What are the beliefs, attitudes and practices of rheumatologists with respect to medicinal cannabis?

One out of every five Canadian adults 18 and older has chronic pain, and the most common cause (up to 36% of cases) is arthritis.¹ As of 2015, almost six million Canadian adults have some form of arthritis and the number is expected to increase rapidly as the population ages.²

Medical cannabis has been proposed as a potential treatment option for chronic pain from arthritis.³ Although its efficacy for the treatment of arthritis pain has yet to be determined, the general public appears to be hopeful that it may be a viable treatment option. But has medical cannabis been embraced as a treatment option by rheumatologists?

In 2013, members of the Canadian Rheumatology Association were surveyed on their knowledge and perceptions regarding medical cannabis for their patients. Of the 128 respondents, 55% believed there was some role for cannabinoids in the treatment of patients. However, 70% had never previously recommended any form of cannabinoid therapy to patients and 60% said they would not currently recommend it.

The problem? Only a quarter (26%) had confidence in their understanding of cannabinoids (the chemicals in cannabis), less than third (31%) in their understanding of the body’s natural endocannabinoid system (the system of chemical receptors throughout the body that are involved in regulating some biological processes), and – most significant of all – only 9% in their ability to specify the dosage, frequency of use and method of administration for patients.⁴

The next year, almost the identical survey was conducted among Israeli rheumatologists.⁵ Israel has a history of fifty years of cannabis research, was one of the first countries to legalize medical cannabis, and one of just three nations – with Canada and the Netherlands – to have a national government-sponsored medical cannabis access program.⁶ You might presume that in this environment, rheumatologists would have much greater confidence in their knowledge to prescribe medical cannabis.

Recommendation of medical cannabis to patients was indeed higher among the Israeli, compared to the Canadian, rheumatologists: 61% vs. 30%. Belief that medical cannabis could play a role in treating people with arthritis was higher: 74% vs. 55%. But when asked about their confidence in their knowledge, results were more mixed.

A greater proportion of Israeli than Canadian rheumatologists were confident in their knowledge about the body’s endocannabinoid system: 50% vs. 31%. Confidence in their knowledge of the cannabinoids was the same in both countries: 26% said they were at least somewhat confident, which means close to three-quarters were not.

For being able to specify the dose, frequency and mode of administration of cannabis for patients, twice as many Israeli than Canadian rheumatologists said they were confident in their knowledge: 22% vs. 9%. However, this means that about 78% of Israeli rheumatologists lacked confidence to accurately prescribe medical cannabis.

In some respects, these survey results should be interpreted with caution. After all, the response rate of the Canadian survey was 25% (128/510) and even lower (19% or 23/119) for the Israeli study. It’s possible those who responded were not representative. For example, maybe rheumatologists with the lowest confidence about medical cannabis were more likely to respond.

More recent surveys may be able to give us a more complete and up-to-date understanding of the concerns and barriers for rheumatologists in utilizing medical cannabis as a treatment option. In the meantime, these surveys suggest that there is a need for high-quality, evidence-based education and information for clinicians.