Medical Marijuana and PT: A High Level Overview

Over the past twenty years, marijuana has been progressively legalized for medicinal and/or recreational purposes across the United States. Because of this, we are more likely to come into contact with patients who are using marijuana to manage their symptoms in physical therapy. Therefore, it is important for us to be educated about the uses and options of marijuana for effective patient education.

What is marijuana?

Marijuana plants, also known as cannabis, contain over 100 active compounds called cannabinoids. The two most commonly discussed cannabinoids are ∆9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is primarily responsible for the psychoactive effects of marijuana, while CBD is responsible for its anti-inflammatory or anti-anxiety properties. When consumed, these compounds will bind to receptors within the endocannabinoid system throughout the body (Backes, 2017; Borgelt et al. 2013).

There are many methods of marijuana consumption and each has different considerations. Smoking marijuana tends to elicit responses in less than five minutes but is obviously not great for our lungs. Vaporizing still heats cannabis enough to release cannabinoids, but it is a safer option for lung health.

Eating marijuana in various forms such as desserts or candies, also known as “edibles”, may be better for the lungs, but it also takes longer to metabolize in this way. Because of this, edibles tend to have a higher risk of unanticipated overconsumption. Sublingual options include administration via sprays, drops, or tinctures. There are also topical options, which can be used similarly to lotions (Backes, 2017; Bostwick, 2012)

Who uses marijuana?

Clinical trials of the effects of marijuana have been stifled due to its federal status as a schedule I drug in the United States. In 2017, the National Academies of Sciences, Engineering and Medicine conducted a comprehensive review of the recent medical literature on the therapeutic effects of cannabis and cannabinoids. While they acknowledged the barriers to conducting marijuana research, they found that there was conclusive or substantial evidence that cannabis is effective in the treatment of chronic pain, chemotherapy-induced nausea and vomiting, and spasticity related to multiple sclerosis.

Survey says...

Until the federal prohibitions on research are lifted, we can turn to surveys to understand how and why patients are using marijuana. What stands out in these surveys is that many conditions or symptoms are seen as reasons for seeking both medical marijuana and physical therapy.

1. Corroon & Phillips (2018) surveyed over 2,000 people online to characterize who, how, and why individuals are using CBD. Chronic pain and arthritis/joint pain were the two most common conditions for which the respondents reported using CBD. While less common, people also use CBD to manage migraines, epilepsy, multiple sclerosis, chronic obstructive pulmonary disease, Parkinson’s disease, and Alzheimer’s disease. The most common method of administration of CBD was in sublingual form.
2. Reinarman et al. (2011) surveyed over 1,000 patients from medical marijuana evaluation clinics in California. Back/spine/neck pain, sleep disorders, muscle spasms, arthritis, injuries, inflammation, and headaches were among the most frequent conditions that prompted approval of medical marijuana cards. In addition, almost half of the patients sampled reported that they had previously tried physical therapy for the medical condition for which they sought medical marijuana.

Notice that medical marijuana use is common in managing symptoms that we frequently see in physical therapy practice. For a thorough review of the intersection of marijuana and physical therapy, see Ciccone (2017). Rather than viewing treatment options as either medical marijuana OR physical therapy, we may want to consider the ways patients could use medical marijuana in conjunction with physical therapy.

How could my patients use marijuana?

I know what some of you may be thinking, “wouldn’t marijuana lead to problems with exercise adherence or poor motivation? I don’t want my patients acting like zombies in the clinic.” You’d probably be surprised to hear about the high-level athletes who are using CBD or THC to assist with their training and performance.

In fact, the National Organization for the Reform of Marijuana Laws (NORML) has created a branch entitled, NORML Athletics to “educate the public about the benefits of deliberate cannabis use with an aim towards encouraging persistent self-improvement (athletic and psychological), experiential acceptance, and visualizing human potential.”

NORML Athletics has been promoted by elite professional athletes from hockey, ultra-marathon running, football, fly-fishing, mixed martial arts, and snowboarding, indicating that marijuana can be used in conjunction with a wide variety of athletic endeavors.

A recent survey study from my own lab at Humboldt State University has revealed that people use marijuana before all kinds of exercise—from hiking to weight lifting. Our participants reported that marijuana helps them with focus/concentration, helps them enjoy exercise more, enhances the mind-body-spirit connection, keeps them “in the zone,” and even enhances body awareness (Ogle et al., in preparation). Some of our patients might report the same thing if they use marijuana before or during physical therapy.

Marijuana could also be an option for our patients who are interested in avoiding or decreasing their use of opioids. In fact, Lucas, Baron, & Jikomes (2019) recently found over 69% of a sample of 2,000 medical marijuana patients were using marijuana as a substitute for prescription drugs. These patients were using marijuana instead of opioids/opiates, anti-depressants, non-opioid pain medications, and anti-seizure medications, among others.

The future of medical marijuana

Marijuana is not for everyone. Marijuana is not a cure—it is a tool for our patients to have in their toolbox. Just like Ibuprofen or Baclofen can help patients manage symptoms we see in practice, so can marijuana. Marijuana may help alleviate symptoms related to low back pain, for example, but we as physical therapists can help to identify, treat, and educate patients to more effectively manage their back pain.

The federal prohibition on marijuana research means that doctors do not have clear guidelines on dosages for their patients. It is then up to the patient to determine the correct dose of marijuana for themselves and the physician’s role to listen to patients who are using marijuana to manage their symptoms. We can problem-solve with our patients to identify the right timing, dose, and method of marijuana consumption as part of patient education.

At the end of the day, marijuana is not going away; so it is imperative to be up to date on current best evidence related to marijuana’s risks and benefits. In a study of health care providers in Washington state, the top sources of information about medical marijuana came from news media (57%), patients (53.5%), and other providers (53.1%). The fact that health care providers are more likely to receive information about marijuana from patients and news media than from medical journals should be concerning. In fact, health care providers, medical students, and pharmacy students have overwhelmingly supported that the uses of marijuana should be taught in school and in continuing education.

If you’d like to learn more about marijuana or get involved, check out these resources:

1. Healer
2. Project CBD
3. Doctors for Cannabis Regulation

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References:

1. Abrams, D. (2018). The therapeutic effects of Cannabis and cannabinoids: An update from the National Academies of Sciences, Engineering and Medicine report. European Journal of Internal Medicine, 49, 7–11.
2. Backes, M. (2017). Cannabis Pharmacy: The Practical Guide to Medical Marijuana. New York, NY, USA: Black Dog & Leventhal Publishers.
3. Borgelt, L. M., Franson, K. L., Nussbaum, A. M., & Wang, G. S. (2013). The Pharmacologic and Clinical Effects of Medical Cannabis. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 33(2), 195–209.
4. Bostwick, J. (2012). Blurred Boundaries: The Therapeutics and Politics of Medical Marijuana. Mayo Clinic Proceedings, 87(2), 172–186.
5. Carlini, B., Garrett, S., & Carter, G. (2017). Medicinal cannabis: A survey among health care providers in Washington state. American Journal of Hospice & Palliative Medicine, 34(1), 85–91.
6. Chan, M., Knoepke, C., Cole, M., McKinnon, J., & Matlock, D. (2017). Colorado Medical Students’ Attitudes and Beliefs About Marijuana. Journal of General Internal Medicine, 32(4), 458–463.
7. Ciccone, C. (2017). Medical Marijuana: Just the Beginning of a Long, Strange Trip? Physical Therapy, 97(2), 239–248.
8. Corroon, J., & Phillips, J. A. (2018). A Cross-Sectional Study of Cannabidiol Users. Cannabis and Cannabinoid Research, 3(1), 152–161.
9. Earleywine, M., & Barnwell, S. (2007). Decreased respiratory symptoms in cannabis users who vaporize. Harm Reduction Journal, 4(1), 11.
10. Kondrad, E., & Reid, A. (2013). Colorado Family Physicians’ Attitudes Toward Medical Marijuana. The Journal of the American Board of Family Medicine, 26(1), 52–60.
11. Lucas, P., Baron, E. P., & Jikomes, N. (2019). Medical cannabis patterns of use and substitution for opioids & other pharmaceutical drugs, alcohol, tobacco, and illicit substances; results from a cross-sectional survey of authorized patients. Harm Reduction Journal, 16(1).
12. Moeller, K., & Woods, B. (2015). Pharmacy students’ knowledge and attitudes regarding medical marijuana. American Journal of Pharmaceutical Education, 79(6), 1–8.
13. National Academies of Sciences, Engineering and Medicine (2017). The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC. National Academies Press.
14. Nierengarten, M. B. (2007). Guidelines needed for medical use of marijuana. The Lancet Oncology, 8(11), 965.
15. Ogle W, Copriviza C, Coppen L, Gold G. (2019). Beyond the runners high: cannabis and physical activity. Conference proceedings from ACSM Northwest Regional Conference.
16. Reinarman, C., Nunberg, H., Lanthier, F., & Heddleston, T. (2011). Who Are Medical Marijuana Patients? Population Characteristics from Nine California Assessment Clinics. Journal of Psychoactive Drugs, 43(2), 128–135.