By Kevin Morley, DAT, ATC
While adult-use cannabis remains prohibited in Florida, similar regulations are changing throughout the country on a regular basis. Although the Florida Marijuana Use and Growth Legalization Initiative continues to be left off of the ballot as an initiated constitutional amendment this coming November, the push by Florida residents for legalization persists. Until adult-use legalization, Floridians who meet medical criteria for use will continue to rely on access to cannabis by use of a Medical Marijuana Card allowing purchase at an approved dispensary. Apart from the medical provider who approves the Card, who is guiding these purchases? In truth, many customers don’t need much guidance. They have personal, first-hand knowledge about what works for them, so once they have their Card in hand, their treatment can begin. But what about first-time Cardholders? Or those who qualify for a Card, but don’t know that cannabis could benefit them? Other than word-of-mouth, anecdotal evidence, where are potential customers getting their cannabis-related advice? The need for education in the physician and non-physician medical provider communities is gargantuan. Let’s take a look at a few areas where medical providers can elevate their knowledge surrounding cannabis, cannabinoids, and the endocannabinoid system. Keep in mind they don’t need to be cannabis experts, but some basic insight into the endocannabinoid system, its effects on homeostasis and basic physiological functions will help elevate their awareness of these products. That, coupled with knowledge of the best resources in their area, as well as on-line will give them enough information to make educated recommendations.
Who’s advising who?
In order for us to consider how medical providers are advising potential cannabis customers/patients, let’s peel back a few layers of the health care delivery system onion to find out who is who. It’s not only physicians who advise on cannabis use. With the figurative weaving of hemp products into the fabric of our society thanks to the 2018 Farm Bill, a major barrier to entry has been eliminated. Consumers know what CBD is … or they think they do. And since they heard their co-worker, partner, teammate, teacher, or family member gush about how a hemp product helped ameliorate their pain, inflammation, disordered sleep, anxiety … they are curious now too. But they may not make an appointment with a Card-providing physician just yet. They see a chiropractor weekly, so maybe they’ll ask that person. The chiropractor is part of a wellness center. There are nurses, athletic trainers, physical therapists, mental health counselors there too. Those professionals work with patients every day. Perhaps they have some knowledge about how CBD can help. And since medical marijuana is legal in Florida, maybe there’s an ongoing pathology that qualifies for a Card. Do they know about cannabis too?
There’s not enough evidence
Talk to some of the medical professionals mentioned above, the ones from the wellness center, and ask them about cannabis use to treat post-operative pain after a total shoulder replacement. Or to treat insomnia secondary to anxiety about a missed promotion at work. Many of them will explain that there’s not enough research to support cannabis use in those situations, and while they’ve heard that it helps too, they wouldn’t feel comfortable endorsing it or counseling someone to see a Card-approving physician. The reality of this very real-life scenario is that it happens all the time. Medical providers don’t know what they don’t know. They weren’t taught about the endocannabinoid system in school. CB1 and CB2 receptors weren’t on their radar. But that doesn’t mean that the ECS, CB1 and CB2 aren’t here to stay. What is true is that peer-reviewed studies in high-level journals absolutely do exist … but not in the most mainstream journals medical providers are reading. As such, the research isn’t familiar to them. There’s a chasm here that needs to be spanned for healthcare providers (HCPs) to be able to fairly, and ethically provide current and accurate information to the patients, clients, and athletes seeking their care and counsel.
I’m not an HCP, can I help fix this problem?
This isn’t a quick fix, but YES, you absolutely can. Perhaps you’re a dispensary owner or employee. Maybe you’re a cannabis advocate by profession. Or maybe you’re a current or former cannabis user who wants to shout from the rooftops that cannabis use helped your post-operative pain and allowed you to skip the opioids completely. HCPs, as a group, want to help people. They want to do it safely and within the confines of their scope of practice and ethical standards. The Card-approving physicians are already on board. They understand the ECS, CB1 and CB2, and the landscape of cannabis and hemp products. They’re not your target audience. The “there’s not enough research” folks are your audience. You’re going to need to put together a cannabis dossier of sorts. It needs to be “medical enough” that it has high-level information that they can use. We’re talking studies. I mean real studies. Like double-blind, placebo-controlled studies. Maybe a meta-analysis. Most of the best cannabis-related research is happening external to the United States. That’s ok. This is a global issue not limited to domestic patients and providers. Skip the case reports. They’re interesting, but that’s one of the lowest levels of research. Lastly, consider the specific person you’re addressing. Are they an athletic trainer or physical therapist working in an out-patient orthopedic surgery practice? If so, they’ll really respond to the studies comparing post-operative outcomes and pain measures using CBD v a CBD and THC combo v a traditional opioid. But if you’re addressing a physician assistant or nurse practitioner working in a VA hospital with PTSD patients, you can skip the post-op knee pain articles and focus on those addressing mental health and wellness, anxiety-related insomnia, and emotional trauma. It’s all out there, you just have to look. What’s that adage about leading a horse to water?
Will anything else help? Or is it just studies and research papers?
Tread lightly here because if you trend toward magazines and articles on websites written by non-scientific outlets, you may lose some traction and a whole lot of credibility. In today’s content-rich environment, no, you don’t have to limit your dossier to articles and journals. But you better vet everything you choose to provide. There are some incredible lectures available on TED Talks and YouTube. There are some very informative documentaries on Netflix, Hulu, and other streaming services. Repetition matters. If the NP from the VA center or the athletic trainer from the orthopedic surgery office gets this content in front of them, and they take the time to digest it, the repetitive explanation of the ECS, how it affects homeostasis, the explanation of terpenes and flavonoids, the clarification of isolate v broad-spectrum v full spectrum products will start to make sense. You’ll plant a (cannabis) seed, and you’ll give it time to bloom (flower?).
Where do I start?
That’s the best part, you can start wherever you want. It’s all about baby steps. If you have access to HCPs in the sports medicine or orthopedics space, start your “Cannabis in Sports Medicine” dossier. If your neighbor is a clinical psychologist and has welcomed you into their social circle, then maybe your “Cannabis Use in Mental Health Care” dossier is a better first step. Once you’ve gained entry into the medical community, you’re off to the races. Acknowledging that the spectrum of HCPs is broad, and their collective influence is nearly infinite will open your eyes to a large swathe of potential cannabis educators and enthusiasts who can be your biggest cheerleaders in the current paradigm of medical cannabis use, and in future expansion to adult-use.
Dr. Kevin Morley is the head athletic trainer for the Nashville Predators of the National Hockey League and a researcher in the Global Initiative for Cannabinoid Research and Education at Florida International University. To learn more about FIU’s cannabinoid research and education initiative you can visit their website at https://go.fiu.edu/GlobalCannabis.
Views represented in this column do not reflect that of the Nashville Predators, the National Hockey League, or Florida International University and are solely attributed to Dr. Kevin Morley.