In many ways, Marion Albaum of Toronto, 38, is your typical Canadian mom. She cheers at her son’s minor league hockey games and creates brightly coloured cakes for her daughter’s sleepover parties. Photos of anniversary dinners and birthdays plaster her Facebook page. Not pictured are the nights she spends in hospital with a feeding tube and hovering team of nurses and doctors nearby.
Marion suffers from fibromyalgia and Crohn’s disease. Independently, these two conditions are debilitating. Combined, the pain can be blinding and all encompassing. Marion’s treatment history includes opioids and other prescription drugs. But when her dependence on opioids proved too destructive — she started to shake and sweat if her dose wasn’t constantly increased — her doctor suggested cannabis.
Like the more than 40,000 Canadians who are legally entitled to take cannabis for ailments, and thousands more doing it under the table, Marion swears marijuana is a lifesaver. She says the herb has helped her skirt a major addiction because it’s safer and less toxic than her other pharmaceutical options. She says it makes her a functional parent, wife and friend again. Luckily for Marion, her doctor was open to considering cannabis in the context of an overall treatment strategy. Many clinicians in Canada are not comfortable discussing cannabis with patients, let alone prescribing it.
Health care providers are hesitant to consider medical cannabis for a variety of reasons: conflicting information about cannabinoids in medical literature; irregular concentrations of THC (the psychoactive ingredient) or CBD (the non-psychoactive ingredient) in dosages; taking accountability for prescribing an illegal substance; the potential use of cannabis for recreational purposes; and the harm that smoking cannabis can cause. For these and other reasons, many physicians deny the medical cannabis conversation with their patients.
And that’s a disservice to all, say medical cannabis advocates across the country.
“These aren’t hippies getting high. These are desperate people who find life can be livable again thanks to medical cannabis. To ignore the medical properties of the plant is shortsighted,” says Dr. Arnold Shoichet, a general practitioner in B.C. and director of the medical program at the Medicinal Cannabis Resource Centre (MCRCI), a private clinic based in Vancouver.
“This is a very stigmatized substance. Many physicians and associations don’t accept that there is a potential benefit to this plant. If physicians are denying access then they need to be considering how that will place their patients, especially in end-of-life situations and treatments not responding to traditional medications,” says Lynda Balneaves, PhD, RN, acting associate director at the School of Nursing at the University of British Columbia.
Medical cannabis advocates like Dr. Shoichet and Ms. Balneaves say they understand physician hesitancy, but to say there is not supportive evidence is incorrect. Evidence of its benefits are seen everyday when severely ill or disabled patients are able to function again.
Clinicians and researchers from McGill, Dalhousie and UBC tell Hospital News the short-term solution to the current schism in the medical community includes more funding for clinical research and increased medical education of the existing research.
Under the newest regulations, physicians and nurse practitioners are the gatekeepers to legal cannabis.
“It is not sitting well with many physicians that they are now effectively prescribing a product for which they have little control — or knowledge to guide them — on the dose, concentration, and variety of cannabinoids,” says Dr. Colleen O’Connell, assistant professor at Dalhousie Faculty of Medicine and the research chief at the Stan Cassidy Centre for Rehabilitation in Fredericton, New Brunswick.
That leaves patients like Kristin Nelson of Toronto, 33, unhappy and scared of getting hooked on prescription drugs. She asked her doctor for medical cannabis to help with severe insomnia after her first pregnancy. Her doctor refused and prescribed benzodiazepine instead. Now Kristin finds it hard to sleep without it.
“I think the biggest thing for me is how easily the docs will prescribe a habit-forming pharmaceutical over medical marijuana,” says Nelson who would still like to try medical cannabis. She is waiting to be assessed by a private clinic.
Recent studies show that physicians have disproportionate concerns about the addictive, psychiatric, respiratory and other health hazards of marijuana compared to what is indicated in the scientific literature. When compared to other drugs or substances like cocaine, heroin, tobacco and alcohol, marijuana ranks low in terms of dependence.
“As a physician who has had the opportunity to research medical marijuana, I have a greater comfort with the products available than an average physician. When I support a patient’s prescription, that includes monitoring for effect and outcomes as well as non-pharmacologic approaches to symptom management,” says Dr. O’Connell.
While doctors like Drs. Shoichet and O’Connell base their decisions to use medical cannabis on clinical and anecdotal evidence, they do so knowing that they don’t have the support of the major regulatory colleges or the Canadian Medical Association.
“What we need is this drug to be tested just as vigorously as any other new drug that comes out on the market, and for the federal government to step up to the plate and provide the funding to do those studies,” says Dr. Louis Hugo Francescutti, president, CMA. “If the evidence is there, then I don’t think the profession would have any problems getting behind it. Doctors are not very keen to prescribe with a blindfold on.”
Dr. Mark Ware says it’s time to take the blindfold off and quit standing at the sidelines. Dr. Ware, a practising pain physician at the McGill University Health Centre, researches the safety and effectiveness of medicines derived from cannabis (cannabinoids). He hopes to enhance research and medical education through the non-profit Canadian Consortium for the Investigation of Cannabinoids (CCIC).
“Bottom line, physicians and clinicians need to engage in this process so we can help shape it, so it can be what we want it to be,” says Dr. Ware. “We need to figure out together what is the best way to provide it to suitable patients at a reasonable cost with good quality control and sensible balance between risk and benefit.”
He says one way to increase research is to demand support from the newly licensed medical cannabis distributors.
“They are now the ‘new pharmaceutical industry’, so I believe they have an obligation to fund research,” says Dr. Ware. “It may be difficult to see multiple large scale phase 3 clinical trials in the next five to 10 years. But we are operating with limited evidence and growing clinical need. They can fund helpful studies now.”
At least one medical cannabis producer has stepped up to the challenge with a study focused on osteoarthritis. Prairie Plant Systems announced in May 2014 that Health Canada has formally approved a clinical trial application for a randomized, double blind, placebo controlled, proof-of-concept, crossover clinical trial of vapourized cannabis in adults with painful osteoarthritis of the knee. This clinical trial is the first to be registered with Health Canada after the transition to the new Marihuana for Medical Purposes Regulations (MMPR).
Dr. O’Connell would like to see studies identify which cannabinoids, and in what concentration are beneficial for what conditions. “Physicians and nurse practitioners are hesitant, as unlike any other medication, there is no basis on which to inform on dose and concentration,” Dr. O’Connell says.
Other areas needing further study include testing clean delivery systems where the dosing is easier to control and determining the upper limits if there are any. Clinicians also need more guidance on understanding how the Endocannabinoid System functions and how to better screen patients for therapeutic use.
“We don’t know all the risks yet, and we are working on it. But every day, we prescribe federally approved pharmaceuticals that have significant risks, including death,” says Dr. Shoichet. “There’s never been a death attributed to the use of cannabis and that can’t be said for any other drug I’ve prescribed.”
Studies have already shown a reasonable proof of concept, says Dr. Ware. Cannabis helps patients with nausea, spasticity, mood disorders, and appetite loss to name a few. Whether that evidence base is sufficient for a professional is often a matter of medical judgment.
Western University’s Dr. Richard McLachlan, professor of neurology, is currently investigating the usage of marijuana among epilepsy patients and recording their observed benefits and any adverse effects. He turned to research after more of his patients were asking for him to help them obtain it legally.
“In the 19th century, cannabis was one of the few treatments for epilepsy thought to be effective. There are a number of studies of animal models of epilepsy done before 1980, which give support to the possible use of cannabinoids to control seizures and some that indicated it might make seizures worse. There are few studies after 1980 and none in patients because, as far as I can tell, authorities made it too difficult to carry out such research,” says Dr. McLachlan.
Under Health Canada’s current restrictions, there’s a lot of experimentation – just like with other types of medications.
“Some strains made me paranoid or didn’t help with the pain,” says Marion. “Once I find the right strain with the right combination of cannabinoids, I buy as much as I can.”
“I was a bit apprehensive at first,” says Gloria Kabele, 60, of White Rock, B.C. who was diagnosed with multiple sclerosis at 42 years old. She says it helps her with sleep problems but not the spasticity. “My doctor was supportive and completed the referral form I needed,” says Kabele. “My neurologist was not as supportive.”
A handful of physicians and medical entrepreneurs in Canada are hoping hesitant health care providers, like Gloria’s neurologist, will refer patients to them, rather than closing the door on cannabis treatment entirely.
Specialty clinics like the Cannabinoid Medical Clinic, which is set to open this summer in north Toronto. The clinic’s physicians will see patients on a referral basis to evaluate them for suitability for cannabinoid therapy in its various forms.
“We will work closely with the CCIC to ensure that we are providing proper screening, proper guidance, and follow up after one or two weeks, and then again after three months. The goal is to attain the desired outcome: increased mobility, return to work or reduced opioid usage,” says Dr. Danial Schecter, a Georgian Bay, Ontario based general practitioner and co-founder of the clinic.
Dr. Schecter, and others in this burgeoning field, say he is filling a much-needed void. Until cannabinoid knowledge is integrated into general medicine, clinicians can make patient referrals to experts like him. From a harm-reduction perspective, it’s the best approach since patients are using the substance regardless.
He says the clinic’s strategy includes establishing the standard of care in cannabinoid medicine and increasing medical education.
“We will send letters back to the referral physician so they will understand who we choose, which products we recommend and which side effects to expect,” says Dr. Schecter. “Hopefully, after they send four or five patients, they will get more comfortable prescribing for pain therapy or palliative care.”
Dr. Schecter would like to see cannabinoid integrated in general medicine just like opioid and cholesterol treatment. His goal is to help further the notion that medical cannabis be considered a viable alternative to established treatments.
Another specialty clinic is the MCRCI, which has been in practice in British Columbia since 2010. It’s a private organization that accepts applications from patients anywhere in Canada (in person or via telemedicine) and charges a fee to cover operating costs. If the patient’s health needs are in line with medical requirements, the centre helps the patient access the medical cannabis. MCRCI has plans to open more clinics in Halifax, Montreal, Calgary and Edmonton in the coming years.
Dr. Shoichet works to foster awareness for cannabinoid therapy among those professionals who are more reluctant or less informed. He does this through MCRCI. He also founded Practitioners for Medicinal Cannabis (PMC) a network of specialists and general practitioners committed to fostering professional awareness of all aspects of cannabis in patient care. He says the first step to more knowledge is repealing prohibition – if only for the scientific and medical communities. When it’s legal, he says, scientific understanding will accelerate.
Price inflation is another challenge facing Canadian patients. The cost of growing cannabis is around one or two dollars a gram. The current market cost is around six or 12 dollars a gram – which puts it out of the budget of many. Under the initial regulations, patients were allowed to grow their own plants or have someone else grow it for them, which was a more economical option for many. But now only licensed distributors can grow. Clinicians say the product is now safer, standardized, and independently tested in lab for mold, residue or pesticides. But the price is certainly a negative factor for many patients.
Marion spends around $70 every three weeks. It’s not covered by her insurance.
“There are a lot of other out-of-pocket expenses like my feeding tube supplies. The cost adds up. It would be nice if it were covered,” says Marion.
Another inconvenience is access. When her supply runs out, she can’t just drive up to the nearest pharmacy. She has to wait for a licensed distributor to deliver, which can take days.
What’s needed, says another medical researcher, is a shift in perspective.
“I’ve seen doctors jokingly refer to it as reefer madness. The humor disrespects the serious medicine that it is,” says Balneaves who is the principal investigator of a cannabis access regulations study. “And this humor transfers over to funding bodies.”
Balneaves wants more human-level studies with the whole plant and better education for physicians and nurse practitioners.
Marion continues to smoke her medicine but is considering a vaporizer.When it’s time for a dose, her children know that she needs privacy. She doesn’t like promoting the use of it. It is, after all, still a street drug, and not even endorsed by Health Canada. An estimated 1.5 million Canadians have a criminal record for using, selling or growing marijuana.
“The role of this drug in society, be it medical, recreational or criminal will only be determined by allowing unbiased research to find the answer,” says Dr. McLachlan.
So behind closed doors, Marion inhales. Her pain subsides, if only for a while. And in those pain-free moments she can return to being a normal mom again.