Prescribing marijuana for chronic pain

In this month’s issue we learn that marijuana, when smoked, is of questionable efficacy for managing chronic noncancer pain (CNCP). Deshpande et al reach this conclusion in a systematic review of randomized controlled trials, with the goal of evaluating the efficacy and safety of this substance in the treatment of CNCP (page e372).¹ Their conclusions are unequivocal: generalizing the use of medical marijuana to all CNCP conditions is not supported. The studies available were limited by short duration, variability in dosing and strength of tetrahydrocannabinol, and lack of functional outcomes.

These results do not come as a surprise. Indeed, this study has simply confirmed what most of us thought: that marijuana is not effective for the treatment of pain and that the beliefs of proponents are based more on myth than reality. If this substance were even somewhat effective, Health Canada would have recognized this long ago; pharmaceutical companies would have sniffed out a good business opportunity and brought it to market; and we would be prescribing tetrahydrocannabinol to our patients who are suffering. This study echoes the findings of other reviews that either question the efficacy of this substance or document its adverse effects.^2–4 What is surprising about this systematic review is the lack of data. According to these authors, we have 6 small studies of questionable quality with only 226 patients. That’s it? That’s the full extent of our scientific knowledge of this controversial substance?

Despite this and despite it being a controlled substance, marijuana continues to be used. Many patients experience chronic pain from multiple sclerosis, phantom limbs, various neuropathies, fibromyalgia, and other chronic conditions and use marijuana to relieve their pain. A 2003 survey sent to 209 patients in a pain management unit revealed that 35% had used cannabis to relieve their pain.⁵ In 2011, the Canadian Alcohol and Drug Use Monitoring Survey⁶ reported that approximately 420 000 Canadians aged 15 years and older had used cannabis for medical reasons, half of them for chronic pain. How can a substance purported to have so little efficacy also be so widely used? Is it solely a placebo effect? Or could the substance be producing a benefit that is not being measured?

When the issue of the use of marijuana for therapeutic purposes arises, there are 2 camps. On one side, evidence and regulations state that marijuana is ineffective and might even be harmful. On the other side, patients go ahead and buy what they need. When it comes to marijuana, it is as if we were back in the days of Prohibition: the more Science and Society endeavour to control marijuana, the more the public resists.

So, why don’t physicians prescribe marijuana for therapeutic purposes? Doing so would reconcile the interests of both sides and provide some measure of control over the use of marijuana, while allowing those who want to use it to do so.

Some will say that we should not get involved because marijuana is ineffective. Yet, are the other medications that we prescribe for chronic pain more effective? If this were true, would chronic pain still be an issue? I am not so sure that the substances we prescribe have fewer personal and societal side effects. Marijuana would not be the first product prescribed with the goal, basically, of minimizing personal and societal consequences. Is that not what we do when we prescribe methadone?

If physicians got involved, we could avoid a situation in which patients who say that pot offers them relief are forced to get it wherever and however they can. At present, there is no control over patient consumption and we have no knowledge of the composition, strength, quality, or potential side effects of its use or the associated drug interactions. If we prescribed marijuana for our patients, we could help to eradicate the black market and drug dealers—a market that is almost certainly controlled by the mafia. It would decriminalize consumption and production. At the present time, even with this knowledge, physicians are content to look the other way and let their patients smoke a joint wherever and whenever they can.

Maybe it is time for this to change and for physicians to prescribe marijuana to those who say it alleviates their suffering.

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