Cannabis & Medicine

Not many things can make physicians shuffle uncomfortably in their seats (we've seen it all) but weed?...It's not just the politicians and the public who harbor mixed feelings about this plant and the validity of its medicinal value.

What are all these hang-ups? Here are some of the questions we doctors and researchers have, and which are often shared by the general public: 

• Is it or isn't it that so-called “gateway drug” that so many have claimed it to be for decades? 
• Should it be decriminalized? 
• What diseases/conditions/disorders should it be approved for? 
• Have there been statistically significant studies that prove it's effective in certain disorders? 
• Is it addictive?
• How do we stop our kids getting their hands on it? 
• Is this all just a sophisticated ploy to fully legalize marijuana?

This blog is far too limited to address all those questions, and I'm a doctor, not a politician running for office! Instead, I want to go into whether patients find cannabis useful and how my patients should know they can discuss it uses with me if they want to, but were afraid to before for any reason.

Cannabis, THC, and CBD
The cannabis of medical marijuana has more than 100 active ingredients, and THC (tetrahydrocannabinol) is the one that causes the so-called “high” feeling that we've heard about. CBD (cannabidiol) however, results in no altered consciousness. Even without the high however, there is considerable anecdotal evidence reporting many benefits from CBD, such as relief from anxiety, insomnia, pain and seizures. 

Cannabis also appears to ease a lot of neuropathic pain, including that from multiple sclerosis, which is great news because all the other options are little better than drinking cat's urine (which I am not recommending by the way). Being able to live a fully functional daily life is key for patients who are either disabled from lack of pain relief, or sedated from too much old-school pain relief. Cannabis to the rescue. There are reports of its usefulness in fibromyalgia, endometriosis, interstitial cystitis and other conditions that make most physicians groan and moan, myself included, when we see it on the patient's chart before we walk into the room. We groan because it's so difficult to treat and we feel almost powerless at being anything better than a kindly listener! 

The number one use for cannabis is indeed pain control and, although it's not strong enough for the most severe pains (such as a fractured femur or neck, or recovering from major surgery), it has been found to be rather effective for a lot of chronic pain, especially with advancing age.

Cannabis is categorically safer than opiates and it's a good substitute for over-the-counter drugs like ibuprofen, if people can't take them due to ulcers or kidney problems. You can't overdose on cannabis and it's arguably far less, if at all, addictive, compared with many other drugs, legal or not. 

Cannabis also appears to serve as an effective muscle relaxant as well as remedy for reducing tremors, such as in Parkinson's disease. 

Being an appetite stimulant, nausea and chemo-related weight loss also seem to be qualifying conditions for cannabis.

Patients with PTSD also report dramatic improvements in their symptoms and this condition may be the biggest lobby for federal decriminalization which, in my opinion, is inevitable because elected officials seem to support things that will gain them votes, and the mental health of our veterans is important to the majority of people. 

Muscle wasting in HIV and AIDS also seems to be helped by cannabis, as does IBS and Crohn's Disease. 

The State of Missouri has declared other “chronic conditions as a qualifier for physician certification, which seems to be rather an interesting blanket description. 

Given all the above reports and claims however, the real tests of effectiveness can only really be proven after a few years of well-controlled scientific studies, so my physician friends should behave more as clinicians rather than scientists. As you're aware, we were advising people to quit smoking tobacco long before the studies proved any harm. A clinician has that liberty to make recommendations, whereas a scientist does not, the latter waiting for compelling proof before he is willing to make any bold announcements. I do understand that some, if not most, doctors need measurable and substantial proofs before making any recommendations for treatment or management plan. However, it may behoove us to remember that many of our patients cannot wait years for this proof to finally appear. 

Patients, Please Talk With Your Doctor. Doctors, Please Talk With Your Patients.
Reminiscent of when Viagra first came out, a lot of patients really want to know more about the medicinal uses of cannabis, but are afraid or embarrassed to raise the matter with their doctor. It may even be more taboo than erectile dysfunction was (I still remember the ads on the radio encouraging men to speak with their doctor about it). This won't happen with cannabis of course, until it's federally legal, because you can't advertise federally illegal drugs on TV. 

Unfortunately, there are some in the medical community who are either in disagreement with the benefits of cannabis or consider it unscientific or unethical in some way without any scientifically-derived reason. One’s ethics will of course be dictated by which belief system one holds dear, if any. 

Patients are afraid of being scolded, criticized, chided or judged, so there are some who won't even tell their doctors.  

My approach is that honesty is the best policy. Don't hesitate to have the conversation with your doctor for fear of their reaction in knowing you are using cannabis, or that you’ve been wondering if it might be useful for your condition. They may surprise you and be extremely supportive. If you also tell them that quite frankly, you consider the use of cannabis as part of your medical regimen, and that at the very least, you expect your primary care physician to have studied it enough to discuss it and make a recommendation, I don't think you'll get much push-back if any. 

My unsolicited words of advice for my fellow physicians is that, whether you like it, love it, hate it or just don't know enough about it, your patients are either using it already or they will soon. Get yourself educated on it, keep an open mind about it and don't judge your patients. They're trusting you to be an oracle of wisdom with regard to their health. If you judge or dismiss, you really are letting them down. If you are utterly against cannabis, tell your patient that you're not ready to prescribe it and that perhaps they should look for someone who is. Otherwise, it's just going to be awkward for both of you when they next visit. 

Maintaining the trust from our patients requires us doctors to be honest with them, just as we expect them to be honest with us. The doctor-patient relationship is sacred and our patients' lives hinge on this relationship being very open and clear, without anyone having any problem discussing anything. If we consider it our professional duty to willingly discuss sexually transmitted disease, alcoholism and erectile dysfunction, and the various managements for those issues, then surely a condition that might benefit from cannabis, even just anecdotally, shouldn't be any different. 

It is true that we don't [yet] have sufficient scientific evidence to recommend medical marijuana to our patients, but it is also true that we doctors should always be willing to discuss any issue with our patients. ​