Clinical challenges: medical marijuana and a cardinal rule of medicine

Medical marijuana usually comes up more in the context of a joke rather than real therapeutic care (. . . of course its for glaucoma). Cancer pain is the indication for which marijuana may be appropriate. Unfortunately, there aren’t many scientific studies to guide clinical practice.

Interestingly, this week’s New England Journal of Medicine weighed in on the discussion. In a case study, a patient with cancer presents to her physician with pain and nausea that have been unresponsive to standard therapies. She asks her doctor about marijuana use. The NEJM article does not provide an answer; it presents the pros and cons in the form of two opposing points of view and, via the NEJM website, solicits votes from physicians (readers). The article spurred me to think about this question. I lean in favor of offering medical marijuana. I think it is worth a try.

Treating pain, especially in end-of-life conditions is one of the biggest challenges that doctors face. Pain meds have garnered media attention for their addictive properties and potential for misuse. With that, there has been societal pressure to limit prescribing of pain meds. Unfortunately, this can leave patients with legitimate needs under-treated.

In considering the arguments in favor of trying medical marijuana in this case, I am clearly influenced by¬† the dictum “Primum non nocere,” which translates to “First do no harm.” This stands as one of the cardinal rules of caring for patients. Every therapy/intervention has potential risk and benefits. In the case of cancer pain, failure to offer adequate relief seems to me the greatest risk.

As it pertains to marijuana, individual patients respond differently to various therapies. For a cancer patient who has failed more common treatments, it is reasonable and appropriate for a conscientious physician to explore less traditional options. If the options prove ineffective, there is little if any harm done, especially since marijuana use can simply be discontinued.

Also, it’s possible that a positive effect could arise simply from taking novel steps to care for patients. The placebo effect can be powerful. A fascinating Harvard Magazine article documents the potential for placebos to have real benefits. This can arise in part because of the care and efforts undertaken by a physician. An atypical path (prescribing medical marijuana) might just accomplish such a thing. A skeptic might argue that, if the benefit is placebo-driven then medical marijuana is inappropriate. Countering such thinking, especially if other therapies have proven ineffective, it does not matter why a benefit comes, only that a good has been achieved. Further, while the placebo effect can be suggested across a population in the context of a clinical study, one can never know for certain what underpins a good outcome when caring for an individual patient.

sources: Medical Use of Marijuana (NEJM); The Placebo Phenomenon (Harvard Magazine)

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