Medicinal cannabis presents a unique dilemma for physicians and regulatory authorities because it represents an unapproved treatment with limited good-quality research to inform guidelines that clarify specific age-related indications, dosage, or risks. In addition, many myths portray negative effects, which results in a culture of ill-informed lack of medical support. Despite these barriers physicians have been designated as the gatekeepers of access to cannabis for medical purposes. On 5 May 2015 the College of Physicians and Surgeons of British Columbia (CPSBC) published a standard entitled Marijuana for Medical Purposes, to set out the professional requirements of physicians in BC who plan to support patients in the use of cannabis for medical purposes.
Practitioners for Medicinal Cannabis (PMC) is a nationwide network of specialists and general practitioners among whom there is extensive clinical experience in the medicinal use of cannabis. PMC is committed to best possible patient care, including the informed use of cannabis and cannabis-derived products. As participants in PMC, we write as a group of physicians to share with readers of the BCMJ our concerns about some of the statements included in the CPSBC standard. We also offer access to an information resource and networking with PMC.
First, we consider that the CPSBC standard fails to acknowledge or accommodate the unique and complex nature of cannabis, or how it is used for medical purposes. Cannabis is not a single therapeutic entity. The plant contains many different physiologically active compounds with a wide variety of potential therapeutic uses. Different strains possess a different balance of components, specifically in the balance of THC to CBD. In spite of the commonly held perception that cannabis is smoked, there are other safer, less stigmatized ways to prepare cannabis for therapeutic applications. Effects of a particular product on one clinical situation cannot be assumed to apply to other products or clinical contexts, and each individual patient’s response is unique.
Second, we believe that the CPSBC standard fails to recognize the significance and importance of existing scientific literature. In particular, this includes the enormous and growing literature regarding the body’s endocannabinoid system with which cannabis interacts. As many readers are aware, large-scale double-blind controlled trials are not the only resource that informs clinical knowledge. There is a considerable body of sound evidence to support the use of cannabis for medical purposes that also confirms its relative safety, especially compared with other agents.
The CPSBC standard also fails to acknowledge appropriately the context of more questionable studies that underpin some of the well-established but misinformed myths around cannabis. Given the complex nature of cannabis, it is relevant to note that studies that report on or make correlations between cannabis use and specific outcomes, but which don’t also take into account or adequately address pertinent variables (THC/CBD content, THC/CBD ratios, confounding factors such as cigarette smoking or other drug use, pre-existing mental health issues, age, genetic factors, and recreational versus medicinal cannabis use), cannot be replicated or confirmed in a meaningful way. It is also questionable whether conclusions drawn about cannabis from studies of recreational users can be extrapolated to its use in a medical context.
Third, we question the appropriateness of the College warnings to physicians who consider authorizing legal access to cannabis. The College’s position presents an alarming perspective of a physician’s risk in authorizing the use of cannabis; for example, “may be the subject of accusations or suggestions of negligence, including liability if the use of marijuana produces unforeseen or unidentified negative effects.” This risk is not substantially different from that of prescribing any other substance or undertaking any medical procedure.
Fourth, we take issue with the College’s prerequisite that conventional therapies be attempted before cannabis. The College standard lists eight requirements for physicians. The first of these says the physician shall: “Document that conventional therapies for the condition for which the authorization of marijuana for medical purposes was provided have been attempted to assist the patient in the management of his/her medical condition and have not successfully helped the patient.” We are concerned that this requirement does not duly respect a patient’s personal autonomy and right to make decisions pertaining to his/her own health care. We recommend that the word “attempted” be replaced by “considered.”
Fifth, we are concerned that the CPSBC standard, through its several requirements and restrictions on physician behavior, creates a barrier to care for patients. In addition, the standard does not put the physician’s role or the College’s responsibility into an appropriate societal context. Federal courts have deemed use of cannabis for approved medical purposes to be a Charter right, protected by the Constitution. The College’s mandate of public protection through effective regulation of the medical profession includes protection of those disabled and seriously ill patients who benefit from the medical use of cannabis. The College standard presents considerable challenges for a physician who wishes to provide the professional support that a patient needs in order to exercise his or her constitutional right.
A helpful resource
The College standard lists a number of groups of patients for whom “cannabis is generally not appropriate,” but acknowledges that there are circumstances where exceptions may be made. Several members of our group have co-authored a summary of the relevant literature informing the use of cannabis in the care of such patients. Our intention is to provide a clinical perspective and a nuanced discussion to help physicians balance potential risks against potential benefits when considering a trial of a cannabis-derived product for an individual patient.
If any physician is interested in obtaining an online copy of that summary, please contact the Practitioners for Medicinal Cannabis by e-mail at email@example.com and include “BC standard” in the subject. Any health care practitioner is welcome to participate in PMC, or to submit a question to the network. Through that e-mail address PMC participants share resources and questions about clinical cases, and discuss issues related to the medical use of cannabis.
The following physicians, in alphabetical order, endorse the content of this letter. They are all participants in PMC.
—Donna Dryer, MD, FRCPC
—Caroline Ferris, MD, CCFP, FCFP
—Gwyllyn S. Goddard, BSc, CCFP, MD
—Peter A Gooch, MB ChB
—Philippa Hawley, FRCPC
—Cecil Hershler, MD, PhD, FRCP(C)
—Gill Lauder, MB BCh, FRCA, FRCPC, CPE
—Caroline MacCallum, FRCPC, BSc
—Ian Mitchell, MD, FRCP
—Michael Negraeff, MD, FRCPC
—Conrad Oja, MD, PhD, FRCPC
—Arnold Shoichet, BSc, MD
—Christine Singh, MD, CCFP