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Arachidonoid instead of endocannabinoid? – Insight on physician knowledge about key homeostatic regulatory system

Millions of patients worldwide are using cannabis and cannabis preparations to help assist with medical conditions such as pain, anxiety and sleep. There are several countries allowing citizens and physicians to take part in Medical Cannabis programmes, within these, the majority of clients are using food supplements of cannabidiol (CBD) and the increasingly popular cannabigerol.

At Endoverse we are trying to raise awareness of the basic physiological regulation of the endocannabinoid system which is based on lifestyle inputs in ECS balance.

When it comes to discussing lifestyle changes with practitioners, they will probably suggest increasing Omega 3 and/or Vitamin D intake, as well as looking to increase physical activity, implement a balanced diet, and, if need be, to quit smoking and drinking alcohol. When our clients are seeking a second opinion from their physicians (we encourage patients to do so), our recommendations to support their endocannabinoid system are often referred to as ‘nonsense’ and that although these changes will not do patients any harm, they are usually told that they will not help them.

When speaking with colleagues that are not familiar with the endocannabinoid system, we often face a similar situation through a lack of ECS understanding. There is a simple joke that we are narcotic dealers to proclamation, that their ECS is fine as they are regularly smoking weed (yes, physicians are smoking weed too). Even doctors (and university teachers) involved in Medical Cannabis programs were surprised when we explained the physiology behind ECS.

We share with you our own knowledge from our personal experiences as well as those of our clients with the endocannabinoid system, but what does real data found from the knowledge and findings of physicians show us? There are only a few papers covering this system and they are mainly related to medical cannabis; however these can give us a significant insight about knowledge gaps and what steps need to be taken.

Mary-Ann Fitzcharles et al. (2014) designed an online questionnaire which circulated via email to the entire Canadian Rheumatology Association membership. The objective was to measure confidence of rheumatologists in their knowledge of cannabinoid molecules and mechanisms relevant to rheumatology, and their ability to advise patients about cannabinoid treatments. Over three quarters of the 128 responders reported lack of confidence in their knowledge of endocannabinoids, phytocannabinoids and synthetic cannabinoids. 45% of the respondents did not see any role of the cannabinoids in the management of rheumatic diseases. 70% had never prescribed any cannabinoid formulation and 60% would not even recommend trials with cannabinoids. Over 90% of respondents were not confident in writing a prescription for medical (herbal) cannabis when required to indicate dosing, frequency, and method of administration. The main barrier was fear from history/potential of drug abuse or addiction. The paper suggests that there is a need for in-depth evaluation of cannabinoids in rheumatic disease management, as well as education for the health care community.

Ziemanski et al. in 2015, conducted a study among 426 Canadian physicians to determine the educational needs regarding usage of cannabis for therapeutic purpose. There is a huge discrepancy in initiation of discussion regarding medical cannabis. While 79% of physicians were approached by patient or her/his family member, only 39% of them initiated the discussion by themselves. 69% of physicians had patients that started using cannabis for therapeutic purpose, only 36 physicians ever prescribed medical marijuana, mainly nabilone, dronabinol and nabiximols. 41% of respondents never prescribed pharmaceutical cannabinoid. While the main clinicians concern was that patients who request medical cannabis may actually want it for recreational purposes – 65%, lack of personal knowledge/education or information regarding the use of cannabis for medical purposes was a very important factor – 50%. 70% of respondents agreed, that more education on the topic will make them feel more comfortable and increase their ability to treat patients with the use of medical cannabis. Over the 50% of physicians would prefer peer-reviewed literature reviews on specific topics and online learning programs as part of continuing medical education.

A small study (2017) among 45 U.S. physicians who practice cannabis medicine explored their related education and self-assessed their knowledge as well as their practice. Kevin M. Takakuwa et al. found, that there is the need for more formal education and training of physicians in medical school and residency, more opportunities for cannabis-related continuing medical education for practicing physicians, and clinical/basic science research that will inform best practices in cannabis medicine.

The Cannabis and Cannabinoids Knowledge Assessment Survey (CCKAS) was conducted in January 2020, sponsored by Greenwich Biosciences. Physicians had to self-report among others their level of knowledge of FDA approved cannabinoid therapies and potential cannabis-related therapies. Based on this report there appears to be a lack of understanding regarding:

“How cannabinoids bind to specific receptors in the body – they are chemicals that bind to specific receptors in the body and can create a wide array of effects.”

“Phytocannabinoids – these are found in and extracted from the cannabis sativa L plant. They may or may not interact with the cannabinoid receptors.”

“The differences between endocannabinoids and phytocannabinoids – the human body produces endocannabinoids, anandamide and 2-AG. The endocannabinoids are distinct from plant derived phytocannabinoids. They do not interact with the endocannabinoid system in identical ways, though some features may be shared.”

Kisa and Arnfinsen published in 2020 their assessment of Norwegian physician’s knowledge, experience and attitudes towards medical cannabis. 70% of 102 respondents referred to their knowledge on MC as a treatment option as either no knowledge (23.7%) or little knowledge (46.5%). What is especially interesting is the perceived familiarity with the endocannabinoid system. 43% of responders are not familiar at all, 32% only slightly familiar, while only 1% were familiar with ECS to a very great extent.

When used together it seems that patients and their relatives are more pro-active in both cannabinoid usage and learning about medical cannabis. The main obstacle from a physician’s side seems to be fear of substance abuse masked with medical conditions. In general, there is a significant lack of knowledge among professionals, even if we take into consideration limitation and small number of the studies. There is an emerging need for continuing education as well as for inclusion of endocannabinoid system knowledge in basic medical training.

Moreover, we have to switch our attention from the cannabis plant and phytocannabinoids to the essence of the ECS – lipid metabolism. American pharmacologist Peter S. Cogan says:

“The endocannabinoid system, as it is currently envisioned, is no more inherently cannabinoid in nature than the opioid system is opioid in nature. What’s more, the familiar endogenous hormones and receptors commonly invoked to define it may be more aptly considered as components of an “arachidonoid” system, if any weight is going to be given to human biochemistry in its classification”.

In our opinion, this basic understanding will increase willingness and the ability of professionals to learn and apply their knowledge of this key regulatory physiological system in the best interest of their patients.

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