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Medical marijuana’s therapeutic evidence base remains nascent and controversial but the regulatory landscape is evolving rapidly.
The promise of much-needed tax revenues is helping lead more states to pass legislation allowing the prescription of medicinal marijuana, and clinicians and pharmacists should become familiar with the potential effects on patients and healthcare costs.
That’s according to speakers at the AMCP Managed Care & Specialty Pharmacy Annual Meeting, in Denver, during the March 28 session, “Current ‘State of Affairs’ of Medical Marijuana.”
Early evidence suggests that opioid drug overdose deaths might decline in states that allow medical marijuana, noted Babette S. Edgar, PharmD, MBA, FAMCP, of BluePeak Advisors.
The regulatory landscape is complex and changing fast, said Edgar and her fellow presenter Greg Miller, RPh, a senior BluePeak Advisors consultant.
Medical, legal landscape
Marijuana-derived cannabinoids are under development as pharmaceutical agents. Marinol (dronabinol), a synthetic delta-9 tetrahydrocannabinol (delta-9-THC), was introduced in 1986 as an anti-nausea medication for patients undergoing cancer chemotherapy and was subsequently granted approval for treating nausea and appetite loss among patients with HIV/AIDS.
But the vast majority of medical marijuana is dispensed as plant tissue for smoking or consuming in edibles, or as plant-derived ointments and tinctures.
Marijuana is still illegal under the federal Controlled Substances Act-and the U.S. Constitution’s Supremacy Clause states that federal law supersedes state and local statute, Miller said.
The federal government classifies cannabis as a Schedule I drug, a category reserved for highly addictive drugs with no medicinal purposes. That designation prohibits medical research on marijuana and, technically, prescribing of marijuana.
“However, physicians can recommend its use under the First Amendment freedom of speech,” Miller said.
Despite federal prohibitions, 24 states and the District of Columbia have passed statutes that permit the prescription of cannabis for the treatment of conditions ranging from anxiety and depression to glaucoma, nausea, seizures, and sleep disorders. Several states also allow medical marijuana as a pain treatment.
Seventeen have legalized cannabidiol (CBD), “an extract from the marijuana plant that has no THC content,” Miller added.
The state laws are a result of public demand and the allure of tax revenue, the speakers said. But the federal government might have incentives for tolerating medical marijuana, as well: Medicare Part D prescription medication spending appears to decline in states that legalize medical marijuana.
“For all conditions except glaucoma, fewer prescriptions were written [for pharmaceuticals] when a medical marijuana law was in effect,” Edgar noted. The estimated savings to Medicare have grown as more states have legalized medical marijuana, from $104.5 million in 2010 to more than $515 million in 2014, she said.
“The number of prescription drugs prescribed dropped for indications such as anxiety, depression, nausea, pain, psychosis, seizures, sleep disorder, and spasticity,” Edgar said.
Estimated savings from reduced criminal justice spending following legalization of marijuana exceed $7.7 billion, she said. Nationwide, predicted tax revenues exceed $2.4 billion annually if marijuana is taxed like most other goods, up to as much as $6.2 billion annually if marijuana were taxed at rates similar to those for tobacco.
Support is growing in Congress for federal laws that would harmonize national and state laws on medical marijuana. Proposed, bipartisan federal Compassionate Access, Research Expansion, and Respect States (CARERS) legislation was introduced in the Senate in March 2015 and represents “the most aggressive” proposed federal legalization effort to date, Miller said.
Because marijuana is a Schedule I drug, research on its potential clinical or therapeutic benefits remains nascent. There is no consensus, for example, regarding its effects on psychosis or schizophrenia, Edgar said.
Opponents to marijuana legalization point to increased use for nonmedicinal purposes. Youth are more likely to try marijuana for the first time following legalization, Edgar said.
An important goal of the bill was to try to ensure that states were not in conflict with federal law by removing marijuana from Schedule I drug status. The bill would also have allowed Veterans Affairs clinicians to offer opinions to veterans about medical marijuana.
There are also concerns about public safety related to drugged driving and acute cognitive impairment at workplaces, attention deficits, and impulse control and crime. Learning and educational attainment concerns are also frequently voiced, as are concerns about long-term decision making and cognitive performance associated with chronic use.
Implications for pharmacists, physicians
Pharmacists and clinicians will need to become comfortable with discussing medical marijuana with patients, the speakers agreed. “Many in different states are still unsure about the potential repercussions of prescribing,” Miller noted.
Continuing medical education credits are available through groups like the Cannabis Training Institute to familiarize physicians and nurses with medical marijuana-and Edgar noted that continuing education programs for pharmacists are also in development.
Marijuana still entails considerable social stigma and ambiguities about the boundaries between medicinal and nonmedicinal utilization.
“If you look at the culture of marijuana, you’ll see that early medical-side adopting states are now the states that have passed recreational-use legislation as well,” said Edgar. “Stigma is a huge issue and one that we as pharmacists are going to have to discuss. There will have to be a huge educational effort to get people past stereotypes. Marijuana is a good drug that can be used for a number of indications.”