Well, this cartoon says it all.
Why Are Physicians So Reluctant to Use Cannabinoid Medications?
Cannabinoid medications, or medications derived from the cannabis plant, have been shown to have potential therapeutic benefits for a range of medical conditions, including chronic pain,1-3 epilepsy,1 neurodegenerative diseases like Parkinson disease,1,4 Alzheimer-type dementia,1,5 chemotherapy-related nausea and vomiting,1,6 unipolar depression and anxiety,1,7 and insomnia.1 However, despite the growing body of research supporting the efficacy of these medications, many physicians remain hesitant to treat patients with them. There are several reasons for this reluctance, including concerns about lack of training, lack of infrastructure to write an actual prescription, lack of standardized dosing, and potential side effects.
Medical Education and Training Needed
Lack of training and education on the subject is a significant concern. Cannabis has traditionally been viewed as a recreational drug rather than a medication, and many physicians may not be familiar with the latest research on the medical uses of cannabinoids.8 Medical training programs traditionally have not included much education on the endocannabinoid system or the therapeutic potential of cannabis, leading many physicians to feel unprepared to discuss these medications with their patients.9
As the medical use of cannabis becomes more widespread, medical schools and residency programs are beginning to include more education on the subject.9 However, this is still a relatively new area of study, and many practicing physicians may not have had the opportunity to receive this training.10 Worse, many physicians who lack this education are confronted with patients who, having read information on the internet, believe that they are more knowledgeable than the physician. In many instances, the physician may agree without understanding how flawed this information may be11-14,15 and how important it is for them to intervene to correct misinformation.
Lack of appropriate medical infrastructure certainly factors into the reluctance of physicians to consider cannabinoid-based therapies for their patients.16 One of the most important reasons for prescription of conventional medications, in addition to providing the patient with clear instructions on when and how to use the medication, is to stave off financially conflicted advice or upselling at the point of sale. In this country, almost all cannabis regulatory systems are based on a nebulous “recommendation,” rather than an actual, legally binding prescription. As a result, patients, even those who are advised well by their doctor on what to get and how to use it, are misled by dispensaries to increase sales. This often leads to patients getting wrong, extra, or irrelevant products and believing cannabis lore that is not scientifically valid. At best, this wastes patients’ time and money, at worst, it leads to delayed treatment or negative outcomes.
Federal Regulation Needed
Lack of oversight by the US Food and Drug Administration (FDA) also plays a role. While some cannabis-based medications have been approved by the FDA, most products derived from the cannabis plant have not gone through the rigorous testing and approval process required for conventional pharmaceuticals.16,17 This process, including standard, phased trials, not only assures safety and efficacy, but also provides dosing guidelines. Without data on dosing and administration, it is a challenge for physicians to determine the appropriate dosage for patients, which reinforces their hesitation to use cannabis-based medications, particularly for patients with complex medical conditions.17
Furthermore, the lack of FDA oversight means that these products are not subject to the same quality control standards as conventional pharmaceuticals. As a result, patients may be exposed to contaminants such as pesticides, heavy metals, or other harmful substances in cannabis-based products.17 While most states are regulating these products for safety, it varies from state to state how rigorous these regulations are and how thoroughly they are being enforced.16
Physicians may also be hesitant to use cannabinoid medications due to potential side effects. Like all medications, cannabis can cause side effects such as dizziness, nausea, and cognitive impairment.17,18 For some patients, these effects may be significant enough to outweigh the potential benefits of the medication.
We must also recognize that much new drug information is not disseminated throughout the physician community by the FDA, or by the publication of research, but rather by continuing medical education events that are often supported by the drug manufacturer. In my experience with a wide range of cannabis companies, most industry companies are not conducting their own product research, nor are they particularly interested in physician involvement. As a result, they are not sponsoring these events. Most sponsored cannabis events are focused on the value of the plant material but not in any rigorous, data-driven, physician-acceptable fashion.
Last, physicians may be reluctant to prescribe cannabinoid medications due to their concern over lack of clear evidence supporting their use.17 Some of the evidence for the therapeutic use of cannabinoids is based on small-scale studies, which are sometimes neither blinded nor randomized. This can make it difficult for physicians to determine whether these medications are likely to be effective for a given patient. Additionally, physicians are only recently becoming aware of potential interactions with other medications.18
While there is growing evidence to suggest that cannabinoid medications can be effective in treating a range of medical conditions, many physicians remain reluctant to prescribe them. Factors such as concerns about legality, lack of standardized dosing, potential side effects, lack of clear evidence, and a lack of training or education on the subject may all contribute to this reluctance. As research continues to accumulate and the legal landscape continues to evolve, it is possible that we may see a shift in physicians’ attitudes toward cannabinoid medications. However, for now, many physicians continue to approach these medications with skepticism.
Dr. Tishler is President of the Association of Cannabinoid Specialists (ACS), an international nonprofit focused on health equity for patients. The ACS strives to bring human evidence–based treatment to patients by educating clinicians and lawmakers on the value, risks, and ethics of cannabinoid treatment. The ACS provides a range of educational materials to members and the public. For more information, please visit cannaspecialists.org.
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