Abstract and Introduction
Introduction: Over the last decade, the use of medical marijuana has expanded dramatically; it is now permitted in 16 states and the District of Columbia. Our study of family physicians in Colorado is the first to gather information about physician attitudes toward this evolving practice.
Methods: We distributed an anonymous web-based electronic survey to the 1727 members of the Colorado Academy of Family Physicians' listserv. Items included individual and practice characteristics as well as experience with and attitudes toward medical marijuana.
Results: Five hundred twenty family physicians responded (30% response rate). Of these, 46% did not support physicians recommending medical marijuana; only 19% thought that physicians should recommend it. A minority thought that marijuana conferred significant benefits to physical (27%) and mental (15%) health. Most agreed that marijuana poses serious mental (64%) and physical (61%) health risks. Eighty-one percent agreed that physicians should have formal training before recommending medical marijuana, and 92% agreed that continuing medical education about medical marijuana should be available to family physicians.
Conclusions: Despite a high prevalence of use in Colorado, most family physicians are not convinced of marijuana's health benefits and believe its use carries risks. Nearly all agreed on the need for further medical education about medical marijuana.
In November 2000, Colorado passed Amendment 20, which provides an affirmative defense for the use and possession of marijuana by people with one of the following 8 "debilitating medical conditions": HIV/AIDS, glaucoma, severe nausea, severe pain, cancer, cachexia, seizures, and muscle spasms. To obtain a medical marijuana registry card, patients must complete an application that includes a physician certification that may be completed by any Colorado-licensed physician, attesting that they have one of the above conditions and may benefit from the use of medical marijuana. In October 2009, the US Department of Justice issued a directive that it would not pursue federal prosecution against people who comply with state laws allowing possession of marijuana for medical purposes. After this announcement, applications to Colorado's medical marijuana registry increased from 300 per month to 1000 per day. Colorado now leads the nation in per-capita medical marijuana registrants; Colorado physicians have recommended marijuana for an estimated 163,856 patients, more than 2% of Colorado's population. Colorado has seen a dramatic increase in the number of marijuana dispensaries—brick and mortar shops where patients may purchase marijuana in various forms once they have a medical marijuana registry card—and leads the nation in per-capita dispensaries, with more than 800 in the state. As of December 31, 2011, the date of the most recent statistics published by the Colorado Department of Public Health and the Environment, 94% of registrants were using medical marijuana for chronic pain and 17% for muscle spasms (a patient may be registered for multiple conditions).
Despite the dramatic increase in the use of smoked medical marijuana, there are few clinical trials demonstrating its benefits. Several studies found that smoked marijuana was superior to placebo for acute pain, chronic neuropathic pain, chemotherapy-induced nausea and vomiting, and cachexia associated with HIV.[4–13] However, the generalizability of these studies is limited by the small numbers of subjects enrolled (between 5 and 67), the lack of dose standardization of the active compounds in the smoked marijuana used in the studies, and the difficulty blinding participants. Other studies of smoked marijuana for these conditions have shown either no significant benefit or exacerbation by marijuana of the condition being studied.[9,14,15] The Institute of Medicine report Marijuana and Medicine: Assessing the Science Base concluded that "scientific data indicate the potential therapeutic value of cannabinoid drugs, primarily THC, for pain relief, control of nausea and vomiting, and appetite stimulation; smoked marijuana, however, is a crude THC delivery system that also delivers harmful substances."
Substantial concerns remain about marijuana's adverse effects. Acute effects of marijuana use include sedation, dizziness, anxiety, and psychosis. Nine percent of users develop dependence, including impaired control over use, difficulty stopping marijuana use despite its harms, and development of a withdrawal syndrome when use is discontinued. Regular users are more likely to use other drugs, including cocaine and heroin, particularly when they initiate use of marijuana as adolescents. Marijuana users also experience cognitive deficits, which manifest as dose-related impairments in reaction time, information processing, motor performance, and attention. Heavy users report decreases in verbal learning, memory, and attention; it is unclear whether and how quickly these deficits resolve after stopping marijuana use. In addition, marijuana use is associated with a doubled risk of developing schizophrenia. Among users who already have psychotic disorders, ongoing marijuana use is associated with increased psychotic symptoms. Use of cannabis during adolescence also is associated with an increased risk for depressive disorders as well as attempted and completed suicide. Finally, long-term marijuana smoking is associated with increased respiratory symptoms suggestive of obstructive lung disease, and the use of both marijuana and tobacco seems to increase symptoms of obstructive lung disease synergistically.
Although there is limited high-quality evidence for the medical benefits of smoked marijuana, it is permitted for medicinal use in states that comprise more than 25% of the US population. Although medical opinion and expertise should be one of the major forces informing legislation for medical marijuana, Colorado's Amendment 20, and similar legislation in other states, passed with little consideration of physicians' attitudes toward medical marijuana.
Indeed, we have little information about how doctors nationwide feel about either the use of marijuana as a medicine or the role of physicians in recommending marijuana to patients. A 1989 physician survey regarding outright legalization of marijuana found that 41% of respondents were in favor of legalization, but it did not address marijuana use for medical purposes. A 2005 survey of 960 physicians from multiple specialties found that physicians generally were less supportive of medical marijuana use than the general public. A survey of oncologists found that 30% supported rescheduling of marijuana for medical purposes by the Drug Enforcement Administration. Another study of oncologists reported that 54% of oncologists surveyed agreed that marijuana should be available by prescription. Even though primary care physicians provide much of the health care for patients with the conditions for which marijuana is largely being recommended, namely chronic pain and muscle spasms, there are no studies that focus on primary care physicians and their attitudes toward medical marijuana.
This article presents the results of a survey that asked family physicians in the state of Colorado about their attitudes toward medical marijuana in general and as currently practiced in Colorado. We chose to carry out this survey in Colorado because of the high rates of medical marijuana use and because it is one of the few states that compiles and publicly releases statistics about the people who apply to the state's medical marijuana registry. Although Colorado has some outspoken physician proponents and detractors of medical marijuana represented in the media, there still are no data that capture the attitudes of most practicing physicians who have the opportunity to recommend medical marijuana. Furthermore, the vast majority of patients on the Colorado medical marijuana registry have had marijuana recommended to them by one of a small number of physicians: 49% of recommendations have been made by only 15 physicians. There is little information about whether and how often most primary care providers are recommending medical marijuana. The aims of our survey were to gather information that may inform policies regulating medical marijuana and to evaluate the need for further medical education on this relatively new and rapidly growing area of medical practice.
J Am Board Fam Med. 2013;26(1):52-60. © 2013 American Board of Family Medicine