At the Family Medical Forum in 2017 — the largest family medicine conference in Canada — Dr. Sarah Giles was angry.
The family physician was upset for a few reasons, including that drug reps were lining the pathway to the food area (meaning docs were forced to walk through sales booths to eat), and lunchtime talks sponsored by pharma companies were not clearly labelled as such.
But what really stuck out to Giles was how many cannabis companies had set up shop in the event’s exhibitor hall.
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Cannabis companies are becoming an increasing presence in the medical industry, touting the drug as a remedy for a variety of ailments, from pain and anxiety to endometriosis and glaucoma — and they do it with little oversight.
The legalization of recreational marijuana in 2018 no doubt helped legitimize cannabis in the eyes of many patients. But some experts say they’re concerned that pot is being pitched as a miracle cure when there is still little research into its benefits.
The College of Family Physicians of Canada (CFPC), which hosts the event, confirmed to Global News that there were 16 cannabis vendors at the last Family Medical Forum in November 2018.
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The organization said it will only allow approximately 10 cannabis vendors at the forums in 2019 and 2020 and will “reassess” that number each year.
But Giles is concerned. She isn’t comfortable with the way cannabis companies are trying to sell medical marijuana to doctors.
“Marijuana is the next OxyContin, where everyone’s like, ‘Oh, it’s not addictive, it’s harmless, it’s good,’ and people are kind of using it willy-nilly because you can get it prescribed and not prescribed,” she said.
“I think we will look back at this time and just be like, ‘What the hell was going on?'”
Is medical cannabis effective?
Many cannabis companies have been quick to tout the drug as a pain reliever and a therapeutic product — which has created some pushback.
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“If we look at the evidence for marijuana as a therapy or as a medicine, for pain or for anything, frankly, it wouldn’t meet the threshold for what we consider a body of evidence in medicine,” said Dr. Abhimanyu Sud, a pain expert and the academic director of the Safe Opioid Prescribing program at the University of Toronto’s School of Medicine.
Sud points to a recent systematic review of medical marijuana that found the drug wasn’t a very effective treatment for pain (the review says that if cannabinoids do improve pain, it is neuropathic pain and the benefit is likely small). He also says it’s not proven to be effective for anxiety, either. Where there is some evidence for cannabis, he said, is around treating certain kinds of seizure disorders.
But beyond that, there are a lot of legitimate concerns that require further research about using cannabis.
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Giles echoes this and says she’s seen first-hand the harm cannabis can have on certain people.
“I see a lot of people who smoke a lot of pot and end up with marijuana-induced psychosis,” she said.
A recent study published in the medical journal The Lancet found that daily use of high-potency cannabis is “strongly linked to the risk of developing psychosis.”
Health Canada also warns that cannabis use increases the risk of developing mental illnesses such as psychosis or schizophrenia, especially for people who start young, use it frequently or who have a family history of mental illness.
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Dr. Lydia Hatcher, an associate clinical professor of family medicine at McMaster University, sits on advisory boards for cannabis companies Canopy Growth and Tilray and says there’s “moderate” research around medical cannabis for pain.
“The National Academy of Science and Medicine, which is a big United States organization, did a very thorough review and found moderate evidence that it helps with chronic pain,” she said.
Even with limited research, the common belief that cannabis is safe and helps treat many health problems stems from the way medical marijuana became legalized and is now marketed, Sud said.
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“There was a judicial decision in 2000 that said that it’s unjust to restrict access to marijuana for medical purposes so the federal government was compelled to produce an access-to-marijuana act — but this was not an evidence-based decision; this was a judicial decision,” he said.
“Now we have recreational legislation, and we are working against this idea that marijuana is relatively safe. If it wasn’t medicine, why would it be legalized?”
Should docs be getting their cannabis knowledge from pot companies?
Marketing efforts by cannabis companies paired with legislation has pushed pot to the forefront of many patients’ minds.
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Still, many doctors have expressed discomfort around prescribing cannabis to patients, citing a lack of evidence that it’s an effective treatment for things like pain, sleep disorders and anxiety. There are also concerns around dosing.
But that’s where licensed producers come in.
Jordan Sinclair, the VP of communications at Canopy Growth, said the cannabis company operates “continuing medical education” events that educate “physicians about cannabis science.”
There’s a knowledge gap, he says, as many doctors aren’t educated on the drug.
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“Physicians don’t understand this medicine because it’s not included in medical schools,” Sinclair said.
These learning workshops or panels are common in the pharmaceutical industry, and drug companies often pay doctors a speaker’s fee or honorarium to present at such events. Sinclair says Canopy Growth, which owns brands including Tweed, Spectrum Cannabis and Tokyo Smoke, gives doctors who present at their cannabis educational sessions an honorarium, too.
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While doctors are free to make their own decisions, Sud says paid presentations or informational talks with industry can lead to bias and conflict of interest. Research shows that pharma reps present only selected, usually positive, information about their drugs to doctors and may omit potential risks.
Sud says there’s reason to be concerned that cannabis companies may follow the same route.
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Part of leading cannabis education also means producers are investing in their own research.
Canopy Growth recently announced a partnership with the NHL to research if CBD can help treat post-concussion neurological diseases in former hockey players. Tilray has started studying how older adults use cannabis. Aurora Cannabis launched a research project with McGill University to study the effects of CBD “as a therapy for chronic pain and related anxiety and depression.”
There’s a dark history, however, of industries like sugar and tobacco publishing misleading studies or suppressing research that went against their own interests. Sud also points to research that shows industry-sponsored studies are often biased in favour of the sponsor’s products.
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And within the medical industry, there’s no greater recent example of lying about the effectiveness of a drug than Purdue Pharma, the manufacturers of OxyContin. Evidence shows that the drug company intentionally misled doctors and patients on the drug’s effectiveness and lied about its addictive nature.
Sinclair acknowledges that a cannabis company researching and educating on the benefits of cannabis may present as a conflict of interest but insists that as long as there’s disclosure and a third-party literature review process, there’s no need for concern.
He also points to the process of hiring Dr. Mark Ware, who was an associate professor of family medicine and anesthesia at McGill University, as Canopy Growth’s in-house chief medical officer. Sinclair said Ware had to step down from certain academic positions so there was a clear distinction between his role at Canopy Growth and outside work.
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“And if you do that, you’re relying on the audiences’ intellect, and when your audience is doctors, you can be very confident that it’s going to be taken into consideration.”
How are cannabis companies pitching pot?
Outside of educational events and exhibiting at medical conferences, doctors say some cannabis companies are acting unethically when it comes to interacting with health-care professionals.
While health care is provincially legislated, the CFPC — the professional association that certifies doctors in the country — has nationwide policies when it comes to how docs should interact with the drug industry.
These policies say that doctors cannot accept gifts from pharma reps and should disclose if they’re receiving an honorarium or speaker’s fee from a drug company when presenting related material at a conference. In other words, the goal is to be transparent around any potential conflicts of interest.
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Research shows that gifts from the pharmaceutical industry — even things as small as pens — can affect a doctor’s prescribing habits. A recent study published in JAMA Network Open found “a strong association” between aggressive marketing of opioids to doctors in the U.S. and increases in prescribing the drug.
The CFPC says that health-care professionals should adhere to the same code of conduct when it comes to interacting with cannabis companies, but Giles says licensed producers do not play by those rules.
“It used to be that doctors would get concert tickets, they’d get trips skiing, all of this stuff. Then the rules changed to say that basically the only thing doctors can get is food, but the marijuana producers haven’t signed onto that,” said Giles.
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Hatcher said she’s heard of cases where cannabis companies act unethically and offer incentives to doctors to prescribe their product.
“There are physicians — and I have no proof positive of this but I hear this through talk and from patients — who are sending all their patients to company ‘X,’ and I have heard there are companies who are paying physicians to do that, which is absolutely non-ethical and shouldn’t be allowed,” she said.
“I know there are also physicians who are seeing patients through Skype and non-recognized methods of telehealth and prescribing that way, which is also not ethical.”
On a smaller scale, Hatcher says pot producers hand out branded merchandise, like pens and notepads.
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Canopy Growth and Aurora Cannabis both said they hand out branded pens and the like but do not give doctors gifts. Despite multiple requests, representatives from Aphria and Tilray did not respond to requests for comment.
Sinclair says that because of the unique space cannabis operates in, it’s up to licensed producers to develop their own approach to industry interaction.
“There are guidelines out there for pharmaceutical sales, and we use those to inform our own approach,” he said. “We’re always in this area where the normal rules don’t apply so we have to chart our own course.”
Differences between Big Pharma and cannabis
Unlike with prescription drugs, it’s up to patients to decide what licensed producer they want to buy from with their medical script.
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Hatcher says she doesn’t tell her patients where to get their medical cannabis and says it’s up to them to do their own brand research.
“It’s complicated research because, at least at the present time, there are at least 30-plus companies doing direct-to-consumer selling… and then once the patient has selected their licensed producer, we just do the prescription,” she said.
“That means as long as the physician is using that approach then the bias really is the patient’s bias.”
Giles says there’s a reason cannabis companies are putting themselves in front of doctors, even if it’s up to a patient to decide where they will buy their medical marijuana.
“All of these doctors think they’re immune to having their prescription habits influenced, yet every study shows we are all susceptible to it.”
—With a file from Patrick Cain
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