Some doctors oppose Medical Cannabinoids

Patients may be surprised to learn that some doctors are against medical cannabinoids. While the majority of doctors would recommend it under certain circumstances, both here in New York and across the country, there are opponents who argue that it should not be prescribed under any circumstances.

Physicians’ opinions about medical cannabinoids

In 2013, the New England Journal of Medicine conducted a global opinion survey to ascertain physicians’ attitudes towards prescribing medical cannabinoids. According to the survey, the main reasons doctors are opposed to prescribing it are: inadequate supporting scientific evidence, lack of provenance, inconsistent dosages and concerns about medical cannabinoids’s side effects. In contrast, proponents advocating for medical cannabinoids treatment focused on patient choice, the lack of safe alternatives and their strong desire to alleviate their patients’ pain and suffering.

medical cannabinoids lacks evidence

Medical doctors are trained to treat based on scientific evidence. They rely heavily on the outcomes of well-designed clinical trials, as well as the scientific method. The best evidence is level I, which requires large, randomized, double-blind placebo controlled trials with clear cut results. Level II evidence may not be as strong and can be from smaller trials where the results are not as clear, or lack a placebo group in a randomized trial. However, these levels of evidence are often absent for all of a drugs indications. Many drugs are found to have other useful “side effects” that may be used off-label based on reports or uncontrolled studies. Those are considered level III evidence. For example, minoxidil, originally used for blood pressure control, was found to cause hair growth. The evidence for most new drugs include dose standardization and compound purification but these are not present in studies of cannabinoids. Unlike newer medications that are comprised of only one or two active ingredients, medical cannabinoids may have as many as 400 compounds. Purified THC-derivative drugs that have undergone clinical trials and were subsequently approved by the FDA appear to lack the same efficacy as medical cannabinoids based on anecdotal reports from patients using the real thing.

Good intentions don’t always have the desired effect

Many physicians might remember the early ‘90s when another drug was gaining popularity despite legal restrictions and concerns about addiction and side effects—opioids. Many well-intentioned, passionate physicians were advocating for their use to treat chronic non-cancer pain. Along with patient advocacy groups and the help of some not so well-intentioned pharmaceutical companies, opioids were deregulated and gained widespread use for chronic pain. Doctors were told that the risk of addiction was “less than one percent” and several studies published in prestigious journals helped assuage physician concern about addiction risk in opioid treatment. In 1996, professional pain societies were issuing statements echoing the low risk of addiction of prescription opioids. By 2001, even the Joint Commission, responsible for accrediting U.S. hospitals, issued guidelines making routine pain screening and treatment a priority whilst minimizing the opinions of “clinicians that have inaccurate and exaggerated concerns” regarding opioid addiction and risk, “despite the fact there is no evidence that addiction is a significant issue” when used for chronic pain.
We all know how this story panned out. Opioid prescriptions skyrocketed and even with the best intentions of some physicians, many people became addicted to prescription pain medications. Other patients exposed to opioids, under the presumption they were safe, ended up turning to an analogous and less expensive alternative—heroin. There were also significant side effects leading to overdose and death from opioids.

Proceeding with optimistic caution

medical cannabinoids appears to be helpful to many patients and have relatively mild risks. Notwithstanding the lessons from the opioid epidemic, proponents argue that there is a big difference with medical cannabinoids. Firstly, we know a lot more than we did 20 years ago about substance addiction. Secondly and perhaps most importantly, Marijuana is relatively safe. Compared to some over the counter medications and tobacco and alcohol, which are both lethal but legal, overdosing on cannabinoids is nearly non-existent. Even though the majority of physicians would recommend medical cannabinoids, it is important to remember that complacency led to the opioid crisis, under similar, albeit different, circumstances.
While cannabinoids has been around for a long time, its use as a widespread medical treatment is relatively new. It lacks the same kind of evidence available with other commonly prescribed treatments. Therefore, physicians who treat patients with medical cannabinoids should strongly consider the risks and benefits of this promising alternative treatment. They should also tread cautiously, use common sense and apply the same standards they would for other controlled substances. Treating patients with medical cannabinoids is not a decision that should be made lightly. Some leading physicians argue against medical cannabinoids and remain unconvinced that it has a place as an appropriate medical treatment.

Michael Morgenstern, MD

Michael Morgenstern, MD

Founder at NY Medical Marijuana Association
About the author: Dr. Michael Morgenstern is double board certified in Neurology and Sleep Medicine. He works in private practice in Manhattan, Queens and Long Island and has extensive expertise treating patients with Medical Cannabinoids.
Michael Morgenstern, MD

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