Changing doctors opinions and prescribing practice is hard – just ask the pharmaceutical companies who spend millions trying to do so.
The biggest influencer in most areas of clinical practice is what doctors have learned at medical school and what they see and hear practised in their first few years of their training. Whilst new research and guidelines are important contributors to a doctor’s prescribing practice, overcoming these historical norms remains a challenge.
And this is the situation the UK medical cannabis movement currently faces.
As someone who has spent 20 years working with, and researching cannabis dependency, I have treated many hundreds of people whose lives have been negatively influenced by use, through dependence or its impact upon their mental and respiratory health.
I have known many happy, pretty functional people who smoke cannabis and experience predominantly positive experiences. While dependency at 10% of users (higher for those starting in adolescence) should not be ignored, it is a harm we want to minimise, and it will certainly not replicate the ongoing, prescription opioid-addiction crisis.
I have had patients who have disclosed their use to me with the specific intent of seeking my opinion on the medical utility of cannabis for a particular condition. Their reasons for disclosure often vary; Sometimes they are after justification for their use, sometimes they genuinely wanted to know if it might be useful, and other times they thought I should know, as part of their assessment and treatment.
I always value their willingness to share that detail and in some cases I fully support their rational for cannabis use. While I couldn’t say it was first-line or highly evidenced I know enough to provide what I thought is reasonable advice.
As we move forward and hopefully find the current regulatory obstructions to prescribing cannabis in the UK wane, doctors are likely to see many more patients seeking cannabis for their conditions.
For doctors to step confidently into this arena there will need to be enhanced training of current medical students, further education and new guidelines support a change in culture and the preconceptions of current practitioners. It will require caution in the conditions we choose to start treating with cannabis. It will require more research and engagement of the medical cannabis community in dynamic feedback loops, so clinicians and patients can learn together what works best.
In the same way that cannabis is not a single drug – with over 100 active cannabinoids – medicinal cannabis will not be a single medicine.
From ratios and doses of THC and CBD, to preparations, will it be; flower, resin, oils, liquid or tablet, or to route; vaping, oral, suppository, or topical, and then there are the dosing regimes; we have so much to learn. Selecting and navigating cannabis medicines is going to be way more challenging than managing prescribed opioids or benzodiazepines.
But the speed with which the medical world has woken up to therapeutic potential of cannabis gives reason to be optimistic.
Special licenses for cannabis did not arrive on the back of a landmark study; It was these stories that created such an overwhelming emotional response that things had to change. The spirit generated by these patient stories should act as the fuel to generate change in doctors’ subjective perceptions – and create a space for the cannabis evidence base and guidelines to catch up.
Things are changing; led by the heroic stories of parents fighting for their children’s lives.
By Professor Adam Winstock