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Canadian Rheumatology Association: Medical cannabis not a substitute to standard care
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Medical cannabis is not an alternative to standard of care for any rheumatic disease, and rheumatologists must exhaust all current treatment strategies for pain and sleeplessness — including nonpharmacologic methods — before considering a trial for cannabinoid products, according to a position statement released by the Canadian Rheumatology Association.
“The [Canadian Rheumatology Association (CRA)] recognizes the need for improved pain relief in patients with rheumatic diseases,” the statement noted. “With the legalization of cannabis, Canadians are increasingly turning to their physicians for guidance regarding medical cannabis use, which has already entered mainstream medicine. Medical cannabis has not been subject to the standard review required for drug approval by Health Canada.”
According to the statement, “In the absence of studies examining the effects of medical cannabis in patients with rheumatic diseases, rheumatologists should be prepared to offer pragmatic advice in a caring and empathetic way to ensure harm reduction.”
In a list of 11 overarching principals included the position statement, the CRA stressed the dearth of published studies on the effects of medical cannabis among patients with rheumatic diseases. In addition, according to the statement, the few studies currently available that have examined medicinal cannabinoids report limited benefits and a high risk for adverse events.
Although the CRA acknowledged that medical cannabis may provide symptom relief for some patients with rheumatic diseases, the group added that it is also highly associated with numerous short-term adverse effects, including immediate psychomotor effects, dizziness, appetite changes and effect on mood, and the rare serious adverse effects of disorientation and psychosis. In addition, the long-term risks associated with medical cannabis among patients with rheumatic diseases remain unknown, according to the statement.
However, the CRA also noted that patients may seek out a prescription for medical cannabis, and may already using it to self-medicate to treat pain and sleeplessness.
When considering a trial of medical cannabis, the CRA reported that rheumatologists should avoid cannabinoid treatments among patients who are younger than 25 years, those with allergic reactions to cannabinoid products, women who are pregnant or breastfeeding and those with a history of psychotic illness, substance abuse disorder, previous suicide attempts or suicidal ideation.
In addition, rheumatologists considering a medical cannabis trial should have a full clinical knowledge of the patient and clearly discuss with the patient treatment goals and possible adverse events. The CRA also advised that cannabis should not be smoked, but rather inhaled through a vaporizer or consumed orally, and that products with lower THC and higher CBD are preferable. Patients receiving medical cannabis treatment should start with a nighttime dose, with a slow increase to a maximum of 3 g of dried product or equivalent, the statement read.
Rheumatologists should follow patients treated with cannabis for 4 to 8 weeks after initiation and should discontinue treatment in the absence of any appreciable clinical effect, or in the event of substantial adverse effects. Patients who continue cannabinoid treatment should be re-evaluated at least every 3 months to assess efficacy, according to the CRA.
“Despite a patient’s understanding of the lack of scientific evidence to support a benefit, and the potential increased risk of harms, some patients may choose a trial of medical cannabis over other options,” the statement noted. “Rheumatologists must endeavor to maintain an empathetic therapeutic relationship with their patients, avoid personal biases, and ensure harm reduction for both patients and society.” – by Jason Laday
Perspective
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William Dolphin, MA
The Canadian Rheumatology Association (CRA) does well to recognize that patients may not just seek advice about using medical cannabis, but may currently be self-medicating with it. Our research further indicates that patients hesitate to talk to physicians about cannabis out of concern for how they may be stigmatized. Indeed, one recent survey found roughly half of patients were not disclosing their use of medical cannabis to their doctors. This highlights the importance of the CRA’s suggestion that rheumatologists “offer pragmatic advice in a caring and empathetic way to ensure harm reduction.” But what constitutes harm reduction in this context?
Cannabis has been widely identified as a potential substitute for conventional analgesics and anti-inflammatories because of reduced risks. Yet the position statement of the CRA casts cannabis use itself as the harm, claiming there is a “high risk of adverse events,” including psychosis — that is highly misleading. While clinical trials of cannabis are limited, they universally report side effects to be relatively mild and well-tolerated. The association between cannabis use and psychosis is inconclusive and limited to those with genetic risk who use large amounts of cannabis frequently very early in life, not therapeutic use.
The CRA claims patients should understand “the lack of scientific evidence to support a benefit” but a recent report by the National Academies of Science, Engineering, and Medicine concluded that “there is substantial evidence that cannabis is an effective treatment for chronic pain in adults.” Rheumatologists will do well to explore that evidence.
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