Berks County Medical Society Medical Record Winter 2019 - 28

A Visit to the Dispensary
continued from page 27

the screen because the patients had the minimal sense to
avoid usage when screening was imminent. Also there
were no controls for other characteristics, such as maternal
socioeconomic status, intellectual abilities, smoking, or
alcohol use. There are many biochemical mechanisms
for fetal harm due to the action of marijuana on the
brain due to more CB receptors in the developing brain,
stimulating dopamine release when cannabinoids attach
to receptors. Interestingly, 24% of pregnant women in
one cohort who admitted to using marijuana in pregnancy
did it to relieve significant nausea and vomiting.
The chemical components of marijuana are many
cannabinoids, primarily Tetrahydrocannabinal (THC),
Cannabidiol (CBD), and Terpenes. THC, which produces
the psychoactive effects, and CBD, which shows use
for pain relief and seizure control, are synergistic
and many believe that the terpenes also contribute
to the action of the herb. This may be why synthetic
cannabinoids may not be as effective as herb extracts.
There is a new product, by a well-known pharmaceutical
company, recently awarded FDA approval for two rare
hereditary seizure disorders in children (Dravet's and
Lennox-Gestaut) and is primarily CBD, which is now
easily and legally available in PA, in many forms, over
the counter. It is easy to find - just ask Dr. Google.
Cannabinoids are lipid - soluble and stored in fat. It
may take 30 days to clear in some individuals.
In his book Stoned, Dr. David Casarett, a palliative care
specialist from Penn, makes a compelling case for the use
of marijuana in his field, as well as in others that deal with
significant pain issues. It seems reasonable to use marijuana
for compassionate indications, such as terminal cancer pain
and unremitting seizures that inevitably lead to significant
brain damage. As with any medication, there needs to be
a realistic, non-judgmental assessment of risk v. benefit.
Many physicians retain pre-conceived notions based on
unscientific evidence from the past. On the other hand, the
small amount of prospective, controlled, randomized trials
is a realistic concern. The problem for us in medicine is
simple - medical marijuana is here, so we need to educate
ourselves whether or not we decide to prescribe it.
To find the details of Act 16 in PA, the best source is
medicalmarijuana.pa.gov. To prescribe marijuana, a physician
needs to complete four hours of training. I spent many more
hours than that just learning enough to write this article
and do a Power-Point presentation for OB/GYN physicians,
and I still do not know the correct way to prescribe it.

28

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For a patient, there are several steps including application
for a medical marijuana card (requires physician certification
that one of the 20 approved conditions exists, and $50 to
the Commonwealth). Then she or he visits the dispensary,
is counseled by a pharmacist, and buys the recommended
capsules, tincture, or "vape" cartridges. The main strains
available are Sativa and Indica, but there are many "brands"
with colorful names such as Lemon Skunk, Pineapple
Express, and Super Silver Haze! No smoking products are
legal for medical use, although recreational users who smoke
have no greater risk of lung cancer than non-smokers.
Medicinal use would expose the user to more smoke,
perhaps being a hazard. Most doses are too low to produce
significant psychoactive effects but the THC does seem to
be an important component. Rav Ivker, D.O., who practices
"holistic" medicine in Colorado, does suggest proper dosing
and ratio of THC to CBD for various medical conditions.
He prefers Harlequin or Lucy in 1:1 ratio THC:CBD. The
certifying physician is required to see the patient frequently
and patients can only purchase a one-month supply (pretty
expensive but not sure relative to illegal purchase).
The American College of Obstetricians and
Gynecologists (ACOG) published a committee report
recommending against use of marijuana in pregnancy
and a relative contraindication in breast-feeding (the level
of cannabinoids in breast milk is eight times higher than
in plasma) while the American Association of Pediatrics
believes that breast-feeding is completely contraindicated.
PA has now added itself to the real-time laboratory
of human research in the US. Perhaps if we can collect
scientifically-based evidence in our country, we can
feel more (or less) comfortable with the legalization
of medical marijuana in PA and other states.
Note: The opinions in this article are those of the author,
not the PA Medical Society. Sherry L. Blumenthal, MD,
MSEd, FACOG, is Co-chair Women Physicians Caucus,
PAMED; Past Obstetric member, Board of Trustees,
PAMed; Past Chair, PA Section ACOG; and Member
of Board, Montgomery County Medical Society.


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Berks County Medical Society Medical Record Winter 2019

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