Need a cannabis Rx? Your doctor may not feel OK giving you one

Dr. Cherilyn Cecchini, a resident at Children's National Health System in Washington who graduated from medical school in 2015, has some questions about medical marijuana.

How do you recommend it? She wants to know. How do you identify the conditions that are best treated with medical cannabis? What are the dosing regulations?

Cecchini, who is 28, isn’t alone with these questions. The majority of U.S. states have legalized medical marijuana — that’s 29 states, Washington D.C. and counting — the plant’s popularity is soaring among the general public, and this week the Food and Drug Administration approved the first cannabis-based medication in the U.S. But some of the nation’s doctors say they feel unprepared to talk with their patients about medical marijuana.

A new LinkedIn survey fielded in March found that early-career doctors who practice in those states are less likely to feel comfortable talking to patients about medical marijuana compared to more experienced physicians, a finding that raises questions about whether docs are getting the information they need to best engage with patients on this topic.

Many of these physicians say their hesitancy stems from their belief that the currently available clinical data is lacking. Another question is what kind of education doctors should receive in medical school about medical cannabis.

Only 9% of medical schools have documented curriculum on medical marijuana, and nearly 90% of residents and fellows do not feel prepared to prescribe medical marijuana, according to a survey conducted by researchers at the Washington University School of Medicine and published in September.

“Physicians have for almost 100 years lacked any training for the use of cannabis,” said Dr. David Nathan, a psychiatrist and director of continuing medical education for Penn Medicine Princeton Health. He also runs an organization called Doctors for Cannabis Regulation. “It’s true in my own education. The discussion about marijuana use has been limited to abuse potential and the potential for misuse and dependency, and very little about the potential benefits of the medication.”

Pop culture tells us that younger generations will tout the benefits of marijuana. But experts say younger docs may be more reticent to prescribe alternative or holistic treatments, and in the case of medical marijuana it also has to do with the lack of education in medical school and the absence of the kind of randomized, controlled clinical research preferred by the medical community.

The LinkedIn survey, conducted from March 22, 2018, to April 1, 2018, queried 615 practicing physicians in the U.S. The participants, all of whom have LinkedIn profiles, were chosen at random and reflect different specialties and years of experience.

Of the 320 physicians who work in states where medical marijuana was legal at that time we conducted the survey, 65% of the docs who have been practicing medicine for less than 10 years said they feel comfortable engaging in a conversation with patients about medical cannabis, compared to 76% of physicians with 10 to 20 years of experience and 73% of doctors with more than 20 years of clinical practice under their belts.

Those early-career doctors are more likely (34%) to recommend medical marijuana in rare situations, like terminal illness, compared to mid-career doctors (26%) and late-career doctors (21%).

Medical residents in legalized states are slightly less likely (67%) than practicing physicians of all ages (71%) to say they feel comfortable talking to patients about medical marijuana.

Why? Many say they would feel more comfortable with a FDA-regulated product.

“Many of us are choosing to wait,” Dr. Shlomo Shinnar, a neurologist for Montefiore Medical Center in New York and president of the American Epilepsy Society, said in an interview in mid-June. “Many of us may change our mind. But in the meantime many of us are waiting for the FDA decision.”

Earlier this week, that decision arrived. The regulator approved GW Pharmaceuticals’ Epidiolex, a cannabidiol (CBD)-based treatment for two rare forms of epilepsy. CBD is different than tetrahydrocannabinol (THC), which gives users the feeling of being high.

Opinions are also shifting among the general public. Eighty percent of Americans between the ages of 50 and 80 years old say they “strongly or somewhat support” the use of medical marijuana with a doctor’s recommendation, according to a 2018 survey conducted by AARP and the University of Michigan.

And just a few months ago, John Boehner, the former Republican speaker of the House, publicly shifted his stance on marijuana legalization in a tweet.

In fact, states that have legalized medical marijuana have seen a drop in Medicare Part D and Medicaid prescriptions for conditions in which medical cannabis can be used as an alternative treatment, like nausea or pain, according to a pair of studies conducted by the University of Georgia’s David Bradford, a professor of public policy, and his daughter Ashley Bradford, a master's degree student there.

All of these changes prompt questions about what role medical marijuana will (and should) play in mainstream medical care, especially if physicians don’t have the information they need to make informed recommendations or give an educated “no.”

“The public is behind it,” said Dr. Alfred Kulik, an eye surgeon turned registered cannabis physician in New York. “Now it’s actually the doctors. Doctors don’t prescribe it. Doctors are afraid of it. They are creatures of habit. That’s a big problem.”

In 2015, one year after New York legalized medical marijuana, Kulik quit his practice and registered with the New York State Department of Health. Now he works with patients referred by other patients or by doctors who don’t have medical marijuana certifications. (Less than 2% of the roughly 96,000 physicians in New York are certified in the state’s medical marijuana program.)

Even with regulated state certification programs and informed patient requests in place, some doctors are still concerned about several things, like addicts trying to get in the door or Drug Enforcement Administration agents tracking behavior that falls outside the law.

About one-quarter (22%) of the physicians surveyed by LinkedIn and who practice in states where medical cannabis is legal say they are concerned about negative ramifications for expressing their views on medical marijuana.

Several of these doctors said the primary limitation to feeling more comfortable about recommending medical marijuana has been the lack of clinical data and FDA regulation. “There are different strains of marijuana, some with very high THC,” one early career psychiatrist told LinkedIn. “If it was subject to the rigors of the FDA like medications are, then I would be more comfortable with it.”

“I do not feel well versed in the data or literature,” said an early career plastic surgeon.

Neither physician recommends medical marijuana even though both practice in states where it is legal.

Other physicians view medical marijuana simply as another tool in the toolkit. “There's no blurry line about it. There are benefits that can be attained,” wrote a primary-care physician with more than 20 years of clinical practice. “But, like any other medication, there are risks — so why discuss it any differently than other medications?”

Another survey, fielded by researchers in Boston and published this year, had similar results. Of the 400 oncologists it surveyed, only 30% felt informed enough to make medical marijuana recommendations, but 80% talked with patients about medical marijuana and 46% recommended it.

Even with the FDA approval of a cannabis-based therapy developed by a publicly traded drugmaker, a move that may assure some physicians to treat these epilepsy patients, that approval also creates the option for doctors to recommend treatments off-label. A commonly cited study from 2006 estimates that 20% of all prescriptions are written by physicians for off-label indications.

Two more states are expected to vote on legalizing medical marijuana this year; Utah is scheduled in November, and Oklahoma voters will head to the polls on Tuesday. If they vote in favor of legalizing medical cannabis, Oklahoma would be the 30th state in the U.S. to legalize the drug.

As states consider legalization and medical experts look for new ways to treat pain at a time when the opioid crisis has ravaged communities, physicians say those changes put the onus on doctors and medical schools to better understand their clinical perspectives on medical marijuana.

“It will depend on the provider to initiate the conversations and not back away given all these changes,” Cecchini said. “Increasing the comfort of practitioners is going to be key.”

What’s your take? What role should medical marijuana play in mainstream medical care? Share your thoughts in the comments, using #MedicalMarijuana.