It does not matter to me whether American physicians prescribe medical cannabinoids, but it does matter that whatever we prescribe is based upon high-quality unbiased data with attention to safety and cost, especially as it relates to the typical emergency medicine patient. That is why I am confused that a highly regarded magazine like EMN dedicated to the clinical practice of emergency medicine has a regular feature on the use of medically prescribed cannabinoids. (The Case for Cannabis by Sherry Yafai, MD; http://bit.ly/CaseforCannabis.)
The only FDA-approved medically prescribed cannabinoids in the United States are for extremely rare seizure disorders (which do not decrease the frequency of status epilepticus) and for compassionate use in unique chronic pain and often end-of-life conditions (AIDS anorexia, refractory nausea in chemotherapy). In neither of these situations are there robust convincing data nor would we prescribe them from the ED.
It is important and fascinating to consider the hypothesis of cannabinoid analgesia and its medical and societal implications if true and if it could be accomplished safely and justly, but we must not confuse (as we often do) animal research, small observational datasets (even in meta-analysis), and personal experiential anecdotes with large, well-conducted, high-quality trials.
The International Association for the Study of Pain issued a position statement on March 18 about using cannabinoids to treat pain after a full review of the international literature. They concluded, “[D]ue to a lack of evidence from high quality research, [we do] not endorse the general use of cannabinoids to treat pain.” (https://bit.ly/3A1hnXz.)
As an emergency physician, I am not seeing the case for Cannabis. Why am I getting a message almost every month based on inadequate science for outrageously expensive drugs I will never use in the ED? It is not about marijuana; it is about the understanding and distribution of high-quality science and its wise applications.
Mark Mosley, MD, MPH
Dr. Yafai responds: Unfortunately, you are correct to some extent. Writing for Epidiolex (CBD), Marinol (synthetic THC), or Sativex (1:1 CBD:THC) is not in the typical arena of an emergency physician because there are not yet clear indications for these medications. But there are no indications for EPs to write for Viagra, some antiseizure medications, or Botox (to name a few). That does not mean that we are not educated on a vast number of medications and their side effects because patients who take these medications land in the ED.
As the medical and recreational legalization of Cannabis moves forward at a rapid rate each year, it is our responsibility to be educated on this fascinating, widely-available, widely-used medication. If you haven’t seen a patient using Cannabis, hemp, or CBD in the ED, it is simply because you haven’t asked.
As medicine has evolved, we have created more specific categories of pain, so to dub one medication the cure for all types of pain is silly, as you have pointed out in your own prior EMN columns. Cannabis-based medications do have some great studies specifically for neuropathic, cancer, and palliative pain. In fact, these are studied more often than our off-label use of gabapentinoids, benzodiazepines, and opioids because Cannabis has something to prove.
There are, in fact, multiple large studies, like “Multicenter, Double-Blind, Randomized, Placebo-Controlled, Parallel-Group Study on the Efficacy, Safety and Tolerability of THC:CBD Extract and THC Extract in Patients with Intractable Cancer-Related Pain,” which enrolled 177 patients. (J Pain Symptom Manage. 2010;39:167; https://bit.ly/3ydnw0P) This is just one of many such studies. A PubMed search of “Cannabis” and “randomized controlled trials” reveals 681 results. A search for “Cannabis,” “pain,” and “randomized controlled trials” since 2001 reveals 55 results. (https://bit.ly/3y7lNKE.)
Of those studies, 13 are on neuropathic pain, nine are on multiple sclerosis and motor spasticity, two each are on cancer and palliative care, arthritis (osteoarthritis and rheumatoid), HIV-related pain, and opioid interactions, and one is on sickle cell pain management. Given the large number of studies, I would suggest continuing to read my column because I get into the weeds of each study. All of these are types of patients we see in the ED, all of whom could benefit from a discussion about Cannabis and the utility of it for their pain management, especially when you consider that they are probably showing up in the ED because their pain is being poorly managed.
By all means, Dr. Mosley, you should not recommend a medication that you don’t support. But as an EP, you sure do need to learn about it because it is already showing up on your ED doorstep.