Dr David Casarett wanted the ground to open up and swallow him.
"It has zero medical benefits, whatsoever."
And he was pretty sure he was right. He had to be! Dr Casarett had never learned about it in medical school, nor had he ever heard of it being used in the clinic. As far as he was concerned, it had no place in the realm of medicine.
His patient, a retired English professor in her 70’s, just stared at him, a mix of amusement and pity painted on her face. She had pancreatic cancer and, as a palliative care physician, it was his job to be up-to-date on the best treatments available to keep her comfortable.
But he hadn't been prepared for this.
"Could marijuana help me, doctor?” she'd asked.
When he replied, she just smiled and nodded. The woman then reached into her handbag and pulled out a thick stack of papers—randomized controlled trials discussing the benefits of medical marijuana for conditions like epilepsy and multiple sclerosis.
"Maybe you should read these before offering an opinion...doctor.”
That night, Dr Casarett read each of the articles and several others. When he saw his patient the next morning, he told her that the treatment had promise and that she should try it.
"I tried it six months ago, doctor. It was amazing. I've been using it every day since.”
She’s not the only one. Over a million patients in the US, alone, rely on medical marijuana for symptom control—many millions more use it around the world. As regulations about the control and distribution of cannabis relax globally, the body of research touting the benefits (and potential risks) of marijuana is rapidly growing. To some, it seems like an impossible panacea. The number of conditions and symptoms that cannabis can potentially treat flies in the face of the model that we’re all used to—one drug for one receptor or pathway. But as researchers continue to explore the endocannabinoid system and the function of exogenous cannabinoids within that system, a pronounced shift is taking place within the medical world.
We’re no strangers to the therapeutic potential of plant-inspired medications. Aspirin and digoxin are two classic examples. But these fit neatly into the traditional treatment paradigm of one molecule for one receptor or pathway. Cannabis is a whole new beast. Although synthetic cannabinoids and isolates are sometimes prescribed in practice, clinical evidence supports the existence of the entourage effect—a synergistic benefit that is derived from using the whole plant rather than a specific phytochemical within it. With hundreds of cannabinoids, terpenes, and flavonoids working together to create an effect (and impacting different patients in different ways), the implications are clear—cannabis is not a one-size-fits-all kind of drug!
And this matters. A lot. It matters because this treatment paradigm lies outside of the comfort zone of most doctors. Many of us are highly unlikely to prescribe it, even if given the opportunity to do so, precisely because we don’t really understand it.
In the early 20th century, the situation was very different. When an American politician, Harry Anslinger, decided (for dubious reasons) to wage a war on cannabis, the American Medical Association staunchly opposed him. Numerous members spoke out against Anslinger’s claims about the dangers of cannabis and said that proposals to outlaw it were unfounded. Their complaints, however, didn’t matter in the end. A plant that had been used medicinally for a millennia suddenly became a threat to society and was eventually criminalized.
Over the past couple of decades, cannabis has slowly made a comeback. But the stigma still exists and, for the most part, the topic isn't included in medical school curricula. As a result, many doctors don’t know enough about medical cannabis to consider prescribing it. In a profession driven by evidence-based guidelines, that’s understandable. With hundreds of potential cannabis strains capable of treating dozens of different types of symptoms and patients, performing randomized controlled trials (RCTs) that study one specific formulation in the context of one specific condition is nearly impossible. So, for the most part, cannabis has remained a fringe treatment within medicine. But according to Dr Casarett and many other physicians working in this field (where the use of medical marjuana is legal), our biases against the drug are the real reason we don't entertain the prospect of prescribing it.
The stigma surrounding cannabis is compounded by a lack of education on the topic. Currently, cannabis education is largely provided through expert-led conferences such as Cannabis Europa (London) and CannMed (US). However, the stigma (and evolving state of research) still holds many physicians back from exploring it further. Dr Casarett argues that it’s our responsibility to learn about and acknowledge the use of cannabis because, whether we like it (or know about) or not, our patients are using it! With 3% of adults worldwide admitting to being regular marijuana users, there’s a pretty good chance that many of your patients are using it too.
This leads us to an important question. If the cannabis plant, which had been used medicinally for thousands of years (and which was, at one point, considered part of medical practice) can be so easily written off by the medical community—thanks to decades of stigmatization—is it possible that we’ve been ignoring other potential wonder plants too?
Springing up like mushrooms
In the 1960’s, another plant was slowly sprouting into the halls of medicine.
Dr Timothy Leary, a Harvard psychologist, was studying the effects of psilocybin (a psychedelic found in magic mushrooms) when he received a sample of something that would revolutionize neuroscience—LSD. This consciousness-altering drug, which had been accidentally developed by a Swiss chemist trying to create a stimulant, was sent to Dr Leary in a bid to further understand the therapeutic potential of psychedelics.
Psychedelics had been used in shamanic rituals for millennia, but now, for the first time, they were moving into the labs and test tubes of distinguished researchers.
And so began almost two decades of fervent investigation into these mind-altering drugs. Over 1000 research papers were published in the 1950’s and 60’s and the results were astounding. In study after study, LSD was shown to effectively treat depression, anxiety, PTSD, and addictions when other drugs did not. But, as these research drugs found their way onto the black market, prohibitions inevitably rolled in and psychedelics were largely forgotten.
Today, 50 years after LSD was first banned, psychedelics are making a comeback.
Across the world, microdoses of LSD are being used by entrepreneurs to sustain their focus and energy, by psychotherapists who are secretly integrating magic mushrooms into their sessions, and by clinics using MDMA to treat refractory PTSD. Perhaps most importantly, regulators are beginning to approve psychedelic studies for the first time in decades, allowing researchers to fully explore the potential of psychedelics in treating a variety of mental illnesses.
This growing acceptance of psychedelics as a potential source of treatment led to the opening of the world’s first psychedelic research unit in London this year—the Centre for Psychedelic Research. The research findings have shown promise, suggesting no link between mental illness and psychedelic use. However, as the research world warms up to the idea of using psychedelics to treat mental illness, those who would likely be prescribing them don’t seem to agree.
In a survey looking at psychiatrist attitudes toward hallucinogens, researchers found that most psychiatrists still believe that the use of psychedelics increases the risk of long-term cognitive problems and poses risks for mental health. Interestingly, younger psychiatrists were more likely to be optimistic about the potential use of psychedelics for mental illness. Older psychiatrists, who may still remember the demonization of psychedelics that occurred in the mid-to-late 20th century, were more likely to view it as hazardous.
Like cannabis, the use of psychedelics in treatment will probably face resistance from the medical community because of the stigma that surrounds it. However, as the research grows in favor of using cannabis and psychedelics for specific conditions, there is hope that the medical community will be able to move past skepticism and embrace these medications as legitimate tools in a therapeutic arsenal. But this first requires an acknowledgement that stigma exists and that it doesn’t have a place in medicine.Ultimately we’re scientists, and if the data tells us that cannabis and psychedelics will help our patients, then we’d better start listening! [click to tweet]
What’s your view? Should psychedelics be widely available? Should they be available on prescription? More importantly, should psychedelics and cannabis become a standard part of care? Should they not be used in medicine at all? We’d love to hear your opinions! Please let us know your thoughts in the comments box below!