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Dr. Marion McNabb has been conducting surveys related to medical cannabis for about five years and her most recent endeavor is to gauge the knowledge, interest, and understanding of medical cannabis in healthcare professionals. In this interview, she discusses her latest study as well as her background and key insights into the medical cannabis industry.
One of the most common statements people hear about medical cannabis use in the United States is that there needs to be more research, clinical trials, and studies on the plant’s long-term effects. What people don’t often hear is that research in the US has been substantially limited and restricted due to the Federal government’s stance that cannabis is a schedule I drug making it illegal. Despite this, there has been research both in the US and in other countries. While we still have a long way to go to understand this plant medicine and how it can best serve people, one public health doctor is taking the initiative to gather as much information as possible now. Dr. Marion McNabb has been conducting surveys related to medical cannabis for about five years and her most recent endeavor is to gauge the knowledge, interest, and understanding of medical cannabis in healthcare professionals. Here, she shares her plans for this latest study as well as her background and key insights into the medical cannabis industry.
Can you tell us a little bit about your medical background and how you became interested in the cannabis industry?
Dr. Marion McNabb: Yes, I am a public health doctor by training. I have about a 20-year career in global public health. My background is working in HIV/AIDS, family planning, and maternal child health, mainly in low-income countries such as in Africa and Haiti. I worked on training healthcare providers in a new clinical area. I worked with doctors and nurses around HIV in a country where that was a new disease area and new treatment that clinicians needed to learn. I developed continuing medical education courses and different job aides for doctors and nurses to deal with HIV in clinical care settings and do research and using digital technologies to help. For example, using mobile applications, SMS technology, and clinical decision support tools for doctors, nurses, pharmacists, lab techs, and so on.
About five years ago, when it became legal for adult use cannabis in Massachusetts, I left my global public health career to basically transfer a lot of the skills and tools from global public health to the cannabis industry. Because cannabis is still federally illegal, it's been restricted and difficult to research the plant and research the plant in human and clinical populations. I set out to advocate at the design of the industry in Massachusetts for the research license that is now operational here and integrating cannabis education into institutions of higher education and conducting research studies.
A couple of years ago, I partnered with the University of Massachusetts-Dartmouth (UMass Dartmouth), and we have now conducted five different research studies together related to cannabis from a medical cannabis use perspective, as well as an adult use perspective. I've also been involved in developing a number of cannabis education programs, together with Holyoke Community College and Boston University as well as other universities such as UMass Dartmouth.
Now, I’m excited to be leading to research studies together with UMass Dartmouth and about 15 different colleagues. One study is around COVID-19 in medical cannabis and adult use cannabis consumers and the impact of COVID-19. And the second is called the “Healthcare Provider Knowledge, Attitudes, Practices Related to Medical Cannabis Research Study” that we are doing together with Medicinal Genomics (1,2).
I think what's exciting about medical cannabis and adult use cannabis is that there's more opportunity for not only research, but implementation. We know that medical cannabis is providing relief for a number of health conditions and symptoms. Not only should we continue to study the plant, but I think we should also design clinical implementation protocols and dosing protocols to help healthcare providers integrate this into their simpler regular practice.
Can you tell us more about the “Healthcare Provider Knowledge, Attitudes, Practices Related to Medical Cannabis Research Study”? What inspired you to form this informative research entity? How can healthcare professionals take part in the study?
McNabb: Yes, it started as a result of the launch of the Cannabis Patient Care magazine and the webinar event that we did online on Veterans Day (3). Actually, because of that event, one of the attendees was from Medicinal Genomics—who are leaders in cannabis science and research from the genomic plant side of the category and have been colleagues and friends of the Cannabis Center of Excellence, the nonprofit I founded, which has been running research studies for quite a while. So, they attended that webinar, which was part of the launch of the Cannabis Patient Care magazine and shared some valuable information from the Veterans Study that I conducted. Medicinal Genomics reached out to me afterwards. They organize and run the annual CannMed conference, which brings together researchers, clinicians, and experts from the medical cannabis and adult use fields every year. They also offer continuing medical education credits and different educational courses throughout the year as well as podcasts related to the science around cannabis. They reached out with an interest in understanding more about healthcare providers’ current knowledge and training related to medical cannabis and what they would be interested in learning in the future.
My nonprofit, the Cannabis Center of Excellence (COE), is very much interested in medical cannabis and advancing the field of not only using data that we collect to provide advocacy and move it forward, but also to really provide evidence-based background for training and educational purposes. So, Medicinal Genomics reached out to run a research study. We put together this anonymous survey, which basically asks any kind of healthcare provider what their knowledge and training and current practices are related to medical cannabis. What they are interested in learning about in the future and how they're interested in learning that. The study launched in May 2021 and will be running through August 2022. We'll be presenting the preliminary results this year at the CannMed conference in early October. We will also share results in the spring of 2022 at the 15th annual clinical conference on cannabis therapeutics run by Patients Out of Time. Final results will be presented at CannMed 2022. Sign up and stay tuned.
If you're a healthcare provider, you can take the survey. It’s about 10 minutes to take and you'll be entered to win a free pass to the CannMed 2021 conference, including the CME portion of it, which is an $820 value. And you'll also be entered to win an Amazon gift card for participating. Check out the COE website for regular updates on data collected through the study.
In addition to presenting at the CannMed conference, we’ll also over time be sharing the results back out with the clinical community just to encourage awareness about the importance of topics such as the endocannabinoid system or medical cannabis in pre-service, healthcare provider education as well as nursing, pharmacy, clinician, doctor, and dentist educational programs.
What do you hope will come out of the “Healthcare Provider Knowledge, Attitudes, Practices Related to Medical Cannabis Research Study”?
McNabb: What I hope will come out of the study—what we're really trying to do this year—is not only engage healthcare providers and respondents to the research study, but also to carry the idea and the information forward to their colleagues.
What I'm hoping is that by taking the research study, it will raise awareness among healthcare providers about the topic and encourage them to reach out and share the research study with their fellow clinicians, one to help get more opinions and ideas. But also, to start a behavior change campaign.
We do have a swag store at the Cannabis Center of Excellence. We have T-shirts and hats and different swag that really works, that has fun slogans on it that aim to destigmatize medical cannabis and cannabis research. We've developed a specific line for healthcare providers and raising the awareness of this alternative medicine of medical cannabis. If folks take the research study, they can also continue to support the research by buying one of the pieces of swag, which helps fund our work and continues to raise awareness.
What I hope, again, what I will get out of this is information from healthcare providers about what their knowledge is, about what they want to learn, and how they want to learn it so that we can move the field of medicine forward in an innovative way by including medical cannabis as an alternative.
I would like to also really thank our study sponsor, Supercritical Labs and Chris McElvany. Without his financial support, we couldn't make this study possible. And we're also looking for additional study sponsors and partners. Please feel free to reach out (contact email@example.com). We really appreciate the support. Couldn't do this kind of work without our partners.
Again, to circle around what I'm what I'm hoping for is continued awareness raising among the healthcare provider community that patients are using medical cannabis. It’s available and becoming more increasingly available in states. And I feel the healthcare providers can learn more about the topic.
Do you think there should be more research into the medicinal properties of the cannabis plant and its interactions with the endocannabinoid system?
McNabb: Yes, I think there's enough research to integrate cannabis as a first-line or second- or third-line therapy for several symptoms right now. But I also believe that we can continue to do more research around the medical benefits.
Specifically, around different combinations of cannabinoids and terpenes and how those impact specific conditions and demographics, people profile, so to speak. I also think there's really a good opportunity to understand more of the endocannabinoid system, as you mentioned, within our own bodies.
What endogenous cannabinoids are in play? Cannabis can have a positive impact, but also understanding what the risks are associated with integrating medical cannabis, particularly with a patient who is taking several medications. There are polypharmacy patients. It's important to understand drug–drug interactions and the side effects that may happen by introducing cannabis and certain cannabinoid profiles. Particularly, in those patients with a pharmacy cocktail, such as opioid or fentanyl.
There is evidence that cannabis can be a good treatment alternative to help people reduce the use of opioids or other harmful substances such as alcohol and tobacco. But I think those need to be done under clinical supervision and there's opportunity to continue to research in those areas.
Have you encountered hesitancy or judgment in the medical community to viewing cannabis as a potential medical treatment?
McNabb: Yes, lots. And I think that stems from the fact that the medical community and in all types of education from physician, nursing, and pharmacy, the endocannabinoid system and the value of medical cannabis is removed from education. Also, it’s worthy of noting that medical cannabis was included in the US Pharmacopeia (USP) and removed in the early 1900s.
Our medical education in the last several decades has been squarely focused on pharmaceutical and chemical-based interventions as primary care treatment options. So, the understanding of the medical community around medical cannabis is limited right now.
I think, additionally, in the last 50 years or so, there was a “Reefer Madness” campaign which was a structured, engineered public awareness campaign that really looked to demonize cannabis. And that alongside a war on drugs that targeted people of color and arrested folks for cannabis has jaded, so to speak, the medical community.
So, I think there's room to continue to educate the medical community around where the current research efforts are and where the evidence stands and work to break the stigma that was created through the the war on drugs and the “Reefer Madness” campaigns.
When cannabis was taken off the USP back in the early 19th century, was there an outrage from medical professionals? Is there any documentation of that, that people that were using it were upset that it was taken off?
McNabb: Yeah, that's a good question, I'm going to open this book that my friend gave me here. Yes, the American Medical Association (AMA) reached out at the time. I'm looking at this book, The Emperor Wears No Clothes, by Jack Herer (4).
There was outrage. There was outrage by the American Medical Association that was upset by the removal of this from the US Pharmacopeia and the tax on cannabis. To quote the book from the section titled “Did Anyone Consult the AMA?” (4): “The AMA doctors had just realized ‘two days before’ these spring 1937 hearings, that the plant Congress intended to outlaw was known medically as cannabis, the benign substance used in America with perfect safety in scores of illnesses for over one hundred years.”
The AMA was brought in at the end and they did not accept really their testimony and moved on. There was a lot of political pressure associated with the removal of this. The AMA and drug companies testified against the 1937 Marijuana Tax Act because cannabis is known to have so much medical potential and never caused any observable addictions or death by overdose.
Twenty-nine years passed, however, before American scientists could begin to even look at the cannabis medicine again. And that's when Dr. Raphael Mechoulam in Israel discovered and isolated THC delta-9 in 1964. And it's worthy of noting marijuana was America's number one analgesic for 60 years before the rediscovery of aspirin, around 1900. From 1842 to 1900, cannabis made up half of all medicines sold with virtually no fear of its high.
Clearly, cannabis has been used as medicine in the United States and then removed from the pharmacopeia. But it's also been used as medicine around the world for thousands of years.
Do you recommend any educational resources for healthcare professionals seeking to learn more about the benefits of medical cannabis?
McNabb: Yes. I would say if you're interested in learning some of the research results we have from our observational self-report studies over the last couple of years around how cannabis patients, consumers and veterans are reporting using medical cannabis you can go to www.cannabiscenterofexcellence.org and check out some of our research results. We’ll be having more educational videos and resources for download soon.
And then additionally, Medicinal Genomics, as I mentioned, runs CannMed and it's an excellent conference. It's going to be held September 29–October 1 this year in Pasadena, California, with speakers from around the world as well as clinicians and researchers in the cannabis industry. They will also offer continuing medical education credits and we'll be presenting the preliminary results from this research study. CannMed will be a great place to learn more about the latest and greatest clinical and research in cannabis.
There's also another group called Patients Out of Time that's very worthy of following. They just had their 14th annual clinical conference on cannabis therapeutics last month. I was honored to be a part of it as well. They offer of continuing medical education credits every year too and offer great educational opportunities.
And then out of the study, the healthcare provider knowledge, attitudes, and awareness study, we will be developing good, targeted content for healthcare providers based on what they report they want to know. Stay tuned. And if folks are interested in being a content contributor, writer, or being part of this effort in a deeper way, we welcome that. Please definitely feel free to reach out to me directly, firstname.lastname@example.org.
With the growing interest and increased legalization in cannabis, do you believe it will become a more sought out treatment option by healthcare professionals?
McNabb: Yes, I do. I think when legalization happens cannabis will be more sought out if it is reimbursed by health insurance. And as part of the mainstream medical system. In terms of the health insurance, what we're finding in the research studies that I've run is that more than 70% of people report using medical cannabis to reduce the use of prescription or over-the-counter medications. Often those prescription or over-the-counter medications have side effects that are unwanted by these respondents. By shifting to medical cannabis, it relieves some of the side effects of those medications. Therefore, improving the quality of life, ability to return to work, improves family relationships, and so forth.
All those factors come into play when you want to reimburse a treatment option. Health insurance should look more towards reimbursing medical cannabis because of the benefits of return quality of life, and therefore a reduction on the cost of the insurance company to keep covering medications or one medication that covers the side effects of another medication. If you think about somebody who's on a cocktail of 10 or 12 medications, the cost to the insurance company for long term chronic care is a lot. But if somebody is introducing medical cannabis to reduce that, you could see the cost savings and improve quality of life.
Anyway, I think that is something that would be attractive to healthcare providers. I think also, we have done a disservice to our healthcare providers by not including this education around the endocannabinoid system, which is a fundamental system in our body that interacts with every other system—the endocrine system, the nervous system, the immune system. It’s unethical to not include this, especially when you're talking about medicine and research. I think our healthcare providers deserve to know about this. And once they start to learn about it and start to feel more comfortable that they know as much or more about medical cannabis than their patients, then they'll want to see it as an option.
The other barrier that exists, I think, for medical providers is the lack of guidance around dosing and types of cannabis for different types of health conditions. Really drilling down into those nuances of dosing by health condition, by age, and understanding what drugs may interact by dose and what titrations you should do and what tolerance levels exist in certain patients, what delivery mechanisms are best, all of those. I think providing some clinical tools around that for healthcare providers will help them feel more comfortable in the future, integrating medical cannabis as an option.
Do you think healthcare professionals would feel more comfortable if there was more of a pharmacy model where their patients have a real prescription and then they go and get it filled rather than going to a budtender? Do you think something like that would ever come to the US?
McNabb: Yes, I think it already has in some ways. Some states are tending towards the pharmacy model. Georgia, as an example, will be licensing pharmacies to dispense low THC oil and products. I think there is. Canada has the purchase from that model. I think there are going to be examples of where physicians are going to feel more comfortable.
That is their status quo. They write a prescription then you go to a pharmacy and pick it up. I mean, I think that that should be available and would help the clinician. I just want to make sure that wouldn’t box out anybody from having access to cannabis. I'm a proponent of making sure that the community can have access to it. So having dispensaries that are medical dispensaries that are available and accessible to patients that have discounts that ensure that cost isn't a barrier, all those things are very important to me. I think having a clinical model of going to a pharmacy is important, but then also ensuring that that doesn't limit access.
People should also be able to grow their own medicine at home, which is something that I promote. But back to what would help healthcare providers feel more comfortable. I think what's interesting and a real opportunity in medical cannabis is that it is personalized medicine. So, compounding and formulations for particular conditions become very important.
Think about, in advanced cancer, say, one type of breast cancer. Dr.Dedi Meiri who's a professor in Israel who I greatly admire, has been doing quite some significant research and trying to understand different cannabinoid formulations and profiles on different cancers and different types of cancers. What he's found is that there are unique circumstances in cannabinoid combinations, in terpene combinations that affect particular cancers. One strain may affect one breast cancer type, but may not affect another breast cancer type. It's that personalized.
When you walk into a dispensary now that has only 10 different options or types of cannabis, it's limiting because you may not have that particular profile that may impact your particular health condition. It goes back to how can we get into this personalized medicine? Is that through a pharmacy route? Hey, pharmacy, can you create this formulation where we have a CBN, CDC, and THC at a 3:2:1 ratio, that's a tincture. Because that’s the personalized medicine that we need for that patient? Or are we trying to, like, step back up and create sort of generic broad-spectrum types of medical cannabis? If this makes sense, that may impact a variety of conditions and have great opportunities for all different types of formulations.
I think in the cannabis industry, not limiting the farmer and not limiting the cultivator or the processor will be your best bet because there’s so many ways that you can cultivate or formulate or manufacture processed cannabis. If we move only to high level multi-state operators (MSO), mass-produced quality and mass-produced mid-level quality, we're really missing out on the natural benefits of the plant and sacrificing that for profit. It'll be interesting to see how the pharmacy model plays out in Georgia and other states versus a dispensary model with the budtender.
That is primarily the delivery in some states. The last thing I would say is the delivery with the budtender—there are opportunities to educate that budtender and that patient advocate. Not everybody needs to be a healthcare professional necessarily in medical cannabis to deliver counseling. We have lots of experiences in healthcare that you have lay counselors in HIV, for example. Those are the primary first frontline workers for an HIV patient, and they are not actually healthcare providers. I think let's not shame the patient advocates or the budtenders because they do know a lot about cannabis. I think they could also learn more about medical cannabis, especially in states where adult use is legal and not lose the focus of medical. But stay tuned. The Cannabis Centre of Excellence will be coming out with some materials around that.
What do you hope will change in the cannabis industry? Where do you find the most difficulties and how do you deal with them?
McNabb: I guess the change I would like to see is in two places, social justice and the race for money. Right now, in the cannabis industry, I think there is some push in Massachusetts and in other states to really work towards restorative justice, to right the wrongs of the failed drug war. And I think that's very important. It's something that's been a cornerstone of my work for the last five years—advocating and working towards the area of social justice in the industry. And what that means is, I believe, big industry and small business participating together. Providing opportunities for those who've been negatively impacted to have priority access to the cannabis industry and fair and transparent business deals to happen for industry grow and success for both small and big business.
I'm hoping that change will continue in the cannabis industry where we continue to support black and brown businesses, women owned, veteran owned, disability owned, and LGBTQI owned businesses. That dovetails into this race for money. I see MSOs gobbling up other MSOs and small businesses in this race to be at the top in the race for money. And now with the recent push for social equity and social justice, some flags flying that we are the better company or the better groups that are doing this. I would just hope that that has meaningful programs and money attached to those statements.
I also hope that this race for money really doesn't elbow out all the small farmers and all the small businesses that deserve an opportunity that may not always be able to compete with the large law firms that are hired by these MSOs. The difficulties faced, I think one of the biggest difficulties, is funding in the cannabis industry.
Another area that needs change is licensure and funding to get licensure for small businesses. Difficulty for me, personally, in the cannabis industry is funding for research. It's been a quite a challenge. There are no pots of money lying around, major pots of money for cannabis researchers. I've had to work with colleagues to convince businesses to use marketing budgets and other budgets and funding to support our research studies over the years. And it's not been easy. It'd be great in the future to see some change in cannabis where companies are committed to understanding that the work that, say, the Cannabis Center of Excellence or Cannabis Patient Care magazine are doing really helps their business and shines a good, positive light on the cannabis industry to engage healthcare providers and doctors. The cannabis industry should be vested and participating and supporting funding, research, education. and social justice activities.
Do you have any other medical cannabis research in the pipeline?
McNabb: Good question. Well, for this time being, we're going to focus on closing out the COVID-19 study and analyzing that data and being able to present and publish that. And then also really focusing in on this healthcare provider study this year.
One study that I would love to work on but need funding for is pediatrics. Pediatric cannabis is a real driver of legalization in some states such as Georgia, for example, where pediatric epilepsy and epilepsy patients were at the forefront of leading or advocating for legalization. But then there's also, in Massachusetts, the one pediatrician that was recommending medical cannabis just retired. And there are several families that are now left with being forced to pay $200+ every few months to get their child's medical card renewed. And that's more expensive than an adult. There are only one or two places that you can get that in Massachusetts. And that's criminal to me. There's been a lot of advocacy around trying to change that at the Cannabis Control Commission. There are several people that have stories that are negatively impacted currently and continue to advocate in Massachusetts right now that I'm in touch with. I think their voices need to be heard.
I'd love to run a study around this. We are collecting data and information from pediatricians in our healthcare provider’s study. So that may be a launch to say, let's investigate this more. But it's criminal to not have access for kids and for kids to pay more than double what adults pay for a medical card.
If somebody does help fund your research, do they get to see the data?
McNabb: Yes, absolutely. If partners fund the research, they get exclusive access to the very detailed research results, both in presentation form they can use in their own education and advocacy. As well as presentation for their staff and clients or patients as well. They also will get wide marketing research.
We'll be doing several events and press releases around this and acknowledgement on our website of the support for the research studies. I will also be publishing this in the peer-reviewed literature. Funders will be acknowledged there and knowing that their support is advancing science in that way and contributing to publications like Cannabis Patient Care magazine. It also raises their visibility among the healthcare provider community so that healthcare providers think about their name first when thinking about medical cannabis and commitment to research and education.
Companies can also do custom studies with us. We've been in discussions with companies about pediatric studies or other different types of research or educational programs together.
We don't have to always do research, but we love to do that. Custom studies, custom education programs—that's how we how we partner with the industry. And not only the cannabis industry, but outside of cannabis industry, healthcare provider industry and anybody who really is interested in supporting our work.
This month we are launching our citizen science data partnership model where companies can partner with the COE for training, technical assistance, data access, and other benefits. You can become a partner by visiting: www.cannacenterofexcellence.org
Are there different levels of funding options?
McNabb: Yes, absolutely. For the healthcare provider study, there are levels of $1000 to be a study partner. It’s a low-bar commitment with a high value return. We have an email listserv of 2500 and social media well over 1500, combined with our other partners for social media sharing.
We will be hosting a Cannabis Citizen Science Data Showcase event this fall, where we'll be launching our annual and quarterly data membership where companies learn more about our partnerships. Our annual rates will be published this month at: www.cannacenterofexcellence.org.
People will be able to sign up for either a quarterly or annual membership to get access to our data and the reports that come out of it and data, insights, and trends. We also provide downloadable social images and educational materials that companies can use in their staff trainings. In addition, we offer access to the data, events, and recordings that we do throughout the year and our annual events and networking showcase. We'll be doing lots of in-person events in the future as well. Together with our partners, Elevate, Minorities for Medical Marijuana, and more.
To learn more about Dr. McNabb and her current research please visit: https://www.cannacenterofexcellence.org/hcpmedcannstudy.html