Medical marijuana: what doctors need to know about Canada’s new rules

Herbal marijuana is not an approved drug in Canada, but court rulings have required reasonable access to a legal source of marijuana when authorized by a physician. On April 1st, Canada’s current regulatory system for medical marijuana will be replaced entirely by a new set of rules. These new regulations will have important implications for both doctors and patients.

For information on what patients need to know about medical marijuana, read Healthy Debate’s Personal Health Navigator article: Hazy Evidence on Medical Marijuana Use .

This article explores what doctors should know about the new rules for herbal marijuana for medical purposes, including the evidence for its use, available alternatives (including pharmaceutical cannabinoids), and the position of regulatory bodies such as the College of Physicians and Surgeons of Ontario. This article focuses on the use of marijuana to treat chronic pain, which is its most common therapeutic use (other potential uses not covered by this article include treatment for spasticity, anxiety, insomnia and nausea).

Note: in this article, the terms “marijuana” and “herbal marijuana” are used to describe the cannabis plant, usually dried and then consumed by smoking. The term “pharmaceutical cannabinoids” is used to describe approved medications that either mimic or contain active ingredients found in the cannabis plant.

Canada’s new rules for medical marijuana

Under the old regime, doctors who believed their patients might benefit from herbal marijuana for medical purposes signed a declaration to Health Canada, attesting that alternative therapies had been attempted or considered, but had either failed or were inappropriate. Under this system, the authority of whether to grant permission to use marijuana rested with Health Canada. Patients who were granted permission to use marijuana for medical purposes had the option to grown their own, assign someone to grow it for them or acquire it directly from Health Canada.

The new regulatory regime takes Health Canada largely out of the equation. Doctors will now be expected to issue their patients prescriptions for marijuana, much as they would other controlled substances, such as opioids. However, unlike other prescriptions, doctors will send the appropriate medical document directly to a licensed producer of medical marijuana. As of April 1st, these licensed producers will be the only legal source for patients to acquire marijuana for medical purposes. Licensed produces can either send marijuana directly to patients, or to a patient’s doctor.

These new regulations were opposed by most physician groups, including the Federation of Medical Regulatory Authorities of Canada and the Canadian Medical Association. These organizations argue that the new regulations continue to put patients at risk, because there is no standardization in the purity and potency of smoked marijuana, and insufficient evidence about its benefits and risks. “Doctors shouldn’t be told to prescribe marijuana until it has been subjected to the same rigorous testing and approval standards as other prescription medications,” says Rocco Gerace, Registrar of the College of Physicians and Surgeons of Ontario.

Marijuana not first-line therapy for any medical condition

Doctors considering prescribing marijuana to patients should note that marijuana is not first-line therapy for any medical condition. For nausea, ondasetron is both more potent and longer-lasting than marijuana. Likewise, there is a wide range of pain relievers with substantially better evidence than marijuana. There is a clear consensus among experts that when patients request marijuana for legitimate medical conditions, approved therapies should be tried first, and marijuana can be tried if these first-line agents fail to prove effective.

Limited evidence for the use marijuana to treat chronic pain

Herbal marijuana has not been approved by Health Canada under the same standards used to approve other prescription medications. In order for a prescription medication to be approved in Canada, its safety and effectiveness must be established through multiple phases of clinical trials.

In contrast, research into the safety and efficacy of herbal marijuana is much less extensive. Pre-clinical research has established an anatomical basis for the potential pain relieving effects of marijuana, but there have been few studies that have demonstrated effective pain relief in humans.

Randomized placebo controlled trials demonstrating the effectiveness of herbal marijuana for pain relief have focused exclusively on neuropathic pain (complex, chronic pain associated with damage to nerve fibers). These trials have been limited to neuropathic pain associated with a small number of conditions: HIV, diabetes, multiple sclerosis, surgery, and trauma (including spinal cord injury). But, Meldon Kahan, Medical Director of the Substance Use Service at Women’s College Hospital notes that research from Washington State’s medical marijuana program suggests that these are not the conditions for which most patients are seeking marijuana. “Most medical marijuana users tend to have a diagnosis of fibromyalgia, back pain or arthritis. There’s no evidence that marijuana will help these patients,” he says.

Also of concern is the safety of herbal marijuana. The intoxicating effects that have made marijuana popular as a recreational drug carry a number of known risks. In addition to the risk of dependence, these include impaired learning, memory, alertness, reaction speed and judgment, all of which affect driving and work performance. Long term use of marijuana during pregnancy can inhibit the development of neuronal pathways in fetuses and in early childhood and adolescence. In young adults, marijuana dependency can result in mild, but potentially permanent impairment of executive functions such as problem solving, and has been associated with a decline in IQ and the risk of psychosis.

In addition to the side effects associated with the intoxicating effects of marijuana, marijuana smoke contains toxic compounds. As a result, long term use of smoked marijuana can cause inflammation of the airways, resulting in chronic cough and wheezing. Marijuana smoke also appears to be a risk factor for lung cancer. Safety concerns about the effects of marijuana smoke may be alleviated somewhat by vaporizing marijuana, rather than smoking it.

Mark Ware, a scientist at McGill University and the executive director of the Canadian Consortium for the Investigation of Cannabanoids, agrees that the evidence for herbal marijuana’s safety and effectiveness is limited. “Very little research has been done to date, because the climate of prohibition made it very difficult to access research funding, legal marijuana for research purposes, and accurate use data,” he explains. He also notes that the prohibition on marijuana has meant that research has tended to focus on its harms, rather than its benefits. But Ware believes that the limited clinical research that does exist is very promising. He is hopeful that Canada’s new rules will facilitate more and better research into the safety and effectiveness of marijuana.

Pharmaceutical cannabinoids vs. herbal marijuana

While herbal marijuana has not been approved as a drug by Health Canada, several pharmaceutical cannabinoids – which contain or simulate the active ingredients found in marijuana – are approved and available in Canada. Unlike herbal marijuana, these pharmaceutical cannabinoids have undergone phase 3 clinical trials and are available in standardized dosages.

There are two pharmaceutical cannabinoids approved for use in Canada. Nabiximols (trade name Sativex) is a mouth spray that contains both cannabinoids found in marijuana: tetrahydrocannabinol (THC) and cannabidiol (CBD). Nabilone (trade name Cesamet) is a pill that mimics THC, the cannabinoid associated with the intoxicating effects of marijuana.

Kahan says that doctors who believe marijuana might help their patients should always begin by prescribing pharmaceutical cannabinoids, rather than herbal marijuana. In addition to having more robust evidence about effectiveness, pharmaceutical cannabinoids appear to be safer, he explains. Pharmaceutical cannabinoids do not tend to produce the same level of euphoria, making them less prone to abuse than smoked herbal marijuana. Also, since pharmaceutical cannabinoids are administered through pills and mouth sprays, they do not pose the same respiratory and carcinogenic concerns as smoked marijuana.

Doctors may also prefer to prescribe pharmaceutical cannabinoids, because while patients must pay out-of-pocket for herbal marijuana, nabilone is covered by both the Ontario Drug Benefit program and Alberta Health, as well as some private drug plans.

Ware agrees that doctors should try pharmaceutical cannabinoids before prescribing herbal marijuana, particularly if a doctor is relatively inexperienced with prescribing marijuana. But he does note that inhaled herbal marijuana may still have an important role to play for some patients. “Because inhaled marijuana is absorbed through the lungs, rather than the stomach, it can take effect much faster and may have a more powerful – though shorter term – effect on pain,” he says. Ware likens the difference to short-acting versus long-acting opioids, though he notes more head-to-head trials of inhaled herbal marijuana versus pharmaceutical cannabinoids are needed in order to better understand their respective clinical indications.

Screening for risk factors

Kahan urges doctors considering prescribing marijuana to screen their patients for a number of risk factors.

“Doctors should screen all patients who request medical marijuana for a cannabis use disorder and for factors that put them at risk for developing a cannabis use disorder,” he says. These risk factors include younger age, current or past problems with marijuana or other substances, as well as active mental illness. Patients with risk factors should not be given a prescription, he advises.

Patients who have a cannabis use disorder should be offered counseling and follow up, says Kahan, and those who are not able to reduce or quit should be referred to an addiction medicine doctor and/or treatment program.

Other groups at high risk of suffering side effects from marijuana include people with past or family history of psychosis, anyone under the age of 25 and pregnant women or women who may become pregnant.

Refusing to prescribe

Because of the lack of evidence about the effectiveness and safety of herbal marijuana, as well as the danger of abuse, some doctors may wish to refuse to prescribe marijuana to their patients.

In Ontario, doctors have a right to refuse to prescribe marijuana under the policies of the College of Physicians and Surgeons of Ontario (CPSO). The CPSO is currently revising this policy in light of the new federal regulations, but Gerace expects its substance to remain unchanged.

The College of Physicians and Surgeons of Alberta recommends that their members not prescribe marijuana for medical purposes.

Proceed with caution

While effective treatments have been developed for many types of chronic pain, not all treatments work for all patients. As a result, Ware believes doctors have an ethical obligation to be open to new therapies that might help patients for whom existing medications are ineffective. “The suffering of some patients is the impetus for us to continue to explore medical applications [of marijuana],” he says.

Kahan, however, worries that expanding the use of medical marijuana could put patients at risk of abuse. “The prescription opioid crisis was created when we loosened regulations around opioid prescribing,” he remarks; “I hope history doesn’t repeat itself.”

Doctors who do choose to prescribe marijuana to their patients have precious few resources to help guide them, as no clinical guidelines currently exist. These doctors are urged by experts to consider smoked herbal marijuana only after conventional therapies and pharmaceutical cannabinoids have been tried, and to screen their patients for risk factors.

Note: this article is not intended as a prescribing guide for clinicians. Doctors considering prescribing herbal marijuana or pharmaceutical cannabinoids to their patients should consult other sources, including Health Canada’s Information for Health Care Professionals: Cannabis and the Cannabinoids and Daily Amount Fact Sheet.

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    • regan breemersch says:

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  • Bernie says:

    The educated people involved in the allowing alcohol and cigarets on the market, I believe should not be making any more decisions on what a person should or should not take, they failed the first step , now something softer which doesn’t have as many negatives as the first two mentioned seems to have gotten a bad name , like it was taboo , I believe its all to do with who gets all the money . If they would give it a serious thought about marijuana vs alcohol & cigarettes , you would have to say Who ruined who’s life. Do we really need this group of people under control . I repeat they failed on the first step , Maybe if they rid the first two and we will have a better place to live in. No body wants to go there . Lets just cut the red tape and put on a happy face , the world will be a better place.

  • Wayne Phillips says:

    this article is, for the most part, why patients are being denied access. It is more an expose on how access is to be thwarted.

  • Rick G. says:

    Wow…this is Big Pharma propaganda. What an absolute joke. Cannabis IS the front line treatment for at least one medical condition–OPIOID ADDICTION! The result of Big Pharma pushing and doctors overprescribing dangerous addictive drugs such as Percocet and Fentanyl. This has become even more apparent as companies like Insys, who make fentanyl, donate huge money to fight against medical cannabis legalization. You claim limited evidence effectiveness of cannabis for chronic pain; however, it has been effectively used for thousands of years. If anything, opioids have not been sufficiently clinically tested and, when they have, they have shown dangerous addictive properties that have been ignored and swept under the carpet. This is NOT a journalistic article–it is a misleading and misinformed OP-ED.

  • Randy says:

    Why with all the side effects other prescription drugs have ,we need to be open minded to medical marjiuana for helping those who need it.Because it does help many people.That is a fact!this should also be covered by OHIP because it is part of our healthcare system.Be OPEN MINDED PLEASE!

  • Steffen says:

    “The College of Physicians and Surgeons of Alberta recommends that their members not prescribe marijuana for medical purposes.”

    The link you posted in “recommends” is dead, but upon looking up the CPSA comments on medical marijuana I could find nothing suggesting they shouldn’t prescribe it. Can you provide a new link that backs up that statement?

  • p.joseph says:

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  • Northern Pain Sufferer says:

    I just turned 54. I have suffered from back pain for at least 14 years. I also have nerve damage that sends spasms of pain down my thigh, and neck/shoulder pain from a car accident. My doctor gave me Tylenol 3. I have 30 pills for 30 days – they don’t work unless I take much more than recommended and then I get the side-effect of intolerable pain in the area where my gall bladder once was. There are also 3 different meds that are supposed to stop the pain and a seperate pile of 18 pills a day just for the spasms in my thigh. I am also bi-polar. I believe that I exhausted the variety of pills my psychiatrist pushed on me – I never felt any better; although I was certainly sedated into non-movement and unable to fully wake up quite a few times. 3 weeks ago I started to research HOW to use marijuana because I have never smoked in my life and somehow the idea of learning to smoke while coping with my asthma and the inhaler that has the side-effect of causing osteoporosis just seemed like a stupid idea. I settled on a vaporizer and bought some marijuana from a friend of a friend (no idea what the strain is). It made me forget about the pain and for the first time in a long time I didn’t need to load up on pills. I also buy OTC meds to try to kill the pain everywhere in my body. Thinking this would be the answer to my prayers, I trotted off to my doctor in hopes that he would sign the magic paper to allow me to get marijuana legally. He wouldn’t – citing the fact he had young children, didn’t want every pot head to storm his door, and he already had enough problems with Native Canadians wanting narcotics to even contemplate starting to OK marijuana. Strangely he was fine with my using marijuana and didn’t discourage me, saying, if it works and you are careful – well good for you.
    I don’t live in a town where you can even find another doctor – you are stuck with whomever you have and you are lucky to even have a doctor. I’m hundreds of mile away from a city where you can find a doctor who works for a marijuana dispensary group. Plus I am on disability from the province and CPP disability – I can’t afford to pay for the gas to get anywhere and I can’t afford to pay a couple of hundred dollars for a strange doctor to sign a paper that allows me to be out of pain. My meds are all paid for by the province so this isn’t something I am doing just for the fun of it. Currently I buy my marijuana out of province so that I can pick the right strains for me. My family says I am much calmer and easier to get along with since I started using the vaporizer. I should give this up? Frankly the province could pay for $60 worth of marijuana and save themselves about $450 a month if only someone would realize that marijuana isn’t the horrible deadly plant they want us all to believe it is. It isn’t much use to patients to dangle the prize of “no pain” in front of them and then let them find out that no doctor will sign the required papers. We want to follow the law, we want to be legal, we want to be responsible but we are not being given that choice.

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  • Pain Jain says:

    This article is based on US studies, as someone who has been on Pain meds for over 12 years and just recently tried mm for back pain and inflammation I can tell you it works. Should it be regulated like big pharma? No! Why? When big pharma gets into the picture it becomes all about creating dependence, and right now this drug is not addictive. I am addicted to not feeling horrible pain, but I don’t go through 4 days of withdrawal after stopping it. PAIN causes mental instability issues, it becomes an all enveloping the huge elephant in the room that takes away quality of life. I do not trust a company that see’s my pain as a way to ensure their profits. We still need to change the focus of doctors to get away from band aids and finding cures.

  • rj says:

    As people begin to flood south to get their MMJ, the provinces will lose out on a huge tax base. Their tourist industry is already booming with Cdn tourists and fewer are coming here. Money is what talks. Colorado alone had revenues of $998 Million for 2015. No province can turn their nose up at that for very long.

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  • Saima Sheikh says:

    I had sever sciatica and ended up with ruptured discs and sever nerve damage that a discectomy surgery couldn’t fix. A few years after this I was diagnosed with fibromyalgia. It’s been 8 years now, I’m 35 yrs old and the pain has become unbearable. I have to small children who watch their mother try to keep it together. My husband of 15 yrs cries at my condition now. It truly is unbeatable. Tylenol 3 with codiene, tramadol, tramacet, ralivia, gabapentin, lyrica, zoplicone, amitriptylene, Ativan, OxyContin and now fentanol patches. This is my progression in meds in the last few years. What more can I try? I have been to every doctor, specialist, alternative medicine practice I can think of. What more does my doctor need to write me a prescription for medical marijuana or its extract? I cried in her office yesterday and she just refuses to consider it….this was my first time asking. What do I have to do in Alberta to get the extract to begin dealing with the pain without my doctor?

    • Leighton Tieszen says:

      Hi. Your posting is old, perhaps you’ve already found the help you were looking for?

      I just recently went to my Dr. for severe insomnia and anxiety symptoms. I had used marijuana years ago and researched it before my doctors appointment. He listened and prescribed MM. Today, 3 months later life is good. I sleep like I did as a baby. My anxiety seems to be drastically reduced. I’m thankful for my doctors help. If there’s something I can do let me know.

  • Don says:

    I think the ayes have it!! Let get this stuff legalized and helping people where it is appropriate.

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  • Gerard Vincent says:

    Hi, I am going to my family Doctor tomorrow to discuss the and beg for prescription marijuana.I have chronic back pain as well in my legs for a few years now.Tried everything and presently taking 1 patch 100 Mgph + 1 patch 25mgph fentanyl and 4 mg hydromorphone 3 times daily with very little or no effect at all.Anyone who looks this up can see it’s a lot of pain meds but those opiates are killing me in many ways.I support marijuana with all my heart as I just found out without knowing my own brother who like me was never into drugs.It takes away pain in his hands from working over the years and has been operated for carpal tunnel on both hands.Hope she will take a strong look .Thanks..Gerard..

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    I need to find a doctor in Ste. Agathe des Monts, Qc that would prescribe this to me..all has been tried to eliviate the tinnitus and pain with even epileptic meds and nothing has worked.. I am 71 yrs old and suffering so terribly that I cannot function because of the pain and noise it causes ..I really need help and had been offered the medical marjuana before but the doctor when I went back to see him had retired..
    Not knowing much about it, I didn’t try to find anyone else..but watching on CNN about it has given me hope..because I am at my wits end and it bothers me so much that I tremble inside so bad..I no longer have friends because it prevents me to be socail..I NEED HELP.. please.

  • Robbie says:

    I had a 5th and very severe concussion in May 2013. Since then I’ve been wracked with daily migraines, dizzy spells, neuralgia, mood swings and other PCS symptoms. I’ve used locally grown, quality marijuana in a vaporizer since 3 weeks after my accident. It’s the only thing that has worked. My neurologist tried Tramadol and Gabapenetin, both made me feel like I was dying. In contrast, the vaporizer cannabis improves ALL my symptoms, as well has cleared my lungs of the damage done from working in a bar during the smoking years. Being that it is a bronchodilator it has really made me breathe much better, not the same effect with a joint or water pipe at all.

    Using Cannabis medicinally has saved my life and made me a much more productive person. Also, I don’t have to have my liver function monitored like some of the Rx’s we tried. I’ve been very honest with my Docs about this and they both agreed that it’s an effective low risk intervention.

    Tmor I go to my MD to ask for a referral to get my RX for Cannabis. I’m very hopeful we will have a polite discourse and come to an agreement. I would like have it legal and controlled so I can narrow down a solid dosage plan and not worry about being arrested for posession. Though I doubt any judge would convict with my medical history, lack of criminal record and the fact that I’m not abusing it or even using more than once a day in some cases.

    To say that I’m happy about the laws being changed lately is an understatement. I think we still have some serious work to do, but people are getting much better treatment. The problem is that most are doing it illegally and without medical supervision like me.

    To be clear, I’m a personal trainer, in great shape, eat well and don’t drink at all. I’m not some pot head looking to get it for free. I’m still divided on legal recreational use, though it would drive millions in tax and take millions out of the crime syndicates and regulate the strengths, strains, etc. The tricky part is the details.

  • Leonard Darlow says:

    I have received a prescription from my doctor and the pharmacy I deal with is unable to fill it due to backorder from the manufacturer. I have ingested natural marijuana and it helps considerably with my chronic neck pain due to c spine injury. Where can I get this prescription filled in Northern Ontario, Canada.

  • Joe Charles says:

    I have done my own research on the benefits vs negative effects of marijuana and believe that this article is clearly biased. I support and encourage the legalization of marijuana for several reasons. I will continue to use marijuana for the effective relief of my stress, PTSD, and back pain because no other prescribed medications have offered me the same benefits. I would likely use it even if I was not experiencing a variety of pains because marijuana has several other benefits AND IT SIMPLY FEELS GOOD. Make alcohol, unhealthy food and World of Warcraft illegal instead.

  • David Anthony Linge says:

    I suffer from seizures. I have tried every conventional medication that the doctor gave me, with no success. I smoked Cannabis in the late 70’s/early 80’s, but quit when I got married and had children. An article I read stated that Cannabis is extremely effective in treating seizure disorders. I decided to buy a gram of marijuana from a street dealer. I smoked 1 “joint” that had about 100 mg. of marijuana in it (I got 10 “pinners” out of a gram). The results were absolutely astounding. Not only did I have no seizures after smoking the 100 mg. joint, but the medicinal effects lasted for 3 days after smoking the initial joint. I immediately booked an appointment with my family Dr., and brought in all the paperwork to register for the medical marijuana access program. According to the stipulations laid out by Health Canada, I was a prime candidate for marijuana therapy. I was shocked when the Dr. refused to sign the application. I have been to at least a dozen doctors asking them to sign my form, but was met with disgust and ridicule. I had planned on growing 5-6 plants to treat my condition (my disability leaves no money left to buy it, let alone food). Absolutely NO doctor will sign the form to allow me access to the only medication that worked to stop my seizures. Then, I found that there are numerous doctors that would sign all my MJ access forms for a paltry $400. I do not have $400. If disability gave enough money to be able to afford the $400, I could have access to my medication, but sadly, disability will not pay for “unproven treatments”. Now Our illustrious dictator, Stephen Harper, has made it impossible for me to have access to my medication, and even if they did accept my application, I would have to pay MORE than street prices for my meds.

    So, now I have become a criminal in the eyes of Harper because I managed to get “clones” and have planted them up in the mountains. This is saddening that as an otherwise, law-abiding citizen, I am now classified as a “dangerous drug manufacturer”. Well Mr. Harper, f*ck you. Come and get me for growing my own medication. My name is published, as well as my email, so you should have no trouble sending your DEA sponsored agents to come arrest me for my right to have access to the medication that allows me to lead a fairly normal life. I heartily await our day in court. Come get me, you jerk. I am not scared of you, our your law. I look forward to fighting this issue in court, and even if I am put in jail, it will be worth it. I am sorry I cannot donate, but I live on $1.25 for food.

    • David Anthony Linge says:

      Sorry, that was $1.25 a DAY for food. 1 can of sardines, $1.00, 4 slices of bread, .20 cents, and .05 cents for the spinach I put on my sardine sandwiches. Sorry for the extra post.

  • lots of sciatic pain says:

    the drug companies cant make enough money so they dont want it to happen and they have lots of cash so they can slow the process down and you can be sure they will

    • Mike S. says:

      It really is a joke all around. They can’t patent the plant, they can’t get Marinol to work as intended because its just not as effective as regular medical grade marijuana, if people grow it themselves they won’t be able to regulate OR tax it. It doesn’t matter that it could potentially be a boon for some people, it doesn’t fit their agenda so they’ll fight it. All they did by passing these new laws is just push it back underground and people will continue to grow it albeit illegally now.

  • Manfred Humphries says:

    There has never been a fatality recorded from a cannabis overdose (unless accompanied by testosterone misadventure), so why is there such reluctance to prescribe medical cannabis? Let me see if I understand:
    1) There are no guidelines or protocols which outline potency, frequency and which constituents work best on which conditions. Would it work to instruct your patients to start small and work their way up to an effective dosage of a particular strain that seems to work for them, then modify their prescription to fit their experience?
    2) The provincial, state and federal medical associations appear to be in denial about the possible beneficial effects of cannabis. Is it possible for them to publish even-handed information about cannabis, bearing in mind that there has never been a fatality recorded from a cannabis overdose?
    3) Federal law in Canada is a mishmash of mis-understanding and misfires, apparently based on outdated beliefs, false information, bad counsel from Health and Agriculture Canada, and the over-riding fear of creating controversy by legalization. There were 37,000 registered medical cannabis users last year; that number with increase by an order of magnitude now that Health Canada has butted out. The impact on the cost of care delivery in Canada will be nothing short of phenomenal, so whose interests are you serving by not encouraging its use?

  • Ian Mitchell says:

    I want to thank you for an interesting article, although I found the tone disappointingly negative.

    “Marijuana is not first line treatment for any condition” — unfortunately, we are dealing with conditions that have poor treatments available. In the case of sciatica, one of the causes of neuropathic pain, the evidence for any treatment is weak. ( The situation is hardly unique to the cannabinoids.

    When we talk about medications for pain, let us examine some of the first line treatments.

    Acetaminophen is a common and effective pain medication that is first line for many chronic pain conditions such as arthritis. But it is particularly toxic in overdose, especially in children and the elderly and a recent Toronto Star article points out the dangers of this agent. If it was introduced in the market today, it would never be approved as an over the counter agent.

    The best thing that can be said about acetaminophen is that it is far safer than what are typically second line agents, the NSAIDs. These agents come with a high mortality risk (about 16 000 dead in the US every year), due to gastrointestinal bleeding. Newer agents were said to have less risk of GI bleeding, yet increased the risk of heart attack. In the case of Vioxx, this was an FDA and Health Canada approved agent, that killed tens of thousands. Given the overly close relationship between pharmaceutical corporations and the approving agencies, approval of a drug by a federal agency should not be seen as a measure of efficacy or safety.

    Opiates are either second or third line for chronic pain, although based on poor quality studies on relatively short durations. From a previous Healthy Debate

    She notes Health Canada’s mandate to ensure drugs are safe, and highlights that while the safety of short-term use of prescription opioids for acute pain has been well established, “no one has proven that they [prescription opioids] are safe and effective for long-term chronic, non-cancer pain.”

    Codeine should probably be removed from any formulary. It is inconsistently metabolized prodrug that allows the clinician to kill children or prescribe what is essentially a placebo.

    Tramadol has been felt to be a useful new agent. But what else are the drug companies hiding besides a oxycontin-like high and unspoken addiction issues?

    Oxycontin bears special mention if only for Purdue’s multiple episodes of malfeasance

    Most patients are rightly concerned about the high frequency of physical addiction that comes with chronic opioid therapy and a number of CTP patients have expressed their frustration to me that their physician is happy to write a prescription for Percocet, but not for cannabis. Deaths from prescription opiates are particularly high in my health authority (IHA), with the rate of deaths from patients using their own, prescribed antibiotics is the same as the number of people we are losing to drunk driving. Opiates are also much more lethal when combined with alcohol than cannabis.

    With regard to federal approval and opiates, we should be very aware of their prominence in the regulatory sphere, including the recent bumping of a critic from a parliamentary prescription drug panel in favor of a representative from Purdue Pharmaceutical, makers of OxyNeo.

    Gabapentin can be effective for some people with neuropathic pain. But if you are concerned about the level of literature that supports cannabis, you really should look at the concerns regarding the studies of gabapentin which make interesting reading and have led to massive settlements against the drug company against promotion of their drug for off label indications.

    When we get down to this level, we can start to compare agents. In neuropathy, gabapentin has an NNT of 3.8 while low to medium vaporized cannabis showed an NNT of 2.9-3.2 And no risk of overdose. And while many people show inordinate concern about diversion into the black market, the same concern should be applied to both Tramadol and Lyrica

    Another issue to address is cost. A bottle of Sativex currently runs at $226.70 (for a 10 day supply, and don’t forget about the mucosal burning with administration) and while ondansetron is a very effective medication for vomiting, the rapid dissolve preparation sells for approximately $7/pill, easily over $200 for a 10 day supply. Either of these could easily create patients costs of several hundred dollars per month, compared to the very low cost of cannabis that is available to the home CTP grower, and will now be banned by the new regulations.

    The safety of CTP is also mentioned as a risk, though as a practicing clinician, I would have to rate it as one of the least risky drugs I ever prescribe. Aside from the absence of direct toxicity in overdose, any respiratory or malignancy concerns can be removed by vaporization (I think you would find very few prescribers who would recommend smoking). There is no evidence that even smoking cannabis causes COPD any malignancy risk has only been seen in heavy users. I would encourage the vaporization of concentrates in e-pens as a potentially useful delivery system. The current provision of solely dried plant material is inconsistent with harm reduction principles.

    You may have overlooked the followup article regarding the Dunedin paper, which demonstrated that IQ decreases were more easily explained by socioeconomic cofounders. In the same vein, you quote a study from 2003 to support the assertion that cannabis can cause psychosis, yet ignore a Harvard study published this year that does not support your conclusions.

    Some note is made of the restrictions on research that have lead to this state of affairs. There have been urgent calls for research into cannabidiol, and yet there has been no weakening of the schedule of these drugs. Cannabidiol is currently Schedule 2 in Canada, despite having no street value or psychoactive effect. This is beyond a third line drug for the treatment of pediatric epilepsies, such as Dravet’s syndrome, and yet has been found to be one of the few things effective in treating these children. There is no provision in the new regulations to produce cannabidiol concentrates that could be used to control the seizures in these Canadian children, forcing them to consider emigrating to have access to this medication.

    There is no reason that research couldn’t be carried out here, but not as long as the research material is banned from being produced and likely to get you thrown in jail. The stigma attached to cannabis is also felt by patients who would like to try the edibles, oil and concentrates that are enjoyed by patients in other jurisdictions, but will not be supported by the new Health Canada regulations.

    As Canadian physicians it is also important to take a public health approach and look not only at the effects of clinical cannabis on the individual, but also on society. Two recent studies have shown some impressive positive effects on US states that have legalized medical cannabis. Legalizing medical cannabis does result in some spillage into the recreational market, but this has the interesting effect of decreasing the frequency of binge drinking.

    States who legalized medical cannabis noted a 10 percent decrease in suicides in males 20-39 that was consistent between states. They were also found to have a 9 percent decrease in traffic fatalities in the year following legalization. and

    • Fiona McMurran says:

      I recently asked my daughter’s epileptologist if she would consider prescribing medical marijuana for my 29-year-old autistic daughter, whose seizure disorder (she has three types of seizures, including tonic-clonic) has been steadily getting worse. She has exhausted all the anti-psychotic medications, and surgery is not an option, since seizure activity occurs in three different areas of the brain. Can you direct me to any research on cannabidiol used to control seizures in adults?

      • AA says:

        CBD has not been approved for human clinical testing, but here is an old article about CBD compared to your typical antiepileptic drugs on rats with induced seizures.

      • David Anthony Linge says:

        Hi. I suffer from seizures as your daughter does. From my personal experience, the Cannabis has eliminated my seizures. I am an activist in this area. There is a new marijuana strain developed in Colorado that contains practically no THC (the chemical that gets you “high”), but has a large content of CBD’s that are believed to be the active ingredient that prevents seizures, but has no mind altering effects. This strain is called “Charlotte’s Web”. It comes in a liquid form that has been used on infants and toddlers with no ill effects, and very positive results in reducing/eliminating seizures. If your daughter does not want the “high” associated with regular Cannabis, this might be the strain for her. Good luck and best wishes!

      • Beth says:

        Is there anywhere in Canada that I can purchase Charlotte’s Web .
        Do you know of a Doctor in Ontario that will give a prescription for this to a 4 year old with 100 of seizures per day ?

    • Lionel Marks de Chabris, MD says:

      Thank you, Dr. Mitchell. An excellent counterpoint to the notably negative Healthy Debate article.

      I will copy your piece and keep the references handy when I am forced to debate the usefulness of medical marijuana with my colleagues – an unfortunately frequent occurrence these days as we move towards the new regulatory structure.

    • Pat Kelly says:

      Excellent, thoughtful response to a very biased article. I am a cancer advocate and have become interested in the issue of accelerating implementation of a national pain strategy in

      Chronic pain is one of the most common reasons Canadians go to their doctors, occurring in an estimated 30% of the adult population. Despite its high prevalence, only 32% of Canadian medical schools provide formal training in pain management, including training in the safe and effective use of potent analgesics, most notably opioids. Veterinary schools devote an average of 87 hours to pain management education compared to the mean 16 hours in medical schools.

      Its not at all surprising then, to learn that with so much pain and so little medical expertise, Canadians are struggling to find relief any way they can, including thru the maze of medical marijuana options.

      Pat Kelly

    • Sandra Wright says:

      Hi, as a person who has lived with chronic pain I have to agree with all you said. I have gone down the list you mentioned and ended up in hospital due to way too many narcotics in my system. They were prescribed and taken as told. I eventually got off all of them and quit smoking cigs. However I still have to deal with this pain. I have now been prescribed marihuana and it helps so much with not only my pain but also nausea and appetite. I can vouch as a user that this has helped more than any other method I have tried. And I have tried them all! I really wish I had the option of edibles or tinctures in Canada and it would also be great if Trillium would cover the cost of it as it is a prescription and a lot cheaper then all the narcotics I was on! Also cheaper then other alternatives such as massage and chiropractors and acupuncture. I sure hope Canada’s laws change soon!

    • Aaron says:

      excellant response to a onesided argument against cannabis. i have been occasionally taking cannabis for 3 years now and have found it easily out performs prescribed drugs. cancer is hard enough already and i don’t need drugs that cause worse problems then the condition they are supposed to fix.

    • rj says:

      I was on Gaba for shingles for 5 wks when I realized that despite the pain, I was going to die if I didn’t stop taking it. I had the good sense to taper off over about 10 days. No idea what might have happened if I’d suddenly stopped.

    • Kandice says:

      I think you should have written the article! Well thought out, educational, informative and very interesting.
      Thank you !

  • David Walker says:

    I applaud patient driven initiatives but it would seem prudent to add some sort of true evidence about risks and benefits into the mix. After all, without such evidence, patient initiative would see Zamboni invasive “rescue” treatment for MS being widely performed (remember all those remarkable endorsements) along with a variety of other unproven remedies misleading and often harming the public.
    The medicalization of marijuana use is, in fact, a back door process of allowing its use by means of a physician’s imprimateur – a situation in which the profession is being co-opted to assuage political nervousness.
    If our society is prepared to accept the risks and personal euphoric benefits of marijuana (as we do for alcohol), then we should have the guts to legalize it, control it, regulate it and not impose on docs the pressure to prescribe it. “Primum non nocere” applies. It should not be our job.
    The next step will be a challenge to list marijuana on the ODB and as a benefit in private insurance plans- after which wait times to see the doc will be quite remarkable. Easy script and free weed – what could be better?

    • Dean Unger says:

      Has there not been “true evidence” research / trials, as pertains to risks and benefits done when the synthetic THC / CBD drugs were manufactured by pharmaceutical companies re; Nabilone?

  • Pain Doctor says:

    In Ontario, doctors have a right to refuse to prescribe marijuana under the policies of the College of Physicians and Surgeons of Ontario (CPSO). The CPSO is currently revising this policy in light of the new federal regulations, but Gerace expects its substance to remain unchanged.

    The fact that this is even mentioned is concerning. Given the paucity of quality evidence for medical benefit there is little more than public opinion driving demand at this point. That the CPSO would consider mandating prescribing is a shameful concession to politics. One would hope that the CPSO would advocate for evidence-based prescribing of any medication.

    • Jeremy Petch says:

      Perhaps this passage is unclear. The CPSO is not, to our knowledge, considering making such prescribing mandatory. The purpose of their policy is to clarify for physicians that they have a right to not prescribe herbal marijuana, precisely because of the paucity of evidence. Our understanding is that it is being revised because the old policy specifically refers to the Federal program that is being eliminated on March 31st. Gerace is not able to speak to exactly what the new policy will say, because that is ultimately up to the council of the CPSO, not the registrar.

    • Robbie says:

      I agree. But the off label use of Gaba and other drugs hasn’t really been proven through the gold standard of testing has it? I’ve seen MDs routinely guess at whether a drug will work for a patient and then remove it due to horrible side affects. The same would be hard to say about medical cannabis. It works for many, many awful conditions with low risk. Cancer and AIDS patients are just about the most fragile sick people around and it works wonders for their pain management, mood and appetite. How can it hurt someone with bad migraines?

    • cheryl doucette says:

      i have been on medical mariguana for 4 years because of very bad fibermyalgia. i was recently in a car accident and the er doctor found traces of pot in my system. he did not hesitate to suspend my license . i talked to my lawyer and another service provider which i have been with since my mmra expired. my doctor refuses to tell the MTO that he signed the original document. its been suspended for 5 months now and i live 50 km from any town. i had no idea that my doctor was not sending letters in response to the mto. i called the other day and i faxed over all the proper papers needed to prove i am legal. i have had difficulty walking and bending ever since. the pot would help with my fibermyalgia. i am in a very bad depression right now . i have a jaw that i broke twice on the same side and they could only operate on once. i dont have dentures for my bottom jaw and my face now is all deformed because of it. can doctor lie or refuse to do something as important as that. especailly when i really need it i also have bad arthritis. it helps me at night to relax and go to bed with less pain.i call the mto and found out from the message they have on there that its been sent to the tribunal so hopefully i will have it this week.

  • Zal Press says:

    The use of medicinal marijuana is a uniquely patient driven initiative. Political, legal, corporate and social bias antagonists have stood in the way of any significant investment in scientific evidence that informs clinical guidelines. Despite the obstacles, patients have persevered.
    This is also a unique historical opportunity for patients to be the primary influencers of what products are to be prescribed. While physicians may not know the qualities of individual products or the dosages, crowd sourced patient opinion will fill in that detail. Patients will know what strains can suppress pain while keeping one alert enough to work effectively, or conversely, suppress pain while allowing one to sleep comfortably. This may be the first time in history that a clinical trial will be substituted by mass input from crowds of patients.
    Not to be dismissed is the greater mass of recreational users and licensed producers in other jurisdictions, notably Colorado and others, where particular strains will be analyzed, assessed and opinions expressed that will inform all users for any purpose.
    As a patient this is an exciting moment allowing one to be an active participant in a healthcare project. For physicians I can see how this can be a threat to their traditional role as exclusive gatekeepers to medication. For industry producers raised on showering gifts and affection on the medical profession, this is a wake-up call that this model can be challenged and that the voice of the patient needs to be listened to carefully.
    The future of patient engagement and participatory medicine has never looked brighter.

    • John Doe says:

      “For physicians I can see how this can be a threat to their traditional role as exclusive gatekeepers to medication”

      That is an ignorant statement which highlights the actual threat -> patients routinely make choices that are bad for their health. We might as well open up the narcotics cupboards and make it a free for all, or allow ritalin and dexedrin freely roam the streets. If patients had a history of making good, intelligent choices when it came to mind altering drugs, you’d have a point.

      They do not, so your point is moot.

      • jane doe says:

        no matter what you think is being done to protect people from themselves, it is an illusion. this plant has been on the streets for a long time now and people have been helping themselves to it. you talk like it’s something new to be offered out there and that people will kill themselves with it if it is made more available, but it has been available for a long time and no one has died from it yet. but here we are with people dropping dead all around us from overdosing on patches and other dangerous prescription drugs! and these narcotic drugs you speak of have already been roaming the streets for a long time now. your point is moot.

    • Dean Unger says:

      Good evening, Zal. I am a magazine editor from British Columbia, and would like to use your statement here in a story I’m working on, if I may. The editorial will appear is Gonzo Okanagan – The story I am working on at present will be an inaugural launch of an ongoing investigative series on the subject.

      Sincere Regards,
      Dean Unger


Jeremy Petch


Jeremy is an Assistant Professor at the University of Toronto’s Institute of Health Policy, Management and Evaluation, and has a PhD in Philosophy (Health Policy Ethics) from York University. He is the former managing editor of Healthy Debate and co-founded Faces of Healthcare

Mike Tierney


Mike is the Vice President of Clinical Programs at Ottawa Hospital.

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