The College of Family Physicians of Canada drew the ire of Canadian cannabis advocates in February, when it published a set of guidelines meant to help primary-care physicians decide when to prescribe cannabis.
Cannabis and its chemical constituents, concluded the guidelines published in the medical journal Canadian Family Physician, "are not recommended for most patients and conditions by far."
Cannabis is "an ineffective and useless substance," wrote the journal's associate scientific editor Dr. Roger Ladouceur in an accompanying editorial entitled "The cannabis paradox."
"Study after study, analysis after analysis, and review after review have all reported the same findings: cannabis has little place within current therapeutic arsenals, except as a last resort in very specific situations or when nothing else has worked," wrote Ladouceur.
The state of marijuana for medical purposes in Canada is indeed a paradox of sorts.
The number of Canadians who are legally using cannabis to treat medical conditions ranging from chronic pain to seizures, from muscle spasms to insomnia, is growing at an astounding rate. At the same time, the attitude of the Canadian medical establishment remains skeptical, at best.
Those attitudes are evident in the official positions of the Canadian Medical Association, the venerable advocacy and lobbying organization that represents more than 85,000 physicians across the country.
In its August, 2016 submission to the federal government's cannabis legalization task force, the CMA called for the government's existing medical cannabis system to be abolished after the legalization of cannabis for recreational purposes. (That regulatory framework has existed, in evolving forms, since 2001. The government didn't accept the CMA's recommendation, and the federal medical cannabis program is set to continue in the near future.)
Federal legalization of cannabis "does away with the need for a separate medical system when these substances are available to anyone who's interested in trying them," said Dr. Jeff Blackmer, an Ottawa-based physical medicine and rehabilitation specialist who helped develop the CMA's cannabis policies in his role as the association's vice-president of medical professionalism.
In an interview, Blackmer said "probably the majority of physicians aren't comfortable authorizing this substance." The federal government's requirement that physicians authorize legal medical cannabis use in the first place is "a responsibility that clearly was never requested" by Canadian doctors, he said. (Physicians aren't required to prescribe cannabis for patients who request it, but patients do need a physician's approval to sign up for the legal medical cannabis regime.)
Blackmer said some doctors struggle with prescribing medical cannabis because they aren't willing to base clinical decisions on what the medical establishment considers low-quality or anecdotal evidence about the benefits of the drug.
While the CMA recognizes "that some patients do seem to derive benefits" from cannabis, Blackmer said, that isn't enough for the association to consider cannabis a medicine just like pharmaceuticals.
"We're not a regulatory body, we don't prescribe regulations that if a physician doesn't follow it, their licence is at risk or anything like that," explained Blackmer. "But we have, certainly I think, very consistently urged caution when it comes to the use of cannabis for medical purposes."
At what point would the CMA acknowledge that cannabis can be used as medicine?
"The obvious answer would be, once that research meets the standard that's required for all other prescription medications," he said.
That means large-scale, double-blind, randomized controlled trials — and when it comes to cannabis, that kind of research is no easy task.
The medical profession's preference for those traditionally designed pharmaceutical studies excludes the vast majority of research on the therapeutic potential of cannabis.
For example, one frequently cited systematic review and meta-analysis of medical cannabis research published in the prestigious Journal of the American Medical Association in 2015 started with 505 "potentially relevant" studies but included only 79 in the final analysis. More than two-thirds of those studies didn't involve the cannabis plant itself or its individual chemical components —known as cannabinoids— but rather, cannabis-derived drugs or synthetic cannabinoid products produced by pharmaceutical companies and approved by government regulators.
Mitch Earleywine is a professor of psychology at the State University of New York at Albany, sits on the advisory board of the National Organization for the Reform of Marijuana Laws and authored the 2002 book Understanding Marijuana, a New Look at the Scientific Evidence.
"To say I looked at 1,500 articles" when researching that book, said Earleywine, "is not an exaggeration."
Earleywine described the lack of traditional medical research on cannabis as a kind of catch-22. Despite the huge amount of existing research on cannabis, said Earleywine, "the classic, randomized clinical trials, which are super-expensive, have not been funded."
"And so, plenty of people can make that complaint and can say it's true, but we can't get (U.S. government research agency the National Institute on Drug Abuse) or a lot of the standard funding sources to fork out any funds."
Earleywine said he once applied for a NIDA grant to pursue research on the use of vaporizers to consume cannabis, but "before I was even done with the abstract I called one of the people there and they just laughed at me."
"There's no way a harm-reduction thing for marijuana is going to get funded," he said. "And I was kind of heartbroken, because they wanted grants that said 'marijuana is evil,' basically."
Until relatively recently, the vast majority of research questions asked about cannabis were about the potential harms of the drug, he said.
"It's changed over the last two decades, but generally it was, 'How do we keep adolescents from using?' 'How horrible are the negative consequences for users?' 'What's the probability of developing dependent symptoms?' and then that unfalsifiable gateway nonsense — 'How does this turn into you being a heroin addict?' basically."
Even the few researchers "who have had the opportunity to do anything about positive impacts or medical utility have to jump through enormous hoops to get to just have enough funding to run some pilot data," said Earleywine.
Dr. Mark Ware, a Montreal-based family physician who practises pain medicine and serves as executive director of the Canadian Consortium for the Investigation of Cannabinoids, has his own theory about why so much cannabis research has been premised on questions of harm and danger.
"I think that one way to look at it is that there's been a lot of focus on recreational cannabis use as opposed to medical... and as a result of that dichotomy, the focus on recreational cannabis use has always been population health issues around, 'What are the known potential safety considerations for people using cannabis for non-medical purposes?" said Ware.
"And those include the psychosis issues, and mental health and driving, and so on."
Ware said he's confident that high-quality research on the medical applications of cannabis is on the way.
Cannabis legalization in Canada has been touted as one potential path to that kind of research, but Earleywine is skeptical. He said there's just not going to be much money to be made from researching a plant that can't be patented.
"Why would anybody fund a randomized clinical trial? It's not going to pay off," he said. "Why put a half-a-million dollars into one of those when you don't have the market cornered on the drug?"
Hundreds of thousands of Canadians have already decided they don't need the medical and scientific establishment to pass final judgment on the benefits and risks of cannabis for medical purposes. They're already using cannabis for medical purposes, legally and illegally.
In a recent Health Canada survey, 97 per cent of self-described medical cannabis users said the drug helped them manage their conditions.
At the end of September 2016, 98,460 medical cannabis users were registered with Health Canada's legal medical marijuana program, which requires a doctor's authorization in order to purchase cannabis directly from government-licensed producers. By September 2017, 235,621 people had signed up — an increase of nearly 140 per cent in a single year.
That's just a subset of the unknown total number of medical cannabis users in Canada. According to Health Canada's survey, only 19 per cent of those who reported using cannabis for medical purposes said they did so through the legal medical cannabis program. That suggests Health Canada's official medical cannabis registration figures vastly understate the number of Canadians who are using cannabis for medical purposes.
Ware said the rapid increase in legal, registered medical cannabis patients could have a couple of different causes. It could be "that those patients are finding a way to go from having previously been using cannabis outside of the legal framework to now transitioning into a legal framework," he said.
It's also possible, he said, that the physicians who are authorizing all those registrations are doing so "because they're seeing the benefits, because they are recognizing that this is a potentially useful therapy for these patients of theirs."
Dr. Mark Kimmins is one of those physicians. In his previous career as a colorectal surgeon, he practised in Anchorage, Alaska when that state legalized cannabis for recreational purposes in 2015.
"And my patients began to teach me the benefits of cannabis as a medicine," said Kimmins. "I began to observe significant benefits in the use of cannabis as an adjuvant treatment to traditional pain medicines after surgery, and I began to record that and track the experience of my patients, and I began to write about that experience."
Kimmins now works as the medical director at Sunniva, a medical cannabis company that operates in Canada and California. Sunniva is the parent company of Natural Health Services, a chain of Canadian clinics where patients consult with doctors who can authorize their entrance into the legal medical cannabis program. Natural Health Services says it has helped more than 75,000 people sign up with Health Canada.
"Cannabis was a legitimate medicine across North America until the early 1900s," he said. "And at that time, multiple North American pharmaceutical companies were actually not only selling cannabis, but they were actually manufacturing cannabis; companies including Eli Lilly, Parke-Davis, Bristol-Myers Squibb, Burroughs Wellcome, etc., were all producing, manufacturing, testing, and distributing cannabis as medicine in North America."
Canadian legalization, Kimmins said, "will only be positive" in terms of fostering the kinds of medical cannabis research that could elevate cannabis to the status of a mainstream medicine once again.
"Firstly, it will remove the stigma and let people know that this is something that they can utilize without fear of breaking the law and without using something which is prohibited."
Lifting that stigma, he added, will allow academics to do top-quality research.
"And talking to the medical scientists who are interested in doing this research, they are predicting in the next five to 10 years that we will get the type of rigorous data that will support this product the same as any pharmaceutical."
In the meantime, he said, doctors who are interested in learning about the medical benefits of cannabis must educate themselves by doing their own research.
Dr. Sana-Ara Ahmed started educating herself about cannabis in 2015.
An anesthesiologist who practices chronic pain management in Airdrie, Alta., Ahmed wanted to learn about the role the plant could play in addressing what she called "the chronic pain epidemic in Canada."
Ahmed said her medical training as an anesthesiologist focused on physiology and pharmacology, but didn't include any education about the human endocannabinoid system — a series of neurotransmitters and receptors that regulate key biological functions and can be affected by the cannabinoids contained in cannabis.
"When I started learning about it, I recognized that there was a gap in my knowledge, there was a gap in all MDs' knowledge," said Ahmed, who described the decision to include cannabis in clinical practice as a "very personal decision on how you practise medicine."
"I don't want to do any harm in my practice, and opioids are harmful. They're killing Canadians. Medical cannabis is not harmful. There's not a single recorded death secondary to medical cannabis, or cannabis use.
"For myself, it became an identification that I was working from a place of compassion, I was working from a place of having dignity and honour for my patients. And acknowledgement of their pain, and looking for alternatives so that I could empower them so they can manage their life better. And if medical cannabis was a better alternative for them, then I had to have it in my tool kit."
Physicians, said Ahmed, have been conditioned to accept the research criteria of the pharmaceutical industry.
"We're in the infancy of a new era when it comes to treating patients with a plant-based medication.... The need right now is a conversation for all medical specialties to come together and apply our knowledge to a unique situation, which is going back to the roots of how medicine always began — it started from a plant, and then we learned how to use it, and then we learned how to synthesize it," she said.
"But before we start synthesizing it and disseminating it, we need to learn how best to use it."