The Cannabis Conundrum*: What every clinician should know about marijuana.

Tomorrow, September 9, 2020, Dr. Kevin Hill of Harvard University and I will be publishing the book Medical Marijuana: A Clinical Handbook.

This may seem unconventional to some within the medical community. Marijuana, defined by the federal government as plants of the species Cannabis sativa that contain more than 0.3% of the intoxicant tetrahydrocannabinol (THC), is a Schedule I drug and can only be legally obtained in states with medical or recreational programs. Meanwhile, cannabidiol (CBD), a compound found in high concentrations in mature hemp (which is defined as C. sativa plants that contain less than 0.3% THC by dry weight), is available over the counter and has shown only limited efficacy during clinical trials.

However, rarely a week goes by without a major development in the study of cannabis. From the discovery of new cannabinoids like tetrahydrocannabiphorol (THCP) and cannabidiphorol (CBDP) to new indications for FDA approved cannabis-based medicines like Epidiolex, it is clear that there is an army of researchers working overtime to better understand the science of the plant.

Cannabis researchers are not the only ones dedicating their time to learning about it. People from all walks of life are searching for information about cannabis-based medicines, especially CBD, which was an unknown entity to even regular marijuana users just a decade ago. This has led to a surge in the number of articles about everything from the differences between cannabis, hemp, and marijuana to the latest research about the reputed health benefits of THC, CBD, or one of more than 500 compounds found in C. sativa.

Unfortunately, a combination of relative ignorance about cannabis and the highly competitive media environment has led to a surge in misinformation about the plant. Additionally, polarizing media outlets have added another layer of confusion, especially when the plant is pigeonholed by the countercultural stigma with which it was branded over fifty years ago.

Duty to My Patients

The word “doctor” is derived from the Latin verb doceo, which means “to teach” or “to instruct.” This should come as no surprise, as it is part of our responsibility to provide patients with advice, especially when it comes to potential treatments for their conditions.

When my patients would ask for my opinion about cannabis, I felt ill-equipped to respond. To those who believed it was a panacea, I would temper their optimism. To those who believed it was the devil’s weed, I would remind them that it has been used for millennia without causing civilization to collapse. When asked to paint an evidence-based, unbiased portrait of the plant, however, I found myself at a loss.

Many clinicians are in a similar boat. To those of us who graduated from medical school prior to 2000, cannabis was synonymous with marijuana, and we knew that marijuana was a Schedule I drug that people used as an intoxicant. That was about it. Even younger medical graduates have not been taught extensively about the endocannabinoid system — the biological system that is activated by cannabinoids created within the body (endocannabinoids) or cannabinoids that occur in plants like cannabis (phytocannabinoids) — because it was only discovered in the 1990s. Even many textbooks today contain incomplete information.

I soon realized that:

1. Cannabis was readily available to patients.
2. Many were already using it.
3. They had questions about its risks and benefits.
4. Many within the medical community, including myself, did not have all the answers.
5. Consequently, patients were relying on whatever information was available to fill in the knowledge gaps.

This seemed like a dereliction of duty, and I decided to learn more to better advise my patients. I relied on science and tried to avoid picking a side in the decades-long debate about medicinal cannabis. My goal was to simply read as much as I could and share what I discovered with my patients.

Meanwhile…

During my research, I also witnessed the destructive force of the opioid crisis at work. Having been a part of the psychiatric inpatient unit at a New York City hospital for 29 years, I have observed a steady rise in both addiction to opioids and overdoses. It is a tragic pattern that is well-documented: An otherwise healthy person is prescribed opioids following an injury or surgery; they become addicted; their provider ceases to fill their prescription; they are given the option of withdrawal or the illicit market; they choose the latter; and they begin using more potent opioids like heroin and fentanyl.

The next step is all too familiar.

As this crisis was unfolding, I came across several studies (Hohmann and Suplita, 2006; Rahn and Hohmann, 2009; Boychuk et al, 2015; Petzke et al, 2016; Muller et al, 2018) claiming that cannabis could play a role in pain management — possibly as an alternative to opioids. This only fueled my research and I found myself delving deep into the weeds trying to better understand this pharmacological chameleon, which can contain hundreds of potentially therapeutic compounds.

The amount of information became overwhelming and the idea of sharing what I had learned in a brief review went out the window. A far lengthier and more nuanced approach was necessary.

I eventually approached Dr. Hill with the idea of publishing a book to document what I had found and to write it specifically for clinicians. I respected Kevin as an addiction specialist, a clinician, and a writer on the topic of cannabis, and I recognized in him a similar desire to cut through the politics and to arrive at an accurate depiction of what continues to be one of the most misunderstood plants on Earth. What was needed, we agreed, was a medical textbook on cannabis to educate medical professionals, as well as a regularly updated website that tracks new findings from more recent studies. Such a book would include only evidence-based studies on cannabis and be compiled in such a way that the busy clinician would be able to turn to it as a quick reference.

What we produced is Medical Marijuana: A Clinical Handbook. Written by clinicians for clinicians, it includes information on the biology and chemistry of cannabis; the history of its use; the evolution of regulations regarding its use; the pharmacological profile of its major constituents; its effects on various bodily systems; and much more.

To conclude, cannabis is not a fad. It is a medicine that has been used for millennia and many of our patients have used it regularly for years. It is not our duty to scold them or to tell them that it’s harmless. Our duty is to better understand the science of the plant, to potentially recommend it should we feel it is appropriate, and to inform our patients about its risks and benefits to the best of our abilities.

*”The Cannabis Conundrum” is also the title of Dr. Rob Streisfeld’s recent book.