Cannabis and the Doctors, or, Should We Maintain Canada’s Medical Cannabis Program?
Assisted by interviews with Dr. David Hepburn, cannabis educator; David Hutchinson, cannabis patient consultant; and Alan Cassels, Researcher with UBC Pharmaco-epidemiological Studies.
On April 5 2018, a meeting of the Canadian Consortium for the Investigation of Cannabinoids (CCIC) was shaken by a minor revolt. Dr. Jeff Blackmer, speaking for the Canadian Medical Association (CMA), stated that post legalization, there should be no need for a separate medical cannabis program in Canada. Dr. Mark Ware, speaking for the CCIC, disagreed; in his view, clinical oversight of patients will always remain essential. This stark opposition might have started a useful conversation. Instead, participants booed Blackmer’s comments, and Blackmer walked out, highlighting a doctor-cannabis animosity that has become too familiar. What went wrong? And what could they have talked about?
We should recall that the medical cannabis program in Canada is no one’s master plan. It was built by government reactions to a series of activist-patient arrests, and subsequent charter challenges that ran from 1998 to 2015. Courts in Canada have consistently upheld Canadian patients’ rights to consume cannabis if they believed that it was helping them. Both federal Liberals and Conservatives have responded by providing access to cannabis, but only on the condition that patients get their doctors to sign official recommendations. Unhappily, no one asked the doctors if they wanted to participate.
Few doctors were educated on cannabis-based medicines; and few had learned about the body’s endo-cannabinoid system. The court challenges featured expert witnesses on cannabis medicine. HC could have called on them to help train Canadian doctors. But it didn’t. The CMA responded with hostility, telling its members that there is no good quality evidence for recommending cannabis as a medicine. Provincial colleges have reacted with crippling restrictions on participating physicians. Consequently, eight out of nine Canadian doctors say “no”, leaving most Canadian patients with nowhere to turn, outside of informal sources.
These conditions leave us with angry medical authorities, frustrated scientists and patients, and a broken system that post legalization, may get worse. Here are some quandaries confronting doctors.
When assessing a medicine, MDs expect to see the results of randomized controlled trials (RCTs). RCTs are typically underwritten by pharmaceutical companies, who recoup their costs by patenting the resulting medicines, and maintaining a monopoly on production for a set time period. There is no cannabis strain that could be the sole medicine for any illness; thus, cannabis offers no chance of obtaining such a patent. As dollar costs for RCTs run into the multi-millions, we can’t look to pharmaceutical companies for help, and we can’t realistically expect governments to take their place. Sympathetic MDs have argued that, since cannabis is an herbal medicine, has a long history of use, and does not have the toxicity of pharmaceuticals, it should not be held to the same standards. But this stage, we have two groups of medical professionals that simply do not share a language.
When a patient asks for a prescription, HC forms in hand, a lengthy, non-standard conversation must follow. The BC College of Physicians and Surgeons, for example, requires doctors to put prospective cannabis patients through a test, to assess their potential for becoming addicts. They have to check the patients’ pharmaceutical records. If they do not know a patient well, they must speak with another professional that does. They are supposed to try patients on other medicines first. Once cannabis-based medication is begun, they are required to assess patients every three months. That’s a lot of time.
Doctors are used to doing the explaining. With cannabis requests, they find themselves facing patients bearing research papers, supplemented with information based on the patients’ own experience, a reversal of roles that most MDs find unacceptable. In addition, filling forms for a program in which one has no training seems hardly professional.
Patients in this system are equally at a loss.
For patients approaching an MD, problems abound. The doctor is required to know you well. But one in six Canadians has no family doctor. If you are one of those, you are out of luck. Patients must be at least 25 years of age. If you are a 23-year old, recently injured in an accident, you are not eligible. If you have a parent known to have been an alcoholic, you may be ruled out. And if you won’t try pills first, you may be dismissed.
Licensed Producers, patients’ sole, officially legal source of cannabis, sell only dried flowers, and a dilute oil infusion. But many Canadians have been relying on concentrates, tinctures, edibles and topicals, still illegal, that they buy online, from dispensaries, or from local medicine makers. A charter challenge to preserve these resources is set to begin in the BC Supreme Court in September. In the meantime, patients have reason to worry.
Patients must confront doctors’ suspicions that they are primarily after a high, though it seems clear that few doctors have any idea what this word means. Alcohol, tobacco, and caffeine produce highs; so do prescription opioids and tranquilizers. But these are unacknowledged. That fact, ignorance, in essence, keeps cannabis medicines at a disadvantage, a problem for which there is no easy remedy.
So, given that flowers and mild infusions will soon be available at Canadian cannabis shops, with other products to follow, need there be a separate medical cannabis program? Some activists argue that doctor acceptance is needed to normalize cannabis. But plainly, doctor acceptance cannot be coerced. Others note that without a medical release, patients in hospitals, and in care, might be denied access. But many such patients in Canada have already been denied access, as institutions are slow to change. This is a thorny question, worthy of public discussion. It would be nice to see a broadly based forum on the subject, with all sides given a fair hearing.
Judith Stamps. Published by The daily Hive. July 2018.