____________________________________________________ Medical Marijuana and Other Cannabinoids
used as first-line therapy for any indication. Instead, its great- est therapeutic potential comes from treating patients with chronic conditions refractory to standard therapies [2]. The initial primary concerns of the Institute of Medicine (IOM) over medical marijuana were possible pulmonary harms and inability to control and replicate drug concentrations, but these are being resolved by availability of vaporization and, in Canada, Holland, and some U.S. states, by large-scale cannabis growing with quality, purity, and reliability consistent with pharmaceutical standards [8]. Despite substantial progress in the scientific understanding of cannabis mechanisms and the available outcomes of rigorously designed RCTs, this information is not reaching healthcare providers who practice in states legally permitting medical marijuana use [9]. This information transfer is essential to elevate the knowledge base of benefits, risks, and indications for medical marijuana and to improve patient interactions when this controversial topic is raised [9]. Provider demand for this information was captured by a survey of Colorado family practice physicians, of whom 82% endorsed including medical marijuana education in family practice residency training and 92% expressed interest in medical marijuana continuing education. However, only 19% agreed that physicians should recommend medical marijuana to their patients. One concerning finding was the significantly greater influence of news media in the decision to not recom- mend medical marijuana to patients. While these results were based on a 30% response rate to the surveys, they indicate that physicians are uncomfortable recommending medical marijuana but recognize the importance and unmet need of education and training on its clinical use [10]. In other words, lack of education is a fundamental cause of healthcare professionals’ reluctance; more specifically, this results from knowledge deficits in the therapeutic value, appropriate indica- tions, contraindications, dosing, and benefits/risks balance in medical marijuana, all of which can be addressed by continuing education [2; 11]. The urgent need for medical marijuana continuing education is underscored by findings that primary care providers refusing medical marijuana involvement has led to naturopathic doctors (NDs) filling this void by opening medical marijuana authoriza- tion practices in states granting NDs this function. Prescribers’ discomfort is also influenced by fears over revocation of their license to prescribe controlled substances, with medical mari- juana legally allowed in some states while remaining a violation of the federal Controlled Substance Act [12]. This concern is similar to the widespread fear over opioid analgesic prescribing, that doing so heightens risk of law enforcement or regulatory scrutiny and possible sanction or prosecution. This barrier to patient care is amenable to educational intervention by pre- sentation of the potential benefits and factual reassurance that by authorizing medical marijuana consistent with state laws, the risks to one’s licensure are essentially nonexistent. Unlike
INTRODUCTION Cannabis, or marijuana, was introduced to the United States as a medicinal product in the mid-1800s and was widely prescribed by physicians as a therapeutic until 1937, when sanctions were levied against medical or recreational use and physician prescribing. Prohibition culminated in 1970 with passage of the Controlled Substance Act, which formalized the criminalization of marijuana possession or use, regardless of quantity or context. Despite its illegal status, public demand for medical access led to the legalization of marijuana for medical use in California in 1996; as of 2023, voters in an additional 38 states and the District of Columbia have followed suit. In addition, 23 states have also legalized recreational cannabis use [1]. Popular demand and legal access to medical marijuana began despite the lack of well-designed randomized clinical tri- als (RCTs), the result of decades-long federal law enforcement obstruction. However, numerous RCTs have been published since 2000, markedly clarifying appropriate indications and contraindications. In aggregate, the published clinical research strongly supports medical marijuana use in alleviating chronic neuropathic or cancer pain, spasticity, nausea and vomiting, weight loss and wasting syndrome associated with chronic debilitating condi- tions, and potential opioid dose reduction with analgesic enhancement as co-therapy in long-term opioid analgesic use [2; 3; 4]. Possible efficacy is suggested in fibromyalgia, post-traumatic stress disorder (PTSD), seizure disorders, and irritable bowel syndrome/Crohn disease. Contraindications include a personal or family history of psychoses; age younger than 18 years; and pregnancy or breastfeeding. Medical mari- juana users are unlikely to develop negative immune effects, cognitive impairment persisting beyond the acute dose, or psychotic disorder when appropriately screened. Lifetime addiction prevalence is 1.5% to 9% in recreational users and unknown in medical users [5; 6]. However, about 11% of recreational marijuana users report daily use, compared with one-third of medical marijuana users [7]. In states with medical marijuana laws, 83% use cannabis recreationally and 17% use it for medical reasons. The sociopolitical controversy surrounding nonmedical marijuana use frequently spills over into discussion of medi- cal marijuana, obscuring objective discussion of the scientific basis. Value judgments play an even greater role in legal and regulatory decisions related to marijuana and other drugs that are used for recreational purposes [8]. Kalant offers two important suggestions to physicians weighing medical mari- juana benefits/risks [2]. First, medical use and non-medical use are unrelated. For example, heroin can be legally prescribed in Canada to relieve suffering in patients terminally ill with cancer. No one has suggested heroin should therefore be available for non-medical use, and to think differently about marijuana lacks a rational basis. Second, marijuana is not
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