The results of the current survey indicate that Israeli rheumatologists lack confidence and have significant concerns regarding the use of medical cannabis for patients suffering from rheumatic disorders. This outcome is not surprising and is in line with previously reported data.12 It is notable, however, that despite this lack of confidence, those rheumatologists who responded showed relatively high levels of openness to the idea of using medical cannabis. The results indicate that the vast majority of responders (and presumably of rheumatologists in general) lack knowledge regarding basic topics such as dosage and route of administration, and hold concerns related to a broad spectrum of patient-related issues, ranging from psychiatric effects to motor vehicle accidents, as well as concerns pertaining to the societal effects of utilizing cannabis such as “leakage” from patients to others and recreational use. In view of such extensive concerns, it may appear to be surprising that responders nonetheless presented some degree of openness to the possibility of using cannabis. This finding may indicate both the high awareness of the need to improve pain management, and a degree of curiosity regarding a novel field of treatment and research.

As noted above, an identical survey has recently been published regarding the attitudes of Canadian rheumatologists to the use of medical cannabis.11 Thus it was possible to compare the current Israeli results with the Canadian ones. While three-quarters of responders in both countries were not confident about their knowledge of cannabinoid molecules or ability to write a prescription for herbal cannabis, this comparison yielded some significant differences between the two countries.

The proportion responding with “no role” for any cannabinoid treatments in Canada and Israel was 45% versus 17%, respectively. The proportion reporting never previously having recommended trial of any cannabinoid was 70% versus 39%, respectively; whereas 30% versus 48%, respectively, believed there was some role for pharmacologic or herbal preparations; and 28% versus 83%, respectively, were “willing to prescribe herbal cannabis if other treatments failed.” The majority of respondents were not confident to write a prescription for herbal cannabis, 90% versus 78%, respectively. The reason why Israeli rheumatologists may be more open to this option is difficult to explain. One possibility may relate to the rapidly changing scope of medical cannabis in Canada, accompanied by rapidly changing legislation, which may increase feelings of uncertainty and concern among Canadian physicians (and rheumatologist in particular). In the past decade the courts in Canada have ruled that a blanket prohibition to use herbal cannabis (marijuana) for medical reasons was unconstitutional, obligating Health Canada to develop regulations to allow possession of herbal cannabis for selected medical reasons. Thus, access to medical herbal cannabis in Canada has been driven by public appeal to the courts, and the medical community has had limited voice in the debate. Additionally, the knowledge that herbal cannabis in Canada is used mostly for musculoskeletal complaints, rather than the anticipated use for end-of-life care, or for management of symptoms related to human immunodeficiency disease, has come as somewhat of a surprise for the health care community. Finally, in the absence of evidence for use of herbal cannabis in the rheumatic diseases, this conservative stance by Canadian rheumatologists can be justified. Other cultural and societal factors may also play a role.13

While the current results may not be surprising for many rheumatologists who are well acquainted with the caution and reticence expressed by their colleagues, it is noteworthy that these results describe a snapshot of a situation in flux. As the number of patients being treated with medical cannabis continues to rise, it becomes increasingly likely that a rheumatologist treating patients suffering from musculoskeletal pain will be encountering increasing numbers of patients who either are interested in cannabis treatment or indeed are already being treated with medical cannabis by a specialist from another discipline (e.g. a pain specialist, neurologist, gastroenterologist, etc.).14 This reality makes it imperative for the rheumatologist to at least be as well-informed as possible about the effects and outcomes of such treatment, as well as gauging how such treatment may be interacting with other medications the rheumatologist may wish to employ (e.g. narcotics, anticonvulsants, etc.). Moreover, the rheumatologist will have to be aware of the ways in which cannabis may be affecting disease activity measures. Needless to say, similar concerns may also arise in the case of the large group of patients who are using cannabis illicitly,15,16 either recreationally or as self-medication. In this context, however, things become even more complex due to the non-standard dose of active ingredients used, as well as the co-administration of additional recreational drugs or alcohol. Beyond these practical issues, the legitimate role of cannabis and cannabinoids in the management of rheumatic disorders is an issue well worthy of the attention of the rheumatological community, on both a clinical and a basic scientific level.

As noted, chronic pain and in particular centralized pain, such as that typical of fibromyalgia, continue to be unmet medical needs,17 responding in a very incomplete way to current FDA-approved medications. The proportion of patients who achieve worthwhile pain relief (defined as at least 50% pain intensity reduction) is small, typically 10% to 25% more than with placebo, with numbers needed to treat to benefit (NNTs) usually between 4 and 10.18,19 This challenging problem is not one that should be ignored or relegated to others by rheumatologists. Thus, referring a rheumatological patient to be treated for pain by a specialist in another field (e.g. a pain specialist) is problematic and costly, and may lead to an inconsistent clinical trajectory. In view of these considerations, it seems particularly important that rheumatologist should be as well-acquainted as possible with all aspects of treating pain in rheumatological patients, including whatever knowledge exists regarding the use of cannabinoids.

While the precise mechanisms through which cannabinoids act in chronic pain are far from being well understood, the field of studying the endocannabinoid system has burgeoned into a massive and fascinating area of research.20,21 While fibromyalgia for instance has long been hypothesized to represent a condition of “endocannabinoid deficiency,”22 this view may be an over-simplification, and it appears likely that the end-result of cannabinoid activation represents an intricate interplay between various agonists,23 receptors, and breakdown enzymes,24 with far-reaching effects regarding pain, sleep, mood, cognition, etc. Current research has not yet delineated with any precision how and when it is best to activate this system for optimal clinical response and what long-term effects this activation will carry with it.25,26 At a strictly clinical level, using cannabinoids is currently somewhat analogous to “using antibiotics”: one knows they may do a lot of good, but one would really like to know which specific active molecule is being used, at which dose, and for which specific indication.