Cannabis, endometriosis, and a high time?

Abstract

The article proposing cannabis for the treatment of endometriosis is superficially argued and shows disdain for concerned patient care.1 For the medical profession, the addition of another dangerous drug into the mainstream medication market is a serious consideration. Maybe the authors proposing it is ‘high time’ for wider cannabis use have a warped sense of humour? Maybe they have not read about the psychotic-inducing and detrimental mental health issues associated with cannabis consumption. Or its intoxication with consequent poor short-term decision-making, hindered social coordination and mounting driving errors. Or its demotivation and links to educational drop-out rates, or its habituation, addiction, and cannabis disorder potential. In calling for debate on the pros and cons of medicinal cannabis in gynaecology, even the most myopic protagonists would concede there are dangers in cannabis use as an analgesic. In choosing to focus on the narrow use of cannabis as an analgesic for endometriosis, the authors avoid any perspective. Their ‘considerable’ mention of the demerits of medications to treat endometriosis is fair, but their failure to mention any immediate or long-term side-effects of cannabis is hardly even-handed. As researchers ‘undertaking randomised controlled trials’ they will surely present the drawbacks for readers' consideration? There is not a single word to suggest there may be side-effects of cannabis for treating the pain of endometriosis – let alone any dangers in general gynaecology and obstetrics. Solid pharmaceutical evidence for the use of cannabis in the treatment of endometriosis (or any other gynaecological condition) is lacking and the authors agree it is ‘urgently’ needed. However, they argue that such trials ‘are by no means an essential prerequisite prior to prescription’ - the rationale of this disregard being their replacement ‘by a diversity of approaches that involve analysing the totality of the evidence base.’ Say what? But the evidence base is clear – cannabis is a dangerous drug, so failing to accept the facts when they go against your premise is illogical and unprofessional. Prescribing one analgesic agent rather than another that has no effect on the underlying cause of the pain can only hope to persuade the patient to think she is ‘better’. Homeopathy claims that ‘if you think you are better, then you are better.’ Analgesic roulette is homeopathy and not what endometriosis suffers should be offered.2 Evidence-based medicine rests on three pillars, the best available evidence, clinical expertise, and patient preferences. The evidence produced in favour of cannabis thus far is equivocal and anecdotal. The clinical experience in Australia and New Zealand is minimal and unpublished, with patient preferences only, in the protagonists' words, ‘worthy of continued investigation’. The latest systematic review concludes that interpreting existing studies precludes ‘a definitive statement about cannabis for gynaecologic pain relief’.3 Asking doctors not to ‘wait for higher level evidence’ before prescribing cannabis in gynaecology or obstetrics is speculative at best, but against the principles of good medicine, especially in view of the evidence which is available which demands caution.4 Let us weigh the benefits and harms of any progress in our discipline and then – and then only – act in our patients' best interests.