Why is the Endocannabinoid System still not taught in Medical Schools?
The Endocannabinoid System (ECS) is an extensive part of human physiology – with receptors in almost every organ of the body including the lungs, heart and brain. This signalling system is comprised of CB1 and CB2 receptors, with CB1 found mostly in the central nervous system (CNS) and CB2 primarily in the peripheral nervous system (PNS). As these receptors are linked to almost every system of the body, the ECS is involved in a huge plethora of functions – including homeostasis, sleep, mood, pain, appetite, fertility, and memory.
Whether or not you are a Cannabis user, you have an ECS that regulates your overall health and wellbeing, and your body produces its own natural cannabinoids as part of this. The body’s own supply of cannabinoids are known as endogenous cannabinoids, and those that are derived from external things such as the cannabis plant, are known as exogenous cannabinoids. The two are structurally similar, which means that exogenous cannabinoids interact with the body’s receptors in much the same way as endogenous ones.
The body’s supply of endocannabinoids can become disrupted via things like pollution and toxins, stress, hormonal imbalances and other common afflictions of modern living. This is why many people are turning to exogenous cannabinoids from mother nature to aid in restoring some of the balance. The market is teeming with options, however choosing the right product is not simple – it requires investigating purpose, formulation, bioavailability, dose and some self-experimentation.
A big name in bringing education and progress to the field is Dr Ethan Russo, a board-certified neurologist and psychopharmacology researcher:
“There are more cannabinoid receptors in the brain than there are for ALL the neurotransmitters put together.’ The significance of cannabinoids for the body is undeniably important – and the ECS has the potential to have a powerful impact on the body. It’s a significant part of the makeup of every human being, and can have a substantial impact on our health.“
Yet as a proven system, discovered as early as the 1990s, it’s still not a part of mainstream medical curricula. There certainly seems to be both a place and pressing demand for endocannabinoid education, so why is this?
A Curriculum That’s Decades Behind
Medical school is an already lengthy and challenging process, and by the end, students often still feel as though they are starting from square 1, and are relatively ill-equipped for the quantum leap to real life on the wards. It’s therefore not hard to see why fitting new material into an already dense curricula is difficult.
The issue is compounded by the need to attempt to keep up with exponential rates of progress. The industry is constantly discovering, evolving, adapting and changing, but sometimes our slow and inflexible old frameworks can hinder this progress, and keep us stuck. Our understanding of human physiology on both a reductionist and emergent basis, is constantly being updated. Doctors and students alike participate in a lifelong learning process to ensure they stay up to date.
Studies worldwide have been articulating the life changing potential of the ECS since its inception in 1992, however when reached for comment, most medical schools say they simply do not have the space or time to include it on the curriculum. According to Dr Ethan Russo, the common response is that institutions would have to remove something else, in order to make room for such new developments, something that they feel they cannot afford to do.
“The medical curriculum is just jam packed, I went to medical school in the 70s, and even at that point there was just no slack in the schedule. What one has to cram into particularly the first couple of years of basic science, is rather astounding. And now there’s been an additional 40 years of scientific discovery that also has to be incorporated. Administrators are always going to be defensive about that. The typical response is ‘what will we eliminate?’ However, that ignores the scientific importance of this system and its fundamental role in regulating physiology in every aspect.”
Understanding how The ECS operates, is integral to understanding how every other system in the body works, therefore the curriculum should be incorporating its role throughout. So far this has not been done, perhaps because it would call for a sweeping overhaul of the way medicine is taught. It is the belief of Professor David Nutt, who has dedicated his entire life to such a field, that:
‘Cannabis has to potential to usher in new paradigms in healthcare’.
The ECS As Integral To All Other Major Systems
It is of course easier to continue with the old, than to have to go through the uncomfortable transition period of breaking everything down to make space for the new. However, Dr Ethan Russo explains that “one could easily argue that you can’t understand how neurotransmitters in the brain work without knowledge of the ECS.” This also implies that there are more opportunities for cannabis to work with the body than conventional pharmaceuticals.
The ECS is responsible for maintaining homeostasis, which is the body’s natural balance. It ensures the optimal functioning of all systems, and is often described as the way the brain communicates with the body (the mind-body connection).
“Everything in the body is connected, and this is the glue” – Dr Russo
When the ECS is not functioning correctly, many other systems are affected as a result. Endocannabinoids have been observed to directly and indirectly affect a variety of physiological systems that influence appetite, pain, inflammation, thermoregulation, intra-ocular pressure, sensation, muscle control, energy balance, sleep, stress, motivation, mood and memory. All of these things have the potential to impact the quality of our daily lives on a grand scale.
Chronic illnesses are deemed to last 3 months or more and are medically ‘incurable’. Affecting a large proportion of the population worldwide, for the entirety of their lifetimes, it could be that we are missing a large piece of the puzzle, and cannot afford to be delaying the adoption of cannabinoid science.
One argument for not including The ECS on the curriculum is that there have previously been no pharmaceutical drugs that directly interact with it. This is a bit of a catch 22, as how will there ever be enough drugs to interact with a system that is not even taught? However, this is already rapidly changing.
The first FDA approved Cannabinoid Medication was Epidiolex, in June 2018, which is used to treat a rare form of childhood epilepsy. As Cannabis legality spreads, cannabinoids are likely to be increasingly incorporated into drugs and used to treat all kinds of ailments.
However, there are still many obstacles to overcome. As guidance on usage and dosing is relatively lacking, prescriptions can often still be difficult to obtain. Therefore in spite of the medication being available, not many people are actually receiving it. Although not necessarily a negative, the pharmaceutical compounds also tend to focus on synthetic forms of Cannabis, as opposed to the natural plant-based alternatives, for patenting and profit-driven purposes. Because of the way the sustainability of the industry operates, medications have to be formulated with profit rather than patient in mind, as an order of priority.
This leaves many desperate people turning to the black market for supply. Owing to supply and demand, the black market is tailored to abuse, as the highest demand comes from those who abuse the drug and are looking for the strongest concentrations to achieve quick recreational highs, after having built a tolerance. A higher dose does not necessarily make a compound more therapeutic.
The other reason black market substances are not as therapeutic is that they are not regulated, so it is near impossible to know the exact cannabinoid constitution of the compound you are buying, along with the conditions in which it was stored and grown – all things that affect its effect.
There is another hurdle when it comes to research. Cannabis still holds an official status as a ‘schedule 1 drug’ which has ‘no currently accepted medical use’. We already know this to be untrue, however the false stigma perpetuated by War on Drugs has for a long time made this difficult to change, and in the process created irreparable social, financial and physiological harm to the health of society.
According to Dr Russo, the prevalent negative propaganda around cannabis affects the lack of research and teaching, despite endogenous cannabinoids playing a role in the ECS regardless of cannabis use.
“One has to imagine that a prejudice against cannabis, a fear of cannabis, and lack of funding is spilling over into a pejorative effect on education about the endocannabinoid system”.
Whilst we must certainly be careful not to glamourise the irresponsible use of such compounds, we do need to make an educated transition away from abuse and harm, to one of health and healing. Any compound is like a knife – it depends on how and why you use it. A knife can be used as a weapon, or it can be used by a skilled surgeon to fix and to heal.
Hope For Change
With people like Dr Russo paving the way forwards, there is hope that over time things will begin to change for the better. The progressive, university of Maryland School of Pharmacy now offers a Master of Science (MS) in Medical Cannabis and Therapeutics. Associate Dean Andrew Coop explains:
“The reason we started the programme was because so few programmes focus on the health benefits of Marijuana. The pluses, the minuses, the strengths, where further research needs to go, where the indications have good, strong evidence, and where there is no strong evidence. We are teaching 150 students at the master’s level to understand all aspects – but also to be able to critically assess what the current state of the art says and doesn’t say, and what further studies need to be formed so that we can move forwards in a systematic manner…. To me, the bottom line is that we need to change at the federal level, such as the MORE ACT, before we’ll see more medical schools include it in their curriculum. Once we get things such as the decriminalisation of Marijuana, I predict more schools will include it. There is a want and a need for education in all aspects of Marijuana.”
The course is holistic in nature – comprising not only of scientifically dense material such as ‘genomics and pharmacognosy’ (medicinal drugs obtained from plants or other natural sources), but also the rich history and culture of cannabis and its use. However, until plants such as Marijuana are legalised, the research and development will be undeniably delayed.
Those with chronic diseases suspected to be associated with ECS malfunction must wait. Dr Russo himself is still waiting on funding for the resources needed to be able to provide things like a diagnostic test for fibromyalgia, something that could change the lives of millions.
“The failure to address ECS education appropriately is in unforgivable breach of scientific trust, and a major disservice to public health”.