CRx MAGAZINE

Summer 2020

COVID-19: Telemedicine and Cannabis — Can Telehealth Bridge a Gap?

In addition to the many ways in which the COVID-19 pandemic has altered daily life, it appears to have triggered an uptick in cannabis use as well, says Mikhail Kogan, MD, medical director for the George Washington University Center for Integrative Medicine in Washington, D.C. “People are having a hard time getting some of their medications or might not have the same access to their physicians,” he explains, “but they are still in pain. They are still experiencing side effects from cancer treatments or surgeries, and they are still looking for solutions. Naturally, we’re seeing an increased demand in cannabis.”

It’s not surprising, then, that telemedicine, or telehealth—defined as the remote diagnosis and treatment of patients using telecommunications technology—has been an essential tool during the COVID-19 emergency. Along with the increasing adoption of telemedicine on a broader spectrum, many states have also allowed for medical cannabis counseling and certifications to be done via telehealth services. Though state policies on telemedicine vary greatly, many believe the recent advancements during these unprecedented circumstances may be the momentum this modality of cannabis consultation needs to move forward permanently.

As of press time, more than two dozen states had temporarily lifted restrictions and allowed for medical cannabis recommendations made via telemedicine. Board-certified anesthesiologist and pain medicine physician Anand Dugar, MD, says he would like to see those changes last—though he’s unsure they will. Dugar is the owner of Green Health Docs, a medical marijuana card certification company that he founded after witnessing first-hand the damage caused by the opioid epidemic. The shift to utilizing telemedicine, he says, has been relatively smooth, though it poses some unique challenges.

“For in-person office visits, patients would bring in everything they need, including their licenses and medical documentation,” Dugar says. “With telemedicine and these verifications being done remotely, it requires a little bit more organization to gather everything. But that barrier is easily overcome. In terms of the physical exam, for a cannabis evaluation that’s not a huge factor, so we don’t see it as a hindrance to move to a virtual exam.”

Leslie Mendoza Temple, MD, medical director for the Integrative Medicine Program at NorthShore University HealthSystem, agrees that the inability to perform a physical exam isn’t a significant problem. “A physical exam is important, but it’s not the only factor when it comes to the decision to recommend medical cannabis for pain,” she says. “What’s more important is a good documented history of pain medications, injections, surgical procedures, and courses of physical therapy. Yes, there are times you examine an area and you witness an abnormality—but pain is also well captured through their medical history, and that’s true whether it’s through telemedicine or in person.”

According to Temple, patients are more fearful and anxious than ever during this pandemic and their pain might be at its worst. Even so, they can’t get physical therapy, acupuncture, massage, or chiropractic care—which is why telehealth has been so valuable. “I think it’s safe to say that the pandemic has broken the tie for patients on the fence about trying medical cannabis for their pain,” Temple says. “Because of that, the interest remains strong, if not surging.” Temple would love to see telemedicine secure a permanent place, as she’s been witness to the hardships that many of her patients have faced in making in-person visits.

“Telemedicine has the power to remove so much of the stress and the burden on patients,” she says. “I have quite a few patients who are disabled, and coming to physically see me is a big production. It requires wheelchairs and coordination with their caregivers. I even had one patient who had to schedule an ambulance transport just to be able to see me in person and fulfill that requirement. Had I been able to see this patient via telehealth, it could have spared a $1,000 ambulance ride.”

Lingering Concerns
Though the success of telemedicine so far has been promising, the physicians CRx has spoken with all acknowledge concerns.

“I think that when you eliminate the possibility of a physical exam, it does open the door to a risk of cutting corners,” Kogan says. “The concern is that physicians may try to squeeze in more patients and not provide adequate care.” However, he adds, cutting corners can be a concern for doctors who counsel on cannabis in person, too; it’s not a problem that’s solely in the realm of telemedicine.

Temple agrees. “The ‘doc-in-a-box’ concept raises some concerns whether they’re recommending cannabis via telemedicine or in person,” she says. “These are physicians who don’t have a continuity practice but are only certifying patients for cannabis. This does raise some questions. Do they have any sort of real relationship with their clients after they certify them? Have they spent a lot of time reviewing their medical histories or screened for addiction? Are they checking back in to see how the patients are doing after they’ve received their certifications? If the answer is no, there’s a problem. Pain is complex. You’re doing a disservice to the patient if you’re just recommending cannabis and never seeing them again.”

Since corners may be cut either way, assuming doctors are following proper protocols and committing ample time to patients, Kogan says, there isn’t that much difference between telehealth and in-person counseling.

“Recommending cannabis is very heavy on counseling,” Kogan adds. “The majority of the time spent with patients involves walking them through everything—and that can be done in person or virtually.”

However, he also understands the concerns that have been raised about state licensure. This poses the risk of being a slippery slope. Although patients couldn’t easily travel out of state to see a different doctor, the use of telemedicine provides connectivity across the country. Since state laws differ, this could be potentially problematic.

“When you open things up to telemedicine, it’s now easy to see patients from different states—but if you’re not licensed in that state, that’s a problem,” he says. “So, how do you handle that? It can get  complicated and is obviously an issue that needs to be addressed.”

Here to Stay?
Going forward, the physicians express hope that telemedicine for cannabis will continue to be offered in at least some shape or form.

“While I still believe that being seen in person is the gold standard, I think we can deliver good medicine via telehealth,” Temple says. “I really hope that it’s here to stay. We are proving that we can offer high-quality care and put less burden on patients, and it would be a disservice to take that away.”

Even with the limitations and barriers to overcome, telemedicine is a positive, Kogan says, and overall a good thing for the field. “And I think it’s even solving some scheduling problems because we’re able to see more patients in a more efficient way. That could mean that patients don’t have to wait as long to be seen and can start getting help that they need sooner.” He sees patient demand being a powerful force going forward.

Dugar agrees. “I think there’s an opportunity for consumer sentiment to begin inspiring change,” he says. “With more primary care visits being performed via telemedicine, I think more patients are going to demand that they be able to utilize telemedicine services in other ways. Although I think we’ll see restrictions go back in place in a lot of states, I do not believe this is the end of telemedicine and cannabis by any means.”

— Lindsey Getz is an award-winning freelance writer in Royersford, Pennsylvania.

Cannabis and COVID-19
Inform Patients to Use Caution

Although there’s been an increased interest in cannabis during the pandemic for many reasons including heightened anxiety and pain, the closure of physical therapy offices, and less accessibility to prescription drugs—physicians say patients should be aware that smoking could potentially increase the severity of COVID-19’s effects.

The virus isn’t yet well understood. One study led by the University of Miami will be looking at how medical cannabis patients have been affected by the coronavirus outbreak.

“I think as physicians we have to tell patients that smoking or vaping cannabis could potentially increase COVID-19 severity,” says Mikhail Kogan, MD, medical director for the George Washington University Center for Integrative Medicine in Washington, D.C. “It’s always best to be cautious. There’s still a lot we don’t know. This makes it really important that physicians are counseling patients. While they might need pain relief from cannabis, there could also be some risks associated with starting smoking or vaping it during this outbreak.”

— LG

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