RESEARCH

The Efficacy of Medical Cannabis

Removing the stigma, doing no harm

BY STEPHEN DAHMER, MD

What if suddenly you could not prescribe NSAIDs, corticosteroids or beta blockers because “there is not enough research.” Think of the impact this would have on your patients. Unfortunately, many of your patients are missing the benefits of medical cannabis for this exact reason. As a profession we need to move beyond this.

Cannabis is the most widely used psychoactive substance in the western world and has been used medicinally for at least 5,000 years. Phytotherapies (plant medicines), from common birch to willow bark, while materia medica for many of our modern pharmaceuticals, are also incredibly complex and difficult to research in their natural form. Nonetheless, current evidence supports exploring medical cannabis for patients that might benefit.

Regardless of our personal opinions, our patients and peers are already making decisions about cannabis, potentially from questionable resources like doctor Google. Support for allowing medical cannabis is strong: 76% of doctors, 93% of Americans, and 83% of veterans support its legal medical use. At the time of writing this, 36 states have effective medical cannabis laws, 13 states have laws pertaining to low-THC, high-CBD cannabis and no states have repealed effective medical cannabis laws. In some form, 49 states acknowledge the medical benefits of cannabis.

Statutes establishing the medical cannabis program in Minnesota were enacted in 2014. Minnesota licensed physicians, advanced practice registered nurses and physician assistants can certify a patient’s qualifying medical condition. They must be enrolled in the Medical Cannabis Registry before certifying a patient’s qualifying condition. Of the 24,643 physicians with active Minnesota licenses, there are 3,739 practitioners that have registered for the medical cannabis program. Estimates as low as 1.4% of all those Minnesotans dealing with chronic pain had linkage to care or saw a provider that certified patients for medical cannabis.

Deceptive statistics

Unfortunately, most research to date has been funded by NIDA (National Institute on Drug Abuse) and has focused on the harms associated with the plant, further supporting a long history of stigma. Nearly half of the 30 journals that have published the largest number of cannabis studies contain harm-associated words in their titles, such as “abuse,” “addictive/ addiction,” “dependence” and “forensic.” How might our opinion of any other medication might change if such resources were mobilized to study its potential for harm? In addition, research funds for products our patients are using are limited, and there is a daunting thicket of regulations to be negotiated at the federal level—those of the Food and Drug Administration (FDA) and the Drug Enforcement Administration (DEA)—and at the state level. Designation as a Schedule I substance in the Controlled Substance Act only adds even more complexity and expense to any clinical evaluation. Frustration with these barriers to research, enough to make even the head of NIDA reluctant to conduct studies on Schedule I drugs like marijuana because of the “cumbersome” rules that scientists face when investigating them, has even led me to accept a policy position with the U.S. Cannabis Council (USCC).

In the United States prescribing medications is regulated the FDA, which most of us accept as an important system overdue for an overhaul. Of critical concern to the FDA and all of us is that the products we prescribe are safe. Naturally, we also assume they will present therapeutic value; however, here the bar can be surprisingly low. When Prozac went through its initial clinical trials, the patients reporting the best results were from the control group taking the placebo. We all know that not all patients respond the same to all medications. This is where the art of medicine comes in. When a patient first presents with hypertension, it usually takes some experimentation to find what will work best, and it oftentimes will require three different medications to achieve the best outcomes. Based on thousands of years of use, anecdotal reports and extensive research, we know that cannabis is a remarkably safe medication when used in the medical context. There is no known case of a lethal overdose, and we have been monitoring patients closely in Minnesota since the inception of the program.

Sometimes there are no results. For the many patients who report positive outcomes, medications with far greater risk and downstream complications oftentimes are replaced. It is important to be aware of and open to this option.

Supporting the patient

Additional research

Additional research holds the promise of better informing us of both benefits and risks of cannabis, but it isn’t so simple. The issue with cannabis is not a lack of research, but rather the complexity of plant medicines which offer a challenge to the well-designed, randomized controlled trials of single-constituent pharmaceuticals to which we are accustomed.

The cannabis plant can produce many therapeutic benefits and creates multiple research challenges when analyzed by the “One-Molecule, One-Target Paradigm” reductionist approach which has served us well in acute care medicine. Further research is paramount to optimizing the complex pharmacognosy of the plant as a form of personalized medicine while minimizing harm.

Emerging research around the endocannabinoid system, a biological system in which endogenous lipid-based retrograde neurotransmitters bind to the proteins in the cannabis plant and are expressed throughout the vertebrate central nervous system and peripheral nervous system, supports a wide range of therapeutic benefits and are well worth further study. Much of what we do in clinical practice is not crystal clear. To approach health and disease in the absence of absolute clinical evidence is no new challenge. Unfortunately, many of us may feel, when dealing with cannabis, that we prefer to turn our backs to the matter—despite solid evidence that this plant might offer a unique and versatile tool for some of our most difficult to treat patients. As clinicians, including with cannabis, we need to weigh the needs of individual patients against

States acknowledge the broader social issues and make best decisions based on medical benefits of cannabis. nuanced individual data points specific to the patient. Patients who are currently suffering from complicated and intractable conditions, who are unrelieved by currently available drugs and might find relief with cannabis, are those we see often at Cannabis Patient Centers (CPCs). These patients find little comfort in a promise of a better drug 10 years from now, and many have already tried FDA-approved synthetics without the same subjective, yet positive, clinical response. As with other therapies we offer, our assessment of the scientific data on the medical value is but one component of complex clinical decision-making. Don’t be fooled by the mainstream mantra that the evidence is not there. In 2017, over 10,000 studies were reviewed by the National Academies of The Efficacy of Medical Cannabis to page 264

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