When it comes to advising people to use cannabis for various problems I think the answer is yes. Only a small fraction of people who can access recreational cannabis will be asking physicians for advice on using these products. There are a confluence of reasons but basically they involve cultural factors, political factors, the marketing of cannabis products, expense, and the inconvenience of seeing a doctor for advice and prescriptions when you can get advice from other people including dealers and producers. I would go as far as saying that many of the advisors will be prominent media figures giving advice on the use of cannabis and expanding the marketplace. It follows that the education of physicians should take these factors into account.
It is easy to get into disagreements on Twitter. I think most physicians including myself are
fairly easy to disagree with because we are not invested in “winning” an
argument. As a psychiatrist I know that I certainly am not going to win against
an ideologue or somebody was interested in calling me names. This week I got
into a disagreement about the role of physicians in medical cannabis. The controversy was sparked by an article written by a medical student about why medical cannabis should be discussed in medical schools. Any
reader of this blog knows that my position has been that medical cannabis is basically
a political lever to promote the widespread legalization of so-called
recreational marijuana. I also believe that every state in the United States
will eventually have recreational marijuana. I don't argue that point - I know it will happen. At that point, we will have a
better assessment of the risks involved with this policy and they will be
significant.
The issue this week was a post suggesting that medical
students and physicians should have more training in “medical cannabis”. My
position was that if most states go the way that Colorado went physicians will
be entirely superfluous in that process. It comes from my knowledge of
interaction of American culture and the wide availability of recreational cannabis
products in the state of Colorado. Medications especially those that are self-reinforcing
or put more basically the ones that can get you high, attain mythical status in
the American culture. Practically
everyone I know hoards opioids. That
supply of oxycodone or hydrocodone that is typically given for some type of
injury used to be held onto for years. Neighbors would trade pills back and
forth over the fence. Opioids no longer sit in a medicine cabinet for years as people actively seek out opioids to get high or sell. Most Americans have a set idea of what opioids they would
like for pain and that decision-making process is complex based on their
experience and also what they’ve heard from other people. The reality of that process is quite
different.
In my opinion pain has been inadequately studied and
continues to be inadequately studied. The concept of “self-medication” is at
the top of that list. I usually hear about it in the form of this sentence:
“Look Doc, if you can’t get rid of this (anxiety,
depression, insomnia, pain, fatigue, distractability) I know how to get rid of
it for at least four hours.”
When I inquire about the method it invariably comes back to
alcohol or some type of consciousness altering drug. I use the term consciousness altering because the drugs used are not necessarily addictive. A good example is
a combination of antihistamines and muscle relaxants to cause a state of
delirium and sedation. Alcohol is frequently used as a way to address chronic
pain. The medical cannabis initiative basically started around the issue of
chronic pain and terminal pain. From there it has expanded indications in those
states that list their own like Colorado and Minnesota. A lot of people address
the issue of chronic pain by altering their conscious state. I certainly have
no problem with that in certain circumstances but it is a major unaddressed dimension in the treatment
of chronic pain.
The American Society of Addiction Medicine (ASAM) has a
lengthy position statement (1) on the physician’s role in medical cannabis. They
review the need for scientific study and a regulatory process that will provide
pure and consistent formulations from companies in a similar manner to the
pharmaceutical industry. It is the only way to come up with standardized dosing for specific conditions. The only problem I have with that statement is that it
is fairly naive to think that people with a choice between purchasing high cost
pharmaceutical grade medical cannabis and recreational cannabis that claims to
have the same cannabinoid content will choose the former whether it is “prescribed”
or not.
That leads me to what I see as the role for physicians in a
society that has widespread availability of recreational cannabis. Colorado is
a good case in point. Looking at what cannabinoid products are available in a
Colorado gas station, it is hard to imagine that people will be consulting
physicians for what products to use. I recently found a web site for Colorado gas station cannabis with a wide range of smokable and edible cannabis products. The edible products contained up to 250 mg THC per bar. Physicians currently have the role of
certifying conditions for people who will get access to medical cannabis. In
Minnesota advice about medical cannabis comes from the pharmacists dispensing
it and not from physicians. There is widespread advice available on the
Internet about how any interested user could start using cannabis.
All of these factors, lead me to conclude that there will be
a very limited role for physicians in recommending cannabis or prescribing it. There have been
limited medical studies of cannabis and limited indications. There are basically
two FDA approved applications and even those medications will be obsolete when
people have access to the recreational and less expensive forms. There is no
logic at all to declaring a botanical product is on the one hand “medical” and
on the other hand “recreational”.
A larger role for physicians will be in the treatment of the
medical complications from cannabis and people who become addicted to it. As millions and millions of people start
using legal cannabis – the number of people addicted to it will also increase.
The best way to address cannabis in a medical school
curriculum doesn’t require an extensive course in medical cannabis for an ever-increasing
political list of indications. It should
not teach medical students that they are going to have a central role in the
acquisition and prescription of cannabis.
It can be done in the following courses:
1. Basic science:
neuroanatomy and neurophysiology – the endocannabinoid system’s critical role
in basic physiology and clinical correlations.
2. Basic science: pharmacology
– detailed pharmacology of cannabinoids.
3. Addiction course-
there needs to be a basic 2-week course added to the medical school curriculum
on addiction and the prescription of drugs that reinforce their own use with
necessary risk mitigation techniques.
Many medical schools have a 6-week course in psychiatry that is usually
based on an inpatient unit. I recommend adding two
weeks to that with experience in an addiction clinic. I currently work in a
program where we provide two week training programs to residents, medical students, and physicians for this purpose.
4. Elective course - experience
in specialty programs where there may be more cannabinoid use (pain clinics,
palliative care, toxicology) that can be tailored to a student’s interest.
5. Clear identification of resources for further study - during lectures I always mention the major addiction texts and their organization. Additional state-of-the art references could be posted in a self study syllabus - primarily because a clinical focus would not allow enough time to cover the necessary basic science.
6. Advice on the regulatory burden - in the foreseeable future that means familiarity with the statutes and regulations in each state. Medical schools generally do not teach these practical aspects of medical care. States recognize that physicians can't prescribe a CSA Schedule 1 drug, and limit the physicians role to certifying the conditions that qualify the patient for medical cannabis. Some states require physicians to get approval for that role. That seems like overkill to me. Any medical record with the qualifying condition listed should lead to certification and would probably be more objective.
5. Clear identification of resources for further study - during lectures I always mention the major addiction texts and their organization. Additional state-of-the art references could be posted in a self study syllabus - primarily because a clinical focus would not allow enough time to cover the necessary basic science.
6. Advice on the regulatory burden - in the foreseeable future that means familiarity with the statutes and regulations in each state. Medical schools generally do not teach these practical aspects of medical care. States recognize that physicians can't prescribe a CSA Schedule 1 drug, and limit the physicians role to certifying the conditions that qualify the patient for medical cannabis. Some states require physicians to get approval for that role. That seems like overkill to me. Any medical record with the qualifying condition listed should lead to certification and would probably be more objective.
In closing are there possibly ways where physicians will end up in a more central role? Only if the FDA and other regulatory bodies put them there. For example, in my post on Epidiolex I asked about the patentability of CBD products, specifically this one that was an extraction product of cannabis. Physicians prescribing these FDA products need to learn to prescribe them like any new product, but is there a chance that FDA approved and patented cannabis products are a threat to the products available for recreational and medical use from dispensaries? There is currently a story circulating saying that the FDA is going to ban all CBD oil use except for Epidiolex and it will cost all users $32, 500 a year. That would favor the pharmaceutical industry but I don't think that will happen. It is more likely that other products designed to affect the endocannabinoid system will be developed like standard pharmaceuticals and that will lead to physician prescribing - if there is anyone left at that point who is not using recreational cannabis.
George Dawson, MD, DFAPA
Supplementary Information:
I recently encountered an interesting twist by a cannabis advocate in a state where recreational cannabis is not yet legal and medical cannabis is strictly controlled as non-smokable products. He argued that the terms recreational cannabis and medical cannabis should be changed to cannabis for non-prescription and prescription use. He argued that this would normalize the political process since nobody designates alcohol as recreational or medical. The obvious reason is that alcohol has extremely limited roles as a medication. The term medical cannabis may have lost some of its luster as a politically correct approach.
References:
1: The Role of the Physician in “Medical” Marijuana. ASAM Public Policy Statement (2010) Link
Graphic:
Downloaded from Shutterstock per their standard licensing agreement.
