Should you prescribe cannabis?
As a pain specialist, I’m asked for cannabis every day, which has forced me to learn all I can about this drug. As a result, I’m able to help my patients benefit from cannabis and reduce its risks. I believe all physicians have a duty to do the same.
The lack of science and evidence around cannabis is very real, and very important to point out. With legalization, we’re clearly heading into murky waters — but let’s realize we’re here because 75 percent of our population has said cannabis should be de-criminalized and should be a medicine.It’s not fair for us to bury our heads in the sand and refuse to prescribe it
or even discuss it with patients.
Over eight years ago, a patient of mine had a skiing accident. She had been on opioids and anti-depressants for persistent neuropathic pain, until she discovered cannabis — without the help of physicians. She confided in me that two to three puffs of a joint morning, noon and night controlled her pain without severe side effects. This became the sole ‘medication’ she relied upon to enable functioning in her daily life.
There’s nothing surprising here. Pain is a condition which results in a hyper-excitable nervous system: your nerves have gone haywire; they’re firing constantly. None of the medications in this space — such as opioids or anti-inflammatories — do a great job of calming that nervous system, but cannabis certainly is a medication that globally reduces CNS hyper-excitability. But people need to understand the dosing: the analgesic effects typically occur with just two or three puffs.
And that lack of understanding — or the refusal by too many physicians to educate themselves — is a big part of the reason cannabis has a bad name. Given that many doctors are even less educated than some of our patients regarding the cannabis industry and the rudimentary science to date, our misconceptions about its dangers often lead them to send patients down the wrong path. How does that square with the Hippocratic Oath?
For example, many physicians who are anti-smoking send patients to the oils (the most profitable cannabis sector). But it can be harder to get a standardized experience with oils because some companies’ oils are de-carboxylated to a greater degree than others and not consistent. Each lot could be completely different from a physiological standpoint. Furthermore, some physicians will tell pain patients only to use the non-psychotropic CBD in oil form. But that can cost anywhere from $120 to $160 for a bottle, and they may eventually need several bottles per month. And despite all of that money, many of my neuropathic pain patients often tell me that they’re not getting much effect from CBD alone.
I do tend to direct my patients initially towards vaporizing instead of smoking or oils. We know it works, and we’ll know more about the safety profile of vaping over the next few years — but for now, it does seem like a better choice than smoking. Over time the oils will become more reliable as the industry and the science matures. I also tell naive patients to start with a product containing less than 10 per cent of THC. So many middle-aged people walk into a dispensary because they want to treat a pain condition and pick up a product that’s 26 per cent THC. Then they get uncomfortably high because when they were teenagers they smoked pot that likely contained around four per cent THC.
Currently, I absolutely steer patients away from edibles. Someone can take an edible and within ten minutes they feel nothing so they take another and another. Forty minutes later, when the high hits them like a ton of bricks, they could be driving on the highway. Let’s avoid setting patients up for failure: Start with what we know and where we have credible scientific data to date, which is in the inhalational dosage form. That’s what people have been consuming for centuries. I understand the distrust around cannabis. We have put a medical lens around a recreational drug, and it’s often an awkward fit. And we have moved too fast to create an industry, unfortunately run by venture capitalists. But the science will catch up. And in the meantime, we have millions of people who are going to be using cannabis whether we like it or not.
As doctors, we like to be right all of the time. We always must stand behind on evidence and science. But despite the lack of answers, this drug has been thrust into our wheel house. So let’s do right by our patients and make every effort to educate ourselves about it — and talk to our patients about it in useful, non-judgemental ways. •
Dr. Clarke is a professor in the Department of Anesthesiology and Medical Director of the Pain Research Unit and Transitional Pain Service at Toronto General Hospital. He has consulted with Scientus Pharma and Avicanna Inc. to research and development companies within the medical cannabis industry.
The majority of my patients asking for cannabis are trying to treat anxiety, depression or insomnia. That’s why I won’t prescribe it — I won’t be a party to self-medicating with unregulated, understudied drugs. Not when there are effective, evidence-based treatments for all of these complaints.
Putting the word “medical” in front of marijuana doesn’t make it so. In the Wild West that is the prescription pot landscape right now, a doctor’s signature doesn’t confer legitimacy. We don’t know the intended effect, the right dose, what strain of cannabis to use for which condition, the contraindications or the side effect profile. All we have are some anecdotal reports from people who found personal benefit from using pot.
Not to mention a lot of people’s conceptions of marijuana are based on their own recreational use as teenagers, when it was a pretty benign substance. Nowadays, it’s much more psychotropic, and we don’t know if it could contribute to the onset of schizophrenia, exacerbation of anxiety or onset of depression.
If someone is in pain, I’ll offer the traditional treatments because these are backed by evidence and we know their risks and benefits. Sure, there’s a case for cannabis as an alternative to opioids for a minority of chronic pain sufferers and a few other exceptions. But in my internal medicine practice, I’ve found the vast majority pushing for pot need something else entirely.
And that’s where the problem comes in. Most physicians have heavy caseloads and busy waiting rooms. We don’t always have enough time
to dig deeper, to find out why a patient is suddenly not sleeping well, or to get them to open up about a lifetime of social anxiety. And our current OHIP funding structure doesn’t encourage much psycho-social counselling in the ambulatory environment.
Still, with a little dialogue, I quickly find that psychological counselling using Cognitive Behavioral Therapy, or support for the underlying root problem is what my patients really need. Not everyone is happy to hear that message, which makes me the bad guy when I have to say no. Talk therapy works, but it’s a whole lot less pleasant than getting high.
Then there are the people who want to legitimize their recreational use and get their prescriptions paid by supplemental insurance. It’s a lot like needing two glasses of scotch at the end of the day to unwind — if you got your scotch for free. Are those the patients we want filling up doctors’ offices?
I’m not taking a stand on whether cannabis should be legal for recreational use. But because of the lack of evidence around its risks and benefits, it doesn’t fit into the medical model. Just like physicians shouldn’t be forced to write sick notes for employers, and we aren’t in the business of doling out doses of scotch, we shouldn’t be forced to confer fake legitimacy on marijuana as a medical treatment. Until there’s enough credible evidence that cannabis is medicine, and as long as I have other good options, I won’t be prescribing it. •
Dr. Bonta is a Clinician Educator in the Department of Medicine and a specialist in General Internal Medicine at Toronto General Hospital.