Marijuana continues to be the most highly abused drug in America. The arguments for and against the legalization of marijuana continue to escalate. This piece is not intended to set the stage for a legalization debate about marijuana. Instead, I want caution practitioners whose patients under their care test positive for marijuana. Marijuana use is still forbidden by Federal law and patients who self-medicate or abuse marijuana should not be prescribed controlled substances.
Unfortunately, many physicians are often faced with the dilemma of whether or not to prescribe controlled substances to patients who drug test positive for marijuana. This is particularly the case in states that have modified state laws to legalize marijuana. These changes in state law do not change the Federal guidelines that physicians must follow. As a former career DEA agent, I remind physicians that marijuana is still an illegal Schedule I controlled substance with no accepted medical use in the U.S. The fact remains that all state laws have Federal oversight, as stated in the Supremacy Clause of the Constitution. "The Supremacy Clause is a clause within Article VI of the U.S. Constitution which dictates that federal law is the supreme law of the land. Under the doctrine of preemption, which is based on the Supremacy Clause, federal law preempts state law, even when the laws conflict."(1)
When a physician becomes aware that a patient is using marijuana, alternate methods of therapy should be implemented other than prescribing controlled substances. Physicians should also take steps to refer the patient for treatment and cessation if any illegal drug use is revealed, including marijuana. Physicians should also keep in mind that the marijuana produced today is much more potent than the past and using high potency marijuana in conjunction with controlled substances is not safe for patients.
Is there such a thing as FDA approved medical marijuana? There are two FDA approved drugs in the U.S. containing a synthetic analogue of THC (tetrahydrocannabinol), which is the principal chemical (cannabinoid) responsible for marijuana's psychoactive effects. A synthetic version of THC is contained in the FDA approved drugs Marinol (Schedule III) and Cesamet (Schedule II) which are prescribed to treat nausea for cancer patients undergoing chemotherapy. Marinol is also prescribed to stimulate the appetite of cancer and anorexia patients (2). The FDA is currently overseeing trials being conducted on Epidiolex (3), a drug manufactured by GW Pharmaceuticals and developed to reduce convulsive seizures in children. The drug contains cannabinoids from marijuana, referred to as cannabidiol or CBD, which does not contain the psychoactive properties of traditional marijuana and does not produce a high. If this drug receives FDA approval, it would make history being the first approved drug containing CBD in the U.S.
Additionally, DEA has issued a special registration to a research laboratory at the University of Mississippi to cultivate various strains of marijuana for clinical trials (4). This research will continue, but as of this writing, ingesting or smoking botanical marijuana or the cannabis plant itself is not federally approved as an accepted medical treatment in the U.S. Patients who smoke or ingest marijuana need to be aware that they are breaking Federal law and could be prosecuted under Federal statutes. Furthermore, physicians should be testing for marijuana use and if detected, they should not prescribe controlled substances, regardless of their diagnosis and the patient's symptoms, as per current Federal statutes.