Many Veterans Health Administration (VHA) primary-care providers have knowledge gaps around cannabis and are uncomfortable talking with patients about its use, a nationwide survey has found. In addition, the survey found substantial variation in clinical practice regarding prescription opioids in patients who also use cannabis, likely reflecting "the dearth of evidence," researchers write in Pain Medicine. These findings, they say, "suggest a need for more widespread clinician education about cannabis, as well as an opportunity to develop more robust guidance and evidence regarding management of patients using prescription opioids and cannabis concomitantly." The survey is both one of the first to examine clinicians' knowledge, attitudes and practices regarding cannabis and the first to include only VHA clinicians, according to Dr. Devan Kansagara of Oregon Health and Science University in Portland and colleagues. As of the report's publication, cannabis is legal for at least some medical uses in 33 states plus the District of Columbia and legal for recreational use in 11 states plus the District of Columbia. Alongside this signal change, the authors note, the perception of cannabis's clinical benefit has "rapidly outpaced the evidence. For example, chronic pain is the most common indication for medical cannabis, but the evidence regarding its effectiveness for chronic pain is largely inconclusive." Another issue with cannabis, the paper points out, is that "its role is not well defined in clinical care: It is not an illicit substance, not clearly a pharmacotherapeutic agent, and not always a recreational drug." Further complicating the situation for VHA providers is that they are not permitted to endorse cannabis use, even in states in which that is legal. The VHA does, however, allow clinicians to discuss cannabis use with their patients and to make individualized decisions about opioid prescribing for patients who are using medical cannabis. The 47-item survey focused on three domains (clinician knowledge, attitudes, and practice) and was distributed to 341 providers in primary-care divisions spanning the 23 VHA regions. Surveys were returned by 249 allopathic physicians, osteopathic physicians, and nurse practitioners across 39 states and the District of Columbia. A quarter to one-half of respondents showed knowledge gaps as to cannabis terminology, the psychoactive effects of cannabis components, VHA policy and evidence about the benefits and harms of cannabis. For example, 30% falsely believed that cannabidiol causes euphoria. Although about two in five respondents favored medical-cannabis legalization in all states and a similar number thought cannabis is moderately to extremely helpful in treating certain kinds of pain, 82% expressed concern about the mental-health risks of cannabis. An area of emphasis in the survey was how clinicians responded when tetrahydrocannabinol (THC) was found in the urine of patients who were receiving opioids. Nearly three-quarters of respondents (73%) were likely or extremely likely to taper opioids in patients with THC in their urine, and 61% were likely or extremely likely to change treatment plans because of THC-positive drug screens. Further, providers in states where cannabis is illegal or legal only for medical use were significantly likelier than providers from states where recreational cannabis is legal to taper opioids, and also to report being likely or very likely to alter treatment plans if urine testing was positive for THC. Dr. Kansagara told Reuters Health by email, "we are far from knowing whether cannabis is actually an effective substitute for opioids and whether patients do actually reduce opioid use when using cannabis. There are studies that suggest opioid use does not actually change." The bottom line on cannabis' effects on pain, Dr. Kansagara said, is that "we have insufficient evidence about the effectiveness of cannabis for most types of chronic pain." Dr. Gregory T. Carter, chief medical officer at St. Luke's Rehabilitation Institute in Spokane, Washington, who has done similar research, told Reuters Health by email, "it is important to realize that both compounds (cannabis and opioids) produce analgesia, although through separate and distinct mechanisms.” "Cannabis does not suppress breathing or enhance the depression of breathing caused by opioids, which is the main danger in terms of opioid overdose," said Dr. Carter, who was not involved in the new survey. "More research is needed in humans," he added, "but there is anecdotal evidence to support a synergistic effect between cannabis and opioids and it does appear to be safe to use them together. However, this should only be done under close medical supervision." —Scott Baltic. Source
