Don’t Ask – Don’t Tell… The Cannabis Communication Gap in Medicine

Physicians in the United States are in a bit of a quandary when it comes to medical cannabis.  Patients are afraid to be honest with their doctors about the use of medical cannabis because it is  illegal. This creates a knowledge gap when diagnosing, treating, or recommending treatments.  Physicians do not have all the needed information to make the best recommendations. All healthcare practitioners are not legally able to speak about medical cannabis.  The laws and restrictions for medical cannabis differ from state to state. For many providers there is still not enough research to recommend cannabis as an option, even when it is a legal option.  The main reason that the evidence is not available in the United States is that cannabis is still a schedule I category drug.  Federally speaking, even in the states where medical cannabis has been allowed in varying degrees of legality, the actual cannabis plant itself is a federal offense.  

 Other countries who have been able to legalize medical cannabis are possible sources for more research and treatment guidelines.  A group of Canadian family physicians created a simple guideline for prescribing medical cannabis in the primary care setting. (1) This was needed for assisting in the recommendation and prescribing of medical cannabis to patients in Canada where it is legal and obtainable.  

In February 2010, the Center for Medicinal Cannabis Research (CMCR) at the University of California San Diego shared five clinical trials with the Governor of California that were done by looking at the medical records of 1655 patients who utilized medical marijuana.  The data came from medical charts and doctor interviews throughout California who specialized in medical cannabis.  Most patients stated they had tried other therapies including prescription drugs prior to considering medical cannabis.  The most common reasons they utilized it were for pain, depression, anxiety and insomnia.  Approximately half of them noted that they used medical cannabis as a substitute for prescription medications.(2)

Physicians who prescribe or direct their patients on the use of medicinal cannabis are in the position to counsel their patients on the safe use of cannabis products.  They give suggested doses and offer multiple route options.  They also monitor them for efficacy and side effects just as they would a prescribed treatment. They do this even though as healthcare providers they do not have access to adequate peer-approved evidence, agreed-upon guidelines, standardized dosing, and basic clinical education. This is historically done by pharmaceutical companies in the US. Their motivation for doing research on new medications is to bring their products to the marketplace for profit, and this takes years.  It is generally known in the medical world that new treatments take fourteen to seventeen years of research, discovery and clinical trials to reach the bedside. Only then can they be incorporated into western medicine’s guidelines of practices.  A national government-sponsored survey in 2016 showed that cannabis was the most commonly used illicit substance in the United States. (3)  It seems that the country is not able to wait over fourteen years for medical research to catch up on the ways that medical cannabis can be used as a medicine.  

There are many barriers to researching the validity of cannabis as a medicine in the US. According to current law, if a researcher seeks to engage in a clinical trial with cannabis, they need approvals from BOTH the Food and Drug Administration (FDA) and also the Drug Enforcement Administration (DEA).  The best guess for how long it would take to get this approval is at least a year if all goes well.  Once that time-consuming federal approval process is obtained, there are a very limited number of farms that are able to grow and dispense cannabis plant material for research in the US. These barriers of time, product and legality are overwhelming and unfavorable when seeking to find the evidence needed to support the solution people are already using. (4) In 2020, Representative Anna Eshoo (D-CA) summarized this by saying “Investigators cannot conduct research on cannabis until they demonstrate that it has medical use, and they cannot show that it has medical use until they conduct research. (5)

There is evidence that shows that the medical use of cannabis is valid and effective.  In fact, the evidence is so overwhelming and obvious that the National Academies of Sciences, Engineering and Medicine (NASEM) reported this in 2017.  Here are some of their conclusions.

—      CONCLUSION 4-1 There is substantial evidence that cannabis is an effective treatment for chronic pain in adults. (6)

—      CONCLUSION 4-3 There is conclusive evidence that oral cannabinoids are effective antiemetics in the treatment of chemotherapy-induced nausea and vomiting. (6)

—      CONCLUSION-4-7(a) There is substantial evidence that oral cannabinoids are an effective treatment for improving patient-reported multiple sclerosis spasticity symptoms, but limited evidence for an effect on clinician-measured spasticity.(6)

—      CONCLUSION 4-19 There is moderate evidence that cannabinoids, primarily nabiximols, are an effective treatment to improve short-term sleep outcomes in individuals with sleep disturbance associated with obstructive sleep apnea syndrome, fibromyalgia, chronic pain, and multiple sclerosis. (6)

The NASEM data shows that in spite of the lack of research as well as the barriers and restrictions around adequate and structured clinical trials, there still appears to be definitive data for cannabis to be considered as a medical treatment option. Current knowledge on cannabis use suggests that cannabis presents an appropriate alternative therapy option for patients who have sleep disturbances, movement disorders, and pain.  Furthermore, it should be considered as an adjunct complementary medicine option for the treatment of chemotherapy-induced nausea and vomiting. (7)

The fact that continues to override the warnings of danger and the potential barriers to the research of cannabis is that there has never been a death attributable to cannabis.  No deaths at all have occurred due to the effects of cannabis. (8)  This record of safety is well above and beyond any other medications that are used for pain.  The Hawaii Medical Association has recommended to the federal government that medical cannabis be removed from the Schedule I status to a less restrictive status such as Schedule III which is where the synthetic THC Marinol has been placed. (9)

Putting aside all disagreements, the one point that all are in agreement on is that there is a need for more research.  This obvious fact leads to some potentially complicated issues.  One issue is the ethical dilemma of accepting money for research from companies that will profit from the research. In the process of clinical research, there is strict oversight to be sure that the evidence is objectively obtained and truthfully reported.  All potential competing interests or reasons to consider bias must be listed.  One of the most glaring historical industry examples of abuse of power is the tobacco industry. (10)  There were strategic measures made by this industry to shape or control the outcomes of research so that results benefited the tobacco industry. (11) Another similar example is the alcohol industry when in 2018 the National Institutes of Health (NIH) stopped a $100 billion study on the benefits of alcohol, for it was found to be mostly funded by the alcohol industry (12).  If the cannabis industry is sponsoring and supporting the research then there is room for bias and all parties must seek accountability and objectivity.  

Standardization of research is challenging with cannabis.  Traditional healing methods in general and botanical medicine in particular, are not always amenable to the reductionist western scientific paradigm.   There are multiple ways that people use cannabis including smoking, vaping, topical, sublingually and others.  For example, how does one standardize the smoking of cannabis so that all participants in a study receive equal doses?  Besides the issue of what dose to use, there is the actual cannabis product being used.  Whether it is whole plant research, pharmaceuticals, isolated extracts, edibles, etc, in order to create evidence, there must be standardization of research methods.  The current paradigm states that true research True research must be controlled, randomized and repeatable with the same results to consider it to be evidence. (13)

When one considers funding barriers, the standardization challenges, the approval time and expense, how will ethical, objective and valid cannabis research be done? These are the questions we shall face in the times to come. A recent analysis of funding in the United States, Canada and the United Kingdom revealed more than $1.5 billion was spent on cannabis research from 2000-2018 with the majority spent on the potential harm, misuse and negative effects. (14) An article in the BMJ Publishing group in 2020 describes a complicated network of relationships between those who are cannabis proponents lobbying for greater availability and how they are linked to a campaign to create a large and lucrative recreational market for cannabis in the UK. (15)  The funding for cannabis research is available from people who will profit from positive results.  There needs to be integrity within the cannabis industry so that they will not fall into the same conflict of interest that the tobacco and alcohol industry has faced.  Possibly a third party research foundation could be established.  No matter how the research is funded, it must be fair, objective and not swayed by privilege or money.   

The quandary of the physician and patient relationship only seems to deepen when one looks at all facets of the medical cannabis dilemma.  The efforts it takes to consider medical cannabis as an option for healthcare are real and present. It is still unlikely that patients will be honest about their use of medical cannabis with their physicians.  Doctors in the US are often choosing to use the “don’t ask, don’t tell” method to stay out of difficult conversations.  Until there are more facts and evidence and less fear, we can be sure that the knowledge gap will persist.  The positive side is that there is a conscious effort to discuss the need for research, and the first step toward any solution is the awareness of the problem.   

(1)Allan GM, Ramji J, Perry D, Ton J, Beahm NP, Crisp N, Dockrill B, Dubin RE, Findlay T, Kirkwood J, Fleming M, Makus K, Zhu X, Korownyk C, Kolber MR, McCormack J, Nickel S, Noël G, Lindblad AJ. Simplified guideline for prescribing medical cannabinoids in primary care. Can Fam Physician. 2018 Feb;64(2):111-120. PMID: 29449241; PMCID: PMC5964385.

(2) An Analysis of Applicants Presenting to a Medical Marijuana Specialty Practice in California

Helen Nunberg, Beau Kilmer, Rosalie Liccardo Pacula, James Burgdorf

J Drug Policy Anal. Author manuscript; available in PMC 2013 Jun 5.

Published in final edited form as: J Drug Policy Anal. 2011 Feb; 4(1): 1. Published online 2011 Feb. doi: 10.2202/1941-2851.1017

(3) Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results From the 2016 National Survey on Drug Use and Health. Rockland, MD: Center for Behavioral Health Statistics and Quality; 2017. [Google Scholar]

(4) May 14, 2020 N Engl J Med 2020; 382:1876-1877 DOI: 10.1056/NEJMp2003095

(5) U.S. Congress House Committee on Energy and Commerce. Hearing on “Cannabis policies for the new decade: ” statement of Anna G. Eshoo, Chair, Subcommittee on Health. 116 Cong. Washington, DC: Government Printing Office, January 15, 2020. [Google Scholar]

 (6) National Academies of Sciences, Engineering, and Medicine. 2017. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press. https://doi.org/10.17226/24625.

 (7) Therapeutic potential of medicinal marijuana: an educational primer for health care professionals Yara Mouhamed, Andrey Vishnyakov, Bessi Qorri, Manpreet Sambi, SM Signy Frank, Catherine Nowierski, Anmol Lamba, Umrao Bhatti, Myron R Szewczuk

Drug Healthc Patient Saf. 2018; 10: 45–66.  Published online 2018 Jun 11. doi: 10.2147/DHPS.S158592

 (8) Iverson LL.  The Science of Marijuana. New York: Oxford University Press; 2000.  [Google Scholar]

 (9) Therapeutic Benefits of Cannabis: A Patient Survey

Charles W Webb, Sandra M Webb

Hawaii J Med Public Health. 2014 Apr; 73(4): 109–111.

 (10)Ethics of Health Research Supported by For-Profit Cannabis Companies: What Have We Learned from Big Tobacco? Ellen L. Burnham, Michelle N. Eakin and Smita Pakhale 

https://doi.org/10.1513/AnnalsATS.201811-764LE       

(11) Malone RE. Changing Tobacco Control’s policy on tobacco industry-funded research. Tob Control2013;22:1–2. Google Scholar

(12) Rabin RC. Major study of drinking will be shut down. New York Times, 2018 June 15;Sect A:17.

(13)The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research, National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Health Effects of Marijuana: An Evidence Review and Research Agenda. Washington (DC): National Academies Press (US); 2017 Jan 12.

(14)Cannabis research data reveals a focus on harms of the drug, O’Grady C. Science 2020; 369(6508):1155.  Copyright 2020 American Association for the Advancement of Science DOI: 10.1126/science.369.6508.1155

(15) Tobacco cash behind cannabis research in Oxford, BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1044 (Published 18 March 2020)