The European Association for Clinical Pharmacology and Therapeutics is currently distributing a survey to European health professionals in order to analyze their knowledge and perceptions of medical cannabis, a product "like no other".
Interview by Benoît Blanquart, translated from the original French version
Émilie Jouanjus is a pharmaco-epidemiologist at Université Toulouse-III-Paul-Sabatier (Toulouse III - Paul Sabatier University) in Toulouse and a member of the Réseau Français d’Addictovigilance (French Addiction Surveillance Network). Her expertise led her to join the WHO working group on the consequences of recreational use of cannabis in 2015. She is also co-chair of the young pharmacologists working group of the EACPT.
Prof. Jouanjus: The EACPT launched this study on a European scale because the attitude towards cannabis is changing very rapidly. For a long time, its use was illegal almost everywhere in the world, but over the last ten years or so this situation has been evolving very fast. This is particularly true in Europe, where many countries have already allowed its use for therapeutic purposes – such as Germany and Italy – and others are considering it. Experiments are in progress in France, the Scandinavian countries, Poland and Portugal.
The goal of these programs is to allow access to cannabis-based medications for conditions such as multiple sclerosis spasticity, neuropathic or cancer pain, HIV-related cachexia, or rare forms of epilepsy when conventional treatments have failed. Health care providers will have an increasingly important role to play in relation to cannabis, whether it be prescribing it, dispensing it, or supervising its use.
Prof. Jouanjus: Ideally, medical personnel will be able to look at medical marijuana from a strictly clinical point of view: to evaluate its effectiveness and its side effects. The feedback of all the actors involved in healthcare is all the more crucial as the scientific evidence is still limited for now.
But what exactly do healthcare professionals know about medical cannabis? This is an emerging and complex topic: cannabinoids are not a single pharmacological class and their pharmacological properties vary considerably.
Lack of knowledge or bias may distort the perception of medical cannabis. As cannabis has rapidly gone from being a prohibited drug to a medicine, it has acquired a certain image of harmlessness. The general public sees it as rather unharmful. Health professionals are familiar with its neuropsychiatric effects but may underestimate others.
In a previous study, I described 35 cases of cardiovascular problems related to cannabis use, as identified by the French Addictovigilance Network between 2006 and 2010. These cases were mostly young men with no previous medical history. Some had acute coronary syndromes, others peripheral complications such as arteriopathy of the lower limbs or even Buerger's disease. I also found three severe cerebral complications. In total, nine of these patients died, and these cases are probably just the tip of the iceberg.
If medical cannabis is to be widely used, it is absolutely necessary that medical practitioners manage to consider it as any other medication to objectively measure the balance of benefits and risks.
Prof. Jouanjus: This can be felt in the field. In the state of Colorado, where the prevalence of cannabis use is high, most family physicians who participated in a study doubted its effectiveness and feared adverse effects. In contrast, in countries that have adopted the use of medical cannabis, some prescribers prefer it to opioid pain relievers or benzodiazepines.
It is also a hot topic in the world of scientific publications. The New England Journal of Medicine has been very supportive of medical marijuana, after a heated debate among its readers. For me, when I published the study on the possible cardiovascular complications of recreational cannabis, it made some waves, especially in the United States.
Prof. Jouanjus: The sociological concept of "distance to the object" is fundamental in this context. Having direct knowledge of a product changes the way it is viewed. In the United States, a study conducted among pharmacy students showed that those who reported having used recreational cannabis had a more favorable view of the indications for medical cannabis. Our survey therefore explores the direct relationship of health professionals to cannabis in general.
In order to evaluate the perceptions, we included some very open questions similar to "association of ideas". The goal is also to understand what the term "cannabis" evokes in the participants. In the end, in this survey we address very clinical aspects among other things: What do you think are the indications? Who should be able to prescribe it?
Prof. Jouanjus: Physicians, nurses, pharmacists... The knowledge, attitudes and beliefs of all those involved in care have an impact on the treatment. Studies already carried out in Anglo-Saxon countries have included, for example, oncology nurses, pharmacists and radiotherapists: and they have shown that no group of professionals had sufficient knowledge about medical cannabis.
In another survey, pharmacists proved more competent than neurologists and nurses regarding general knowledge about cannabis: such as the number of phytocannabinoids in the plant, adverse effects of cannabinoids, legal status of cannabis products or its derivatives, etc. In contrast, nurses had more favorable attitudes than neurologists and better knowledge of cannabinoid properties and clinical applications than pharmacists. It therefore seemed important to us to address all health professionals, especially since paramedical staff's roles are gradually expanding.
Prof. Jouanjus: We will do a descriptive statistical analysis. Then, depending on the statistical significance of our data, we will perform a logistic regression. For instance, we will investigate whether the legal status of cannabis in different countries is a factor that affects caregivers' attitudes.
I work in a research unit dedicated to public health, the Centre for Epidemiology and Research in POPulation Health or CERPOP (In French: Centre d'Epidémiologie et de Recherche en santé des POPulations). It is a mixed unit (INSERM - University of Toulouse), consisting of epidemiologists and clinical specialists, but also lawyers, experts in ethics and philosophers. And these experts suggested that we add certain questions to our survey. They will then help us analyze the results, ideally in collaboration with sociologists and psychologists.