Mrs. M.P.

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Spinal Stenosis, Pain and Medicinal Marijuana. PSP Managing Pain Cases. Explain the physician’s role in the MMPR (Marijuana for Medical Purposes Regulations).. Describe a professional and responsible way to excuse yourself from that role if you are uncomfortable.. ID: 530123 Download Presentation

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Mrs. M.P.

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Mrs. M.P.

Spinal Stenosis, Pain and Medicinal Marijuana

PSP Managing Pain Cases


Explain the physician’s role in the MMPR (Marijuana for Medical Purposes Regulations).Describe a professional and responsible way to excuse yourself from that role if you are uncomfortable.List resources you can access to assist you and the patient.Provide a rationale for the exploration of cannabis as a therapeutic agent.

Learning Objectives


Canadian Federal Law prohibits the possession and use of cannabis, which is punishable by imprisonment.The Canadian Charter of Rights and Freedoms guarantees every citizen both liberty and security of the person. The Courts recognize that possession and use of cannabis may be pivotal for security of the person in certain medical circumstances, and thereforeFor Canadians in those circumstances, prohibition is contrary to their Charter Rights, and the Government is required to provide a process to exempt them from prohibition.

Physician’s Role in MMPR


The ensuing Government Regulations (Marijuana for Medical Purposes Regulations (MMPR) place responsibility for deciding which patients are medically qualified to be exempt from prohibition in the hands of Health Care Practitioners. Physicians have the option (according to Regulatory Authorities) personally to decline accepting that role.A physician who supports a patient's qualifying to use cannabis for medical purposes must specify "the daily quantity of dried marihuana to be used by the patient” in g/day. 

Physician’s Role in MMPR


How could you professionally and responsibly excuse yourself?From discussing itFrom supporting an exploration or application for exemption

If you are uncomfortable….


“Physicians are advised by the College of Physicians and Surgeons that they should not prescribe any substance for their patients without knowing the risks, benefits, potential complications and drug interactions associated with the use of that agent.  Currently, that caution includes marijuana in its smoked form.  Because I am not versed in the evidence related to marijuana use, I do not feel comfortable supporting your use of it.”

Some suggestions:


“According to Health Canada, dried marijuana is not an approved drug or medicine in Canada, and the Government of Canada does not endorse the use of marijuana.” “I respect the Government’s position on this, and am professionally not comfortable to discuss this with you.”

Some suggestions


“If you still feel it may help you, I can assist you to find a physician who is more conversant with the issues related to medicinal marijuana. “

Some suggestions:


Other suggestions:



83 yr. old widow in assisted livingHas close relationship with daughter nearby who comes to medical appointmentsSpinal stenosis – clinical and imagingConstant pain in both legs / some back painSleep disturbed – wakes q2h with painMood lowMild Cognitive Impairment

Case Description


PHQ-9: 13 (moderate depressive symptoms)GAD-7: 9 (mild anxiety symptoms)Opioid Risk Tool: 1 (low risk)Brief Pain Inventory: Pain Scores: low 4, high 7Pain Interference from BPI: 44/70

Case Description


Referred to spinal surgeon – non operativeTried epidural steroid – did not helpTylenol – 1000mg TID – modest benefit of back painGabapentin titration to 300 mg bid – modest benefitRemains moderate – severe pain, with poor sleep

Case Description


Medical history:Right THR 2009 – status goodPartial Colectomy 2012 for cancer – no recurrenceHypertensionMild cognitive impairmentMedications:HCTZ 25 mg odAtenolol 50 mg odGabapentin 300 bidMetoclopramide 10mg od

Case Description


Opioid trial: Informed consent.Oxycodone 2.5-5 mg q4h prnGradually progress to 10mg Oxycodone CR q8hPain control 50% improvement Reports sleep improvedConstipation controlled with daily laxativeOverall satisfied

Case Description


One year later returnsOpioid still working but feels overall pain control diminished.Sleep deteriorating againWorried about being on opioidsBrings up query regarding medical cannabis instead of opioid

Case Description


How would you proceed?

Next Steps


Respectfully decline to engage in the conversation or support the patient further. Engage in discussing medicinal cannabis but decline to support an exploration of usage or application for an exemption.Engage in discussing medicinal cannabis and supporting an exploration of usage and application for exemption.

Next Steps


Explain the physician’s role in the MMPR (Marijuana for Medical Purposes Regulations).Describe a professional and responsible way to excuse yourself from that role if you are uncomfortable.List resources you can access to assist you and the patient.Provide a rationale for the exploration of cannabis as a therapeutic agent.

Learning Objectives Recap


Practitioners for Medicinal CannabisPose a question : pmcaccess@gmail.comJoin the groupLook for a physician for referralRefer to the Medicinal Cannabis Resource Centre ( Consortium for Investigation of Cannabinoids ( Canada Document on Medicinal CannabisCollege of Family Physicians of CanadaResource document created by Dr. Pam SquireSample Informed Consent Document

Resources you can access




There is a sound scientific basis for how cannabinoids and cannabis-derived medicines might affect a number of medical conditions. There is historical evidence of a wide safety profile for cannabis, there having been no deaths attributed to overdose. There are convincing anecdotal reports of medical benefit, but limited high quality clinical data to assess benefits and risks of cannabis used for medical purposes.

Provide a Rationale for Cannabis as Therapeutic


There is no standardization of the composition of plant-based cannabis products available. Cannabis contains 60+ cannabinoidsTHC (delta-9 tetrahydrocannabinol)CBD (cannabidiol)Are two important ones, with different medical effectsThe “entourage effect” of the components acting in concert is postulated as an explanation for why the plant appears to be more effective than single components or pharmaceutical derivatives.

Considerations in the “exploration” of a trial


Response to medicinal cannabis is unique to the individual and will vary with the patient’s sensitivity, tolerance to side effects, medical condition, severity of symptoms, cannabis strain used, and route of administration.Possession and use of cannabis remains prohibited for Canadians in general. The exemption for medical purposes is the only avenue of access to a legal supply of cannabis. Many Canadians use it for other than medical purposes. The patient may already be well informed about the aforementioned statements, and possibly have some personal experience of the medical effects of cannabis. 

Considerations in the “exploration” of a trial


 “I feel that medicinal cannabis may be an option in your treatment.  I’d like to discuss with you some of the risks and side effects so that you and I can explore whether this is a good option for you.”“If it appears to be a good option for treatment, we’ll set functional goals for you, ensure that there are no drug interactions to be concerned about with your other medications, and explore how we might introduce a trial of cannabis.”

Moving Forward


Mrs. Gilron started with cannabis capsules from compassion club at dose of 0.25 grams q8h – a “low” THC varietyShe reported improved sleep with 7 hours continuousPain subjectively betterNo side effects so farNo feeling ‘high” or distorted realitySaw cardiologist pre trial – who was unconcernedBP and HR remained stable

Follow up


Continued use of oxycodone CR 10 mg q8hAdvised to reduce to 10 mg bidIncrease cannabis to 0.33 mg q8hContracted flu, hospitalized, vomiting.No cannabis for a weekRestarted with cannabis lozenges (0.25 grams, q8h)Stabilizing after fluEvaluation of the “exploration” is ongoing.

Follow up

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