Clinical applications and use of medicinal cannabis

Abstract

Over the years, cannabis has been utilized for its medicinal properties to address a myriad of complaints including muscular spasms, insomnia, depression, pain and nausea. The dopamine-mediated euphoric effect, which was later attributed to the ability of the tetrahydrocannabinol component of cannabis to activate the CB1 receptor in the human body, has led Western countries to criminalize use of cannabis in the first half of the twentieth century. In recent years, numerous studies have heightened awareness about cannabis's potential medicinal benefits, demonstrating its efficacy in such clinical contexts as chemotherapy-induced nausea, epilepsy and multiple sclerosis spasticity. In Malta, the 2014 Drugs Dependence (Treatment Not Imprisonment) Act was amended in 2018 to allow for clinical use of authorized medicinal cannabis products. This was followed shortly after by the enactment of the Production of Cannabis for Medicinal And Research Purposes Act which delivers a legal framework for the possibility of producing cannabis in Malta for medicinal and research purposes. The developing potential of medicinal cannabis in patient care demarcates a shift in attitude towards cannabis from a legislative perspective that will however also require a clear and measurable change in perception by healthcare professionals in order to translate into benefits in delivery of medical care to patients. This research aimed to explore the therapeutic potential of medicinal cannabis by analyzing current international literature on its indications, contraindications, and administration modalities. This data was also intended to assist in proposing a simplified stepwise framework for clinical trials in this field. Through dissemination of a 25-item questionnaire that was validated by an expert panel ahead of distribution., the study also assessed the perceptions and concerns of the Maltese healthcare professionals on the use of medicinal cannabis, extracting pertinent considerations and uncertainties, and noting attitudes to help evaluate critical issues that ought to be addressed when reviewing the potential clinical use of medicinal cannabis within the Maltese healthcare context. Statistical analyses identified a weak positive correlation between the age of doctors and their propensity to favour prescribing medicinal cannabis (r= 0.20, p= 0.040), mostly among males (r= 0.34, p= 0.009). Both pharmacists (r=0.41, p< 0.001) who had higher knowledge of medicinal cannabis evidenced a more favourable approach to its clinical use, believing that patients could derive benefit from medicinal cannabis and feeling more comfortable in discussing its integration as potential therapy with patients. In doctors this proved to be a stronger predictor of prescription attitude than knowledge and education categories assessed in a hierarchical regression analysis (β= 0.71, p< 0.001, t=6.84). Comparison of results reflected similar statistical patterns for both doctors and pharmacists in terms of attitudes, beliefs and knowledge of medicinal cannabis. A systematic review was conducted following PRISMA guidelines. Searches were performed in PubMed, Ovid, Web of Science, and Cochrane databases using predefined terms related to medicinal cannabis and its clinical applications for a variety of conditions. Eligible studies mostly included randomized controlled trials, cohort studies, and case-control studies evaluating the therapeutic efficacy of medicinal cannabis across various conditions. Data on clinical outcomes, administration modalities, and adverse effects were extracted and analyzed. The clinical trials and studies assessed were also considered in the clinical trial framework proposition, ensuring its compliance with current compliance regulations for clinical trials in the European Union. Questionnaire dissemination to Maltese doctors and pharmacists returned 200 responses, which were utilized for the development of a series of educational initiatives including a lecture series and a patient information brochure. These were validated via feedback from an expert panel. Survey results were in line with those recorded in multiple other regions and, in general, suggested acknowledgment of potential benefits for patients but also hesitancy in engaging with clinical use of medicinal cannabis. The main concerns expressed by healthcare professionals were poor formal education on the subject, unclear evidence-based clinical guidelines and limited training opportunities. It transpires that there is need for vigorous interventions in order to prepare a workforce of healthcare professionals in dealing effectively with discussing with and dispensing medicinal cannabis to eligible patients. Requirements include a significant investment of time and resources, as well as a willingness on the part of healthcare professionals to engage with the latest research and to learn about the various ways in which cannabis can be used as a therapeutic alternative in some clinical contexts.