Recently the Journal of the American Medical Association (JAMA) posted a study entitled "Prevalence of Cannabis Use Disorder and Reasons for Use Among Adults in a US State Where Recreational Cannabis Use Is Legal". The study looks at cannabis use disorder (CUD), questions what the frequency of CUD is with medical use and nonmedical use, and takes into account whether the state has legal recreational cannabis access.
Jordan Tishler MD, president of ACS, released a response to JAMA, in which he questions the instruments of the study, as well as examines whether patients received medical care from their doctor or simply received a medical card. Read the full response below:
Study Findings and Flaws
This study found that 1 in 5 cannabis users in Washington state met criteria for Cannabis Use Disorder. This was methodologically sound; however, our group notes two important confounders for people using cannabis under the care of a physician.
The study instrument likely overestimates medical users’ CUD, and the study definition of medical-users doesn’t differentiate between self-medication and physician-guided treatment.
The study instrument, Composite International Diagnostic Interview Substance Abuse Module (CIDI-SAM) was designed, as were the DSM-5 criteria, prior to the common use of cannabis as a medication. It is likely to overestimate CUD in medical patients.
Most medical-users who scored positive were in the mild category. Questions like, “Do you spend time accessing, or worrying about access to cannabis?” would be positive for patients, and would be positive for patients using other medications like antihypertensives, too. At least 3 questions on this instrument have questionable validity in medical use, and as it only takes 2 positive answers to constitute mild CUD, this instrument likely overestimates CUD in patients. The CUDIT-SF eliminates these questions and might have given a truer picture for patients.
Prescribers and Medical Cards
More salient from a therapeutic standpoint, is whether those reporting medical-use received ongoing guidance from their prescriber. Many self-designated medical users neither seek nor receive appropriate medical care or supervision of their cannabis use. As with any medication, it is a fundamental role of a physician to provide that guidance, ensuring the greatest benefit with the least risk. We don’t expect patients to successfully and safely use antibiotics, anti-arrhythmics, or opioids without supervision. This is so fundamental that instructions are embedded in our prescribing system and on every bottle of medication.
The abundance of cannabis card-mills across the United States dismays us[3-4]. Patients get medical advice from lay personnel in the dispensaries. Even if the purveyors had full knowledge, the incentives are perverse.
It is crucial to stratify “medical users” by whether they truly got medical attention beyond procuring a card. We believe that true medical guidance would mitigate the risk of CUD – a hypothesis worthy of study.
All medications carry risk and a major part our job as physicians is not only to prescribe the medications, but to mitigate risk via informed consent, education, and monitoring of our patients’ use and outcomes.
1) Lapham, G. T., Matson, T. E., Bobb, J. F., Luce, C., Oliver, M. M., Hamilton, L. K., & Bradley, K. A. (2023). Prevalence of Cannabis Use Disorder and Reasons for Use Among Adults in a US State Where Recreational Cannabis Use Is Legal. JAMA Network Open, 6(8), e2328934. https://doi.org/10.1001/jamanetworkopen.2023.28934
2) Bonn-Miller, M. O., Heinz, A. J., Smith, E. V., Bruno, R., & Adamson, S. (2016). Preliminary Development of a Brief Cannabis Use Disorder Screening Tool: The Cannabis Use Disorder Identification Test Short-Form. Cannabis and Cannabinoid Research, 1(1), 252–261. https://doi.org/10.1089/can.2016.0022
3) Yafai, Sherry MD. The Case for Cannabis: ‘Marijuana Mills’ Erode Public Trust in Medicine. Emergency Medicine News 45(1B):10.1097/01.EEM.0000918864.89782.9a, January 17, 2023. | DOI: 10.1097/01.EEM.0000918864.89782.9a