INTERVIEW
Expanding hope for patients
TOM ARNESON, MD, MPH Research Manager, Office of Medical Cannabis, Minnesota Dept. of Health Dr. Arneson provides a clinical and research perspective to implementation of the state’s medical cannabis program and oversees research on the program’s impact. He received his Bachelor of Arts degree from Harvard, his Doctor of Medicine degree from Mayo, and his Masters of Public Health degree from the University of Minnesota. He is board-certified in public health and general preventive medicine.
The Minnesota Legislature passed a law in 2014 legalizing the manufacture, sale, and use of medical cannabis. Minnesota has a vertically integrated program that only permits two registered manufacturers to grow, cultivate, and sell the medicinal products. To obtain medical cannabis, patients and health care providers are required to register with the Minnesota Medical Cannabis program patient registry. Physicians can choose to participate and “certify” patients who have been diagnosed with at least one of the qualifying medical conditions required for registration in the program. The registration process is confidential and simple, and the Board of Medical Practice protects physicians from any civil or disciplinary penalties.
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What does your work as the research manager of the Office of Medical Cannabis (OMC) entail? A distinctive part of Minnesota’s program is tracking what happens with enrollees, including what they purchase and what they and their certifying provider report as benefits and harms. I helped design how information is collected during program participation and my staff and I are now organizing and analyzing data from the first year of the program. I also summarize existing research literature and spend significant time doing presentations and communicating with clinicians.
But there is also positive feedback from physicians— in particular about patient benefits. This comes both through informal conversations and through survey comments for each patient they certify. The hope that medical cannabis products would facilitate patients reducing dose or discontinuing opioid and benzodiazepine drugs is now being fulfilled for numerous patients. There will be more specific data on this question in 2017 when survey results for patients certified for intractable pain start being tabulated.
As of September 15, 2016 there were 564 physicians registered in the program, along with 86 advanced practice registered nurses, and 36 physician assistants. What are the goals of the medical cannabis program? The number of registered physicians has been growing The objectives of the law that established the steadily, and in fact has picked up over the past couple program were to allow therapeutic use of medical of months. cannabis and to prevent its misuse or diversion. The allowed cannabis products are more medical in Many physicians feel that there is no research to nature than in most other states’ programs, in that support the efficacy of medical cannabis. How do they are ingested as capsules, liquids, or vaporized you respond to this claim? oils. Required third-party laboratory testing ensures The nature and amount of research varies greatly product safety, content, and consistency. Minnesota’s by condition. There is a report on the OMC web program is more restrictive than programs in many site that summarizes clinical trials for each of the other states—a point of criticism for many—as it does qualifying conditions in the Minnesota program. For not allow smoking or edible forms. Currently, there are some qualifying conditions the clinical trial evidence no reports from law enforcement of diversion and no is almost non-existent. For others, it is strong enough reports of serious adverse events. that a cannabis extraction drug very similar to drugs being produced in the Minnesota program has been Please share some of the responses you have received approved by the equivalent of the FDA in Canada, Israel, the United Kingdom, and multiple other from physicians, both positive and negative. As might be expected, there is much skepticism European countries. As has been covered extensively and some passionate criticism. But there are many— in the media, clinical research on cannabis in the U.S. including some of the skeptical and critical—who has been made very difficult by onerous federal rules are open to the possibility that the program could resulting from cannabis being a Schedule 1 drug. offer benefit to patients of theirs who have not been Much of the clinical research has been conducted doing well with their current therapies. A frequent outside of the U.S. response is that more research is needed before cannabis-based medications are used—in particular, What can you tell us about the endocannabinoid large clinical trials of long duration. Closely related, system (ECS)? many physicians express the belief that cannabisThe human ECS is a set of ligand molecules, based medications should follow the traditional route mechanisms that modulate their creation and of approval by the FDA rather than state government destruction, receptors and other cellular structures programs. Physician control is also an issue. Though they activate, effects of activation on cell processes, participating clinicians can see via their web account and resulting consequences for the body’s physiology. the products their patients buy and symptom change The ECS is often referred to as a homeostatic system, and side effect info, physicians do not prescribe the helping the body maintain constancy of internal cannabis products. They can advise the patient what environment despite the body’s response to external they think they should use, but the decision is made by environmental challenges. Various types of cannabis the patient in consultation with a pharmacist working receptors are found throughout the body, with one type at the cannabis distribution centers who is employed especially dense in certain parts of the brain and central by the cannabis product manufacturer. Other nervous system and another densely located on certain responses include fear of getting in trouble with the cells of the immune system. The ECS has been shown federal government, lack of knowledge about cannabis to interact with several of the body’s other systems. and the endocannabinoid system, the added time and stress of discussing cannabis with patients, and Why are so few physicians familiar with the ECS? potential for abuse and addiction. And some dismiss The ECS has not been part of their training. It was the program as a front for recreational legalization of only about 20 years ago that the first awareness of its marijuana. existence started to develop, and research about it has
MINNESOTA PHYSICIAN NOVEMBER 2016