Who could benefit from medicinal cannabis?

Type “benefits of medical cannabis” into Google and you’ll get links to articles such as “23 Health Benefits of Marijuana” and “50 unexpected benefits of cannabis (you might not know).” Sounds great. Given this sort of hype, it’s not surprising that large proportions of physicians say they had been asked by patients to approve medical cannabis.¹²

A prescription pharmaceutical approved for marketing by Health Canada can legally be sold across the country for the indications (i.e., diseases or symptoms) laid out in its Notice of Compliance (NOC) or, under special circumstances, for other purposes through a Special Access Program request. Approval to be marketed doesn’t necessarily mean federal, provincial or territorial public drug plans will pay for it – that’s another step. But theoretically, the drug should be used consistently for the same reasons across the country.

The situation is different for medical cannabis. In its 2013 review of the available experimental and/or clinical studies on medical cannabis (Information for Health Care Professionals³), Health Canada listed its potential uses as:

• Treating intractable pain, such as neuropathic (nerve-related), acute post-operative, chronic non-cancer or cancer pain, or pain associated with conditions such as arthritis, fibromyalgia (a chronic condition characterized by widespread musculoskeletal pain and fatigue), or migraines or other headaches
• In palliative care for relief from pain and other symptoms or enhancement of quality of life
• Treating chemotherapy-induced nausea and vomiting
• Stimulating appetite and facilitating weight gain in patients with Acquired Immunodeficiency Syndrome (AIDS), cancer or with some other form of disease-related anorexia (loss of appetite)
• Relieving spasticity (muscle stiffness, tightness or paralysis) in multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS) or spinal cord injury or disease
• Reducing the risk of seizure in people with epilepsy
• Reducing motor symptoms such as trembling or tics in dystonia (muscle spasms and abnormal posture), Parkinson’s disease or Tourette’s syndrome
• Controlling psychiatric syndromes such as anxiety, post-traumatic stress disorder (PTSD) or insomnia
• Treating inflammatory bowel diseases or irritable bowel syndrome

This looks a bit like the list of indications in a NOC – and is taken as such but some people — but it’s not. Health Canada stresses that this information is only a summary of available information and states “cannabis in not an approved therapeutic product” and “this document should not be construed as expressing conclusions from Health Canada about the appropriate use” of cannabis or cannabis products.³

To date, out of the possible indications for medical cannabis listed by Health Canada, the College of Family Physicians of Canada has produced “guidance” for only two: chronic pain and anxiety.⁴ This leaves significant gaps for practitioners. It’s not surprising that up to two-thirds (64%) of physicians cite the lack of clinical guidelines as a barrier to recommending medical cannabis.²

In looking for information to guide them, some practitioners might look to our neighbours to the south. In the U.S., 29 states, plus the territories of Guam and Puerto Rico and the District of Columbia, permit medical cannabis. Each state operates its own medical cannabis access program and publishes its own indications for use. In New York state, for example, the patient must have one or more of five symptoms (cachexia or weakness and wasting, severe or chronic pain, severe nausea, seizures, or severe or persistent muscle spasms) because of one or more of the eleven conditions (cancer, HIV/AIDS, ALS, Parkinson’s disease, MS, spinal cord injury with spasticity, epilepsy, inflammatory bowel disease, neuropathy, Huntington’s disease, or chronic pain).⁵

In New Hampshire, “qualifying medical condition” is defined in one of two ways: 1) one or more of ten symptoms resulting from injury or one or more of 16 diseases or 2) moderate to severe chronic pain, severe pain that has not responded to other treatment, or moderate or severe PTSD. In addition to conditions cited by New York State and Maryland, New Hampshire also includes symptoms associated with Alzheimer’s disease, hepatitis C, muscular dystrophy, chronic pancreatitis, traumatic brain injury, and Ehlers-Danlos syndrome (progressive blindness due to increased pressure within the eyeball).⁶ In Nevada, approved conditions include some but not all of the conditions named by other states but leaves the door open for its use for “additional conditions, subject to approval by the Division [of Public and Behavioral Health].” ⁷

In Maryland, with the exception of glaucoma and PTSD, the emphasis is upon symptoms rather than disease states. In this state, to access medical cannabis patients must fall into one of three categories: 1) is in hospice or receiving palliative care, 2) has a chronic or debilitating disease that causes cachexia, anorexia, wasting syndrome, severe or chronic pain, severe nausea, seizures, or severe or persistent muscle spasms, or 3) has glaucoma (gradual loss of sight because of increased pressure within the eyeball) or PTSD.⁸

Confused by this conflicting advice? How do you think practitioners and patients feel? Although there are some consistencies in what different jurisdictions suggest are recommended uses for medical cannabis (e.g., similar symptoms), there are also differences.

The benefits or risks of medical cannabis don’t stop or start at political or geographic boundaries. If as a society we want to use medical cannabis efficiently and safely in all parts of the country, we need clear and consistent guidelines for physicians, decision-makers and patients. Guidelines can only be developed when there is a sufficient body of good-quality and focused research to analyze. The Michael G. DeGroote Centre for Medicinal Cannabis Research is dedicated to advancing this field of research and ensuring rapid and accurate dissemination of information as it emerges.