Recently, I am being asked this question at least few times daily. Pain is one reason some rheumatology patients may consider use of medical cannabis, a product increasingly perceived as a safe and neglected natural treatment option for many conditions.
So, what is Marijuana?
Marijuana, also known as Cannabis refers to the dried leaves, flowers, stems, and seeds from the Cannabis sativa or Cannabis indica plant. The plant contains the mind-altering chemical THC and other related compounds. Cannabis has been used for both recreational and medicinal purposes since several centuries. Hashish, a cannabis preparation, was found in Egyptian mummies. Marijuana, Hashish, Bhang and Ganja are the most widely used illicit drugs in the world. These psychoactive products are obtained from the plant Cannabis sativa (Indian hemp) and some of its subspecies. Cannabis is perceived as a recreational and harmless drug in some countries, even in leading medical journals and in some sections of the lay press. However, in most countries, it is categorized as a drug of abuse and its use is strictly prohibited.
Most rheumatologists (including myself, until recently) don’t know enough about medical cannabis to effectively advise patients. Surprisingly, despite it being perceived natural (and hence harmless), there have been only few clinical trials and there is no definitive clinical evidence to guide physicians on how best to prescribe medical cannabis for rheumatology patients. However, with medical cannabis approved in Canada and in some states in the U.S., I felt the need to address this for my patients to the best of my knowledge.
To help clinicians provide beneficial guidance to patients interested in cannabis therapies, the Canadian Rheumatology Association has recently issued a position statement and below is the summary of that:
1) Medical cannabinoids should not be used for pain associated with rheumatologic conditions (including osteoarthritis and back pain) owing to lack of evidence and known harms.
2) Medical cannabis is not an alternative to standard care for any rheumatic disease and that evidence for the effect in rheumatic diseases is lacking.
3) Medical cannabis may provide symptom relief for some rheumatic disease patients. However short-term adverse events (including psychomotor effects, dizziness, appetite changes, effect on mood and rare side effects of disorientation and psychosis) are high with medical cannabis use.
4) A prescription should only be provided by a physician who is fully knowledgeable of the patient and is responsible for patient care. Cannabis should not be prescribed following online consultation or by those who project themselves as ‘cannabis experts’ focusing only on prescription of cannabis without attention to global patient care.
5) It should not be prescribed in rheumatology patient under the age 25.
6) Rheumatology patients are usually on prescribed medications and to date there have been no studies that focus on the possible interactions of cannabinoids with other medications.
7) It should not be smoked as inhaling products could promote bronchial irritation which could trigger an inflammatory arthritis flare.
8) Consider cannabis with lower THC and higher CBD content.
9) It should not be prescribed in a patient with history of current or past psychotic illness, substance abuse disorder.
10) It should be prescribed with caution in elderly patients, patients with history of cardiovascular or pulmonary disease.
Despite lack of evidence for use of medical cannabis in rheumatology patients, some patients may choose trial of medical marijuana over other options. This position statement aims to facilitate the dialogue between patients and healthcare professionals in a mutually respectful manner to ensure harm reduction for patients and society. Like everything in life, I always tell my patients to weigh their options in terms of risk vs. benefit. Something that has been helpful for someone or has worked on someone doesn’t mean it will do the same for you. So, I recommend that you have a detail discussion with your primary care physician and rheumatologist before you consider trying medical marijuana.
REFERENCE
Fitzcharles MA, Zahedi NO, Hauser W, Hazelwood G, the Canadian Rheumatology Association. “Position Statement: A Pragmatic Approach for Medical Cannabis and Patients with Rheumatic Diseases.” Journal of Rheumatology (2019), DOI: 10.3899/rheum.181120.