Psychiatry Must Call for More Research into Therapeutic Uses of Cannabis
Eclipsed in the coverage of the presidential election this week, an important referendum on cannabis use was taking place in the background. On Tuesday, 4 states (California, Maine, Massachusetts and Nevada) voted to legalize cannabis for recreational use (a similar initiative was defeated in Arizona) and 4 other states (Arkansas, Florida, Montana, and North Dakota) approved medical cannabis initiatives1.
This means there are now 8 states with legalized recreational cannabis, 21 states with medical cannabis laws, and an additional 15 states that permit some use of cannabinoids (typically products that contain only cannabidiol and not THC). This leaves only 6 states that have not made at least some form of cannabis legal, in at least some circumstances2. However, cannabis remains a Schedule I controlled substance under federal law, despite President Barack Obama’s recent remarks that continued federal enforcement of cannabis use is “untenable”3. President-elect Donald Trump’s position on cannabis decriminalization remains unclear, with him having made remarks both for and against it 4.
Regardless of what happens on the federal level, one thing is clear. Cannabis is not going away. We see this reality in our clinics and hospitals daily, and with the greater acceptance of cannabis use in the culture, more patients are willing to talk about their cannabis use to clinicians.
From my cannabis-using patients, I often hear them finding benefit from cannabis from common maladies such as anxiety or insomnia. This perception is often reinforced by both word-of-mouth accounts from fellow users of the drug and from the propagation of anecdotal evidence from a cannabis industry eager to promote the plant as a panacea.
But here’s the problem: when I am asked what evidence we have on the benefits of cannabis, I usually don’t have much to offer from the scientific literature. And here’s why: our prohibitionist stance towards cannabis for the last 46 years (since marijuana was placed on schedule I of the Controlled Substances Act) has focused largely on the harms of recreational cannabis use. Most of the research that has been conducted has been on single cannabinoids, not on the whole-plant cannabis that most of my patients are using. There has been little research done on the benefits of cannabinoids, in part because of federal roadblocks to this kind of research. This is unacceptable and needs to change.
We, as psychiatric professionals, should be clamoring for this kind of research to be done, and the barriers that prevent it to be removed. If we are to be evidence-based practitioners, then we need evidence. In the absence of well-designed clinical trials of cannabinoids for clearly-defined conditions, we are left with only anecdotal evidence of cannabis’ benefit as a general bromide for a panoply of conditions, but no clear proof that it works, and if it does work, for whom does it work, and if the side effects are less than the benefits.
Without this evidence, our patients are sailing through uncharted waters, and we have no information with which to guide them. This needs to change and psychiatry should be leading this charge, not left in the dust as we currently are now. There is little financial incentive for the pharmaceutical sector to study the potential benefits of whole-plant cannabis (there are phase III trials in process for a THC-CBD extract product, nabixmols, but not whole-plant cannabis), so this research will likely need to be publicly funded, either by individual states, or at the federal level by the National Institute of Mental Health.
For this to change, the status of cannabis as a controlled substance must be changed. This is a complex topic, beyond the scope of this short article, but comes down to two options beyond maintaining the status quo – the DEA either reschedule it to a lower schedule, such as IV (same as benzodiazepines) or remove it from the Controlled Substances Act altogether, and allow states to regulate it as they will (like is done with alcohol and tobacco). If it were rescheduled, then it would be under the same burden of proof that other pharmaceutical agents must pass (which may be difficult for a compound comprised of over 400 different molecules) and would continue to put states with recreational use laws in conflict with federal statutes. Descheduling would allow states to continue to regulate recreational use, while reducing obstructions to more robust study of the potential benefits, along with the risks, of this complex and promising plant.