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Study suggests nation’s health care providers need more education on medical cannabis

While demand for medical cannabis products grows in the United States, a UAB study suggests health care providers are ill-equipped to provide guidance. As the public’s demand for medical cannabis or cannabinoid therapies grows, health care professionals in the United States are ill-prepared to answer their patients’ questions, according to a new study led by researchers at the University of Alabama at Birmingham. The study, published in Epilepsy and Behavior (online before print), surveyed health care providers on attitudes and knowledge regarding cannabis for medical and recreational purposes.

“There is a growing interest in cannabis for therapeutic purposes,” said Magdalena Szaflarski, Ph.D., associate professor in the Department of Sociology in the College of Arts and Sciences at UAB and the study’s lead author. “Cannabis sativa L, also referred to as marijuana or hemp, has been used as material and medicine by humans for over 5,000 years.”

Szaflarski says that over 120 phytocannabinoids have been identified, including the two best known, THC and CBD, or cannabidiol. THC has psychoactive properties and is responsible for the high associated with marijuana. CBD is non-intoxicating and devoid of psychoactive effects.

“Thousands of studies suggest that cannabis/cannabinoid-containing products with a variety of THC:CBD ratios can be effective in treating some of the symptoms associated with HIV/AIDS, cancer, glaucoma, multiple sclerosis, epilepsy, pain, sleep, anxiety, trauma, and other conditions — but there are also risks and much that remains unknown about cannabis-based therapies,” Szaflarski said.

There have been several cannabis-based medications approved for use by the U.S. Food and Drug Administration. The most recent addition is Epidiolex® for the treatment of intractable seizures. UAB was a major site for the Epidiolex studies.

“We know there is a knowledge gap among clinicians,” Szaflarski said. “Previous studies had suggested that as many as 94 percent of epilepsy providers report their patients have sought cannabis treatment for epilepsy, and 64 percent say their patients use some form of cannabis. However, more than a quarter of those providers didn’t feel knowledgeable to make a recommendation to their patients, and only 2 percent had knowledge/information on proper dosing.”

Szaflarski’s team conducted a survey of U.S.-based neurologists, nurse practitioners/nurses, and pharmacists. There were 451 survey respondents, equally divided among the three professional groups. The survey consisted of 29 structured items that tapped into attitudes/knowledge regarding CBD therapies (with a focus on epilepsy), medical cannabis more broadly and recreational cannabis.

The survey addressed perceived effectiveness of CBD/medical cannabis, regulation and availability of products, and stigma associated with recommending CBD treatment. The knowledge domains covered the endocannabinoid system, pharmacology, effects, clinical applications and government regulation. Sociodemographic, professional education, tenure and work setting information was also collected from the survey respondents, as was information on the legality of medical cannabis.

Magdalena Szaflarski, Ph.D., associate professor in the Department of Sociology in the College of Arts and Sciences “Our findings showed that the majority of providers, over 80 percent, favored the use of medical cannabis when prescribed by a medical provider,” Szaflarski said. “Fewer, only 43 percent, supported recreational cannabis. Of some concern was that a significant number considered themselves not knowledgeable at all about medical cannabis or were unfamiliar with issues related to regulation and availability of cannabis products. The test results showed gaps in knowledge: Between 26 percent and 68 percent answered a question incorrectly or didn’t know the answer to a particular question.”

The team reports that attitudes about CBD for epilepsy have changed over time. In the current study, 77 percent of neurologists either strongly favored, favored or somewhat favored the use of CBD for epilepsy, against only 48 percent who said in 2014 that they would advise the use of medical marijuana in severe cases of epilepsy. This suggests growing, though still uneven, agreement among neurologists about CBD use for treating epilepsy.

The authors also report that support for CBD/medical cannabis among all providers in the study was lower than that of the American public’s, which is at 93 percent, according to the Pew Research Center. The study respondents also supported legalization of recreational cannabis at a lower level than did the general public, at 43 percent against a national figure of 60 percent, according to a Gallup News poll.

“A growing number of patients nationwide are looking to health care professionals to prescribe and guide them in the use of cannabinoid-based therapies,” Szaflarski said. “Our study suggests that many are not educated enough on medical cannabis to counsel their patients and recommend specific products or dosing. Patients are often left on their own to seek or obtain products and figure out dosing; such self-treatment may be harmful. Properly educated health care professionals can weigh potential benefits and risks of medical cannabis for individual patients and help mitigate potentially unsafe practices. Thus, professional cannabinoid education nationwide is immensely needed.”

Co-authors on the study are Patricia McGoldrick, N.P., MPA, MSN, Boston Children’s Health Physicians of Westchester; Lauryn Currens, M.D., University of Massachusetts; Dustin Blodgett, M.D., University of Kentucky; Hunter Land, M.S., Canopy Health Innovations; Jerzy Szaflarski, M.D., Ph.D., UAB; and Eric Segal, M.D., Hackensack University Medical Center and Hackensack Meridian School of Medicine.

The study was supported by Greenwich Biosciences, Inc. The content of this manuscript is the sole responsibility of the authors.

Cannabis for Multiple Sclerosis: Prescriber’s Perspective

Although treatment for multiple sclerosis (MS) has advanced significantly in recent years, symptom management remains challenging, prompting many patients to seek alternative approaches such as cannabis for symptom relief. In a survey conducted by the National Multiple Sclerosis Society, 66% of respondents indicated that they currently use cannabis for this purpose. 1

Medical cannabis use is now permitted in 30 states and Washington, DC. 2,3 Because of conflicts between state and federal drug laws, there is no such thing as a medical cannabis prescription. Instead, patients must obtain certification from a physician who is approved to certify patients for participation in the program, based on one of numerous conditions, including MS. Once certified, patients receive a card that allows them to purchase medical marijuana from designated dispensaries.

With increasing legalization and social acceptance regarding the use of cannabis, it is anticipated that the number of people using it to manage symptoms of MS will increase as well. However, evidence supporting the benefits of cannabinoids varies widely in terms of quality and bias.

A 2018 systematic review examined randomized controlled trials pertaining to the symptoms with the strongest evidence base, including 2 that are relevant to MS: pain and spasticity. 4 The authors found that patients taking cannabinoids were more likely to achieve pain reduction of at least 30%, with a risk ratio of 1.37 (95% CI, 1.14-1.64) and number needed to treat of 11. Most studies investigating the effects of cannabinoids on pain focused on neuropathic pain. In addition, a positive global impression of change in spasticity was observed (risk ratio 1.45; 95% CI, 1.08-1.95; number needed to treat=7). These specific benefits are recognized by the American Academy of Neurology as having strong supporting evidence. 5

There is also “indirect evidence that reductions in spasticity, pain, and fatigue may result in improvements in the mobility of [people with] MS,” according to another recent paper. 3 The authors further noted that cannabis use has been shown to reduce the intake of prescription drugs that have more numerous and serious side effects, including opioids, benzodiazepines, and antidepressants. Findings published in 2017, for example, demonstrated that 77% of frequent opioid users had reduced consumption since initiating cannabis use, and many patients also decreased their use of antianxiety (72%), migraine (67%), and sleep-promoting (65%) medications. 6

To learn more about how medical cannabis is currently being used among patients with MS, Neurology Advisor spoke with Clyde E. Markowitz, MD, director of the Multiple Sclerosis Center at Penn Medicine and associate professor of neurology at the Hospital of the University of Pennsylvania, and Thorsten Rudroff, PhD, FACSM, assistant professor in the Department of Health and Exercise Science at Colorado State University, and adjunctive assistant professor in the Department of Radiology at the University of Colorado Medical School.

Neurology Advisor: What are some of the most pronounced benefits of cannabinoids for MS and how are they currently being used to treat MS symptoms?

Dr Markowitz: To date, the major active metabolites [identified] in medical marijuana are Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD), and these have been found to have benefits in individuals with MS, particularly regarding pain and spasticity. Whether there are other benefits is less proven. Animal data suggest immunomodulatory and neuroprotective effects, but these have not been adequately studied in humans. 7,8

Dr Rudroff: Cannabinoids are effective for the treatment of pain and spasticity in people with MS. There is scientific evidence 9 supporting the effectiveness of cannabinoids with a 1:1 ratio of CBD:THC, as noted during a recent meeting sponsored by the National Institutes of Health, Marijuana and Cannabinoids: A Neuroscience Research Summit, in 2016. People with MS are currently self-medicating with cannabis. There are no specific guidelines, so patients must figure out which cannabis product is best for them.

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Neurology Advisor: How do you feel about recommending cannabis, and what are patients reporting back thus far?

Dr Markowitz: [Editor’s note: Although Dr Markowitz supports his patients’ use of medical marijuana when indicated, he does not wish to become an approved physician who can certify patients for program participation, as he does not want new patients to initiate contact solely for this purpose.] In Pennsylvania, approved physicians must be listed on the state’s website, and I am not interested in that. I’m of the belief that I can take care of my own patients and can make recommendations, but I’m not interested in seeing patients for anything other than MS.

Most of my patients who have used medical marijuana have reported fairly good results. Some have been able to come off medications to treat spasticity that can cause sedation, and others have reported decreased pain. Other benefits have also been reported, but there is a lot of variability between patients.

Dr Rudroff: In my experience, physicians are very hesitant to recommend cannabis. They cannot prescribe cannabis, but they can [provide certification for patients to obtain] a card that allows patients to buy medical cannabis in a dispensary. In speaking with patients with MS who participated in my research, several [reported that they had] reduced or completely stopped other pain drugs such as opioids when using cannabinoids.

Again, without any guidelines about CBD:THC ratio, how often to use, and how to use the product, people with MS often have problems finding a physician who supports or is open to the use of cannabis.

Neurology Advisor: What are the top takeaways for clinicians, and what should be the focus of future research in this area?

Dr Markowitz: In the correct patient populations, medical marijuana clearly has benefits. Some patients can’t tolerate the medications that are used to treat spasticity and pain, and this provides the opportunity to treat these symptoms in these individuals without the side effects [associated with the standard medications].

One thing that’s important to understand is that there are many different preparations of medical marijuana — vapor, oil, edibles, and more — with varying amounts of THC and CBD. We do not really have a handle on that yet to really understand what quantities of these compounds are needed to manage specific symptoms.

In addition, while we know about the short-term benefits, we need to know more about the long-term effects in areas such as cognition and learning ability. So, there are a lot of pieces we don’t yet understand — but the same is true for certain other drugs such as opioids, for example.

Dr Rudroff: In my opinion, cannabinoids are an effective alternative to treat MS-related symptoms. However, while cannabis seems to be effective for the treatment of MS symptoms like pain and spasticity, there are so many unknowns. For example, we don’t know much about interactions with other drugs. Also, based on my own research, it seems that cannabis may further impair cognitive function in people with MS, especially in older adults.

More interventional studies are needed to investigate the acute effects of cannabis in people with MS. The best CBD:THC ratio and interactions with other drugs need to be investigated, and longitudinal studies are needed to investigate the long-term effects of cannabinoids.