Primary Care Providers Still Reluctant to Talk About CBD

By Pat Anson, PNN Editor

Edibles, beverages and other products made with cannabidiol (CBD) went mainstream years ago, as public attitudes about cannabis changed and retailers discovered there was a growing market for CBD products.

The same is not true for primary care providers, according to a new survey that found most doctors are still reluctant to recommend CBD to their patients because of doubts about its safety and effectiveness. CBD is a chemical compound in marijuana that does not produce euphoria, but is believed to reduce pain and improve other health conditions.  

In the online survey of 236 primary care providers (PCPs) affiliated with the Mayo Clinic Healthcare Network in Minnesota, Wisconsin, Florida and Arizona, doctors said CBD was frequently brought up during medical appointments, usually by patients. But those conversations didn’t last long, because most PCPs don’t feel they have enough knowledge about CBD and are skeptical about CBD marketing claims.

PCPs in states where marijuana is legal are more receptive to patients using CBD products, while PCPs in states where marijuana is still illegal are more concerned about CBD’s side effects. But regardless of its legal status, most PCPs believe CBD is ineffective for most conditions for which it is marketed, with chronic non-cancer pain and anxiety/stress being the exceptions.

“Results from this mixed methods study show that PCPs practicing in the U.S. rarely screen for or discuss CBD use with their patients and report several barriers to engage in proactive CBD-focused practice behaviors,” wrote lead author Pravesh Sharma, MD, a pediatric psychiatrist and substance use researcher at Mayo Clinic Health System.

In a second, much smaller study, Sharma and his colleagues conducted interviews with 14 PCPs and found a number of barriers that prevent an open dialogue about CBD, including lack of time, discomfort, low-quality evidence, and CBD being a low priority.

“Our study is the first in-depth report on PCP attitudes, experiences, and practice behaviors related to CBD. The findings of our study have the potential to significantly impact future PCP practice behaviors,” they concluded.

The U.S. market for legal cannabis has grown into a $29.6 billion industry, but not much has changed over the years in terms of its acceptance in the medical community. In a 2020 survey of over 1,000 primary care patients in Vermont, only 18% rated their doctor as a good source of information about cannabis. Nearly half of the patients surveyed had used cannabis in the last year, and most of them thought cannabis was helpful for pain, anxiety, depression, arthritis, sleep and nausea.

The effectiveness of CBD is somewhat murky, because CBD products are poorly regulated and vary so much in dose, quality and whether they also have THC. While CBD may be effective temporarily in relieving pain and other symptoms, some researchers are concerned about its long-term effects on children and adolescents.  

“In fact, although CBD is widely available as an unregulated supplement, we researchers know almost nothing about its effects on the developing brain. Of note, these harms apply not only to smoking, but also to ingesting, vaping or other ways of consuming cannabis or its extracts,” Hilary Marusak, PhD, a psychiatry professor at Wayne State University, said in a recent column.

“In my view, it’s important that consumers know these risks and recognize that not everything claimed in a label is backed by science. So before you pick up that edible or vape pen for stress, anxiety, or sleep or pain control, it’s important to talk to a health care provider about potential risks.”

Unfortunately, asking a doctor may not provide many answers.

How To Get Medical Help for Intractable Pain

By Forest Tennant, PNN Columnist

Americans have been trained and oriented to believe that when making an appointment with a medical provider they will walk in, discuss their health issues and receive good care. Those days are long gone if you need care for a painful disease like Intractable Pain Syndrome (IPS).

It is common for persons with IPS to forget how rare this condition is compared to more prevalent diseases such as asthma, diabetes and hypertension. Any person with IPS also has to face the sad fact that the media, government and mental health professionals have condemned and painted every person with IPS as a drug abuser who is not worthy of being trusted with an opioid, benzodiazepine or adrenaline type stimulant.

Things have gotten so out-of-hand that most doctors are afraid to treat pain for fear of government penalties or condemnation by their peers, hospital or malpractice insurance carrier. Many veterans’ hospitals and private health plans now essentially ban the prescribing of opioids.

State and federal policies also make it difficult to travel long distance to access treatment, as that may be seen as a “red flag” that a patient is doctor shopping or visiting a pill mill.

Whenever possible, persons who have IPS should pursue physicians and nurse practitioners in their local community to provide necessary care.

Here are some tips we recommend when visiting a local medical provider for the first time:

1. Do not refer to yourself as a “pain patient,” but as a person with a disease that causes pain. Tell providers what condition you have been diagnosed with: “I have adhesive arachnoiditis, neuropathy, Ehlers-Danlos Syndrome, etc.” 

2. Put together a complete set of documented medical records and bring them to every appointment, including personal identification, local address, insurance coverage, medical diagnosis, MRI’s, lab tests, and list of past treatments. Your records should be neatly organized in a 3-ring binder or file folder.

3. Know your state’s opioid prescribing guidelines and regulations. Do not ask physicians or pharmacists to violate these rules. 

4. Research and understand your disease and carry written materials about it to your medical providers.

5. Identify a local pharmacy and health food store in your community that will fill your prescriptions and carry the supplements you need. Don’t ask a doctor to find you a pharmacy.

6. Know and be able to describe the complications of your constant pain, such as hypertension, tachycardia, elevated cholesterol, diabetes, autoimmunity and hormone deficiencies.

7. Until regular care is established with a provider, a family member -- ideally a spouse -- should attend all appointments to help build credibility and assurance with the provider.

8. Know the name and dosage of every drug and supplement you take, and which ones treat the cause of your pain, suppress the pain, or treat a complication of your pain.

9. Plan on having multiple medical practitioners to treat your conditions. For example, your primary care physician may treat your hypertension or hormone deficiencies, but a neurologist may treat the pain.

10. Due to opioid restrictions, identify non-opioid substances that will substitute or potentiate whatever opioid may be available in your community. Some examples: kratom, CBD, palmitoylethanolamide (PEA), ketamine, oxytocin.

11. Develop a care plan of non-prescription agents to treat the cause of your pain, suppress inflammation and boost hormone levels. 

Know Your Diagnosis

You must have a verifiable, anatomic diagnosis that is the cause of your IPS. The fact that you have intractable pain is not sufficient. You must know the cause of it.

An anatomic diagnosis requires a physical examination plus confirmation with an x-ray, MRI, photograph, blood test, elector-conduction study or biopsy. This information must be documented in your medical record. Equally important is to keep a copy of all test results in your personal possession -- not in some doctor’s office.

Two cases offer examples of mistakes patients can make when when visiting a provider for the first time:

1) A woman consulted with us who was taking three different opioids that had quit providing pain relief. When asked what caused her pain, neither she nor her husband knew. They could not provide an answer.

2) A woman on two opioids and three ancillary agents wanted a letter to support her disability claim. When asked the cause of her pain, she didn’t know, except that her feet and legs hurt, and someone told her she might have fibromyalgia.

Neither of these patients could produce a single page of medical records stating the cause of their pain. Not surprisingly, they also couldn’t locate a doctor to help.

The following are not considered specific enough diagnoses to obtain opioids or disability: bad back, sciatica, failed back, sprain or strain, fibromyalgia, headache, accident, EDS, neck pain or pain from a fall. 

Persons who have IPS or chronic pain are usually taking several drugs, including controlled medications, but don’t always know why they are taking them. If you don’t know why you are taking a drug, you may appear to medical practitioners to simply be a drug seeker who abuses medication or has an addiction or opioid use disorder.  

If you can’t explain in detail why you take each medication, including supplements, you shouldn’t be taking them. No MD or nurse practitioner will prescribe them to you if you don’t know why you are taking them. That is why it is imperative that you learn as much as you can about each medication and supplement you are taking. 

If the only care you are seeking is for temporary, symptomatic pain relief with opioids or benzodiazepines, don’t expect to find pain care. Also, don’t expect acceptance from local practitioners unless you are taking medications to treat the cause of your pain and to permanently reduce your pain. 

Forest Tennant is retired from clinical practice but continues his research on intractable pain and arachnoiditis. This column is adapted from newsletters recently issued by the IPS Research and Education Project of the Tennant Foundation. Readers interested in subscribing to the newsletter can sign up by clicking here.

The Tennant Foundation has given financial support to Pain News Network and sponsors PNN’s Patient Resources section.