Since cannabis has been illegal for over 70 years, and at this time is still illegal at the federal level, there are many aspects of the state-legal medical systems that make no sense from a medical perspective. Qualifying conditions for medical marijuana are one such aspect. Let’s discuss what should be on the list, what should not be, and why we need a list at all.
First, the top 6 that should be qualifying conditions:
Pain is a huge problem, especially in the US. Did you know that the US has about 5% of the world’s population, but consumes 80% of the world’s opioid medication? It’s not at all clear why this is.
Pain is often broken down by type: mechanical like in Osteoarthritis, inflammatory like in Rheumatoid arthritis, or neuropathic like in diabetic neuropathy or small-fiber neuropathy. Many drugs work on one type of pain specifically. Cannabis, on the other hand, seems to be helpful with all types.
Pain management with cannabis has about 70 years of research support and in the words of the National Academy of Medicine (report from 2017) the evidence is “incontrovertible”.
However, the approach to pain management with cannabis is not simple and depends on the specifics of the individual. You should consult your doctor or a Cannabinoid Specialist for appropriate care.
Insomnia is the second most common health complaint to doctors in the US (after pain) and, in my experience, the problem that cannabis treats best of all.
There are some older studies that showed that cannabis could interrupt REM sleep (which is very important for restorative rest), but these older studies are marred by unknown, and likely higher, doses in recreational users (aka research subjects). More recent studies that looked at lower doses do not show this negative effect.
The approach to insomnia varies with the type of sleep difficulty. Some people have trouble getting to sleep, some have trouble staying asleep, and some unlucky few have both.
Mood disorders like anxiety, depression, and PTSD can be addressed with cannabis and may be qualifying conditions. However, this is an area with lesser research, and the research we have shows that the methods commonly described by helpful friends or cannabis industry salespersons are harmful.
The “wake and bake” approach that is often recommended in the community (eg getting high throughout the day) can backfire. Research shows that this can commonly worsen anxiety and depression. Low doses of cannabis taken in the evening or just before bed are more effective without requiring intoxication during the day. Interestingly, it’s not the intoxication that is helpful for the mood, but rather some neurological alteration caused by the cannabis. This benefit persists throughout the next day, even after the intoxication from the medicine has worn off overnight.
Research shows that cannabis is a weak medication for these problems and is often not a good substitute for conventional medications like SSRIs, SNRIs, and others. Using cannabis alongside these conventional meds can be helpful both for the underlying mood and for helping with the inevitable side effects of the conventional medications.
4. Nausea and Vomiting
Nausea with or without vomiting is most commonly associated with chemotherapy for cancer treatment. Sometimes it’s due to other major illnesses. Cannabis can be used to treat nausea. However, it’s worth noting that a conventional medication called Ondansetron (Zofran) is more effective with fewer side effects. Nonetheless, Zofran isn’t always successful or sufficient. Adding other conventional medications like Compazine can be helpful, but cannabis is likely safer and more effective. Thankfully, it’s not an “either-or” proposition and these medications can be used safely and effectively together to achieve the best benefit.
5. Poor Appetite
Often going hand-in-hand with nausea due to chemo drugs, poor appetite, and nutritional deficiencies can be a real problem. Other debilitating diseases can cause weight loss as well, for example, Parkinson’s Disease, ALS, and MS. These diseases are often qualifying conditions.
Cannabis is well known for causing hunger (aka “The Munchies”). Interestingly, it does not appear that cannabis users, at least on average, are heavier than non-users. In cases of debilitating illness, we can use the hunger-producing effects of cannabis to stimulate appetite.
This is a major use-case for cannabis as there are only poor conventional options like Mirtazapine or Megace, neither of which are particularly effective or pleasant to take.
6. Sexual Issues
Sexual issues or dysfunction is a major health problem for all people regardless of gender. Over 60% of males and females will suffer from sexual issues in their lifetime, though the issues vary with sex and age.
Unfortunately, only about 25% of females and less than 15% of males will seek and receive treatment. Part of these dismal numbers is due to stigma about talking about these issues, even with your doctors. It is also partly due to the correct understanding that there are few medications to help. For males, there is a class of drugs for Erectile Dysfunction, and for females, there is one drug for orgasm disorder (which is not very effective or safe).
Cannabis treatment offers real options for people with sexual issues regardless of gender or type of difficulty. It can be helpful for low desire (libido), inadequate arousal (lubrication or erection), early or insufficient orgasm, and can promote feelings of post-coital intimacy.
And one qualifying condition that shouldn’t be on the list: Glaucoma
It’s entirely odd to me and proves the point that state lists of Qualifying Conditions are purely political and not scientific, that Glaucoma is on every state’s list. Glaucoma is a serious disease in which pressure inside the eyeball can increase and crush the retina and optic nerve. This can lead to blindness!
It was discovered in the early 1970s that THC lowers the intra-ocular (inside the eyeball) pressure (IOP). There were government-funded, successful studies that showed that smoking cannabis could lower IOP in Glaucoma patients. Hence it’s on the list.
However, that’s not the full story! THC does lower IOP but only for about 2 hours. This means that a glaucoma patient would have to smoke cannabis every 2 hours or so, around the clock (even in the middle of the night when they should be sleeping). If someone misses a dose, their eyesight is at risk! On the other hand, using conventional medications you put 2 drops in each eye twice a day and done. Clearly, this is a case where conventional medications win, and cannabis should not be used for treatment of Glaucoma.
BTW, CBD increases IOP and could potentially worsen Glaucoma. Given that CBD is now everywhere in our society, this is just another risk posed to unsuspecting users.
In Reality We Shouldn’t Have Any List
We don’t have lists of approved qualifying conditions for other medications that we, physicians, use. Sure, FDA approves medications for an indication (or use) but that reflects the data that were used to prove safety and efficacy. It does not limit our use of that medication for other purposes (called Off-Label uses) and many medications are used off-label. Just one example would be SNRIs like Duloxetine which are approved for depression and neuropathic pain but used for anxiety and for general pain management as well.
This reflects that the expectation of licensed and trained medical practitioners is that they use their training and knowledge to make sound and effective recommendations to their patients. It is why we expect that physicians and other providers keep up with the science (Continuing Medical Education requirements) and hold practitioners liable if they don’t make decisions based on reasonable standards and put their patients’ best interests first.
What is clear is that lawmakers, regulators, lobbyists, and advocates are not qualified to decide how any medication, including cannabis, should be used.
Lists of qualifying conditions need to be abandoned, cannabinoid education mandated for prescribers, and prescribing clinicians held accountable for meeting the standard of Informed Consent, which requires providing their patients with adequate guidance to enable them to make sound decisions.