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Doctors in Md., US struggle with medical marijuana knowledge gap

BALTIMORE, MD-Ryan Vandrey, associate professor, Dept of Psychiatry and Behavioral Sciences Johns Hopkins University School of Medicine, seen here in the school's marijuana smoke research rooms. (The Daily Record/Maximilian Franz)

BALTIMORE, MD-Ryan Vandrey, associate professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, seen here in the school’s marijuana smoke research rooms. (The Daily Record/Maximilian Franz)

With Maryland announcing its first round of cannabis dispensary licenses, patients with certain medical conditions will soon be able to obtain cannabis to treat their chronic pain. But are physicians sufficiently educated to know when to counsel their patients on whether medical marijuana will be an effective treatment for their condition?

“At this point with where we are in the regulatory space, with half the U.S. offering medical use of marijuana, we can’t pretend that it’s not happening,” said Ryan Vandrey, an experiment psychologist at the Johns Hopkins University School of Medicine whose research focuses on the behavioral pharmacology of cannabis.

As the number of states allowing medical marijuana grows — the total has reached 25 plus the District of Columbia — some are working to address this knowledge gap with physician training programs. States are beginning to require doctors to take continuing medical education courses that detail how marijuana interacts with the nervous system and other medications as well as its side effects.

Vandrey has held ground rounds at local hospitals, including Johns Hopkins Hospital, Harbor Hospital, Mercy Medical Center and Union Memorial. Ground rounds are a teaching tool in medicine where a medical problem and treatment of a particular patient is presented to a room of doctors, who then discuss the case. The patients in Vandrey’s seminars have used cannabis to treat a medical condition. The sessions are open to people in the hospital and typically attract 40 to 60 doctors.

“It’s really just an objective way of looking at what we know and trying to make informed decisions,” said Vandrey. He typically goes over data and questions patients might ask about cannabis.

“Some physicians come in and are very well-informed and some are very naive,” he said.

Maryland doesn’t require training but encourages it through its Medical Cannabis Commission website, a policy also followed in some other states.

New York’s state health department has a certification program while Pennsylvania and Ohio are also developing similar programs. Meanwhile, in Massachusetts, doctors who wish to participate in the state medical marijuana program are required to take courses approved by the American Medical Association.

Physicians appear to welcome such direction. A 2013 study in Colorado, for instance, found more than 80 percent of family doctors thought physicians needed medical training before recommending marijuana.

But some advocates worry that doctors may find these requirements onerous and opt out, which would in turn thwart patients’ access to the now-legal therapy, said Ellen Smith, a board member of the U.S. Pain Foundation, which favors expanded access to medical cannabis.

With the current legal status of marijuana, someone will tell a patient to “secretly” try smoking marijuana to deal with an ailment and the patient won’t tell his or her doctor.

“That’s not how medicine should work. The patient shouldn’t be sneaking behind doctors’ backs,” said Vandrey.

Marijuana interactions

Though state medical marijuana laws vary, they have common themes. They usually set up a process by which states establish marijuana dispensaries, where patients with qualifying medical conditions can obtain the drug. The conditions are specified on a state-approved list. And the role of doctors is often to certify that patients have one of those ailments; most commonly, it’s pain related. But many say that, without knowing cannabis’ health effects, even writing a certification makes them uncomfortable.

Education is essential, given the complexity of how marijuana interacts with the body and how little physicians know, said Stephen Corn, an associate professor of anesthesiology, perioperative and pain medicine at Harvard Medical School. Corn also co-founded The Answer Page, a medical information website that provides educational content to the New York program, as well as a similar Florida initiative. The company, one of a few groups to offer teachings on medical marijuana, is also bidding to supply information for the Pennsylvania program, Corn said.

“You need a multi-hour course to learn where the medical cannabis works within the body,” Corn said. “As a patient, would you want a doctor blindly recommending something without knowing how it’s going to interact with your other medications? What to expect from it? What not to expect?”

While it’s important for physicians to be educated about prescribing cannabis, patients need to be able to have honest conversations with their doctor about using it, said Vandrey.

“There is a lot of desire for information both from physicians and from patients,” he said. “I encourage an open dialogue when I talk to both patients and physicians.”

Further research needed

Even with education and training there’s still a lot of research to be done about the medical properties of marijuana. That research is often difficult to complete.

One reason for that is the federal Drug Enforcement Agency classifies marijuana as a Schedule I drug, the same level as heroin. This classification makes it more difficult for researchers to gain access to the drug and to gain approval for human subjects to participate in studies. The White House rejected a petition this past week to reclassify the drug in a less strict category, though federal authorities say they will start letting more facilities grow marijuana for the purpose of research. Currently, only the University of Mississippi can produce it, which advocates say limits study.

From a medical standpoint, the lack of information is troubling, said Wanda Filer, president of the American Academy of Family Physicians and a practicing doctor in Pennsylvania.

“Typically, when we’re going to prescribe something, you’ve got data that shows safety and efficacy,” she said. With marijuana, the body of research doesn’t match what many doctors are used to for prescription drugs.

That said, physicians needs to work with the science they have and stay informed, said Vandrey.

“I think too often, everyone’s aware that we don’t have very good data or science on the medical use of marijuana…but it doesn’t mean we can’t talk about it and we can’t talk about what we do know,” he said, “The conversations that are had, need to be objective and appropriately weighing the risks and the benefits. There’s a tendency to treat cannabis as this special drug and this special thing. You want to treat cannabis as you would treat any other novel therapeutic.”

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.