Clarifying The Role Of Podiatric Physicians In Prescribing Medical Marijuana

The numbers are alarming. Drug overdose is the leading cause of accidental death in the United States with a reported 47,055 deaths in 2014.¹ The majority of these deaths are the result of opioid addiction with 18,893 opioid prescription-related deaths and 10,574 heroin deaths in 2014.

The rate of opioid and heroin-related deaths has quadrupled since 1999 with a staggering death toll of 165,000.² Heroin-related deaths have increased by 286 percent since 2002.³ The tragic progression from opioid to heroin addiction is well-documented.⁴ According to the Centers for Disease Control and Prevention (CDC), 45 percent of heroin users are also addicted to opioid pain medications.4 Opioid addicts are 40 times more likely to be addicted to heroin.

Podiatric physicians often manage acute pain with opioids without complication but those patients with chronic lower extremity pain challenge the podiatric physician to walk a fine and potentially dangerous line. Podiatry’s role in treating patients with chronic pain (diabetic neuropathy, peripheral neuropathy, post-traumatic arthritis, complex regional pain syndromes, etc.) must be part of the solution to reduce opioid usage and addiction. Many states, such as my home state of Indiana, have provided welcome guidelines on opioid prescribing.

The use of medical marijuana is a well-documented alternative to opioids for neuropathic, chronic and neurogenic pain.⁵ Marijuana contains more than 60 pharmacologically active cannabinoids with the primary cannabinoids being Δ9-tetrahydrocannabinol (THC) and cannabidiol.⁶ These cannabinoids act on cannabinoid receptors, primarily in the brain and spinal cord (CB1 receptors), but also throughout the entire body, particularly within the immune system (CB2 receptors).⁷ The CB2 receptor activation explains the cannabinoids’ potential effects on pain and inflammation.⁵ Cannabinoid receptor activation also produces physiological effects including euphoria, psychosis, impaired memory and cognition, reduced locomotor function and increased appetite as well as antiemetic, pain-relieving, anti-spasticity and sleep-promoting effects.⁸

Medical marijuana is currently legal in 25 states and the District of Columbia.⁹ Recreational marijuana is legal in four of the medical marijuana states (Alaska, Colorado, Oregon and Washington). However, marijuana is classified as a Schedule 1 illegal drug under the Controlled Substance Act by the U.S. government, meaning marijuana has no accepted medical use and a high potential for abuse.¹⁰ The classification of medical marijuana as a Schedule 1 drug prohibits physicians from prescribing it at a federal level. Physicians may only certify medical marijuana, with the certification including the treated condition and, in some states, a recommended amount.⁵

In reviewing many state statutes regarding medical marijuana, the definition of “physician” prevents podiatric physicians from prescribing medical marijuana (see California’s definition below) or is unclear on the ability of podiatric physicians to prescribe (see Alaska’s definition below).⁹

California defines an "attending physician" as “an individual who possesses a license in good standing to practice medicine or osteopathy issued by the Medical Board of California or the Osteopathic Medical Board of California and who has taken responsibility for an aspect of the medical care, treatment, diagnosis, counseling, or referral of a patient, and who has conducted a medical examination of that patient before recording in the patient's medical record the physician's assessment of whether the patient has a serious medical condition and whether the medical use of marijuana is appropriate.”¹¹

Alaska defines “physician” as “a person licensed to practice medicine in this state or an officer in the regular medical service of the United States Armed Forces or the United States Public Health Service while in the discharge of their official duties, or while volunteering services without pay or other remuneration to a hospital, clinic, medical office, or other medical facility in this state.”¹²

Clearly, this is an emerging therapy that is rapidly gaining acceptance within the medical community. Hill’s clinical review documented five studies on the use of medical marijuana for neuropathic pain (with all five showing a significant decrease in pain) and six studies for chronic pain (with all six showing either a significant decrease in pain or better outcomes in comparison to other medications).5 Podiatric physicians treat these conditions frequently in addition to prescribing opioids. We must clarify the role of podiatric physicians in prescribing medical marijuana and include our role in the definition of the prescribing “physician.”

Podiatric physicians are allowed to use any of the indicated modalities to treat diabetic peripheral neuropathy. Why then would we not be allowed to prescribe medical marijuana?

Prescribing medical marijuana is an issue requiring resolution along the pathway to legislative parity. We must challenge state laws regarding medical marijuana, much like the scope of practice issues past and present. The appropriate strategy should develop at the national level with podiatrists ultimately employing this strategy state by state. Not only will the patients suffering from lower extremity maladies benefit from podiatric physicians being able to provide an evidence-based treatment with medical marijuana but the profession will continue to close the parity gap as well.

References

1. Center for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, Mortality File. Number and Age-Adjusted Rates of Drug-poisoning Deaths Involving Opioid Analgesics and Heroin: United States, 2000–2014. Center for Disease Control and Prevention, Atlanta, 2015. Available at https://www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_US_2000-2014.pdf .
2. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers: United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011; 60(43);1487–1492.
3. Results from the 2013 National Survey on Drug Use and Health. Available at https://www.samhsa.gov/datahttps://s3.amazonaws.com/HMP/hmp_ln/imported/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf .
4. Centers for Disease Control and Prevention. Today’s heroin epidemic. Available at https://www.cdc.gov/vitalsigns/heroin
 .
5. Hill KP. Medical marijuana for treatment of chronic pain and other medical and psychiatric problems: a clinical review. J Am Med Assoc. 2015; 313(24):2474-2483.
6. Pertwee RG. Cannabinoid pharmacology: the first 66 years. Br J Pharmacol. 2006; 147(S1):S163-S171.
7. Joy JE, Watson SJ Jr., Benson JA Jr., eds. Marijuana and Medicine: Assessing the Science Base. National Academies Press, 1999.
8. Koppel BS, Brust JC, Fife T, et al. Systematic review: Efficacy and safety of medical marijuana in selected neurologic disorders report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2014; 82(17):1556–1563.
9. Medical Marijuana. Available at  https://medicalmarijuana.procon.org/view.resource.php?resourceID=000881 .
10. Controlled Substances Act, 21USC §812. Available at https://codes.lp.findlaw.com/uscode/21/13/I/B/812 .
11. California Health and Safety Code Section 11362.7–11362.83. Available at https://www.leginfo.ca.gov/cgi-bin/displaycode?section=hsc&group=11001-12000&file=11362.7-11362.83 .
12. Alaska Statute Title 17. Food and Drugs: Chapter 37. Medical Uses of Marijuana AS 17.37.010. Registry of Patients and Listing of Caregivers. AS 17.37.070. Definitions. Available at https://medicalmarijuana.procon.org/sourcefiles/ASTitle17Ch37.pdf .