeling regarding potential dangers of cannabis-based product use during pregnancy and breastfeeding.
  • For states that have already legalized cannabis, they should take steps to regulate it.  If taxed, a substantial portion of the revenue should be used for public health purposes.
  • Public health based strategies, rather than incarceration, should be used to handle individuals possessing cannabis for personal use.
  • Supports continued educational programs on substance abuse to include marijuana

It is notable that ACEP does not have policy on legalization of recreational marijuana.  This also includes a proposal last month in San Diego at ACEP18 Council to approve policy language mirroring the first AMA policy listed above.  Discussion on the ACEP council floor in opposition to policies regarding recreational marijuana often centers around the idea that recreational marijuana is not within the scope of emergency medicine, although emergency physicians may have opinions on recreational marijuana as individuals.

Medical use: Thirty-one states have legalized marijuana for medicinal use.  In addition, 15 other states, including Wisconsin, only allow use of low THC, high cannabidiol products for limited medical conditions such as seizure disorders.

Much of existing AMA policy about medical use of marijuana focuses on the basis of physician-patient relationship being free from interference by the government:

  • Cannabis products for medicinal use should be considered for approval by the FDA, not legalized through legislative, ballot, or referenda initiatives.  Any FDA-approved cannabidiol medications should be regulated as other prescription products are, rather than state laws that may apply to unapproved cannabis products.
  • Cannabis products not approved by the FDA will have warning labels indicating such
  • Supports protection against federal prosecution for physicians who discuss cannabis with patients or recommend cannabis in accordance with state laws

The Wisconsin Medical Society (WMS) policy affirms the third point above, and also goes on to state that smoked marijuana should only be used for therapeutic reasons for which we have scientific data regarding safety and efficacy. 

Again of note, ACEP has a noticeable lack of policy in this realm, and in fact did not adopt 3 proposed policies over the last few years, including proposal to protect the right of emergency physicians to prescribe medical marijuana and a proposal to officially take no position on the medical use of cannabis products. 

Research: AMA again takes the lead in ample policy regarding research of cannabis use. They encourage public health agencies to improve data collection of effects of cannabis.  The AMA and WMS have the same following policy:

  • Urge that marijuana’s status as a schedule I controlled substance be reviewed with the goal of facilitating the conduct of research and potential development of medicines
  • Call for adequate studies of cannabinoids
  • Urge federal agencies to fund and facilitate the conduct of research
Interestingly, although the ACEP Council voted to not approve a resolution in 2014 to specifically promote research of medical marijuana, they did just last month approve the very first ACEP resolution regarding cannabis, mirroring language of the first above AMA/WMS policy point.