New guidelines on cannabis prescribing incongruent with patient reported benefits


Recently, the College of Family Physicians (CFPC) published a set of new prescription guidelines regardingmedical cannabis. This document was circulated across Canada to 30,000 family physicians. The expectation is that family doctors take into consideration these new guidelines and prescribe, for the most part, in-line with these new “rules”. The guidelines are being criticized by many as being highly restrictive, ill-informed, and out of touch with the experiences of cannabis prescribing physicians and medical cannabis patients.


One of the many concerns with the aforementionedguidelines is the statement that cannabis poseshigh risks of harm” – this is repeated no fewer than ten times. This is presented as the main reason to avoid prescribing cannabis. As a physician who has written over three thousand cannabis prescriptions for patients, I find high risks of harm to be a stark contrast to my clinical experience. The most dramatic side effects typically seen with medical cannabis are mild in nature and include sedation, dry mouth, temporary mild amnesia, euphoria,and lightheadedness. It is important to note that all of these mild side effects can be prevented with proper dosing and counselling. More importantly, THC is non-toxic, impossible to overdose on, and is extremely safe for the majority of patients. Numerous studies have confirmed that cannabis is safe, yet these studies were not included in the recent analysis by the committee (https://www.ncbi.nlm.nih.gov/pubmed/29398248). While I agree the greatest risk of THC are hallucinations and psychosis, the absolute risk seems extremely overstated by the evidence selected by this committee. In fact, much of the literature actually suggests that the odds of psychosis happening is less than 1:20,000 cases (http://onlinelibrary.wiley.com/doi/10.1111/add.13826/abstract;jsessionid=E585EA4329A1E045F6E9BC7E800E8C10.f01t04). Oddly, the new guidelines used specific studies that demonstrate the rate of psychosis closer to 1:20. I could not disagree more with the guideline committee’s assessment of the literature on harms. Many pharmaceuticals have side effects and risks such as liver failure, kidney failure, stomach ulcers, and even death: cannabis poses none of these risks.


Furthermore, the side effects of cannabis only occur with one ingredient in the cannabis plant, THC. This is not a risk with the other more commonly prescribed cannabis ingredient, CBD. This brings me to my next concern: the guidelines fail to mention CBD as a treatment option. Frontline physicians prescribing cannabis often resort to using CBD cannabis strains (mostly in oil form to be ingested). CBD is not cognitively impairing, it does not cause addiction, and it does not cause any of the side effects that THC does. It is currently being investigated as an anti-epileptic, anti-psychotic, anti-inflammatory, anti-cancer agent. Its therapeutic potential is more than any other medicine we have seen in decades. The most fascinating part about CBD is that it is extremely well-tolerated, given the worst side effects experienced are a bit of drowsiness at higher dosages. I have used CBD oil on numerous occasions, for example, to cure young children with intractable epilepsy, to reduce inflammatory pain for a wide range of diseases (osteparthritis, inflammatory bowel disease, rheumatological arthritic conditions), and to help patients with severe anxiety not responsive to traditional pharmaceuticals to name a few. Somehow, the new guidelines fail to separate CBD from THC and instead it lumps all cannabis together as one form. This is completely inaccurate and demonstrates the lack of experience in cannabis prescribing on the member panel. To treat cannabis as only one medicine ignores the fundamentals of cannabis pharmacology. Our clinic’s medical database of fifty thousand cannabis patients demonstrates that more than 50 percent of patients use CBD only products. The World Health Organization (WHO) recently published an extensive review on CBD that demonstrates it is safe, poses no public health risk, is non-addictive, and has immense therapeutic value (http://www.who.int/medicines/access/controlled-substances/5.2_CBD.pdf). I struggle to understand why the guideline committee failed to address CBDs extreme safety profile and ignore the WHOs analysis.


My last major concern with the guidelines is that it is highly restrictive in terms of the number of disease states that physicians are permitted to prescribe for. The new guideline suggests that only four conditions be considered: chemotherapy induced nausea and vomiting, neuropathic pain, spinal cord injuries, and MS spasticity. While I agree that the current evidence is best for these conditions, restricting prescribing to these four conditions will leave out millions of Canadians suffering from osteoarthritis, rheumatoid arthritis, lupus, crohns disease/ulcerative colitis, epilepsy, HIV, and refractory anxiety. Interestingly, SunLife Financial just announced they are offering coverage for employers for medical cannabis. After reviewing the medical literature they opted to cover moreconditions than the new guidelines suggest physicians prescribe for (http://business.financialpost.com/news/fp-street/sun-life-financial-to-add-medical-pot-option-to-group-benefits-plans). The most disturbing parts of this document, however, is the fact that it is not even recommended for patients who are palliative, deemed to have less than six months to live. The committee somehow thinks it is unsafe for dying patients to use a medicine that can help with pain, appetite, sleep, and anxiety. The idea that pills must be used first, and that palliative patients should be discouraged from medicating with cannabis, is mind-boggling and disturbing.


As a physician, I am struggling to accept these new guidelines. The guideline’s conclusions could not be more different than patient experiences and physician observations. For me to tell dying patients that I cannot prescribe them a safe medication, especially one that is non-toxic and can help palliate multiple end-of-lifesymptoms, seems out of touch with the principles of being a physician. What happened to the ethical principle of “do no harm”? While we all thrive for evidence-basedmedicine, our responsibility is to first use the least harmful medications to help patients. Evidently, cannabis fits this category perfectly. Patients should not have the burden of being forced to try a myriad of medications that they do not want to for their condition, or that they deem more harmful to their health. With proper patient education and counselling on cannabis, patients should be permitted to evaluate the risks and benefits of a therapy and decide with their doctor the appropriate course of action. That is patient-centered care and the art of medicine. To ignore this part of medicine turns doctors into robots following flow charts and patients into voiceless sufferers whose experiences are irrelevant to prescribing. What happened to shared decision-making and patient autonomy? These restrictive guidelines come at a time where we are faced with an epidemic in prescription overdoses. In fact, opiates and other pharmaceuticals currently account for more than 50,000 deaths annually in North America(https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm). Overdose is the second leading cause of death in North America. There is a plethora of research demonstrating that access to cannabis has resulted in less opiate related deaths (https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1898878). So again, why be so restrictive at a time when we should be advising doctors to prescribe anything but opiates?


The medical community should endeavour to do better. Patients trust doctors to help them make informed decisions. The new guidelines, however, are likely to cause a significant backlash and further distrust in the medical community. Ongoing discounting of the benefits of cannabis for millions of users will result in patients having to look elsewhere for their care, further away from physicians. Patients feel like their experiences with cannabis are not being validated and it does not do society any favours by driving these complex, sick patients away from doctors, to alternative practitioners with less training, or even to black markets to get their medicine.


I call on the committee to pause, reflect, and hopefully update these guidelines. I encourage the committee to expand on the number of conditions that physicians should consider when prescribing cannabis. I ask that they address CBD, its overall safety, and encourage its use as a therapy ahead of more harmful pharmaceuticals. I also request that they introduce more flexibility into the guidelines to allow for shared decision-making and patient-centered care.


I became a doctor to help patients heal. These guidelines severely interfere with my ability to help Canada’s sickest patients.

 

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