What is the future of cannabis as medicine? 

Over the next few decades, our healthcare system will continue to evolve into a more “personalized” system, which aspires to be cheaper while providing better health outcomes than our current system. 

The healthcare of tomorrow will be preventive, individualized, and facilitated by digital technology. What would medical marijuana look like in a “personalized” healthcare system? We reached out to three experts to discuss the future of cannabis medicine: 

• Paul Armentano is the Deputy Director of NORML, a leading expert on cannabis policy, and author of a recent book on clinical application of cannabinoids.
• Dr. Jan Roberts is a practicing mental health care clinician, professor at NYU, and founder of the Cannabinoid Institute.
• David Pompei is a pharmacist and co-founder of Fiorello Pharmaceuticals, a New York medical cannabis company.

Healthcare of tomorrow: why “personalized” is here to stay

In 2019, Scott Waldam, MD, PhD, published an article in the medical journal Clinical Pharmacology and Therapeutics titled Healthcare Evolves from Reactive to Proactive, in which he defined our current reactive healthcare model as relying on “interventions that mitigate symptoms of established diseases.” 

In contrast, proactive or preventive medicine intends to prevent disease before it occurs, or to halt the progression of a disease after onset. Additionally, proactive medicine places more emphasis on educating and empowering patients.

According to Dr. Waldman, medicine is shifting from a paradigm that focuses on the “average patient” to “individualized solutions.” This new paradigm can be broadly defined as “personalized medicine,” which means healthcare that is “predictive, personalized, preventive, and participatory.” 

Predictive refers to predicting an individual’s predisposition to a disease before its onset. Personalized means that treatments will be designed for an individual rather than the “average patient.” Preventive suggests intervening – particularly with lifestyle interventions – before disease develops. And participatory means that the patient plays an active role in their treatment. 

One of the novel ways patients participate in their healthcare is by using digital health technologies. Digital health technologies could be anything from a device that monitors your sleep, to an app that allows you to track symptoms and share them in real-time with their healthcare provider, or even the Jointly app. The Jointly app allows consumers to set a wellness goal (such as sleep, improving social experiences, or stress relief) and track how they feel after ingesting a cannabis product.

This paradigm shift from reactive to preventive healthcare is possible because of recent technological innovations and scientific discoveries – many of which come from cannabis-related research.

How cannabis science gave us preventive medicine

At a basic level, preventive medicine is possible because science has given us the ability to understand how diseases progress at a molecular level. As scientists discover more about how diseases progress, clinicians are learning how to intervene before they occur. 

Some of these scientific discoveries are related to the endocannabinoid system (ECS), because the ECS plays a major role in the development or prevention of many diseases.

For example, the ECS is implicated in the stress response and the inflammatory response. Chronic stress and inflammation are known drivers of disease. 

Your immune system is what fights off infections and diseases, and the ECS plays an important role in immune function. Scientists have discovered that there are cannabinoid receptors on immune cells, and that stress, depression, and anxiety affect the function of the immune system through the ECS. 

Additionally, recent discoveries have revealed that the ECS acts as a mechanism by which psychological stressors can lead to disease. These findings suggest that the ECS plays a critical role in the mind-body connection.

New insights into the mind-body connection have led doctors to recommend a variety of wellness practices such as exercise, meditation, social connection, and healthy sleep patterns. These preventive interventions can dramatically reduce the risk of disease. Perhaps unsurprisingly, these healthy habits often exert their benefits through the ECS.

So, our healthcare model is evolving – but what impact, if any, will this evolution have on medical marijuana?

The future of cannabis as medicine

Cannabis has become an established therapeutic option for medical patients who use it to sleep better, to improve their mood, or to stimulate their appetite. However, most “recreational” consumers use cannabis for similar reasons.

Medical marijuana refers to the use of cannabis to treat a medical condition, as recommended by a healthcare professional. Cannabis wellness refers to the purposeful use of cannabis products to improve wellbeing, and may include self-directed use as well as the plant’s medical use in a preventive capacity.

When consumers use a purposeful dose of cannabis to get a good night’s sleep, shift into a positive and open mood, or maintain a healthy balance of energy, they are making choices that optimize their health. Cannabis wellness is a lifestyle intervention that falls under the umbrella of preventive medicine. That is not to say that a healthy lifestyle prevents disease, but it is a preventative measure. 

Let’s see what the experts have to say about the present and future of cannabis as medicine.

Paul Armentano is a leading expert on cannabis policy and author of multiple books focusing on cannabis policy, prohibition, and the clinical use of cannabinoids. He is also the Deputy Director of NORML, the oldest and largest cannabis legalization organization in the United States. Paul Armentano is a legal expert on cannabis policy issues and was the principal investigator for defense counsel in the federal case US v Schweder et al., one of the first legal cases to challenge the constitutionality of cannabis as a schedule I controlled substance.

In the past decades, there has been an evolution in our understanding of the cannabis plant, particularly with respect to how its constituents interact with and modulate human physiology and behavior. This evolution is reflected in changing attitudes and in growing acceptance. While once seen by many as a therapeutic option of last resort, many are now beginning to redefine cannabis’ role as a potential first-line therapy and as a safer alternative to many conventional treatments. Whereas cannabis was once primarily associated with youth culture, it is now embraced by a record number of seniors and older adults. Whereas many once viewed cannabis strictly as a palliative agent, there is now increasing acceptance that cannabinoids possess the ability to modulate the progress and course of certain diseases. And while cannabis was once perceived as something to be consumed predominantly by patients when they were ‘sick,’ cultures are now open to integrating cannabis into model regimens designed to promote and maintain physical and emotional wellness. 

These changes in attitudes are happening both quickly and exponentially — both in America and globally. As we look ahead to how future generations will perceive cannabis, and how they will utilize it in everyday life, it is safe to presume that our scientific understanding of cannabis — how it works, why it works, and what it works best for — will continue to advance. New and more precise methods of ingestion will continue to become available. But among this backdrop of change, people’s motivations for consuming cannabis will likely remain largely the same as it always has. Thousands of years ago, cultures consumed cannabis for its therapeutic properties and for emotional regulation. Those motivations continue to guide the majority of cannabis consumers today and no doubt will continue to do so in the future.

Dr. Jan Roberts, LCSW, is an internationally recognized psychotherapist and educator whose approach merges neurobiology, cognitive processing, EMDR, and mindfulness-based strategies in her clinical practice. Dr. Roberts has a private practice in Manhattan. Additionally, Dr. Roberts is a professor at NYU, the founder of The Cannabinoid Institute, and serves as the faculty advisor to NYU's Cannahealth Student Group and NYU's Student Association for Psychedelic Studies (SAPS). Dr. Roberts serves as a Jointly advisor.

As a clinician, I have a hard time differentiating between medical cannabis use and recreational use. When you look at the major reasons that cannabis consumers use cannabis in recreational or adult use states, it’s for therapeutic reasons - sleep, relaxation, pain, anxiety. 

I have a strong ethical responsibility to do no harm. I’ve seen cannabis work well for some patients and not well for others. I’ve noticed that patients who don’t achieve positive outcomes with cannabis use it differently than those who do - who see it as part of their wellness routine.

I made a concrete decision to focus on cannabis from a wellness and harm reduction approach. I don’t believe that the industry has done enough to provide a balanced view of cannabis from a wellness perspective. And it’s my clinical opinion that if we don’t openly discuss how to use cannabis from a wellness perspective, maladaptive use of cannabis may increase. Wellness is about balance, moving toward health and authenticity. We need more education around cannabinoids and their impact on the mind and body. And we need more tools for people to learn self-regulation.

Overall, I feel we are moving toward the personalization of cannabis as a medicine. Cannabis, via the ECS, can help people learn to live with a healthy mind and body. I have seen cannabis help people identify unhealthy patterns, provide relief from symptoms of trauma, and reduce anxiety. And I firmly believe that cannabis can help struggling patients if they are in a supportive environment. But that doesn’t mean that everyone knows how to use it effectively. That’s why one of my missions is to teach people how to use cannabis in the best way possible. 

Dr. David Pompei, PharmD, MS, is a licensed pharmacist and co-founder of Fiorello Pharmaceuticals, a New York-based medical cannabis company producing medicines for qualified New Yorkers. Dr. Pompei has published scholarly work on the topical use of cannabinoids, educated patients and physicians on qualifying uses, and led advocacy efforts to qualify patients suffering from rheumatoid and psoriatic arthritis for medical cannabis in Connecticut. Dr. Pompei is a Jointly advisor.

Medical marijuana in the US has come a long way since the olden days of Tincture of Cannabis USP. Pharmacists at the turn of the last century used prepared extracts and decoctions of cannabis - (taken with a spoonful of sugar and spritzed w seltzer, the original cannabis beverages!) And while the formulations have vastly improved in their 'pharmaceutical elegance' since that time, many of the basic form factors such as tinctures, flower, and edibles available then would be recognized by customers today.

On the prescriptive side, physicians in the pre-FDA era were given a wide berth for how cannabis was used therapeutically. We see a similar situation playing out today in state-level medical markets, with expanding or broadly permissive formularies for recommended uses. 

In the US, state-level medical marijuana programs typically precede those of adult-usel. What we are seeing in the data are that medical marijuana participation rates have been dynamic as the cannabis market has matured. In more mature adult-use markets like Colorado and California, medical marijuana participation begins to wane. 

This is not to suggest that patients no longer use cannabis therapeutically; there may be a few different factors at play - price and accessibility for sure. But the factor most exciting to me is the evolution of patient education - there are great resources available for patients these days, and it's empowering for a patient to do their own research and educate themselves on what works best for them. 

In an adult-use market, state regulators have tacitly acknowleded that cannabis is considered safe enough to be taken without the oversight of a physician; so, if a patient can self-educate and select, all the better. This is not to say that the physician has been removed from the care plan. I recommend that even adult-market users discuss cannabis with their health care provider to ensure a well-balanced, informed decision.

As a pharmacist, I want the best outcomes for patients taking cannabis for medical use so it’s important that we understand what works and what does not. One of the many challenges confronting the cannabis industry is that the current regulatory environment precludes meaningful clinical research. 

In fact, A recent position paper from the National Academy of Medicine recognized this, and suggested we need to get creative. And, fortunately, there are a number of trial designs and data collection methods focusing on effectiveness unencumbered by the policy and institutional barriers preventing more classical clinical research. In my view, the most promising and personalized effectiveness design is that of the n=1, where patients act as their own control using validated outcome measures to monitor their progress towards obtaining their goals. . 

The aggregation of this data across these outcome measures can lead to insights regarding which products produce which outcomes at what significance in the general population. Performed correctly, this is a meaningful path to identify therapeutic agents of utility not undergoing the formal FDA pharmaceutical review process.

As we look to the future of medical marijuana, we will start to see more continuity in product form factors and brands from state to state, as well as in product manufacturing. I came to the cannabis industry from the pharmaceutical compounding and manufacturing space and - while I've seen a fair amount of improvement - I do believe we still have a long way to go before we are operating with the exactitude of pharmaceutical development. 

For example, at the National Cannabis Industry Association meeting in 2014 Denver, I spoke with a cannabis company that sells a transdermal product. They were making product claims, and I asked if they had any pharmacokinetic data to verify skin absorption. They had no idea what I was even talking about!

I do believe that as we begin to better understand the endocannabinoid system, we'll start to see some pretty exciting stuff. It's hard to say what strategy scientists will take - agonist inhibitors, antagonize inhibitors, circumvent pathways, combination therapies; honestly, it could be a bit of all of those. We'll have to see what the science tells us.

Get started on your cannabis wellness journey

Have you started your cannabis wellness journey? Jointly is a new cannabis wellness app that helps you discover purposeful cannabis consumption so you can achieve your wellness goals with cannabis and CBD. On the Jointly app, you can find new cannabis products, rate products based on how well they helped you achieve your goals, and track and optimize 15 factors that can impact your cannabis experience. These 15 factors include your dose, the environment in which you consume cannabis, who you are with when you ingest, how hydrated you are, the quality of your diet, how much sleep you got last night, and more. Download the Jointly app on the App Store or the Google Play Store to get started on your cannabis wellness journey.