Cannabis specialist Dr Peter Grinspoon explores education and policy in US addiction treatment.
Dr Peter Grinspoon is a primary care physician, an instructor at Harvard Medical School, and a contributing editor to Harvard Health Publications. In his capacity as a specialist authority on addiction and medical cannabis, he has served as an expert witness, medical and scientific advisor, and consultant; he is currently a board member of the international non-profit Doctors for Cannabis Regulation.
MCN Quarterly speaks with Dr Grinspoon about the opioid crisis, the need for broader cannabis education, and the potential of November’s presidential election to transform cannabis policy.
Could wider distribution of medical cannabis in the treatment of chronic illness and pain help alleviate the opioid crisis?
Medical cannabis is helping to ease the current opioid crisis in a number of ways: first of all, it is a viable alternative to opiates for the treatment of chronic pain. Medical cannabis is evidently not as effective as opiates for acute pain, for instance post-surgery or for a broken bone, but it is certainly beneficial for chronic pain: in America, for example, millions of people are experiencing chronic pain as they become more rotund and develop higher rates of knee arthritis and back pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are dangerous: they can damage the kidneys and the heart, they can cause ulcers. Paracetamol doesn’t really do very much; and opiates are harmful for a number of reasons: lowered quality of life, overdose, the risk of dependency. Cannabis is the obvious safer alternative for chronic pain.
Study after study has found that in regions where cannabis has been legalised, either for medical or adult use, opiate prescriptions have gone down; I personally have had countless patients who have switched from opiates to medical cannabis for pain control. Cannabis-based treatment helps people who are using opiates for chronic pain and want to stop; and it is a great option for new patients presenting with chronic pain. We often offer new chronic pain patients cannabis instead of opiates, because opiate-based treatment results in a very dreary lifestyle – you have to get drug tested; you have to sign these opiate contracts; you’re very constipated – it’s just a much better lifestyle to be on cannabis than to be on chronic opioid therapy.
Additionally, for patients who are already addicted to opiates, cannabis can really help them with the withdrawal symptoms. There is some evidence that using medical cannabis can help keep people in treatment for opiate use disorder; it has had similar results to buprenorphine and some studies indicated higher retention in treatment for cannabis than for buprenorphine. Cannabis can be very helpful both as a substitute for opiates in treating chronic pain, and as an adjunct for medication-assisted treatment of opiate dependency.
Methadone and buprenorphine have been proven to lower overdoses and deaths, whereas cannabis hasn’t yet been studied specifically with respect to that. There are a great many anecdotal reports – hundreds of people tell me that they have used cannabis to get off heroin and prescription opiates – but I don’t recommend it for that particular purpose, just because the evidence to date is stronger for methadone and buprenorphine.
Do addiction treatment programmes take the benefits of cannabis in treating addiction into account?
Absolutely not. Addiction treatment providers in this country have been completely indoctrinated against cannabis, partially because they make a lot of money treating people for specious ‘cannabis use disorder’ and partially because they have, in a way, brainwashed themselves against it. They are some of the slowest people to adopt an open mind towards cannabis. Many patients are in favour of it, so to a certain extent some addiction treatment providers are actually losing credibility with patients, because they are taking patients out of opiate programmes if the patients test positive for cannabis. That’s just unconscionable.
The rehab industrial complex in the United States has barely started using methadone and Suboxone, let alone using cannabis: we have this whole industry that has nothing to do with science, following the guidelines of Alcoholics Anonymous which date back to 1937. There is a big lag between what works and what is actually done in this country. A lot of addiction doctors are now on board with methadone and Suboxone; and they are starting to get on board with cannabis, but there is still a major conflict because the bulk of research funding in this field has always gone to people who study the harms of cannabis – the US government has really discouraged any studies into its benefits. Over the last 80 years or so, only those researchers who have that have been interested in pursuing anti-cannabis agendas have received funding; and there has been a lot of collusion between the addiction treatment sector and the US government against cannabis. We’re just starting to emerge from the Dark Ages, in terms of cannabis, in the field of addiction psychiatry right now.
How should clinicians educate themselves further in order to best support patients who may benefit from medical cannabis?
Physicians need to think for themselves. They need to realise that most of what they’ve been taught about cannabis has been propaganda, and they need to find independent sources of education and throw out everything they learned about it in medical school. Then, as my father – who was also a cannabis scholar – said, doctors need to do something really radical, which is actually listening to their patients. In the United States, 94% of people are in favour of medical cannabis: why would that be the case if it didn’t work? Somehow the patients were able to say that the Emperor wears no clothing much sooner than the doctors were; and that’s pretty embarrassing for the doctors – they need to just say, we got this one wrong. We were misled. They need to start again from scratch, with humility and open-mindedness, and educate themselves about the new evidence coming out about how cannabis really does help people.
Cannabis is effective for a number of diseases and conditions that we are currently bad at treating, like fibromyalgia, cancer-induced nausea, and PTSD. One major factor in our failure to treat these conditions may be the fact that we have ignored the endocannabinoid system – it’s only taught in about 10% to 16% of medical schools in the United States. How can we ignore this huge neurotransmitter system? It’s a hangover from the war on drugs; and the US medical education system has been so negligent in adopting this into its curriculum – and if doctors don’t know anything about the endocannabinoid system, how are they supposed to understand how medical cannabis works?
Is it possible that the failure to treat these complex conditions may become a vicious cycle, in that clinicians expect not to be able to treat them so they don’t actively seek new methods of treatment?
Another way, I see is they get discouraged and they kind of give up; and then when patients come along and say they have tried medical cannabis and it works, clinicians tend to write these patients off as using folk remedies – they aren’t curious – when in fact the patient quite likely has stumbled upon something that really does work. That isn’t to say we don’t need a lot more study: we need to standardise and regulate and understand cannabis.
It is very difficult for doctors that there isn’t a standard dose for cannabis. When I prescribe a blood pressure medication for patients, they can take 10mg of lisinopril and I know what the side effects are going to be. When I prescribe medical cannabis, the patient could go to a dispensary and try anything they like. I make recommendations, but I don’t have control over what they do – luckily cannabis is a pretty non-toxic substance. It is a paradigm shift for doctors, which they have to embrace; and which involves more patient agency in their treatment. If there were more dose standardisation and better education – not just about the endocannabinoid system, but practically, about how best to recommend cannabis treatment – that would make it a lot easier for doctors to adopt it.
How does the current US system, where cannabis is illegal under federal law but wholly or partly decriminalised in a growing number of states, complicate the use of medical cannabis?
Our government is utterly braindead about cannabis and has been since they made it illegal in 1937. We’re hoping that will change once we get Donald Trump out of office, but unfortunately, Joe Biden – does not seem to be particularly strong on the cannabis issue. He’s ethical, but he is not a fan of legalisation – and what we need is to legalise it.
Joe Biden will put intelligent people around him; he will be able to appoint good judges, rather than the mediaeval barbarians that Trump is appointing; and we’ll stop putting people in prison for cannabis use or possession – but we need to legalise cannabis so that research can go forward, so that we could standardise dosages, so that we can treat it like any other medicine. Cannabis should be in the realm of doctors, scientists and public health officials; it should never have been in the realm of law enforcement. Criminalising cannabis was never a health issue; it was all about racism, politics and competing commercial interests. That was a mistake and it needs to change.
While Biden’s running mate Kamala Harris is more liberal than he is right now on cannabis, if he wins the election, he will be the president and she will be the vice president – so the buck stops with him, not with her. I think we would have a much more sympathetic administration under Biden; it’s not going to happen overnight, but it’s going to be a much more hospitable environment. Even if Joe Biden, personally, is a bit of a dinosaur on cannabis policy, at least right now he is saying he’s going to legalise medical marijuana; he’s going to expunge the criminal records of people convicted of cannabis offences; he’s going to let states make their own policy, and he’s going to decriminalise cannabis on the federal level.
Really it needs to be legalised, not decriminalised, because if it’s only decriminalised it is still illegal to sell it; and that affects research, because you can’t transfer cannabis samples interstate. However, decriminalisation is much better than Trump, who doesn’t want any state cannabis initiatives at all because they would bring Democratic voters to the polls. It’s like night and day. No matter how disappointed voters are with Joe Biden on cannabis he is a trillion times better than Trump on cannabis, if for no other reason than the judges he would appoint.
Two thirds of Americans support legalisation; around 80% of Democratic voters support legalisation; every other Democratic presidential candidate besides Biden was in favour of legalisation; so why does the Democratic nominee not support legalisation? We are heading in the right direction, but the problem is a lot of cannabis activists, understandably, are so tired of waiting. Biden’s trying to get the middle of the country; he doesn’t want to scare the moderates who don’t particularly want to vote for Trump, but would not be comfortable voting for a very leftwing candidate – but assuming he wins, there is going to be so much pressure on Biden to legalise cannabis, because there is hardly anybody left in the democratic party that doesn’t want to legalise it. He would have a hard time not legalising cannabis, as long as he is elected.
Peter Grinspoon, MD
Massachusetts General Hospital