Why Is Medical Cannabis Missing From Med School Curriculum?

At last count, 48 US states, Washington DC, and 3 territories have legalized cannabis for medical/therapeutic purposes, and 24 for adult recreational use.

In 2020, at least 8.3 million Americans acknowledged using medical cannabis; many of the same patients also reported mixed (ie, medicinal/recreational) use.

Clinical education has not caught up.

There are 19 cannabis education certificate and/or master’s level programs offered in colleges, universities, and graduate schools in 14 US states, meaning that only about one third of the 48 states that have legalized medicinal cannabis have some sort of college or graduate-level curriculum to support patients.

The dearth of cannabis education has also left a large percentage of the more than 1 million practicing physicians in the US — and concurrently, most future prescribers — without a framework to leverage what has the potential to become one of the most important tools at their disposal.

Leah Sera, PharmD, is associate professor and the inaugural program director of the nation’s first Master of Science in Medical Cannabis Science and Therapeutics program at the University of Maryland (UMD) School of Pharmacy in Baltimore.

Sera explained the impetus behind UMD’s program (which launched in August 2019) was the concerns voiced by health professionals; not only were they not learning about cannabis medicine and the endocannabinoid system in academic programs, but more importantly, they lacked the knowledge to help patients coming to them with questions.

“I think that it’s important for health professional educational programs to incorporate cannabis medicine into their curricula so that when we graduate new generations of healthcare providers, they’re better equipped to really engage with a public who clearly wants more information — both to keep them safe and help improve their lives,” she said.

Medical literature has underscored that medical students feel the same.

A 2019 survey of medical school students indicated that although participants expressed mixed feelings about medicinal cannabis, the majority said they lacked adequate knowledge about its therapeutic applications, research, and science and instead relied on anecdotal evidence and social media for information.

The Endocannabinoid System

Arguably, politics have played a large role in slowing broad acceptance of the medicinal benefits of cannabis (eg, fearmongering, the war on drugs), and it is still considered a Schedule 1 drug. These factors are also believed to have contributed to the lack of inclusion in medical school curriculum.

“What it means for cannabis to be a Schedule 1 substance is that the federal government says that cannabis does not have a currently accepted medical use and the highest risk of abuse,” said Sera. “Although there’s been a lot of cannabis research both within and outside the US, it’s very difficult to do gold standard randomized, controlled trials with any Schedule 1 drug.”

“Until very recently (and it may be occurring still), a lot of medical and nursing programs taught that cannabis is bad, has no therapeutic benefits, and it’s highly addictive,” added Nishi Whiteley, cofounder and chief operating officer of CReDO Science, a science and research organization geared toward education, cannabis product optimization, and clinical consultation.

“There’s been an active campaign to malign cannabis, which is an enormous disservice to the patient and to the medical professional who needs to have more tools in their toolbox,” she said.

Despite these challenges, decades of scientific research have consistently shown that the endocannabinoid system helps modulate a wide range of physiologic processes (eg, pain, inflammation, mood, metabolism, and neuroprotection) through its interaction with the major systems in the body, including the nervous, immune, and endocrine systems and digestive symptoms.

This is a key reason why cannabis researchers and specialists have argued for its inclusion within medical education programs.

“Every place we’ve looked, in whatever physiological system, the endocannabinoid system has a role as a homeostatic regulator,” said Ethan Russo, MD, a board-certified neurologist, psychopharmacology researcher, and cofounder/CEO of CReDO Science.

“We now understand that there are endogenous cannabinoids that are similar in structure to what we see in cannabis,” said Reggie Gaudino, PhD, a molecular geneticist and director of the Cannabis Research Institute at the University of Illinois Chicago.

“The endocannabinoid system is like the one ring to rule them all,” he said. “It interacts through all other biochemical pathways and systems in the body to help keep our different processes in balance. Without understanding that system, we create other problems.”

Just the Basics

These cannabis experts said that at the very least, practicing and future prescribers need a foundational education that might include an overview of the endocannabinoid system, how it applies to disease processes, and its major components.

“The endocannabinoid system is a good starting point; it’s how we are used to learning about medications and how biological systems are altered from disease or medication or other treatments,” said Sera.

She explained that this provides a foundation for discussions about the pharmacology of cannabinoids — chemicals within the cannabis plant that have biologic activity in humans and other animals — and how they interact with the endocannabinoid system to produce downstream effects on other organs.

Sera also said that it is important for future prescribers to learn how to interpret different types of medical literature and cannabis studies despite methodological concerns that have plagued the industry and the lack of studies on specific products available in medical dispensaries.

The same is true for counteracting cannabis hysteria in mainstream media every time a new study comes out, said Russo.

“Medical students need to be aware that real issues can arise with cannabis and its potential abuse, which does happen,” he explained. “But the other side of the coin is therapeutics, which is quite distinct in terms of intent and dosages, ie, there’s a distinction between a small dose for therapeutic purposes and a large dose that may produce harm.”

Importantly, this fact has often been overlooked in alarmist headlines and stories that have gained the most traction.

Bridging the Gap

Today, the gap between educational needs and educational reality is large. To address this, Russo and Whiteley said they developed an online, 40-hour advanced medical cannabis certificate program for practicing clinicians.

For professionals interested in learning how to address patient questions in an informed manner, they also created a Foundations of Cannabis Therapeutics course.

Though future prescribers can certainly benefit from these sorts of online foundational courses, the dearth of cannabis education within medical schools has left a large knowledge and practice deficit.

Dustin Sulak, DO, an integrative medicine specialist, cannabis expert, and founder of Intergr8 Health and Healer.com, a medical cannabis education resource in Falmouth, Maine, considers cannabis medicine revolutionary in that it actually alters the way the medicine is practiced.

“Cannabis medicine is a paradigm shift away from single-molecule interventions that have single physiologic targets toward more complex botanical treatments that target many things in the body — most of all, interfacing with the endocannabinoid system,” said Sulak. He used the example of managing pain, sleep, spasticity, and depression all at the same time with the same treatment.

“For any field of medicine to fail to take into consideration the role of the endocannabinoid system in pathophysiology is a shortcoming and a missed opportunity for interventions that improve symptoms and potentially, a cure,” he said.

There is a broader paradigm shift that’s needed, one that requires a new mindset, especially within the medical education and practice arena.

“I think of myself as a patient advocate, not a cannabis advocate,” said Sera. “Cannabis is a potentially powerful tool for some patients that can improve their lives; it’s not about the plant itself.”

Russo is chief medical officer for Indira Pharmaceuticals and receives advisory fees from Carnada. Sulak is equity owner of Healer.com. Whiteley, Gaudino, and Sera reported having no relevant financial relationships.

Liz Scherer is an independent health/medical journalist and frequently writes about cannabis/cannabinoid therapeutics.