Almost 60% of US healthcare providers feel negatively about medical cannabis, while less than 12% view it positively. These results, the product of a survey reported in the forthcoming March 2020 issue of Preventative Medicine, provide a startling insight into the relationship between medical cannabis and those who can prescribe it.
The survey, which investigated the opinions of 1,439 licensed clinicians anonymously from 2011 through to 2017, hints at some of the hurdles cannabis needs to clear for doctors to warm to it. The survey’s authors found that provider advice tended to discourage cannabis use, while the most positive clinician views toward cannabis were for palliative use.
Notably, the findings also reported that the proportion of positive sentiment toward cannabis did increase over time. With the survey wrapping up in 2017, one could hope that contemporary clinicians are better-versed in the therapeutic applications of cannabis.
For those familiar with the current lay of the medical landscape, however, that’s not the case. Leafly turned to Joe Dolce to help unpack this clinician reticence toward cannabis. Dolce is author of Brave New Weed and co-founder of MedicalCannabisMentor.com, an online learning platform that provides evidence-based, research-grounded courses for healthcare providers, dispensary personnel, and in the not-too-distant future, patients. He works alongside Dr. Junella Chin, an expert cannabinoid-prescribing physician who has treated more than 10,000 patients.
For Dolce, the obstacles hindering physicians from getting behind cannabis are clear and need to be urgently addressed. While healthcare providers may be digging their heels in, patients are leveling up with their knowledge of cannabis.
“The problem for patients is that they are often ahead of their providers when it comes to cannabinoid meds, and they often have no one they can turn to for trusted advice on dosing and how to use them for optimal efficacy,” said Dolce.
The origin of the problem: omission in education
One glaring omission that disadvantages doctors can be traced back to med school. “The endocannabinoid system (ECS) is not taught in most medical schools, so healthcare providers have no knowledge of what it does, nor that it is the master regulator of all the other receptor systems,” said Dolce. “Because neither the ECS nor cannabinoid medicine are taught in med school, healthcare providers are largely uneducated about it and quite naturally don’t trust it.”
The ECS isn’t new knowledge, though. Scientists have known about the existence of the endocannabinoid system for more than 25 years. More recently, researchers hypothesized that this internal signaling system started evolving over 600 million years ago, dating back to prehistoric forms of life no more complex than sponges.
Today, studies have demonstrated that cannabinoid receptors are present in skin, immune cells, bones, fatty tissue, pancreas, the liver, the heart, blood vessels, and the gastro-intestinal tract. We also know that the endocannabinoid system participates in multiple processes such as pain, memory, mood, appetite, sleep, stress, immune function, metabolism, and reproductive function.
You could justifiably argue—and some experts have—that the endocannabinoid system is one of the most critical physiologic systems implicated in the establishment and maintenance of human health, operating as a bridge between the body and mind.
But among the least educated are those who need to be the most informed. Many healthcare providers are still unfamiliar with the ECS—at last count, in 2013, only 13% of med schools taught the ECS in any capacity. A recent Leafly report suggests that very little has changed.
Cannabis is botanical medicine, not pharmaceutical medicine
According to Dolce, there are additional barriers that impact clinician sentiment toward cannabis. “Physicians are used to single-action targeted pharmaceutical meds. Cannabis is a botanical medicine composed of over 165 active compounds that work synergistically,” he said. “Botanical meds require more patient education and often, hand-holding. The way most clinics work doesn’t allow enough time for this.”
Dolce also points out that it can be challenging for healthcare providers to allow time to familiarize themselves with something new. “Being a doctor is a stressful and high-pressured job,” said Dolce. “They work a lot, and there is always more to learn and read. Convincing a doctor to spend more time learning about a medicine that is still federally illegal is not the easiest task.”
Prescribing medical cannabis also requires patience and time. Dolce, and many cannabis medicine experts, emphasize that it can take some patients weeks, or even months, to reach their optimal cannabis dose. Learning to dose medicine incrementally to find the sweet spot can be empowering for a patient but can absorb more time in consultation.
“All this being said, teaching patients to self-administer meds is not unfamiliar to clinicians. They do it with diabetic patients using insulin or patients in pain who must self-titrate Gabapentin (Neurontin). And don’t forget those SSRIs,” he said.
Finally, the risk of liability represents a further deterrent. “No insurance company will cover healthcare providers for prescribing cannabinoid meds, so there are structural and systemic reasons docs stay away from it,” said Dolce.
How to move forward?
Clearly, providers need to familiarize themselves with the unique therapeutic profile of cannabis and stay current with research to support patients who wish to try it. According to Dolce, the release of cannabis from the shackles of a Schedule 1 status at the federal level—which restricts cannabis research—is critical to achieving this. But other initiatives could also shift the sentiment of hesitant healthcare providers.
“We need to encourage more high-profile physicians to publicly talk about how cannabis is as effective as over-the-counter meds for pain, insomnia, and stress/anxiety, not to mention relief from nausea associated with chemotherapy,” said Dolce. “I also feel that nurses, nurse practitioners, and health coaches would be well-served to learn about cannabinoid meds so they could then act as necessary support to docs who are already suffering under time and administrative pressures.”
Overall, however, Dolce maintains a somewhat optimistic outlook. “There is a certain amount of hubris that some doctors have about using botanical or so-called alternative medicines,” he said. “But a small percentage of doctors we encounter are increasingly open and willing to learn about cannabinoid therapies, especially because their patients are telling them that they work. Once they become open to it, they’re often sold.”