August 31, 2015
Written by Robert Bonakdar MD, FAAFP

Recently, The Journal of the American Medical Association (JAMA) has been a leading venue for research on medical marijuana. In October 2014, an analysis appearing in JAMA Internal Medicine noted that states which enacted medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate compared with states without medical cannabis laws. This trend appears to occur the year the law is enacted and generally strengthens over time.¹ However, when JAMA published five articles on medical marijuana and cannabinoids in the June 23/30 issue, it was a sign of the times. Currently, 23 states and Washington, DC, have introduced laws to permit the medical use of cannabis. As use and state access policies increase, clinicians are placed in a larger primary role in determining how this therapy may fit into patient care.

Unfortunately, as the JAMA issue exemplifies, there is a large dichotomy between potential benefit and challenges related to actual incorporation into practice. This explains why clinicians, for the most part, don’t bring up the topic.² For example, Dr. Whiting and colleagues, in their systematic review of 79 trials (6462 participants), found moderate-quality evidence to support the use of cannabinoids for chronic pain (especially neuropathic and cancer pain) and spasticity while noting low-quality evidence for other indications, including nausea and vomiting due to chemotherapy, weight gain in HIV infection, sleep disorders, and Tourette’s syndrome. Overall, they noted a significant number of the trials had a risk of bias.³

Similarly, in his clinical review of medical marijuana, Dr. Hill noted potential benefit, especially for chronic refractory pain, while less consistent evidence in other areas. The article attempts to provide guidance on clinical decision-making in this area.⁴ Unfortunately, even after a decision is made to start therapy, questions remain, as summarized in the article “Medical Marijuana: Is the Cart Before the Horse?”⁵ One area of concern is difficulty with consistent patient access as well as the consistency of the products that are obtained. This is discussed in Dr. Vandrey and colleagues’ article that found significant variation and subtherapeutic dosing in edible medical cannabis products analyzed.⁶

Future needs

1. The current scenario in the United States puts the clinician with a refractory patient, especially one with refractory pain, who is considering medical marijuana in a difficult situation. In a more perfect scenario, additional high-level research supported by the government would be available to determine dosing and formulations—this is missing and likely will be for some time due to federal restrictions.7

2. Second, there would also be much more transparency in education and training, as there is in Canada, which would translate to clinician–patient discussion. This would, as Drs. Ware and Ziemianski of the Departments of Anesthesia and Family Medicine, McGill University, note in their article “Medical Education on Cannabis and Cannabinoids: Perspectives, Challenges, and Opportunities,” “allow health care professionals to engage in meaningful discussions with their patients and colleagues.”8

3. Third, there would be additional guidelines and consensus on use. Again, in another example from Canada, the results of a national physician needs assessment were used to identify key clinical educational needs.⁹ Additionally, the Canadian Family Physician published preliminary recommendations for safe use in non-cancer pain, including indications, contraindications, and dosing.¹⁰

In the meanwhile, clinicians should familiarize themselves with these recommendation and, more importantly, with local resources and colleagues who have expertise in this area to best coordinate patient care and access. There will undoubtedly be more to come in this arena, and we hope that clinician education and support is kept in line with patient access as the issue evolves.

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