Stockholm Medical Cannabis Conference

Navigating the Complex Landscape of Medical Cannabis: A Conversation with Dr. Amal Hagos on Ethics, Evidence, and Patient Care

In the rapidly evolving field of medical cannabis, there exists a blend of enthusiasm, skepticism, and caution among healthcare professionals. Delving into this complex landscape, we had the opportunity to engage in a comprehensive dialogue with Dr Amal Hagos, a Swedish medical doctor who specializes in pain management and has a keen interest in medical cannabis. Amal currently works and treats patients at the private pain clinic Aurea Care in Stockholm.

The interview explores a broad range of topics including evidence-based practices, the role of the endocannabinoid system, and the ethical considerations in subsidizing treatments for chronic pain. Throughout the conversation, our subject offered an insightful perspective on the future of medical cannabis, emphasizing the importance of rigorous scientific evidence, nuanced clinical judgement, and a multidisciplinary approach to patient care. Here, I present the detailed Q&A that sheds light on these critical issues and more, as we navigate the uncharted waters of medical cannabis in modern healthcare.

Can you discuss any challenges or limitations you’ve faced in 
prescribing medical cannabis for certain conditions?

Prescribing medical cannabis presents challenges that can be divided into medical and ethical contraindications, although the latter often stems from the former. Medical limitations primarily arise from the scarcity of reliable studies on specific diseases and drug interactions with medical cannabis. For instance, Warfarin’s interaction with medical cannabis has been proven and serves as a contraindication.

Severe psychiatric disorders, cardiovascular diseases, and elderly patients pose unique challenges. In particular, psychiatric conditions like psychosis can be triggered or exacerbated by cannabis. Cardiovascular issues present a risk due to the insufficient data on long-term effects. Elderly patients are especially sensitive to THC and often have comorbidities, requiring a cautious approach.

Another concern is prescribing to children under 25 due to THC’s potential impact on prefrontal cortex development. Additionally, patients with a history of substance misuse, or those with chronic nociplastic pain, are generally not ideal candidates for medical cannabis treatment.

Ethically, the long-term side effects of medical cannabis remain uncertain. For example, some studies suggest a link between chronic use and narrowing of small blood vessels in the brain. Addiction potential due to modulation of pain/pleasure centers in the brain is also an ethical dilemma.

Lastly, chronic use of exogenous cannabinoids could potentially suppress the body’s natural production of endogenous cannabinoids, akin to how anabolic steroids affect the body’s natural hormone production. Withdrawal symptoms, although not life-threatening, can be extremely unpleasant, further highlighting the need for patient education and careful prescription.

Have you noticed any trends in patient demographics that are 
more open or resistant to medical cannabis treatments?

In my practice, most patients are open to medical cannabis treatment, often because they’ve experienced prolonged chronic pain, sleep deprivation, and related psychiatric issues like depression and anxiety. Their quality of life has been severely impacted, and traditional treatments have either been ineffective or caused unacceptable side effects.

These patients usually come to us after exhausting first, second, and third-line treatments. Many have educated themselves about medical cannabis or have been referred by other physicians. During initial consultations, I elaborate on the pros and cons of medical cannabis, and together we assess its suitability, provided there are no medical contraindications.

However, some patients, particularly women aged 35-55, have reservations about potential addiction, tolerance, and side effects. I ensure these concerns are thoroughly addressed before any prescription is made.

What kind of adverse effects have you observed in your patients 
using medical cannabis, and how do you manage these?

In my practice, the most common side effects of medical cannabis include xerostomia, gastrointestinal issues like loose stools, increased heart rate, drowsiness, and increased appetite. While xerostomia rarely causes patients to discontinue treatment—many resolve it by chewing gum or sipping water—other side effects often require dosage adjustments.

We typically modulate the THC:CBD ratio based on their pharmacological interactions and their affinities for specific receptors. For instance, CBD is known to mitigate some psychoactive effects of THC. If a patient requires a high THC dose for pain but experiences drowsiness, we can slightly decrease THC while increasing CBD to maintain efficacy but reduce psychotropic effects.

Similarly, for patients experiencing diarrhea, we adjust the CBD dosage or administer it in smaller, more frequent doses. This approach lessens the amount of CBD available at a given time to interact with CBR2 receptors in the digestive tract, thereby normalizing bowel movements.

How do you go about determining the optimal dosing for a 
patient? Are there specific guidelines or is it largely empirical?

Dosing for medical cannabis is highly individualized. We generally use a two-week titration plan, starting with a low dose and gradually increasing it to a target dose supported by research for pain relief and minimal side effects. However, this isn’t a one-size-fits-all approach.

Some patient populations, such as those with cancer-associated neuropathic pain, may require higher doses compared to those with conditions like inoperable disc herniation. Pain perception is influenced not just by physiological factors, but also emotional and psychological elements. Therefore, an individualized approach is crucial. In some cases, adjunctive pain understanding and acceptance therapy can enhance the benefits of pharmacological treatment.

When patients experience significant side effects like increased heart rate, anxiety, or gastrointestinal symptoms, we adjust the dosage. If, after several adjustments, the side effects persist and the pain remains uncontrolled, we initiate a dialogue about exploring alternative treatment modalities, as medical cannabis may not be the optimal choice for them.

Have you observed any remarkable drug interactions between 
medical cannabis and other medications commonly prescribed for 
chronic conditions?

The most challenging issue we often encounter involves patients on blood thinners. Due to a lack of reliable randomized controlled trials (RCTs) examining the interaction between blood thinners and medical cannabis, it’s risky to proceed with treatment for these individuals. Medical cannabis itself has blood-thinning properties, so combining it with anticoagulants could increase the risk of hemorrhage.

Another concern arises with patients on specific antiepileptic medications like lamotrigine. Despite the potential benefits of medical cannabis for epilepsy-related pain syndromes, drug interactions could worsen symptoms, making it inadvisable to prescribe medical cannabis in such cases.

How closely do you follow the emerging scientific literature on 
clinical use cases for cannabis-based medical products? Does it 
influence your prescribing practice?

I make it a priority to stay current with emerging scientific literature on medical cannabis, both for professional reasons and personal interest. When encountering atypical patient cases, I consult not only with the head physician but also delve into any pertinent, reliable studies related to medical cannabis and the case at hand.

New research findings directly impact my prescribing practices. Updates on contraindications or new indications for medical cannabis use are routinely shared by the head physician, ensuring that our clinic’s approach remains evidence-based and up-to-date.

How do you weigh the evidence from randomized controlled trials 
versus anecdotal evidence when making a clinical decision?

I prioritize randomized controlled trials (RCTs) over anecdotal evidence when making clinical decisions. In my view, anecdotal evidence lacks the rigor and reliability needed for evidence-based treatment. Patients deserve high-quality, safe treatment methods that don’t rely on such unverified information.

That said, I do consider anecdotal evidence when it points to potential safety concerns, side effects, or interactions related to medical cannabis. My medical approach has always been to prioritize patient safety. When encountering such anecdotal reports, I weigh the risks and discuss them with colleagues before making any clinical decisions.

When we encounter unbiased, well-conducted RCTs that offer reliable information, they become a cornerstone in our clinical decision-making process. We also cite these studies in the patient’s medical record, providing a sound rationale for our treatment choices that other healthcare practitioners can reference.

As a practitioner, do you feel the lack of a standardized 
curriculum on the endocannabinoid system hampers the efficacy 
of treatments?

I firmly believe that current research provides ample evidence about the vital role the endocannabinoid system plays in maintaining homeostasis within the human body. As such, I advocate for its inclusion in medical education, both in the context of physiology and pharmacology. This would equip future healthcare providers with the knowledge they need for more effective pain management strategies, including the use of medical cannabis.

During my own medical training, the endocannabinoid system was only superficially addressed, primarily in relation to the risks of cannabis abuse and addiction. However, it offered no insight into the therapeutic applications of medical cannabis. While we studied opioids in depth, exploring their risks such as dependency, withdrawal symptoms, and abuse, a similar educational approach should be applied to medical cannabis. This would allow future doctors to fully comprehend not just the risks but also the therapeutic potential of medical cannabis, enabling them to make informed decisions on its clinical application.

Do you believe that innovations like synthetic cannabinoids or 
targeted therapies will play a role in the future of medical 

The clinical use of synthetic cannabinoids, including isolates of THC and CBD, signifies an important milestone in the evolving landscape of medical cannabis. These compounds undergo stringent evaluation, as should any new pharmacological agent, before gaining approval for widespread clinical use.

By isolating specific pain-relieving components of cannabis, we have the opportunity to further refine these molecules, altering their potency as needed. This could lead to a more targeted therapy with fewer side effects. Currently, we are restricted to THC and CBD isolates of uniform potency. However, the future could see the development of more nuanced cannabinoid formulations, allowing for more precise, controllable, and effective treatment modalities.

In essence, we are in the nascent stages of medical cannabis as a treatment option. I anticipate that as research progresses, we will see increasingly targeted drugs designed to interact with specific endocannabinoid receptors, enhancing both efficacy and safety.

With the growing body of evidence supporting medical cannabis, 
do you foresee a change in prescribing practices among your 
peers in the near future?

The burgeoning evidence supporting the use of medical cannabis in a subset of chronic pain patients is indeed promising, and these are precisely the individuals we aim to treat. However, it’s imperative to also heed emerging data that reveal new interactions and adverse effects of medical cannabis. Such information necessitates frequent updates to our treatment guidelines to mitigate potential complications.

The emergence of medical cannabis as a viable treatment option has captured public attention, partly because of the controversial nature of cannabis, long classified as an illicit substance. Yet, it’s crucial to clarify that medical cannabis is not a panacea for the broad spectrum of pain patients. It should remain a highly regulated substance, prescribed only by physicians with extensive knowledge in both pain management and the pharmacology of medical cannabis.

As it stands, medical cannabis is best considered a third or fourth-line treatment option for chronic pain, given its complex dosing requirements, potential for side effects, and contraindications with various medical conditions and pharmacological agents. Essentially, it remains a less efficient option compared to other available analgesics and should be employed only after other treatments have proven inadequate, and provided the patient has no contraindications.

Looking ahead, if we can synthesize more specific cannabinoid isolates, thereby enhancing both efficacy and safety, there may be scope for loosening existing guidelines. Such advancements could potentially expand the demographic of patients who could benefit from this form of treatment.

How do you handle the ethical implications of prescribing a 
treatment that is still viewed skeptically by a segment of the 
medical community?

The prevailing skepticism among healthcare practitioners toward medical cannabis is both expected and warranted. Practitioners are trained to approach new treatment modalities with a critical eye, scrutinizing their safety and efficacy from multiple angles before making any clinical decisions. This cautious approach is integral to the practice of medicine, fortified by guidelines that are designed to ensure patient safety and should be adhered to whenever possible.

Medical cannabis is not a panacea, contrary to some public perceptions. It has a range of contraindications and can present serious side effects. Therefore, it should never be the first-line treatment for conditions like chronic pain. However, in specific scenarios, the use of cannabinoids may be considered appropriate. For instance, if a pain specialist encounters patients suffering from chronic pain that has proven refractory to first-line pharmacological treatments, as well as non-pharmacological options, and who consequently have a significantly diminished quality of life, then medical cannabis may be considered. In such cases, practitioners should diligently educate themselves about the properties and contraindications of medical cannabis and provide patients with comprehensive information on the risks and potential benefits of this treatment modality.

In your opinion, what are the ethical considerations around 
patient access to medical cannabis, especially considering the 
varying economic backgrounds of patients?

The landscape of pain management has evolved remarkably over the years, offering a wide array of treatment modalities that include pharmacological options like NSAIDs, opioids, antidepressants, and anticonvulsants, as well as non-pharmacological interventions like physical rehabilitation, educational programs, and psychological therapies such as cognitive behavioral therapy. The accessibility and affordability of these treatments within a healthcare system vary, influencing their availability to patients. While chronic pain is rarely life-threatening, especially if the underlying cause has been identified and addressed, it can profoundly affect an individual’s quality of life.

In an ideal world, all aspects of healthcare would be readily available and free of charge to everyone. However, the reality is that healthcare is a limited resource, often funded by taxpayers or insurance payers. The question of which treatments should be subsidized, therefore, is not solely a medical one but also an economic and ethical dilemma. It becomes particularly complex in the context of chronic pain, which is more a matter of quality of life than life and death.

Subsidization and accessibility to treatment modalities, including medical cannabis (MC), differ based on the healthcare infrastructure of a given country. In nations lacking robust welfare or healthcare systems, subsidizing any form of treatment may be untenable. Conversely, in countries with strong welfare systems and societal wealth, there may be potential for subsidizing treatments like MC to make them more accessible, thereby enhancing our understanding of pain management and improving the quality of life for chronic pain patients.

Therefore, the question of whether treatments like medical cannabis should be subsidized and made accessible to all is context-dependent, hinging not just on medical efficacy but also on the economic and social frameworks within which a healthcare system operates.

Stefan Broselid, Ph.D.
Editor-In-Chief, Aurea Care Medical Science Journal