Dilemmas of Dosing: Part III of a III Part Series
Read Part II: The Challenges of Popular Methods of Consumption
In this RYAH exclusive series, “The Dilemmas of Dosing,” we are exploring challenges related to dosing medical cannabis. There is no golden rule, and both patients and providers continue to stumble along as they try to find a consistent, accurate, and effective dose.
If you missed “Part 1: Cannabis Research Fails to Capture Real Patient Data,” we examined the problems with the available research. Poor quality plant material and challenges within a laboratory setting mean physicians have little robust research to rely on when working with patients.
In “Part 2: The Many Challenges Posed by Popular Methods of Consumption,” we discussed the issues with each: smoking, edibles, and vaping. Each method poses challenges to modern medical conventions of predictability, bioavailability, and consistency.
In this third instalment, we discuss the ultimate Catch 22, the patient-physician relationship with the plant. Patients continue to rely on self-experimentation due to a lack of support (or knowledge) from their healthcare providers. And providers continue to struggle with a lack of education and robust scientific resources with which to better their understanding. Without a shift by physicians and the institutions who train them, patients will continue to fumble through dosage without proper guidance.
Part 3: The Role of the Physician in Patient Experience with Medical Cannabis
The story is, by now, a familiar one. A frustrated patient turns to cannabis as a last-ditch effort to treat a challenging medical condition. Typically, she does not seek the guidance of a healthcare provider and sets off on her own, seeking advice from friends, family, and the internet. Initially, she fumbles with dose and ends up with acute intoxication. Since she possesses little information about dose control, cannabinoids, or methods of ingestion, this was only inevitable. She has undergone the all too common experience of self-experimentation.
Self-experimentation is a journey many patients embark on as they try to figure out the medicinal value of the plant. The journey can turn out to be long, tedious, and frustrating. Patients receive little to no guidance from healthcare providers, conflicting information from online sources, and haphazard suggestions from their budtender.
It can take a very long time for patients to arrive at a dose that minimizes side effects while maximizing therapeutic ones. For some, this lack of guidance leads to an acute cannabis intoxication and complete rejection of the treatment.
Cannabis as medicine, even if prescribed in a regulated system, flies in the face of medical and pharmaceutical convention. It’s frustratingly un-doseable. From patient to patient and from one medical condition to another, there is no standard. Patients are frustrated, physicians are nervous, and nobody knows where to turn for answers.
Without Physician Guidance, Patients Self Experiment With Dose
Imagine purchasing an over-the-counter pain medication, like ibuprofen or acetaminophen, without any medical guidance. Instead of finding helpful information on the label about its specific application, like for joint pain, migraine or cold and flu, the label contains nonsensical names like “OG Kush,” “Super Lemon Haze,” or “Cannatonic.” Furthermore, none of the products come with dosage guidelines on the back, and neither the pharmacist nor the physicians are willing to discuss it.
Welcome to the current state of the medical cannabis system, no matter what state or country it operates in. Patients are largely left up to their own devices when it comes to determining the dosage, product selection, and post-treatment monitoring.
There is no other approved medicine on earth that has followed the same confounding evolution as cannabis. No wonder doctors are nervous about talking to patients about it, and no wonder medical colleges have neglected to include it within their curriculums.
This hesitation to move forward continues the anti-cannabis stigma. Patients, even where legal, face judgment or outright rejection by their primary care provider.
Some patients report hiding their cannabis use completely from their doctor. Other patients detail how, even in legalized states, doctors continue to refuse patient requests for medical cannabis in favor of opioids as there is, at the very least, robust clinical research on the latter.
Legalization is spreading, and more patients rely on cannabis than ever before. But, the underlying issues of education and disinformation continue to affect the patient experience. In today’s climate, patients continue to experiment outside the scope of conventional medicine. If cannabis doesn’t enter into the patient-physician conversation in a meaningful way, it will never evolve as a medicine.
Complications from DIsinformation and Policy
Not surprisingly, physicians are wary of discussing the details of medical cannabis with their patients because of a lack of robust clinical study. Robust clinical studies, as discussed in this series, is still next to impossible thanks to the strict scheduling under the Controlled Substances Act (CSA).
Frustratingly, the Drug Enforcement Agency (DEA) is quick to point out the lack of scientific evidence as a reason to continue to deny the therapeutic value of medical cannabis, and thus approve the rescheduling.
As per a “Denial of Petition To Initiate Proceedings To Reschedule Marijuana,” published in 2011, the DEA highlights this political quandary. In the DEA’s opinion:
There is no currently accepted medical use for marijuana in the United States. Under the five-part test for currently accepted medical use approved in ACT, 15 F.3d at 1135, there is no complete scientific analysis of marijuana’s chemical components; there are no adequate safety studies; there are no adequate and well-controlled efficacy studies; there is not a consensus of medical opinion concerning medical applications of marijuana; and the scientific evidence regarding marijuana’s safety and efficacy is not widely available.
Not much has changed at the federal level in the years since this decision was made, with the current US Health and Human Services Secretary, Alex Aza, asserting at a press conference in 2018, “There really is no such thing as medical marijuana.”
Herein lies the problem. There is no official acceptance of cannabis as medicine because of a lack of research, but there is a lack of research because it’s not medicinally accepted. With more than 30 states with medical cannabis regulation, something has to shift.
Physicians, who ultimately want to provide sound advice to protect their patients have their back against a wall. It’s from this position where often physicians err on the side of reason. They either avoid the conversation or deny until there is more supportive evidence.
Gaps in Education, Despite Growing in Popularity
Remember, healthcare professionals still receive little to no training on medical cannabis during their lengthy education. If healthcare providers do receive training on medical cannabis, it is mostly done under their own volition. Even in Canada, where medical cannabis has been legal for 18 years, cannabis education for medical professionals is missing from most post-secondary curriculums.
In Canada, physicians at least have access to several federal or provincial resources on dosage and prescription guidelines. These documents lack substance, however, especially in comparison to conventional dosing guidelines. According to the “Access to Cannabis for Medical Purposes Regulations – Daily Amount Fact Sheet (Dosage)” issued by the Government of Canada in 2016, “There are no precise doses or established uniform dosing schedules for products such as fresh marijuana, smoked/vapourized marijuana, or cannabis oil.”
While the recommendations do attempt to suggest standard daily dose, it’s on an imprecise per gram basis, with little guidance on milligrams per day or the impact of cannabinoids.
The document suggests, “The most prudent approach to dosing in the absence of evidence-based guidelines is to ’start low and go slow.’”
Majority Support for Medical Cannabis, but Discomfort Discussing It
An Environic survey of Candian GPs (performed pre-legalization) found that nearly 70 percent of respondents were uncomfortable prescribing medical cannabis, and 50 percent indicated they were very uncomfortable. Environics suggested this nervousness stemmed “mostly from this emerging industry not fitting neatly into standard pharmaceutical practices or possessing typical clinical trial data.”
In the US, the statistics are eerily similar. For example, in a survey of California pharmacists, 32 percent indicated they have “very little” knowledge about medical cannabis, including the various types. A substantial majority felt the plant had medicinal value, but few knew enough to provide advice to their customers safely.
In Minnesota, a majority of physicians from a small representative survey also believed cannabis was an effective treatment for specific conditions. Still, 50 percent were not ready to answer patient questions on the matter.
In New York, the results were the same. Physicians and other healthcare providers consider the plant as medicinally valuable but are underprepared to advise their patients on best practices, doses, and strains.
In a widely circulated opinion piece from the Journal of the American Medical Association for Internal Medicine, Nathaniel P. Morris MD systematically laid out the issues with the current medical curriculum. His piece makes clear why many providers are uncomfortable with medical cannabis as a whole and unwilling to discuss with patients.
He highlighted that only nine percent of medical schools in the US covered medical cannabis content. He also demonstrated how numerous surveys of medical residents showed overwhelming ignorance on even basic facts about cannabis, including under which category it was scheduled in the CSA or if it was an approved prescription by the FDA.
Patients need answers, and physicians don’t have them. Patients need sound information to improve therapeutic outcomes and to reduce the frustrations of self-experimentation to find the right dose. Improving the patient-physician conversation on cannabis would also reduce the stigma of cannabis use.
However, physicians can only provide sound guidance on cannabis if they have confidence in the science along with a medical education that covered the topic. We know much more about the risks and benefits of cannabis today than in years gone by, but it’s still not enough. It’s not getting translated into physician education.
For the time being, the healthcare system needs to address the growing desire of patients to use cannabis as medicine by providing physicians with the basic resources to manage their questions. Medical cannabis isn’t going anywhere, and the healthcare system needs to adjust for this change starting at the top.