For? Against? Or Too Soon to Comment? The AASM Position Statement on Medical Cannabis and the Treatment of Obstructive Sleep Apnea
The AASM recently released a position statement on the use of medical cannabis for the treatment of obstructive sleep apnea. (1) It states:
“It is the position of the AASM:
- That medical cannabis and/or its synthetic extracts should not be used for the treatment of OSA due to unreliable delivery methods and insufficient evidence of treatment effectiveness, tolerability, and safety, and OSA should be excluded from the list of chronic medical conditions for state medical cannabis programs.” (p. 680)
I agree with the second half of this statement. I think it is too soon to add OSA to the list of conditions for state medical cannabis programs. Thanks to a longstanding ban on research into the medical use of marijuana, there is little evidence available to support medical uses. The research that is available is carefully done and well-documented. Studies by Dr. Carley and colleagues have documented efficacy in a small cohort using a fully-blinded, placebo-controlled, randomized trial of dronabinol. (2) This is just the kind of evidence that the AASM wants for inclusion in the GRADE process in the development of clinical practice guidelines. (3) The problem is that there isn’t enough evidence to support the use of medical cannabis for the treatment of OSA. Yet.
It’s the first half of this statement that concerns me. Stating that a treatment should not be used in a position statement provides a virtual ban on a recommendation by physicians for use. Position statements are powerful in this respect – they can and will be used in malpractice cases. There is no doubt that “Further research is needed to better understand the mechanistic actions of medical cannabis and its synthetic extracts, the long-term role of these synthetic extracts on OSA treatment, and the harms and benefits.” (1, p. 680). The position statement does not reference the GRADE procedure, which, according to a paper on the guideline process reserves a recommendation against a treatment for situations in which “There is a high degree of clinical certainty in the balance between benefits vs, harms (i.e., net harms) of this patient-care strategy. The vast majority of well-informed patients would most likely not choose this patient-care strategy, compared to alternative patient-care strategies or no treatment.” (3, p. 134)
The position statement provides no evidence that harms outweigh benefits. Instead, the position statement says that, “the potential for misuse and increased costs, the lack of evidence on beneficial effects, and risk of side effects including increased daytime sleepiness” outweighs the potential benefits. (1) No evidence is cited in support of this statement. The evidence from Dr. Carley’s paper finds the opposite: Epworth Sleepiness Scale scores were reduced in the treatment group; the incidence of adverse events was not significantly different from placebo; and there was no evidence of tolerability as measured by missed doses. (2)
I need to apologize to Dr. Carley for the flippant tone that I took in my first blog reviewing the results of his study. Studies of cannabinoids provide an opportunity for a significant improvement in the treatment of OSA and should be taken seriously. These studies are in their infancy and need to be nurtured. At this point, I would agree with the AASM that patients should see a physician trained in sleep medicine for treatment of OSA. And it would be wrong for a patient in a state where recreational use is not prohibited diagnosed with OSA to begin using marijuana and assume that their OSA was adequately treated. And I would even agree that OSA should not be added to the list of chronic medical conditions for state medical cannabis programs.
But to state that “medical cannabis and/or its synthetic extracts should not be used for the treatment of OSA” is wrong. It’s too soon to comment.
- Ramar K, Rosen IM, Kirsch DB, Chervin RD, Carden KA, Aurora RN, Kristo DA, Malhotra RK, Martin JL, Olson EJ, Rosen CL, Rowley JA; American Academy of Sleep Medicine Board of Directors. Medical cannabis and the treatment of obstructive sleep apnea: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2018;14(4):679–681.
- Carley DW, Prasad B, Reid KJ, et al. Pharmacotherapy of apnea by cannabimimetic enhancement, the PACE Clinical Trial: effects of dronabinol in obstructive sleep apnea. Sleep. 2018;41(1).
- Morgenthaler TI, Deriy L, Heald JL, Thomas SM. The evolution of the AASM clinical practice guidelines: another step forward. J Clin Sleep Med 2016;12(1):129 –135.