The use of medical cannabis in pediatrics presents a bit of a double bind for physicians as well as the parents of patients. On one hand, cannabis use among minors, in any capacity, is controversial due to evidence that marijuana can damage the developing brain. On the other, even staunch opponents of cannabis would find it difficult to deny sick children treatment that might ease their suffering. In either case, it seems fair to assume that recommending cannabis to children should be a last resort since it will impact them harder than adults.
But this is not so, according to Dr. Bonni Goldstein - Medical Director for Canna Centers Wellness and Education, a physician-owned medical medical group. Goldstein tells Civilized that "children tolerate cannabis very well, almost better than adults." Researchers aren't sure why that is, but one prevailing theory is that a child's cannabinoid receptors, much like the rest of their physiology, have yet to fully mature. So even if pediatric patients consume the same amount of cannabis as adults, they won't experience the same effects because of their underdeveloped cannabinoid receptors.
This, of course, is not to suggest that cannabis treatments for a child should be taken lightly. Instead, Dr. Goldstein maintains that a cannabis recommendation must be made with substantial consideration on the part of the physician, who should guide the patient throughout the process.
Issuing a Recommendation
In many states that have legalized medical marijuana, there is a limited number of conditions that cannabis can be recommended for, such as epilepsy or multiple sclerosis. However, in California, where Goldstein practices, there is an additional option for "any other condition that cannabis may benefit."
"For example, autism might not be listed as a recognized condition to be treated with cannabis," she said. "But, if there is research, and my own clinical experience shows that it might help that person, then I am allowed to recommend it."
But that doesn't give California doctors the right to prescribe cannabis for anything. As in most states, each recommendation has to be submitted to state authorities. If approved, then patients will receive a card or another document certifying them as a patient. For pediatrics, it’s a slightly different system, she explained, but the fundamentals remain the same.
"Children, of course, can’t obtain their own medicine. The parents have to be approved for some something called a 'caregiver license'. This, of course, does not mean they are approved to use the cannabis, but rather that they are able to obtain it for the child to use."
In issuing their recommendation, a doctor must not only take into consideration the patient’s symptoms, but also what other treatments the child might be taking.
"Let’s say a parent brings a child in looking for a CBD treatment," she said. "Then, it’s my responsibility to take note of what pharmaceuticals the child might be on that would inform my advice concerning dosing, and to be on the lookout for certain symptoms."
It is for these reasons that Dr. Goldstein believes that those looking to treat their conditions with cannabis should consult a physician, at least in the beginning.
"There are no fatal issues, but certainly, you’ll still want to be careful," she said. "That’s what physicians do - they help you manage your medication."
Since cannabis is still a controversial medicine, physicians need to be careful to avoid mistakes or lapses in judgment when recommending it because those errors can quickly turn into headlines. That's exactly what happened recently with Dr. William Eidelman – a California-based physician who was stripped of his license after the state Medical Board found that he was “grossly negligent” in prescribing cannabis to a 4 year-old child who supposedly had ADHD.
"The reason that he had problems with the medical board was that the child who came to see him was not properly diagnosed by a specialist," Goldstein told Civilized. "That’s what the board had a problem with—not the fact that it was cannabis that was recommended."
According to most reports, the problem arose when the parent claimed that the child had ADHD based on their own observations. In other words, the child had not been properly diagnosed. And instead of doing his own assessment, Eidelman allegedly took the parent's word for it and recommended medical marijuana for the child.
"As physicians, we are required to do our due diligence," Goldstein said. "If you are not the patient’s primary care doctor, and you are not diagnosing the patient, you need to ensure that the diagnosis is legitimate before moving forward with a recommendation."
Goldstein is not a primary care doctor, either, nor does she pretend to be. She says that it is incumbent on her to ensure that a patient’s documentation is all in in order before she is able to make any kind of recommendation for treatment.
"If somebody calls my office and says 'I have a 14 year-old with terrible anxiety and won’t go to school,' the first question we ask is, has the child been properly diagnosed by a qualified professional?"
She added that, in many cases, it is best for the diagnosing physician to be the one giving the recommendation, as they are already more intimately involved in the patient's care.
"An autism specialist, for example, is far more qualified to make an accurate diagnosis of a patient and are informed enough to make a proper recommendation to meet a child’s needs," she said. "In that case, cannabis can be brought in as just another tool in that doctor’s toolbox for treating the condition."
One might expect that imposing limits on dosage would be a fairly basic aspect of a recommendation. But, as Dr. Goldstein tells Civilized, the typical standard of care in California is actually to not give dosage recommendations, as most doctors are not plant specialists.
However, as research improves, and doctors become better-informed, she feels it is important that a physician be able to provide a patient with some insight into the proper dosage.
"You don’t want a parent who doesn’t know what they’re doing," she said. "If they can’t figure it out, they’re going to ask the layperson at a dispensary, and they’re going to get bad advice. If they aren’t trained in healthcare, how are they going to be able to help?"
Goldstein made note of a recent study based on a treatment for severe autism that listed the cannabis dosage used. She said that data like this is "extremely helpful".
"Now I have, in a clinical trial, what has been shown to be effective," she explained. "It’s not just haphazardly suggesting 'oh, maybe try a brownie.' I can provide a use recommendation, based on established evidence. Really, that’s how it should be."