Mark’s past career choices were murder on his body. As a photojournalist, he carried around heavy camera bags for a decade. Then, as a touring musician, he lugged equipment on and off for 15 years, leaving him with chronic pain in his back and neck.

“The only things that work to alleviate the pain are smoking or eating cannabis, combined with monthly massage therapy,” he says.

But Mark won’t tell his doctor he uses cannabis. He suspects many doctors in Texas, where he lives, might label him a deviant, a lawbreaker and a drug user if he admits he uses marijuana. Even hip doctors often don’t want to know. “One of my recent doctors said straight up, ‘If we were in a different state, it wouldn’t be an issue. But as long as Texas doesn’t have a medical marijuana law, I can’t know that you use that.’”

This unofficial “don’t ask, don’t tell” policy means many patients aren’t getting comprehensive healthcare. Access to healthcare professionals who are educated about medicinal cannabis is a patients’ rights issue, says Eileen Konieczny, a registered nurse and former president of the American Cannabis Nurses Association. “Why in California can you access something that in Georgia and Louisiana, you can’t? It shouldn’t matter where you live.”

Although polls indicate that most Americans approve of marijuana for medical use, many patients and doctors are leery about bringing up the topic during visits. That’s partly because the legal stakes are high: In January, Attorney General Jeff Sessions said the Justice Department should feel free to prosecute marijuana-related transactions, even in states where medical marijuana is legal. It’s also because many doctors just don’t know enough about cannabis to competently answer patients’ questions about it.

Knowledge gaps

A 2017 survey of nearly 500 primary care physicians in Washington state, where marijuana is legal even for recreational use, revealed that although half of them were legally allowed to prescribe medical marijuana to their patients, only 27 percent had done so. The others didn’t feel confident enough in their knowledge of the drug to get out their prescription pads.

When researchers at Washington University in St. Louis surveyed residents and fellows training at the Barnes-Jewish Hospital, 90 percent didn’t feel capable of prescribing medical marijuana. Eighty-five percent said they’d learned nothing about it in medical school or other residency programs. Those stats aren’t too surprising when you consider that only 9 percent of medical schools cover medical marijuana, according to data from the Association of American Medical Colleges.

Marijuana’s classification by the U.S. Drug Enforcement Agency as a Schedule I drug — a status it shares with heroin and LSD — is likely why most medical schools avoid the subject in their curricula, says Beatriz H. Carlini, a public health researcher at the University of Washington’s Alcohol and Drug Abuse Institute. According to the federal government, Schedule I drugs have no medical benefit and a very high potential for abuse.

But the reality is that many patients, like Mark, are already self-medicating with marijuana, which makes doctors’ lack of knowledge about it alarming. Patients who use cannabis for cancer pain deserve to have an educated medical staff, says Ronald F. Tuma, a physiology professor at the Lewis Katz School of Medicine at Temple University in Philadelphia.

Nearly one-quarter of cancer patients use cannabis to help manage their symptoms, a 2017 study found. Yet in a recent study, only 30 percent of oncologists surveyed said they felt confident answering their patients’ questions about it.

Doctors tend to agree that they need to learn more about marijuana, but figuring out how and where they should study up isn’t so clear. In the 29 states and the District of Columbia where medical marijuana is legal, requirements for healthcare professionals who want to prescribe it vary. Florida requires a two-hour training course, while Maryland only requires doctors to verify their credentials and say they understand state regulations related to medical cannabis. Health professionals in any state can take one of two approved four-hour courses that are mandatory for medical marijuana prescribers in New York.

Dr. Matthew Mintz, a Maryland primary care physician, took one of the New York medical marijuana courses, even though it wasn’t required by state law. Getting certified in Maryland was easy, he says, but finding reliable, large-scale studies supporting the efficacy of cannabis wasn’t.

“Some of the best info out there is on dispensary websites, but that’s not a source I’d want to rely on as a physician,” says Mintz, a former George Washington University School of Medicine professor now in private practice in Bethesda, Maryland. “One of the problems with outside resources, especially if you’re on a dispensary website, is that they’re trying to sell products, so you’re not getting unbiased information.”

There is good published research supporting the benefits of medical marijuana for patients with cancer, HIV and AIDS, epilepsy, PTSD and chronic pain. But merely knowing marijuana might help doesn’t make it easy to prescribe. There’s much less scientific evidence that medical marijuana reduces headache pain and anxiety, for example, yet those are two common reasons people request prescriptions.

The knowledge gaps hardly end there: There’s a lack of research on how different marijuana strains affect the body. Doctors don’t know what the best delivery method is, or the optimal amount to consume. Scientists aren’t sure how marijuana works synergistically with other medications, or which drugs it shouldn’t be combined with.

“At this point, it seems there are no accepted dosage guidelines for specific ailments,” says Dr. Edward Alvarez, a cosmetic and reconstructive dentist in the New York area. “One ‘joint’ may be more potent than another, based on so many factors, and that can’t be arbitrary when we are dealing with a therapeutic medication.”

Some doctors are less concerned about filling in the blanks. If cannabis works, they say, why not prescribe it?

“Because the negative effects of marijuana are no worse than those of tobacco or alcohol, I see no reason why patients, especially those for whom Western medicine has failed, shouldn’t be allowed to try it and see if it helps their ailment,” says Dr. Bradley Katz, a neuro-ophthalmologist and co-founder of Axon Optics, a company that makes eyewear for people with light sensitivity. “But I feel bad that I can’t be more helpful in terms of what maladies it’s useful for, where to buy it or how much to use.”

Doctors and dispensaries

Mintz, like many medical marijuana prescribers, says he depends on the patient-care experts or “budtenders” at dispensaries for information about strains, dosages and delivery methods. Yet while some dispensary employees are knowledgeable, others might hinder good patient care, says cannabis specialist Dr. Jordan Tishler.

“On a regular basis, my patients are upsold a plan that isn’t good for them,” Tishler says. “I end up having to ask them what they’re taking, because what I told them to take might not have anything to do with what the person at the dispensary gave them.”

At least one of his patients was told at a dispensary, “I don’t understand what your doctor’s doing, so forget what he said, I’ll tell you what to do.”

“How do you take care of people in those circumstances?” Tishler says.

Tishler, a former emergency room doctor at veterans affairs hospitals, currently serves as both treasurer of the organization Doctors for Cannabis Regulation and president and CEO of the Association of Cannabis Specialists. In addition to working with dispensaries to create a credentialing program, the nonprofit is developing a medicinal cannabis educational program for health professionals, as well as lobbying for better medical marijuana access and responsible regulation. Primary care physicians rarely have the expertise or even the time during visits to discuss medicinal cannabis with patients in the depth they should. But patients still need expert guidance, he says, and they’d be better off seeing doctors certified as cannabis specialists by the association than being directed to dispensaries for advice.

“The model developed since California legalized cannabis for medical use in 1996 is this idea that the doctor’s job is just to say yes or no,” he says. “If that were the case in any other area of medicine, it would be considered malpractice. If someone has high blood pressure, you don’t just tell them, ‘Go get medicine.’ What medicine, what will it do, how much does the patient take? That basic level of informed consent is the basis of how we live up to the patient-doctor relationship of trust.”

Ann, a professor at the University of South Florida, was recently certified as a medical marijuana patient to treat her Crohn’s disease. The prescriptions she gets from Trulieve, a Florida cannabis provider, specify the proper delivery method, dosage and concentration of her low-THC cannabis, as well as the number of times she should take it each day. But while medical marijuana became legal for Florida residents in 2017, it can be difficult for patients to obtain. Waiting lists are reportedly long, and Ann says she only managed to get a medical marijuana card because her friend guided her through the process. “I wouldn’t have known where to start,” Ann says.

Cannabis-based curriculum

One of the few medical schools that cover medicinal cannabis instruction, Philadelphia’s Temple University, instructs students about the biological system known as the endogenous cannabinoid system and the physiological effects that cannabinoids (natural chemicals in cannabis that include CBD and THC) have on the body, explained Tuma, the Temple professor. More schools are following suit, but progress is slow. The University of California, Davis, started offering an undergraduate course covering the “biology of cannabis” in 2017, and says a similar course is being developed for med students.

The Washington attorney general’s office awarded a grant in 2013 to develop a training program for state healthcare providers regarding the scientific basis, clinical implications and legal ramifications of using medicinal cannabis to treat and manage chronic pain, Carlini says. Although the program was developed by the University of Washington, it isn’t offered at the university’s medical school. Health professionals who want to learn about medical marijuana can take the course no matter where they live, and those practicing in Washington state can be certified to prescribe medical cannabis after completion.

Like the Association of Cannabis Specialists, the American Cannabis Nurses Association is developing a certification program for cannabis nurses, as well as urging nursing schools to include medical marijuana in their curricula. A host of schools have cropped up to train budtenders about cannabis. But, Konieczny says, “unless you’re a healthcare professional, you can’t use the information the same way a nurse can.”

“This isn’t voodoo medicine — there’s real science behind it,” she says. “The endocannabinoid system, which was discovered in the ’90s, is the largest receptor system in our bodies, and it isn’t being taught. There’s something wrong with that.”

Tishler agrees that cannabinoids need to be included in pain management education. “They exist and they can help,” he says. “It would be like having a course on treating pain with medication and not mentioning opioids. We have to get to place where cannabis is destigmatized enough where we can look at it objectively.”

In fact, given the opioid crisis in the U.S., medical schools should be teaching sections on chronic pain and pain management, says Dr. Andreas Mitchell, a resident at the University of California, San Francisco, Medical Center.

“I didn’t learn much about the causes, the pathophysiology, screening or treatment of chronic pain [in med school],” Mitchell says. “At some point during my third-year rotations, someone handed me a chart with some medications and dosages that I could reach for, but medical marijuana was not included.”

Mitchell co-authored an opinion piece about medical marijuana education for Stat News with first-year Harvard Medical School student Suhas Gondi. Mitchell and Gondi argued in the piece that case-based learning would be a good way to present medical information about cannabis.

A medical marijuana discussion could be easily incorporated into a case focusing more broadly on a patient with persistent lower back pain who isn’t responding to non-opioid analgesics such as acetaminophen (Tylenol). In case-based learning, the instructor-slash-physician presents a real or fictitious case of a patient with some type of chronic pain, for example. Then students come up with ideas for questions to ask the patient and evaluate the significance of their responses.

“The professor can then use the specific case to walk students through the decision points, risks and benefits of medical marijuana and how the actual recommendation process works, depending on the state,” Gondi says.

Tishler has offered to lecture Harvard Medical School students about medical marijuana, and Mintz volunteered to share his cannabis expertise with students at George Washington University. So far, neither school has taken them up on their offers.

“It’s not legal everywhere and not fully accepted by the medical community, so it’s understandable that they might not want to spend precious class time on it,” Mintz says. “But I make the case that by the time these students graduate and are practicing, it’ll be more accepted. And it would be better that they know about it now rather than waiting.”

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