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(HealthNewsDigest.com) – Five patients have confided to Key West internist John Norris III, MD, that they use marijuana to relieve painful, persistent muscle spasms resulting from strokes or multiple sclerosis.Norris’s patients have been buying their marijuana illegally. “They can get it from some high school kid or bartender in Key West,” he said. But Floridians voted to legalize medical marijuana this past November by a nearly 3-to-1 margin, spurring Norris to enroll in an 8-hour course required of all physicians in the state who want to be able to recommend the treatment to their patients.
Norris paid $995 for the course, cosponsored by the Florida Medical Association and the Florida Osteopathic Medicine Association, and traveled to Miami over Thanksgiving weekend to take it. But even though he passed the final exam, he still doesn’t feel prepared to advise patients who’d like to try medical marijuana.
“The course has no dosing data. You go to the smallest amount possible and then work your way up,” Norris explained. “It’s like trying to prescribe St John’s wort instead of Prozac.” The lack of clear dosing guidelines also makes it difficult to determine whether a patient is misusing medical marijuana.
Further complicating matters, he said, is the fact that “you have no idea of the concentration of the active ingredients,” which vary depending on when and where the plant was grown, and, for edibles and other products containing marijuana, the manufacturing process.
Norris’s complaints highlight the knowledge gaps physicians confront when it comes to medical marijuana, now legal in 28 states, the District of Columbia, Puerto Rico, and Guam. They didn’t learn about it in medical school, and, because it is not a US Food and Drug Administration–approved drug backed by randomized controlled trials, they can’t turn to the Physicians’ Desk Reference for information about dosage, indications, and contraindications. The federal Drug Enforcement Administration (DEA) still classifies marijuana as a schedule I drug, along with heroin and ecstasy, that has a high potential for abuse and no accepted medical use. As a result, studies of its therapeutic use are limited and physicians are prohibited from prescribing it.
“There’s insufficient to no evidence for most of the claims [about medical marijuana],” said University of California, San Francisco (UCSF) oncologist Donald Abrams, MD, coauthor of a new report from the National Academies of Sciences, Engineering, and Medicine on the health effects of cannabis and cannabinoids (constituent compounds in cannabis). “If you like having evidence on which to base your patient recommendations, it’s really not available.”
Abrams and his coauthors reviewed more than 10 000 scientific abstracts. They found that the strongest evidence of a health benefit from cannabis and cannabinoids is in the treatment of chronic pain and muscle spasms associated with multiple sclerosis and chemotherapy-induced nausea and vomiting.
As the number of states that have legalized medical marijuana rises, the need for research becomes even more pressing, according to a recent editorial in Lancet Oncology: “For a product rapidly becoming mainstream, clinical trials and basic research are crucial: The requirement for evidence of the benefits and risks of marijuana use will grow as access increases and regulations, including clear guidelines for safe and effective use, must be developed.”
Because the best evidence of marijuana’s effectiveness is in the management of symptoms related to cancer and its treatment, Abrams has long recommended it to patients. He has written about limited in vitro and animal model studies suggesting that cannabinoids might even help treat cancer itself, although, once again, clinical trials supporting these findings are scant.
Although Abrams recommends cannabis to patients, he recognizes that many questions remain, such as the best strain to treat a particular symptom. When patients ask for his thoughts on such matters, “All I can say is I don’t know,” Abrams said. “I just advise my patients to go to the dispensary and explain to them what you would like to treat. They’re [dispensaries] on the front lines.”
Many physicians aren’t comfortable relinquishing that much control, Abrams acknowledged. However, most also don’t know the difference between CBD (cannabidiol) and THC (tetrahydrocannabinol). Although both are cannabinoids, only THC makes marijuana users high.
Physicians today lack such basic knowledge about cannabis because they never learned about it in medical school. “Physicians could prescribe cannabis in this country until 1942, when it was removed from the [US] Pharmacopeia,” Abrams said. “There hasn’t been education about cannabis as medicine for 75 years.”
Back in 1996, California became the first state to legalize medical marijuana, but a 2-week, 12-hour elective for first-year medical students this past fall was UCSF’s first attempt to educate future physicians about cannabis as medicine, said Abrams, who taught the course.
The UCSF marijuana course was 1 of 20 electives from which students could choose. It could have accommodated 12 students, but only 6 enrolled, Abrams said, adding that he “was a little surprised I only got 6 [students] here in San Francisco.”
At Stanford University School of Medicine, the Department of Anesthesiology, Perioperative and Pain Medicine and the Department of Psychiatry and Behavioral Sciences, Addiction Medicine, have each created a task force to examine how they can better address pain and addiction in the curriculum, said Anna Lembke, MD, who holds a joint appointment in both departments. “We do plan to include something on medical marijuana, mainly focused on what the evidence is for the medicinal and therapeutic effects,” Lembke said.
“People are very passionate about marijuana in California,” she continued. “It’s very polarizing. Physicians should know what there is to know, so at least when their patients ask them about it, they can talk to them about what is known and also what is not known.”
On the other side of the country, a University of Vermont (UVM) Larner College of Medicine pharmacology course, PHRM 296: Medical Cannabis, drew more than twice as many students as expected when it was first offered last spring semester.
The school had to twice change the location of the elective course, as enrollment grew to 99—filling the largest available lecture hall, said Kalev Freeman, MD, PhD, an emergency department physician and assistant professor of surgery at UVM whose wife, a botanist on the medical school faculty, coteaches the class. Thought to be the first of its kind at a US academic institution, it delves into molecular biology, neuroscience, chemistry, and physiology. Students who’ve taken it include undergraduates, medical students, physicians, and a state legislator.
Thanks to the enthusiasm of pharmacology chair Mark Nelson, PhD, Freeman said, he expects that beginning this fall, the subject of cannabis will be woven into the UVM medical school curriculum, instead of offered only as a stand-alone course. In other words, he said, when medical students study psychiatry, neuroscience, cell biology, and chronic pain, cannabis will become part of the discussion. “These kids are going to graduate from medical school, and they need to know some data,” Freeman said.
Freeman’s work as an emergency department physician in Vermont sparked his interest in cannabis. In Burlington, Freeman says, he has seen many patients who overdosed on prescription painkillers.
“Isn’t there something we can give for pain besides Percocet?” wondered Freeman, who is also a molecular biologist. He decided that cannabis, in particular whether it could help people get off of opioids, represented an attractive research question.
Freeman serves as a medical adviser at the Vermont Patients Alliance, a state-licensed nonprofit medical cannabis dispensary and research facility in Montpelier. He is also among the founders of the PhytoScience Institute, which aims to standardize and label US cannabis products by recommending protocols for testing potency and safety.
Ever since Norris, the Key West internist, completed the medical marijuana course, his office has been fielding numerous calls from people he’s never seen as patients. They want a physician’s go-ahead to buy marijuana from a dispensary. He’s not hard to find—the state health department maintains a public webpage listing all of the physicians who’ve completed the training course, along with their contact information.
Physicians aren’t exactly clamoring to recommend medical marijuana to their patients. As of January 20, Norris was one of only 484 Florida physicians—fewer than 1% of the approximately 71 000 physicians licensed to practice in the state—who had completed the required training course, according to the Florida Department of Health.
The course isn’t brand new. It has been offered since 2014, when the Florida legislature passed the first of 2 laws that allowed limited use of marijuana or related products by patients with certain conditions. However, the state’s first dispensary did not open until July 2016.
In Vermont, “It’s not easy to find physicians who will [recommend marijuana],” Freeman said. “They don’t know if it works. They don’t have the information to recommend it. So [physicians] just really shy away from it.” Physicians also fear that the DEA could take away their license to prescribe other drugs, Freeman added.
To fill the void, some physicians are opening clinics whose sole purpose is to recommend medical marijuana to patients. In addition, websites are popping up that offer these recommendations without the need to go to a physician’s office. According to one such website, NuggMD.com, all customers have to do to get an emailed recommendation is pay $39 and have a 10- to 15-minute video chat with one of the California-licensed physicians who work for NuggMD. Any licensed physician can recommend marijuana in California because the state does not require special training or certification to do so. Such websites and marijuana clinics seem to run afoul of policy guidelines approved last May by the Federation of State Medical Boards’ House of Delegates. Under the guidelines, physicians should have an established relationship with patients before recommending marijuana to them.
Norris, who has a sign hanging in his waiting room stating “this is not a pain clinic,” is unmoved by callers claiming that since their state approved an amendment legalizing medical marijuana, it is now their constitutional right to get it. “They think I’m supposed to just go ahead and write the scripts, and I’m not doing that.”
If the callers want to make an appointment so he can examine them and take their medical history, fine, but, Norris said, he will not rubber-stamp recommendations for medical marijuana. “I do not want to be a little head shop doc with bongs in the window.”