What’s a rheumatologist to do in the absence of clinical guidelines for cannabis?

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Rheumatology patients seeking natural alternatives for pain relief are increasingly turning to cannabis. According to a survey by the Canadian Rheumatology Associations, 80 percent of rheumatologists in Canada field questions from patients every week about the use of cannabis to treat symptoms ranging from pain relief to mood disorders.

But this puts rheumatologists in a quandary, say authors of a position statement on cannabis use in rheumatology patients. The statement, which was authored by four Canadian physicians and the Canadian Rheumatology Association, was published in the January 15 issue of the Journal of Rheumatology. Three-fourths of Canadian rheumatologists don’t know enough about medical cannabis to effectively advise patients, the authors wrote.

After all, there have been few clinical trials and there is no definitive clinical evidence to guide physicians on how best to prescribe medical cannabis for rheumatology patients. Moreover, there is no one size fits all approach in treating patients with rheumatic conditions. A treatment that performs well for one condition, may not transcend well for another.

With medical cannabis approved in Canada and in some states in the United States, physicians must be prepared to address cannabis use questions with patients, wrote authors who were led by Mary-Ann Fitzcharles, M.D.

“Despite lack of evidence for use of medical cannabis in rheumatology patients, we acknowledge the need to provide empathetic and pragmatic guidance for patient care. This position statement aims to facilitate the dialogue between patients and healthcare professionals in a mutually respectful manner to ensure harm reduction for patients and society,” they wrote.

The position statement is in line with guidelines issued in February 2018 by the College of Family Physicians in Canada. The guidelines addressed the use of medical cannabis to treat a number of conditions, including rheumatic pain. The group recommended against its use for rheumatic pain citing a high risk of short-term adverse events such as psychomotor effects, dizziness, appetite changes, mood changes, and rare serious side effects such as disorientation and psychosis.

“We recommend against use of medical cannabinoids for pain associated with rheumatologic conditions (including osteoarthritis and back pain) owing to lack of evidence and known harms (strong recommendation),” they wrote.

For more information on the position statement, see:  “Precautions for Medical Cannabis in Rheumatology”

Rheumatology patients face unique challenges, the Canadian Rheumatology Association wrote. They may be seeking cannabis as an alternative treatment for pain relief, sleep difficulties or mood disorders. Or, perhaps because their current treatments are ineffective or because they view cannabis as a natural safer treatment. Or, perhaps because family and friends are recommending cannabis.

“Patients should be informed that medical cannabis is not an alternative to standard care for any rheumatic disease and that evidence for the effect in rheumatic diseases is lacking,” Fitzcharles et al. wrote.

The position statement is designed to provide some guidance for Canadian rheumatologists on how best to address medical cannabis issues with patients. It is for patients considering self-medicating or those seeking a medical cannabis prescription, but it does not apply to pharmaceutical cannabinoid.

“In accordance with the lack of evidence for the effect of medical cannabis in rheumatic diseases, the simplistic response, as endorsed by others, is to recommend against use pending more evidence. The reality is that patients are requesting information, may be considering use, or may be currently self-medicating. Physicians may also have personal biases regarding medical cannabis, either positive or negative. Further, the Canadian legalization of recreational cannabis
allows freer access to cannabis by patients. Rheumatologists therefore have an obligation to provide competent advice,” Fitzcharles et al. wrote.

Still, the association recognizes that patients may seek alternative sources for cannabis, such as a dispensary. “A prescription should only be provided by a physician who is fully knowledgeable of the patient and is responsible for patient care. Cannabis should not be prescribed following online consultation or by those who project themselves as ‘cannabis experts’ focusing only on prescription of cannabis without attention to global patient care,” they said.

REFERENCE

Fitzcharles MA, Zahedi NO, Hauser W, Hazelwood G, the Canadian Rheumatology Association. “Position Statement: A Pragmatic Approach for Medical Cannabis and Patients with Rheumatic Diseases.” Journal of Rheumatology (2019), DOI: 10.3899/rheum.181120.