In her capacity as a palliative care physician at Montreal’s Jewish General Hospital, Dr. Marcia Gillman has seen firsthand the positive impact medicinal cannabis can have on terminally ill patients. A founding director of Quebec’s first cannabis clinic, Dr. Gillman believes cannabis can serve as an adjunct to traditional treatment options, while helping to lower the number of medications being prescribed by physicians. We reached Dr. Gillman by phone to discuss the challenge cannabis faces in a society still reeling from the prescription pill epidemic, the timely need for doctor education, and the role medicinal cannabis can play in treating terminally ill patients.
Generally speaking, how can medicinal cannabis help improve the plight of palliative care patients?
Palliative care patients have a number of symptoms that may be amenable to cannabis, such as pain, nausea, anxiety, sleep issues and poor appetite. I see cannabis as another tool in the toolbox in aiming to improve quality of life. These patients tend to be on a whole packet of medications to control their symptoms as well as other medications to combat the side effects of the medications they’re on. Sometimes cannabis, when effective, will allow us to reduce the number of other medications that patients need to take and, in so doing, limit side effects.
You once remarked, “I could write [patients] a prescription for five different medications to manage their symptoms, all of which have potential toxicities and adverse effects.” In what ways can cannabis serve as a sensible solution to the prescription pill epidemic?
A study published this year found that in the 17 U.S. states where medical cannabis is legal, prescriptions for painkillers and other classes of drugs fell significantly. The average doctor in a medical cannabis state prescribed 1,826 fewer doses of painkillers per year as well as significantly fewer doses of anti-anxiety meds, anti-depressants and sleeping pills. Our traditional pharmaceutical approach in Western medicine has tended to follow what I call the “one-pill, one-ill” model, in the sense that we give one pill to treat one symptom, and another pill to control another symptom. Cannabis doesn’t fit that model because patients seem to find that it works for so many symptoms and conditions. So perhaps it makes sense that we’re seeing a shift in prescribing patterns in states with medical cannabis laws, and I’ve certainly seen this trend in my own practice.
Is there irony in the fact physicians seem reticent to prescribe medicinal cannabis in a society still recovering from the OxyContin fiasco?
It certainly seems that many doctors have fewer objections and less reluctance in prescribing opioids than they do with respect to cannabis. Many physicians often tend to underestimate the danger of opioids while overestimating the danger of cannabis. There are over 16,000 deaths in the U.S. every year from prescription painkillers and no deaths from cannabis. And yet we still have trouble convincing doctors to at least consider cannabis as an option for chronic pain, despite the evidence that cannabis appears to have some efficacy in certain chronic pain conditions.
As you’ve point out, a common misconception about medicinal cannabis is that it’s dangerous. In what ways can the healthcare community lend to public education on the topic?
First and foremost, doctors need to be educated about cannabis. I don’t think doctors can educate anyone else until they educate themselves. I think it’s important for the medical community to appreciate that cannabis is not fatal in overdose, its side effects are acceptable and adverse effects are well described. Cannabis certainly appears, when used in therapeutic doses for medical purposes, to have a better safety profile than most of the traditional medications that we’re using for symptom management.
In your educational presentations to doctors and other healthcare practitioners, what questions are you most often being asked?
Doctors often express concerns about safety. They also want to know what the evidence base is for medical cannabis, and they want to get some idea of dosing guidelines in terms of how and what to prescribe. It’s still not always clear to many doctors that any physician can authorize cannabis; many still think you need a special license. I really have to emphasize in my presentations that any doctor in Canada can authorize medical cannabis.
You’ve also participated on panels at events like the Lift Expo and ReThink Breast Cancer. How does the line of questioning from the public differ from queries you field from physicians?
What I repeatedly hear people asking in these kinds of forums is how to access medical cannabis legally when their own doctors are refusing to prescribe. The lay audience also tends to be much less skeptical about cannabis compared to an audience of physicians, and much more willing to embrace its possibilities.
“The solution to misunderstanding is education, not policy.” Can we apply this adage to the cannabis conversation?
Absolutely. When the MMPR came out in 2014, it was a policy that aimed to make cannabis more accessible to patients, but it didn’t really work out that way. Why? Because I think you can’t, by policy alone, force doctors to authorize cannabis. Many doctors are still refusing to authorize. Again, why is that? I think it’s because they don’t have a good understanding of cannabinoid science, of the endocannabinoid system, of the knowledge and evidence base that we’ve acquired with respect to cannabis. We need more education about the science of cannabis in medical school curriculums, as well as continuing medical education for practicing doctors. In the long run, hopefully education will create change and will accomplish what policy alone cannot do.