Cannabis is the new kid on the block.
Drug companies like Tilray are boasting about new treatments with cannabis. Patients around Europe view it as a miracle drug curing ailments from depression to oncological pain.
But for many doctors, cannabis has work to do if it wants to be taken seriously.
“There are those promoting this as the God-given [substance] that will solve all the problems in the world,” said Paola Cubillos, a Colombian-Canadian doctor who studies and consults on medical cannabis.
It has potential, she said, but current evidence doesnt back the hype.
The lack of evidence on medical cannabis effectiveness causes a dilemma for governments looking to make the substance available for medical purposes.
This makes countries such as France cautious. Its National Assembly just approved a medical cannabis experiment, set to run for two years, that would make cannabis available to roughly 3,000 patients with certain types of epilepsy and multiple sclerosis. This plan was adopted against the backdrop of a long-standing, hard-line approach against medical cannabis in the country, which is also shared across most of the EU.
The lack of evidence on medical cannabis effectiveness — especially in the face of patients increasingly assertive pushes for access — causes a dilemma for governments looking to make the substance available for medical purposes.
The U.K., for example, made medical cannabis legal last year to great fanfare, but strict guidelines say doctors should prescribe cannabis-based medicines only when all other treatments have failed. Portugal, meanwhile, has embraced the cultivation of medical cannabis but makes only one kind of cannabis-based medicine available.
In July, the European Medicines Agency gave the green light to only one cannabis-based medicine, GW Pharmas Epidiolex, for two kinds of seizures. However, the U.K.s National Institute for Health and Care Excellence (NICE) said just a month later that it cannot be reimbursed because it lacks enough clinical trial evidence.
Cannabis sativa plants grown at a farm in Mérindol, southern France. France has adopted a cautious approach towards medical cannabis | Gerard Julien/AFP via Getty Images
A wait-and-see approach, like France is considering, is much smarter than a “free for all” approach that Canada is trying, according to Cubillos. In Canada, “a clinician whos comfortable prescribing cannabis can basically prescribe it for anything and everything under the sun,” she said.
Sally Davies, the U.K.s former chief medical officer, has also called for more data, including information gathered from randomized trials. “Without these, how can we help the patients?” she asked during an address last spring.
But medical cannabis proponents, like Tilrays cannabis expert Philippe Lucas, say theres enough evidence that medical cannabis is safe and effective — and that patient testimonies should not be overlooked.
The science is just getting started, said Lucas, and its “trying to catch up with what patients have told us for all of these years.”
Looking for evidence
The word doctors often use when discussing medical cannabis is “placebo.”
Judith Paice, the director of Northwestern Universitys Cancer Pain Program, described one patient who was using topical treatment featuring cannabidiol (CBD), a non-psychoactive chemical component found in marijuana. He swore by its effectiveness. Paice asked him to bring it in.
When she looked at the product, it did indeed contain CBD, but it also was 5 percent menthol, causing an icy-hot feeling. That may have provided some of the relief, she thought.
For Paice, the issue is that doctors dont even know where in the body the product is going, or whether its even absorbed when placed on the skin.
Until theres more information, say doctors, countries should be cautious about the way they roll out medical cannabis programs.
Clinical trials, specifically randomized control trials, could provide clarity on health effects, but there are too few. One reason is that the wave of medical cannabis legalization around the world is a very recent trend; in the U.S., one of the countries now leading medical cannabis research, it was legalized in the majority of states only three years ago. Its still a prohibited substance at the federal level.
Until theres more information, say doctors, countries should be cautious about the way they roll out medical cannabis programs — and how medical cannabis is prescribed.
Doctors are still willing to accept forms of medical cannabis as a last line of treatment, namely for patients whove tried and failed to find relief from traditional medicines treating rare or serious issues like cancer pain or spasticity caused by multiple sclerosis.
The challenge is that patients want it to be used for other purposes, too. In a 2019 survey, Tilray asked more than 2,000 Canadians taking medical cannabis what symptoms they were using it for. The most common was chronic pain, followed by insomnia, stress and depression.
And many patients are adamant it works. One patient with chronic pain told POLITICO last year that the substance “saved my life.”
The long and winding clinical trial road
Doctors want clinical trials, but know that data gathering takes time — and money.
“Nothing will teach you patience like being involve in a clinical trials,” Lucas said.
For some cannabis companies, the easier route is to make CBD oil, sell it as a supplement and make big money — without having to go through the rigors of a trial.
Winfried Häuser, professor of psychosomatic medicine at the Technical University of Munich and consultant at Saarbrücken Hospital in Germany, notes that what he and other doctors often see are systematic reviews on medical cannabis, that is, meta studies of existing studies.
This research typically compiles a wide range of studies that yield different results, depending on what studies the authors chose to review. As an example, Häuser showed four different studies in four years examining medical cannabis effect on chronic neuropathic pain. They all had varying conclusions.
This week, the UKs Royal College of Psychiatrists will back a two-year study of 20,000 patients on medical cannabis — the largest study of its kind in Europe | Guillem Sartorio/AFP via Getty Images
In the shoddier studies, he said, researchers are “possibly overestimating the positive effects of cannabis-based medicines.”
Lucas also wants more and better studies. But as he sees it, medical cannabis companies cant be left alone in this — they need governments to also invest in the research. One reason is that industry-funded studies arent always trusted.
Another is that theres a lot to test. The increasing evidence coming out over the past 10 to 15 years is “just the tip of the iceberg,” he said.
There are signs that governments are getting more involved. This week, the U.K.s Royal College of Psychiatrists will back a two-year study of 20,000 patients on medical cannabis — the largest study of its kind in Europe,