Medical Marijuana: A Growing Trend

Current State of the Evidence
Schedule I designation makes research examining safety and efficacy of marijuana for a range of diseases difficult but not impossible. Originally promoted for the management of chronic and neuropathic pain, there are varying amounts of evidence for efficacy in epilepsy,multiple sclerosis–associated spasticity, and inflammatory bowel disease. In contrast, current data do not support use in glaucoma or rheumatologic conditions such as arthritis.

What Do Physicians Think?
In early 2014, Medscape and WebMD conducted a survey to solicit opinions of both physicians and consumers about the medical use of marijuana. A total of 1544 physicians participated, representing 12 specialties and 48 states. The survey also included 2960 consumers. The Medscape survey ran between February 25 and March 3, 2014, and has a margin of error of ± 2.5%. Approximately one quarter of participants (24.7%) identified as primary care physicians.

How Do Physicians View the Evidence?
A sizeable majority of physicians participating in the Medscape survey see marijuana as delivering real treatment benefits. Only 15% answered this question with a definitive “no” and 17% said they were just not sure. Essentially half (49%) said the benefits of medical marijuana outweigh the risks. However, there is another sizeable contingent that expressed concern about the risk/benefit ratio, with a combined majority saying the side effects can be mild (38%) or moderate (40%). Opinions expressed are not the result of personal use; less than 1% of physicians in our survey indicated that they had ever personally used marijuana for a medical reason.

Physician Opinion: Legal vs Nonlegal Marijuana States
The majority of physicians (68%) in our survey believe that marijuana should be a medical option for patients. Of note, though, smaller percentages indicated that it should be legal, a percentage that did not vary between physicians residing in legal vs nonlegal states. Half of all physicians in the survey (48%) say their patients have asked about the benefits of medical marijuana in the past 12 months. This conversation was 12% more likely to take place in states where medical marijuana has been legalized (60%). In states considering legalization, only 38% of respondents indicated that their patients had asked.

Does Physician Opinion Vary by Specialty?
Support for medical marijuana also varied by specialty. Oncologists showed the highest level, with 82% saying marijuana delivers real benefits to patients and 69% supporting legalization nationwide. Oncologists also had the second highest level of patient inquiries, at 66%, not surprising given the role of this agent in pain control and cancer-associated cachexia. Rheumatologists ranked the lowest in support for use, with 54% saying it delivers benefits and 44% supporting legalization. It’s not surprising, given recent trials examining use of marijuana in epilepsy and MS, that neurologists reported the highest number of patients asking whether medical marijuana might help them, at 70%.

Physician Opinion vs Public Opinion
Perhaps surprising, more physicians (69%) than non-MD WebMD readers (52%) believe that marijuana can provide real benefits for patients with certain conditions or receiving certain treatments, such as chemotherapy. The minority of both MDs and non-MDs surveyed feel that it has no benefits (15% vs 11%), while 37% of non-MDs are “not sure” about the usefulness of medicinal marijuana, vs only 17% of physicians.

Availability
MDs and non-MDs differed considerably in their views on where and how medicinal marijuana should be available: 53% of physicians vs 36% of non-MDs feel that it should only be available at pharmacies with a valid prescription. Just 19% of physicians vs 41% of non-MDs believe that patients should have access via both pharmacies and licensed retailers (with a physician’s written authorization).

Medical marijuana is legal in 20 states and the District of Columbia, with pending legislation to legalize the drug for medical purposes in 4 others.[1] Although still illegal in 30 states, millions of patients are undoubtably using marijuana for medicinal purposes in these jurisdictions.

Much has been written about politics trumping science with respect to rescheduling marijuana from a Schedule I drug,[2-5] as its medical benefits become progressively more accepted by the mainstream medical community as well as the general public.[6] The Veterans Administration, which is becoming a leader in pain care in the United States, has even approved of its physicians authorizing medical marijuana in states in which it is legal.

Earlier this year, Kondrad and Reid[8]published a large-scale survey-based study of family physicians’ attitudes toward medical marijuana in Colorado — a state in which medical marijuana has been legal since 2000. The results of their investigation were both startling and disturbing. They found that only 19% of respondents believed that physicians should recommend medical marijuana to their patients. However, they also found that 80% of respondents believed that education about medical marijuana should be incorporated into medical school curricula, 82% believed that such education should be included in family practice residency training, and 92% agreed that continuing medical education on medical marijuana should be made available to them. Opposition to recommending medical marijuana as a result of concerns about legal liability or licensure was reported by 23% of respondents, whereas only 13% cited a lack of medical evidence as their reason for opposition. These figures indicate that science is clearly not the primary issue of concern.

These intriguing data tell us that a lack of education is the primary cause of physicians’ discomfort in recommending medical marijuana. Schatman recently addressed the ethical imperative for physicians to consider medical marijuana as a part of their pain management armamentaria. This is particularly important, given the lack of an evidence base for chronic opioid therapy and physicians’ reluctance to prescribe opioids in this era of fear of legal and regulatory sanction.

Why So Reluctant?

In clinical practice, physicians have been found to refuse to authorize medical marijuana out of concern that doing so will place their controlled substances licenses in jeopardy. Although 20 states have “legalized” medical marijuana, it remains a violation of the federal Controlled Substances Act, and the reality of the license to prescribe controlled substances being issued by the US Department of Justice’s Drug Enforcement Administration (DEA) clearly has served, for many physicians, as a deterrent to the authorization of medical marijuana.[10] Physicians who treat patients with chronic pain rely on their abilities to prescribe controlled substances, and fear of losing the privilege to do so has resulted in an unfortunate reluctance to authorize what can be an extremely effective and relatively safe alternative to opioid analgesics.[9]

An unintended consequence of this fear has been naturopathic doctors (NDs) developing “doc-in-the-box” medical marijuana authorization practices in states in which NDs are permitted to authorize medical marijuana. These practices are often cash-only entities; this is particularly troubling in such states as Washington, in which health insurers are required to compensate NDs. Given the financial incentives, these naturopathic providers have loose and easy criteria for authorization of medical marijuana, because they have no controlled substance registrations to lose.[11]

The result is that many recreational users are obtaining legal access to high-tetrahydrocannabinol (THC) “medical marijuana” at a relatively low price from dispensaries. However, a small number of allopathic and osteopathic physicians have overcome their fears of legal and regulatory sanction and have brazenly developed specialized practices consisting primarily of medical marijuana authorization, without expertise in the treatment of the conditions for which they are authorizing its use.