Mary-Ann Fitzcharles, MB, ChB, MRCP, on Medical Cannabis For Rheumatic Diseases
Individuals with a rheumatic disease often experience pain related to their condition. Medical cannabis has become increasingly perceived as a safe and viable alternative treatment option for many conditions, including some rheumatic diseases such as rheumatoid arthritis (RA).
Although cannabis remains illegal at the federal level in the United States, many states have legalized its use for medical purposes.
Through the Cannabis Act (Bill C-45), cannabis use was legalized for both recreational and medicinal purposes in Canada in 2018, which has increased access to cannabis. The Canadian Rheumatology Association created a position statement for physicians to provide patients with evidence-based information regarding the effects and harms of medical cannabis.
Rheumatology Consultant caught up with Mary-Ann Fitzcharles, MB, ChB, MRCP, an associate professor of medicine in the Division of Rheumatology at McGill University Health Centre in Montreal, Canada, about the position statement on medical cannabis as a therapeutic option for individuals with rheumatic diseases.
Rheumatology Consultant: What prompted the need for a position statement?
MF: There is increasing interest in the use of medical cannabis by patients with rheumatic diseases; patients are requesting information, and physicians generally feel insecure regarding their competence to effectively advise patients. The position statement declares that medical cannabis may have an effect on symptoms of rheumatic diseases for some patients, although it definitively states that the evidence for the effect is lacking. In addition, there may be immediate and long-term risks associated with cannabis use, which are largely unknown for the patient population. In the context of the “real world,” we encourage rheumatologists to have open and nonjudgmental discussions with their patients in order to inform them of our current understanding of medical cannabis.
RHEUM CON: Why is the relationship between medical cannabis and rheumatic diseases important for rheumatologists and patients to understand?
MF: There is a large amount of preclinical study which points to attenuation of both pain and inflammation—both features that are applicable to individuals with rheumatic diseases. Current medications are often ineffective for managing pain and are associated with considerable adverse effects. We know that the endocannabinoid system—a modulatory system with roles in the functioning of brain, endocrine, and immune tissues—is upregulated in inflammatory disease such as RA. Therefore, this system has pertinence to an array of rheumatic diseases. Physicians must abide by the principles of evidence-based medicine and “do no harm.” They must look to the scientific literature for answers that will be emerging and not fall into the trap of been beguiled by public opinion and the media.
RHEUM CON: How can a rheumatologist approach the discussion of medical cannabis with a patient?
MF: At this time in Canada, most discussions are initiated by patients. The rheumatologist must remain empathetic and foster a good therapeutic alliance. It is also paramount that clinical care of the rheumatic patient remains the responsibility of the rheumatologist and that patients are not diverted to the care of so-called cannabis experts, with risk of repeating the tragedy of the opioid mills over the past few decades.
RHEUM CON: Is medical cannabis used often in Canada to treat symptoms related to rheumatic diseases?
MF: Patients with rheumatic diseases have easier access to the product since the legalization of recreational cannabis in Canada. This also increases cannabis use. Current statistics show that on average 15% of Canadians aged 15 years or older had consumed cannabis in the last quarter of 2018. Many patients are experimenting with cannabis use for treatment of their symptoms related to rheumatic diseases.
RHEUM CON: Do you think more clinical trials of medical cannabis will be conducted among individuals with rheumatic diseases in the near future?
MF: Clinical trials are necessary to support any substantial recommendation for use of a product as a therapy. We acknowledge the challenges in moving forward with traditional randomized clinical trials for the evaluation of cannabis products. We may need to rethink our method of examining cannabis in rheumatic diseases. This could take the form of longitudinal cohort studies.
Reference:
Fitzcharles M-A, Niaki OZ, Hauser W, Hazlewood G; Canadian Rheumatology Association. Position statement: a pragmatic approach for medical cannabis and patients with rheumatic diseases. J Rheumatol. 2019;46(5):532-538. http://www.jrheum.org/content/early/2019/01/11/jrheum.181120