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Published On June 17, 2019

POLICY

Higher Education

Medical marijuana has swept the country, but physicians aren’t trained how to use it.

The use of cannabis as a therapeutic drug is now legal in 33 states and the District of Columbia. Yet patients who ask physicians whether marijuana can help them are often met with anything but an informed response. For their part, physicians complain about a lack of information about what medical cannabis can do and what role they are supposed to be playing.

While laws have been changing, medical school curricula have not. In a 2017 study published in Drug and Alcohol Dependence, researchers at Washington University School of Medicine in St. Louis found that only 9% of U.S. medical schools included medical marijuana in the curriculum. And 85% of the 258 residents and fellows surveyed said they had not received any education about therapeutic cannabis at medical schools or in residency programs.

“In medical school, we learn about marijuana as an illicit drug, similar to how we learn about other illicit drugs like heroin and cocaine,” says Anastasia Evanoff, first author of the 2017 study and a fourth-year medical student at Washington University School of Medicine. “We’re taught the pharmacokinetics of marijuana in the body. But we never learn how to prescribe it.”

Part of the problem is that physicians aren’t technically allowed to prescribe cannabis, which the U.S. Drug Enforcement Administration still considers an illegal drug. They can simply “recommend” it if a patient has a health condition on the state’s approved list. But without a prescribing system, such recommendations can be ignored, and physicians have no say in what their patients receive at official dispensaries.

“It’s medical malpractice to have 20-something-year-old ‘budtenders’—employees of the dispensaries—making decisions about strains and doses of medical cannabis,” says internist and emergency physician Jordan Tishler, president of the Association of Cannabis Specialists. “We have to change this to the real practice of medicine before medical schools or residency programs will consider making medical cannabis part of medical education.”

Rigor is lacking in other areas, too. Clinical trials have demonstrated that cannabis can alleviate nausea and vomiting from cancer chemotherapy; provide relief from chronic pain and from pain related to cancer, neuropathy and multiple sclerosis; and may help treat epilepsy, glaucoma, post-traumatic stress disorder and Crohn’s disease. But because cannabis is a Schedule I drug—hence illegal—additional trials that could substantiate these and other medicinal claims are notoriously challenging to conduct. While state legislatures have been persuaded to make medical marijuana available, medical schools have so far been reluctant to add this field of study to an already overloaded curriculum.

“Medical schools teach the solid fundamentals of medicine, and we’re impeded in our knowledge of medical marijuana because of the regulatory issues surrounding it,” says Laura Jean Bierut, professor of psychiatry at Washington University School of Medicine. She is the former member of the National Advisory Council on Drug Abuse and co-researcher—with daughter Anastasia Evanoff—on the doctors-in-training and medical marijuana study.

The Association of American Medical Colleges agrees: “U.S. medical education is grounded in evidence-based science. The academic medicine community eagerly awaits the results of research studies currently underway that are examining the efficacy and safety of medicinal cannabis,” writes Alison Whelan, chief medical education officer of AAMC, in a statement for Proto.

Pharmacists, on the other hand, seem more willing to embrace the reality of medical marijuana. Sixty-two percent of U.S. pharmacy schools have already added medical cannabis to the curriculum—and 23% of schools planned to make it part of the curriculum within the year, according to new research from the University of Pittsburgh School of Pharmacy. “Student pharmacists must be prepared to care for patients using marijuana either alone or in combination with prescribed medications, over-the-counter products, and supplements,” write the researchers.

The opioid crisis may offer a more pressing reason to study the applications of medical cannabis. Research has suggested that patients may switch to cannabis as an alternative to opioids for chronic pain. One study found that daily doses of prescribed opioids declined by 14.4% per year in Medicare recipients when medical marijuana dispensaries opened. And a new study of patients with an average age of 81 found that nearly one-third reduced their opioid medications after using medical cannabis and experiencing relief from pain, sleep problems, neuropathy and anxiety. Last year, two Harvard medical students published an essay in STAT, a health-oriented news website, calling for medical schools to teach medical marijuana as a “public health imperative” to help with the opioid crisis.

When the shift does come, says Laura Bierut, it is likely to come from doctors in training, who will push to put more information about medical cannabis on the curricula. “All physicians should get training on medical marijuana,” she says, “but just as often happens with other innovations and new technology, young physicians will likely take the lead in teaching older physicians.”