ROLLING BACK REEFER MADNESS

It became routine after showing the slide on the cannabinoid 1 receptor during Cannabis 101 Grand Rounds that I would ask for a show of hands of attendees who had learned about it in medical school. Occasionally a tentative hand would raise. A silver lining of the current virtual conferencing is that one can actually poll the audience with an immediate tally of the results. Recent data from 40 and 70 respondents confirmed that only 5 to 10% of us were informed of the existence of one of the most densely populated G-protein coupled seven transmembrane domain receptors in the central nervous system during our medical training. Nor did we learn about the rest of the endocannabinoid system. I would joke that this demonstrates the extent of Reefer Madness in our society. Actually, though, it is not a joke!

Five years ago, I was asked to teach a 12 -h seminar to twelve first year medical students during their January Inquiry Immersion curriculum. The title of the seminar was to be in the form of a question so I billed it as “Marijuana: Is It Medicine Yet?” To keep myself engaged, I added a sub-question beginning in the third year-“Can Cannabis Cure Cancer?” The seminar has been well-received and the students always ask why this is the only place they are taught about the health effects of cannabis. In an effort to increase interdisciplinary education, first year pharmacy students have also been invited to select from the list of 30 or so January seminars. Interestingly, this year the course was comprised of only one medical student, heavily outnumbered by the future PharmD’s. That made me wonder whether that might actually be the appropriate distribution.

Two recent pharmacy graduates approached me a few years ago asking what I would think if they opened a dispensary. What a great idea. They returned a year later saying that it required a million dollars down to open a dispensary, so they were establishing a concierge cannabis service instead. They would collect health information and current medications, ascertain what the patient was interested in treating with medicinal cannabis and then make recommendations of products they should seek at the dispensary. For some clients who preferred not to visit a cannabis emporium, a tincture could be delivered to their home. As California is not a state where pharmacists are mandated to have a place in the cannabis dispensing chain, this system seemed a significant advance from getting advice from the local “budtender”.

A think tank representative working with a large local dispensary called a number of years ago in an effort to increase physician-dispensary interaction. They noted that when a physician sees a patient with depression, they might prescribe bupropion 100 mg twice daily dispensing 60, fluoxetine 20 mg daily dispensing 30, or sertraline 50 mg take 4 daily dispensing 120. In the current system, when the patient is told to visit a dispensary, the staff assisting says the equivalent of “Oh, you have depression. Do you want bupropion, fluoxetine or sertraline? What dose and how many?” She questioned whether it wouldn’t be better if the physician could be more directive. Based on what data? As far as I know, no clinical trials have been done on OG Kush flowers, Gorilla Glue gummies, or Ice Cream Cake tincture in people with depression. Physicians generally prefer to make recommendations based on data generated in prospective controlled clinical trials.

This issue of the journal has a special focus on health care provider education in medical cannabis. Currently one can review some on-line Power Point presentations for a few hours and obtain CME credit or pursue a program of 160 hours leading to a Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation Diploma of Advanced Studies in Endocannabinology, Cannabis and Cannabinoids. Although I believe that pharmacists may be our best allies in the realm of assisting our patients make rationale treatment decisions, I also feel that it is imperative that physicians are taught the basics of the endocannabinoid system and the health effects of cannabis and cannabinoids- both the therapeutic potential as well as the adverse effects. As the effects of the endocannabinoid system are so extensive in the human body, information should be interdigitated in appropriate coursework throughout professional education rather than segregated into an optional standalone elective. Intercalating cannabis throughout the curriculum would provide health professionals with the knowledgebase needed to overcome the stigmatized Reefer Madness mentality that has been dominant since cannabis was removed from the US Pharmacopeia in 1942.

Cannabis uniquely spans two cultures as both a therapeutic botanical and a recreational substance. The recreational use of cannabis should not be discounted as it serves a useful role in relaxation for many who might otherwise rely on alcohol or prescription drugs that do not share the safety profile of cannabis. Many health care providers choose not to embrace the plant’s therapeutic potential presuming that any benefit is related to its psychoactive effects. Euphoria is considered to be an adverse experience!

As more clinical trials are conducted with the botanical or its derivative cannabinoids and even terpenes, the body of medical knowledge regarding the medical effects of this enduring botanical will likely catch up a bit to the 21 st Century. In the meantime, health care professionals should avail themselves of some level of cannabis education to emerge from the Reefer Madness/Just Say No mentality that dominated the last eighty years. After all, our patients would benefit greatly if we felt comfortable enough to suggest cannabis as an alternative to some of the more potentially harmful agents in our pharmacy.