John Rosman / OPB
A new website created by an Oregon doctor aims to make it easier for healthcare providers to talk with their patients about the health effects of cannabis. Devan Kansagara is a professor of medicine at OHSU and practices internal medicine in the VA Portland Health Care System. He says patients want to discuss cannabis with their doctors. His goal is to provide evidence-based information that he hopes will empower clinicians to feel more comfortable talking to their patients about cannabis use and answering questions that patients may have. We hear from Kansagara about the website and how he hopes doctors and researchers will use it.
The following transcript was created by a computer and edited by a volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. A new website created by an Oregon doctor aims to make it easier for healthcare providers to talk with their patients about the health effects of cannabis. Devan Kansagara is a Professor of Medicine at OHSU and an Internist at the VA in Portland. He says that patients want to discuss cannabis with their doctors. So his goal is to make those conversations more comfortable, more productive and more evidence-based. Devan Kansagara, welcome to Think Out Loud.
Devan Kansagara: Hi Dave. Thanks for having me.
Miller: Thanks for joining us. What exactly is the problem that you want to solve or the issue you want to address?
Devan Kansagara: This is a project funded by the VA Office of Rural Health, and it’s a collaboration of excellent teams here at the VA and at the Center for Evidence-Based Policy at OHSU and our goals are really to help clinicians feel empowered to have evidence informed discussions about cannabis with their patients. And the secondary objective is to play at least a small role in moving the field of cannabis research forward. And the reason for this is that this is becoming increasingly clinically relevant. So depending on which estimates you read, about 15% of US adults have used cannabis in the last year And about 4% of all US adults use cannabis daily.The evidence around cannabis and its health effects is evolving and accumulating relatively rapidly at the same time the cannabis industry is growing. So we felt that we really needed to have more resources in terms of impartial, up to date and evidence-based information.
Miller: We asked our listeners if they had experience talking about cannabis in a healthcare setting, either as a patient or as a health care provider. And we got some interesting responses. We’ll get to as many as we can. Here’s one of them.
Caller: My name is Janet Garland and I am 67 years old and I have smoked weed off and on since, oh gosh, I don’t know, like 1975 and I have to tell you that I will never admit to a doctor that I smoke weed because the reactions that I get at 67 is really kind of ridiculous, considering all the other drugs that are out there. I do not admit it and I will not admit it until I know that there has been at least a little bit of research going on.
Miller: So she brought up a couple points there. But let’s start with the research one because, as you noted, one of the big ideas behind this effort is to be a kind of clearinghouse for quality studies about cannabis. But we’ve also heard over the years that because of the federal prohibition on cannabis, that research and research funding has been challenging in various ways in this country. So how much data is actually out there right now?
Kansagara:There’s a growing amount of data, but I think everybody – patients, clinicians, researchers – everybody would agree that we need more and better research. That’s absolutely true. There are a lot of regulations in terms of doing cannabis research in the U.S. Some of that’s changing slowly, there’s some regulations passed last year which will make it a little bit easier to do research. And so hopefully that will change. I think in terms of funding of cannabis research, that’s also changing. For instance, the VA is now undertaking its first clinical trial looking at the effects of cannabis on a type of chronic pain. So you know, I think it’s moving in the right direction, but quite a ways to go.
Miller: The broader point that Janet was making is she’s used cannabis for, her estimate is what, 45 years or something. And she said based on conversations she’s had in the past, she would not bring this up now with doctors. What would you tell someone like Janet, or tell to Janet’s doctors to convince them that it is safe for them to discuss cannabis use in a medical office?
Kansagara: I would start with the clinicians and underscore an important point and she’s kind of talking about stigma and that being a barrier to discussing this in clinical settings. I think as healthcare providers we can go some way to reducing that stigma. Part of that is around making this a normal part of health-related discussions. So one thing we advocate for is that clinicians get in the habit of asking their patients as just a routine part of the health intake about cannabis use. We are all trained in medical school to ask patients about tobacco, alcohol use and illicit drug use. But obviously today it’s not adequate to just ask patients about illicit drug use because cannabis in many parts of the country is not an illicit drug and is not thought of that way. So I think part of it is about normalizing the discussion and just as a patient might expect to go to the doctor and have these routine sorts of questions asked, we can do that for cannabis as well.
Miller: On that note, I’ve always wondered, when you, as a doctor ask a patient, for example, how many alcoholic drinks they consume in a week, or if you read that on a sheet that somebody has filled out, how much do you believe the answers you get?
Kansagara: That’s a good question. I mean I’ll just say from personal experience, when I ask my patients about cannabis I try to do it in a non-judgmental and just routine dispassionate way. I found most of my patients to be fairly forthcoming about use. I think that’s true of alcohol as well. Obviously it’s not true 100% of the time, but again, I think it has partially to do with how we ask the questions and whether or not it’s kind of a routine part of care.
Miller: I should note that we did get some voicemails from people who have had positive experiences when they have talked about cannabis with their doctors. Here are two of them.
Caller: Hi, my name is Denise. I live in Dallas, Texas and I’m a breast cancer patient here. I have talked to every single doctor that takes care of me about using cannabis, and they are all 150% supportive. My oncologist suggested that I use cannabis instead of the anti-nausea drugs when I was going through chemo. And of course it relieves nausea immediately.
Caller: My name is Jeff Ryderbach and I’m calling from Portland Oregon. I mentioned to my doctors over many years when I go see them that I use cannabis for pain treatment and treatment of anxiety and I don’t ever get any pushback. They’re always supportive, and I find that very encouraging.
Miller: You are a mid-career doctor right now, meaning that you did your training and your residency something like two decades ago. Did you get meaningful training about the effects of cannabis on various parts of the human body when you were doing that training?
Kansagara: No, we didn’t, and in fact, that’s been true up until recently. In studies looking at graduate medical education curricula up until the last couple of years, very few had offered curriculum around cannabis and health effects. That’s changing. I talked to our medical students every few months about cannabis. They have an afternoon where they have a chance to kind of debate and discuss various aspects of cannabis and health effects. And I’ll say the next generation of doctors is extremely curious and engaged in this question, often having read a lot about it and you know, coming to the table with a lot of knowledge. So I think it’ll change. But certainly when I trained that was not part of our education,
Miller: I want to play you another one of the more dramatic voicemails that came in.
Caller: My name is Michelle and I live in Portland. My husband and I are both retired and receive our health services from a large medicare supplement provider in the metro area. My husband recently experienced some severe anxiety and asked our primary care provider for a referral to a psychiatrist, which he received. As part of the screening process, the psychiatrist asked him if he had ever used marijuana and my husband quite honestly replied that he had recently used some cannabis CBD on some skin issues he was having. At that point the psychiatrist shut down the interview and refused to provide services to him.
Miller: Somebody tweeted at us on Twitter, ‘I have asked my Kaiser Permanente doctors about treating arthritis, aches and pains with CBD oil. They replied they can’t talk to me about this – very frustrating.’ Obviously these are just two anecdotes but there’s a similarity between the two of them. How common is this? Either individual health care providers or perhaps larger organizations saying just don’t deal with these questions or this issue?
Kansagara: It’s a good question and I’m sorry to hear about the patients’ experience. So I work for the VA and as a federal employee we’re not allowed to certify patients for medical cannabis use or endorse its use. But you know the VA also put out a directive a few years ago given how things have evolved to say VA providers should be prepared to have discussions about cannabis because of its clinical relevance. I would say even if you’re a healthcare provider who works for an organization that doesn’t allow you to sign a medical marijuana card, there’s still a lot you can do in terms of informing patients about what the evidence says and doesn’t say about the health effects that you know wouldn’t violate some of these policies.
Miller: We did get one voicemail from a healthcare provider, let’s have a listen:
Caller: This is Sarah Holt, I am a nurse midwife here in Portland and we do need to counsel patients about cannabis use particularly during pregnancy. And I think we all find it fairly challenging. So frequently it seems like it’s sort of a one sided conversation with the patients and families that we work with. I think there’s still shame around cannabis use, particularly in pregnancy, but it’s important for people to know the health issues there. So I know I would personally welcome advice on how to create a more inclusive dialogue with the women that I work with.
Miller: Cannabis use in pregnancy is actually one of the topics that you address under the evidence synthesis tabs on this new website. But here we have a listener asking for, you know, advice for how to have these conversations. In this case, it’s in a particular context of pregnancy, but you know, you could broaden that, I’m sure to many other contexts. Where do you suggest that someone like Sarah start?
Kansagara: Yeah, that’s a good question. I think part of it is knowing what the facts are and what the evidence says and doesn’t say. Then, as with any clinical encounter, I think engaging the patient, hearing their thoughts, hearing where they’re coming from and then kind of presenting the information we have and taking a shared decision making approach, I think goes a long way. With this particular example, we’re actually in collaboration with one of our maternal fetal medicine providers and researchers are developing a brief for clinicians about how to have these discussions with regard to pregnancy, in particular.
Miller: I wonder in your own clinical experience or in the conversations you’ve had with other healthcare providers, what have you heard to be the questions from patients that come up most often?
Kansagara: There’s a few. So by far and away, chronic pain is the number one symptom and medical condition that patients seek cannabis to treat. So that’s the most common context in which we get questions. And I’m hearing an increasing number of questions about CBD and you’ve already played some voicemails where that had come up. So I think there’s a lot of interest in CBD and I think that’s one area where there’s the biggest disconnect between interest and the evidence we have. So CBD unfortunately remains one of the more understudied forms of cannabis.
Miller: Also, isn’t it fair to say it’s also one of the most over promised? That you can find claims that CBD can do just about anything.
Kansagara: Yes, you can. So, so I think it’s been purported to help all sorts of things, some of that comes from basic science work. So there’s what we call biologic plausibility that these different cannabinoids might have positive health effects. But certainly there’s a big distance between having the biologic plausibility and knowing whether or not this works in the human body and what the doses are, that would work and how often you need to take it and so on and so forth, and we just don’t have that work done yet.
Miller: That gets to the broader project you’re a part of, which is trying to make sure that medicine is evidence-based. We’re talking about cannabis, but this is for everything. Why is it that there even needs to be an evidence-based focus? Why isn’t that baked in?
Kansagara: It’s a great question. The term ‘evidence-based medicine,’ surprisingly, is not that old, it’s only in the last two or three decades that that’s really become a routine part of medicine. So I think people have grown used to the idea that there’s a need for empiricism and how we guide our treatment recommendations. But you’re right, I think many people would think, you know, evidence-based medicine as opposed to what? So in this context, we mean that part of what we’re doing is taking a broad look at what’s out there, and trying to tell you if there’s 10 studies on this particular topic, are they all saying the same thing? Did one find a benefit and nine didn’t? So it’s kind of important to look at the landscape of information out there and part of that is also looking at the quality of the studies that are being done – not all studies are created equal. Some are better designed to answer a question than others and that’s part of what we look at as well.
Miller: Devan Kansagara, thanks so much for joining us. I appreciate it.
Kansagara: Dave, thanks so much for having me, appreciate it.
Miller: Devan Kansagara is an Internist in the VA in Portland and a Professor of Medicine at OHSU. Thanks very much for tuning in to Think Out Loud on OPB and KLCC, I’m Dave Miller. We’ll be back tomorrow.
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