Authored by Kitty Victoria*
Introduction
With greater decriminalization of cannabis, attitudes of the general public, patients and healthcare providers are changing. Along with attitudes changing, more research is emerging demonstrating the potential therapeutic value of cannabis. The potential of cannabis as an adjunctive medication for chronic pain or potentially as an opioid replacement is now of special interest in light of the opioid epidemic. A Pew Research Center study reported that the majority (62%) of Americans now support legalization of marijuana, this represents a more than doubling of the percentage of Americans supporting cannabis legalization over the last twenty years [1].
Vermont law
In 2004 Vermont became the 9th state to approve medical cannabis (MC) for persons with severe illness. Subsequently, in 2011, Vermont enacted legislation allowing dispensaries to provide MC to patients. Qualification for MC use varies by state, but generally requires an application with verification of a qualifying condition by a certified medical professional. In Vermont, a healthcare professional must verify that the patient has a qualifying condition and has a “bone fide healthcare professional-patient relationship.” Bone fide relationship is defined as greater than three months (except in the case of a terminal disease). Qualifying conditions in Vermont include cancer, multiple sclerosis, HIV, AIDS, Crohn’s disease, Parkinson’s disease, glaucoma, PTSD (which requires a Mental Health Care Provider Form), and chronic medical conditions that are debilitating, and produce one or more of the following intractable symptoms: cachexia or wasting syndrome, chronic pain, severe nausea, or seizures [2]. Recent years have seen an exponential increase in the number of patients belonging to the medical marijuana registry. On July 1, 2018, recreational marijuana became legal in Vermont. Adults 21 and older can possess up to one ounce of cannabis or two mature plants. Vermont has yet to establish any regulatory framework for retail sales.
The rise of cannabidiol (CBD)
In September 2018, we saw the first rescheduling of whole plant derived CBD, Epidiolex® by the FDA for refractory pediatric seizure disorder, classified as schedule V4. The reclassification of CBD to Schedule V only applies to Epidiolex®; CBD from other sources remains schedule I [4]. This is an unusual situation as schedule I is defined as “substances, or chemicals defined by the federal government as drugs with no currently accepted medical use and a high potential for abuse.” The disconnect exists in that the CBD and Epidiolex® share similar chemical composition and biological activity, however Epidiolex® is labeled as schedule V while the CBD remains schedule I. Despite confusing legal implications, demand for CBD from patients for a variety of indications including insomnia, anxiety, pain, neuropathy, headaches, spasm and seizures continues to rise.
Lack of Research and Education: Lack of research prevents gathering evidence, therefore evidence based medical education cannot progress. This leads to reliance on resources that have little reliability which hampers the discussion between health professionals and patients in regard to treatment recommendations. An article in the Clinical Journal of Oncology reported that while 80% of oncologists have discussed MC with their patients, only 29.4% of surveyed physicians feel knowledgeable enough to recommend medical marijuana to patients, and among those that have recommended medicinal cannabis 56.4% did not feel informed enough to do so comfortably [5]. Studies have shown that greater than 80% of physicians believe education on MC should be incorporated into medical education and that further research is needed [6-8]. Healthcare providers remain somewhat handicapped by the paucity of clinical research in MC with which to guide their patients. Federal Schedule 1 status poses a barrier to research for both MC and CBD as it requires a lengthy process of DEA licensing and site visits.
We report on the results of an online survey of physicians and nurse practitioners/advanced practitioners (NP/AP) as well as a paper survey of oncology patients in Vermont conducted from April to June of 2018. Information regarding attitudes, formal education, perceived uses, benefits and disadvantages of MC was collected.
Methods
This study was reviewed and approved by the University of Vermont (UVM) Institutional Review Board.
Instrument
For the physicians and AP/RN survey we utilized a 15-item questionnaire which was based on questions used in other similar studies, expert opinion from a panel of MC educators, oncologists at UVM, and patient advocates. Two versions of the survey were designed with slight modifications for physicians and advanced practitioners. The first section focused on characteristics of the responders and the second section asked general questions about MC and CBD (Figure 1).
We designed an 11-item patient survey asking questions pertaining to use of MC, types of MC used, indications, frequency of use, whether they are enrolled in the registry, source of information, and if they have discussed MC with their doctor. The items were based on questions asked in similar studies and feedback from oncologists, patient advocates, and nursing staff (Figure 2).
Study Participants and Data collection
Participants for the email survey were residents, fellows, physicians and AP/RN in Vermont. For the paper survey, participants were oncology patients at the UVM outpatient clinic. Surveys were left in an optional patient survey area next to registration.
Recruitment
Recruitment for the email survey was done via university email lists and the Vermont Medical Society membership email list. We also had a link and small description published in a university online journal.
Recruitment for the paper survey was done during registration of patients at the university oncology clinic.
Analysis
The chi-square test was used for most group comparisons. Fivepoint scales were collapsed into three for the analysis. Several of the health conditions had very low endorsement rates, therefore we collapsed endorsements across all products (medical cannabis, THC, CBD, THC/CBD) and used Fisher’s exact test. The software used for the analyses was SAS v9.4 (SAS Institute Inc., Cary, NC).
Results
Physicians and APs:
141 physicians and 60 advanced practitioners filled out the email survey. As in Figure 1A, the population of physicians had more females than males, median time in practice was 5 years, the majority was from internal medicine and family medicine. The AP and nurse group was almost half NP and half AP from a wide range of specialties. Median time in practice was 10 years (Figure 3).
From the physician group, 90% had been asked about marijuana and 96% had been asked about CBD from a patient or family member. In the AP/NP group, 96% had been asked about both marijuana and CBD. For the question “do you believe that MC has important health benefits”, we utilized a Likert scale with 5 choices (strongly disagree to strongly agree). Five percent of the physicians fell into the disagree, over 50% in the strongly agree and agree, and the remainder were neutral. In the AP/PA group, 75% fell in the strongly agree or agree categories, none chose disagree (Figure 4).
We took the physician group and sectioned it into “have” and “have not” had education in MC. Attitudes towards MC were highly correlated with health professionals having had formal education (Figure 5). 75% of physicians and 68% of AP/RN had no formal education in MC. Physicians who had formal education were much more likely (p= 0.0073) to think that MC had health benefits than those without (87% vs 55%). Regarding the follow up question, which asked participants to identify which products they felt had important health benefits, those with education chose CBD and high CBD/low THC products as having the most health benefits more frequently than those without teaching (p < 0.001). Residents and fellows were less likely to recommend MC than faculty physicians (57% vs 37%, p = 0.0004).
Physicians were asked for which indications they would recommended a cannabis product. Sixty-nine percent of physicians with education in MC selected chronic pain vs 23% of those without education. Additionally, 48% with education chose nausea, appetite and musculoskeletal pain vs 19%, 24% and 15% respectively. MC was chosen by both groups as the top recommended product rather than THC, CBD, or THC-CBD, but overall, 58% chose “I do not recommend any specific product.”
Lack of education stood out as the greatest barrier to recommending MC followed by were legal implications, safety concerns, and side effects. Eighty-five percent of physicians surveyed and 87% of APs surveyed agreed that education on MC should be formally incorporated into medical education (Figure 6).
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