What Weed Marijuana & Cannabis Can Teach Us About Stopping COVID-19 on 420

4/20.

Four-twenty is International weed day. I know about this because as a board certified neurologist, I’ve treated patients with cannabinoids, and they have provided me with education in return. Treating patients with COVID-19 in a way is similar using alternative treatments. Everything is new. The unknown may be dangerous. But it may help. The perfect evidence doesn’t exist and it won’t. Physicians and policy-makers need to make important decisions related to COVID-19. They can look at emerging evidence, while learning from other more known entities, quantifying data, when possible, and considering the context before making practical decisions.

International weed day

In 1991, the High Times published a story of a group of teenagers who came upon a treasure map. At 4:20 the Waldo’s set out in search of an abandoned field of cannabis. They didn’t find their treasure that day. But they were credited with coining the term 4:20, as a code-word for cannabinoid consumption, that later went on to be a date associated with a counter-culture movement and “International Weed Day.”

Evidenced based medicine

Physicians are trained to provide medicine based on a high “level of evidence.” That’s what I do for the large number of patients with chronic pain and other conditions (like epilepsy, neuropathies, Parkinson’s disease etc). Sometimes, the evidence-based treatments don’t work well enough. As a physician I want to help my patients in any way possible — any safe way that is — as the (adapted) Hippocratic Oath says “First, do no harm.”

No Evidenced based medicine

In 2016, after learning that New York legalized medical cannabis, I was skeptical, but open-minded. I decided to conduct due diligence for my patients. But unlike other treatments, there weren’t clear guidelines; I couldn’t read about treatment protocols in the Merck Manual or Up-to-Date. I couldn’t ask mentors, colleagues or academics in New York. No one had any experience. No one knew anything (starting to sound like COVID-19). Some so-called experts said there was “no evidence” that this could work (like “no evidence” that facemasks stop COVID-19). Others said it was irresponsible and dangerous to treat patients with cannabinoids (like “facemasks are dangerous”).

Evidenced b(i)ased medicine

There were a handful of academic articles in peer-reviewed journals like the New England Journal of Medicine, and many of these pointed to medical marijuana being unsafe and dangerously addictive drug. But most of these articles had been funded by sources like the National Institute for Drug Abuse and were written by physicians who were treating addiction, not actually treating patients therapeutically.

After several months of research, I was confident the benefits of cannabinoids outweighed the risks. I still needed to develop a protocol. What doses should be used for various conditions? How frequently was follow up required? What administration forms should be used?

Relying on methodological design and adapting them towards longer term treatment for various conditions by utilizing protocols used for other FDA approved medications, I began developing a protocol for treatment. For example, while there was limited data for long term management of patients with cannabinoids, there was vast data for using opioids for long term pain management. I adopted very strict policies, erring on the side of safety when possible. Today, some of my patients think I’m overly conservative, but many would agree this approach is prudent.

To some physicians the process made sense. But others told me that treating patients with cannabinoids was irresponsible, even dangerous. I thought it was ironic, or perhaps it was because, that many of these same doctors were the first on the bandwagon to treat patients with opioids in the 1990s. Still, many of the same doctors telling me it was wrong to treat patients with an alternative treatment, didn’t share this feeling about treating patients with opioids, even as a first-line treatment, in some situations such as where NSAIDS were contraindicated.

What were some things I learned along the way?

1. Not everyone claiming vast expertise has it. “No evidence” for cannabinoids, as it turns out, actually included many randomized controlled trials — there were 28 for pain, 28 for nausea and 14 for stiffness and spasm.
2. Not every peer-reviewed article contains irrefutable information. The “highly addictive” warnings from journals, written by addiction specialists, might be true when considering recreational use in a teenager, but completely different in the context of relieving disabling pain in an elderly patient.
3. While every drug is dangerous, danger is relative. Compared to opioids, cannabinoids are less addictive and safer.
4. Practical considerations and context are important. For example, many patients treated with opioids and medical cannabinoids are able to lower their doses of opiates or other drugs with their own unsafe side effect profiles. This might not be apparent from a study looking at one independent and one dependent variable.

Today we are in a situation where doctors are being forced to confront COVID-19. We don’t have all the evidence, but we need to make smart decisions without delay.

Repeating patterns

As with all history, I expect to see the same patterns repeat. I’m observing a bunch of parallels with the response to COVID-19

1. Individuals claiming to have expertise. They don’t. “Don’t wear facemasks” You should. Some TV experts like Dr. Phil making unfounded claims in an area he knows very little about. Others saying they are “infectious disease” experts (implying they are board certified) without clarifying that their expertise is not based on board certification or clarifying that they have never actually treated a patient.
2. Claims that current best practices are indisputable. They aren’t. Just because things are being done doesn’t mean we shouldn’t question and look to innovate. Mechanical ventilation modes, hospital infection control, sterilization techniques, they should all be examined.
3. Claims that certain treatments are dangerous. Maybe they are. Maybe they aren’t. It’s all relative. Hydroxychloroquine, Remdesivir, Inutabation, Tylenol, they all have pros and cons.
4. Practical considerations and context matter. The benefits and risks actions or inaction should be quantified metrics like quality adjusted life years (QALY) or other metrics.

On four-twenty twenty (420) there is still no text book to instruct us how to beat COVID-19. There are some play books though we can review. Strategies that were employed in the past against SARS, historical plans to defeat Influenza and other outbreaks. We can also learn about making important decisions from alternative treatments, on International Weed Day, when the evidence isn’t clearly agreed upon. When data is incomplete or controversial, as it may be with medical cannabinoids, we can still make important decisions by focusing on the available evidence and trying to fill in knowledge gaps when possible by quantifying data and making practical decisions that take context into consideration.