Medical Marijuana

Even though this blog is about opioid addiction and its treatment, I couldn’t resist an entry about this topic.

What a quagmire this topic is. The pro-medical marijuana folks describe the pitiful little old lady who weighs 90lbs and needs to smoke weed to give her an appetite. The anti-marijuana folks describe the more typical “patient:”  a strapping young 20-something male in wonderful health except for some ailment an unscrupulous doctor was willing to diagnose (for a hefty fee) in order to qualify for medical marijuana.

I’m no fan of marijuana, but I risk losing credibility if I don’t acknowledge several important facts. First, marijuana causes much less harm to the human body than alcohol. If we try to use drug toxicity as a reason to keep marijuana illegal, then how can we possibly justify the legality of alcohol? Second, scientists have found that the marijuana plant contains many chemicals, called cannabinoids, that almost certainly will be useful for the treatment of various illnesses.

However… setting the plant on fire and inhaling the smoke isn’t the safest and most dependable way to deliver the drug, if we really are using it as medication. We don’t tell heart patients to go chew on a foxglove plant. We don’t tell patients in acute and severe pain to smoke a bowl of raw opium. Instead, the medically useful substances are purified and made into standardized doses, to avoid under- or over-medication. This way, we know exactly how much digitalis the heart patient receives, and exactly how much morphine the patient in pain receives. This is a safer, more effective method of treatment.

 Our use of the opium poppy can serve as an excellent example of how to use the marijuana plant appropriately. The poppy, like the marijuana plant, contains intoxicating materials. We refine this material from the poppy into standardized doses of pain relieving medication, like codeine and morphine. Because of the potential for addiction, these are deemed controlled substances, meaning only physicians with a DEA license can prescribe them. These doctors must document the medical condition they are treating, and the patient’s response to treatment. We can use the marijuana plant in the same way.

 It makes much more sense to refine useful substances from the marijuana plant in order to use specific substances for specific conditions. There are more than 400 different compounds in marijuana, and it’s unlikely that they will all be equally useful for the treatment of pain and other conditions.

 We already have one prescription medication that contains a cannabinoid (substance like those found in the marijuana plant), which is dronabinol. Its brand name is Marinol, and its approved uses are for HIV-positive people who have muscle wasting, and also for patients with severe nausea and vomiting from chemotherapy. In the future, I envision many more such cannabinoid medications, used in standard oral doses with accepted treatment protocols.  

 For the people who say they want to legalize marijuana for medical reasons: be serious. Setting a drug on fire and inhaling the smoke isn’t the best way to administer any medication. However, it’s an excellent way to get high, because the drug diffuses from the lungs directly to the bloodstream, causing the addictive rush.

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8 responses to this post.

  1. Posted by Joni on May 17, 2011 at 1:23 pm

    Short, sweet well written post about medical marijuana. I just shared it on Facebook. Do you have a professional facebook page? If so I’d like to follow. Thanks, and keep up the great work!

    Reply

  2. Posted by Jason on May 30, 2011 at 7:02 pm

    Hi Dr. Burson,

    I just wanted to leave a few comments. First, I just read your article about prison inmates with opiate addiction. I thought it was a great article, and I totally agree that the system should change in that regard.

    Now regarding medical cannabis, I also happen to read a lot on the subject and couldn’t help but offer a few replies in a ‘devil’s advocate’ fashion.

    1.)The ‘silver bullet’ approach (i.e isolating one compound from a plant- morphine from opium for example) works in many instances. However, due to the complexity and redundancy of biological systems, using a single agent generally results in many deleterious side effects or reductions in efficacy/tolerance. Many new medications are being developed that have multiple pharmacological effects to obviate some of the above mentioned concerns. Cannabis is like many herbal remedies in that there is hype, lies, folk wisdom but also a grain of truth. THC is not the magic bullet, nor is any other single cannabinoid. In fact, THC administered alone causes more side effects and is less efficacious than cannabis extracts. GW pharm is the best available example of how to do this better: they have a whole-plant sublingually delivered extract that is standardized/GMP etc containing a 1:1 ratio of THC to CBD. CBD is a non-psychoactive cannabinoid which modify’s THC’s effects and has its own as well. However, there are also terpenes (responsible for odor’s of cannabis) and flavanoids in cannabis with therapeutic effects, which act in a synergistic fashion. Whole plant extracts that are free of molds/impurities etc and are standardized are the way to go.

    2.)I agree that smoking is a crude delivery method that is less than ideal. However, the situation is complex due to THC’s pharmacokinetic properties. Orally consumed, its absorption and bioavailability is erratic and unpredictable. Also, when undergoing first pass metabolism, it is converted into a more potent psychoactive: 11-OH-THC. Also, inhalation allows for precise dose titration so one need not consume too much. Vaporizing should be used instead of smoking because it contains virtually no carcinogens, but retains the advantages of smoking. Lastly, although cannabis smoke contains a lot of tar and carcinogens, it’s chronic inhalation does not seem to cause lung cancer, only bronchitits and mild risk for emphysema. This is likely due to the potent anti-cancer and antioxidant properties of cannabis and its many constituents.

    Reply

    • Thanks for writing. I think you may be right about your first point, but I’d like references, if you have them.

      As for your second point…”Inhalation allows for precise dose titration..” I know it does….but seriously, smoking & inhaling aren’t the only ways to avoid first-pass metabolism. You mentioned a sublingual product in your first point. I’d like references for this second point as well.

      Reply

      • Posted by Jason on June 3, 2011 at 2:50 am

        Please note that I did not claim smoking is a method that should be used 🙂 I was just making several statements related to that idea, and again, even though I don’t advocate smoking, was pointing out its minimal harm except in immuno-compromised patients. For them, any pathogenic microbial contams from an unclean grow could be problematic. That is why a.) I am for always screening for its presence/ensuring it is absent b.) Most (keyword) reputable dispensaries perform such tests, as well as quantifying cannabinoid levels c.)Making/keeping cannabis illegal leads to these types of quality control issues.

        Another reason of why its continued prohibition hinders medical benefit, is that most cannabis has been selectively bred to contain only THC (with minimal CBD). This happens because two enzymes, THC-synthase and CBD syntase make their product from same precursor (CBG) and these two enzymes are co-dominant. So a plant can be 2copies of CBD, 2 copies of THC, or 1 and 1. Naturally, illegal substances are always selected more maximal potency. So essentially, the rich chemotaxonomic diversity of cannabis has been somewhat homogenized. Thankfully, many breeders and groups in medical states are combining analysis(using GC,MS etc) and breeding programs, to create a diverse therapeutic armamentarium of cannabis chemovars.One such group is called Project CBD. There is also a renewed interest in “landrace” varieties, which are traditional cultivars from different cultural and geographic regions with varying chemotypes.

        As for my refs, here are a few.

        1.) Advantages of polypharmaceutical herbal cannabis compared to single-ingredient, synthetic tetrahydrocannabinol. John McPartland

        2.) Cannabis and Cannabis Extracts: Greater Than the Sum of Their Parts? Ethan Russo and John McPartland

        3.)Non-psychotropic plant cannabinoids: new therapeutic opportunities from an ancient herb. Raphael Mechoulam

        4.)Cannabidiol: from an inactive cannabinoid to a drug with wide spectrum of action. Antonio Waldo Zuardi

        5.)A chemotaxonomic analysis of terpenoid variation in Cannabis. Karil W. Hillig

        -http://www.gwpharm.com/
        This is the link to GW pharmaceuticals. They are the one’s who have developed the sublingual extract I mentioned earlier. Their main product is Sativex, which contains 1:1 THC:CBD ratio. It has already been approved in Canada and UK(?), its in Phase II and III clinical trials in the US and other places, depending on the treatment indication.

        -http://projectcbd.org/
        I mentioned this above. They work to fund research into the medical effects of CBD, increase the availability of CBD-rich cannabis for patients in medical states, etc.

        -One last question, I’m not sure if you recall, I discussed at length with you on a different post about Buprenorphine/opiates for depression/mood disorders/anxiety. You asked for a list of references, to which I gave you a decent list. Have you by chance checked out any of the studies I listed? I know you are a busy person, but I was just curious. I was enjoying our discussion, when it suddenly ended. Thanks Dr. B!

      • Hello Jason,
        Thanks for the references.
        Sativex will be an interesting medication.

        About the other issue of buprenorphine and depression: of the twenty-two or so references you gave, none were what I was looking for. It’s all well and good to have basic science that tells us why a medication should work…but that’s just a starting point. Ideally, I’d like to see a double-blind, placebo-controlled (not sure how that would be achieved!) large, long-term study of treatment-resistant depressives who were treated with buprenorphine. That’s a reference I’d like to see, but I don’t believe such a study has been done. One of you references mentioned ten patients, but that’s not adequate information on which to prescribe buprenorphine for depression.

        There’s a saying in the doctor world that you never want to be the first doctor to prescribe a new drug – or the last. Not sure I always agree with that, but the point is, I need solid clinical data in the form of controlled trials of patients before I would take the risk of prescribing any medication off label that could cause harm to a patient, much less one that causes physical dependency. I’ve certainly used medications off label, but not ones that cause physical dependency.

  3. Posted by Jason on June 14, 2011 at 1:34 am

    Thanks for getting back to me on everything Dr. B. I always look foward to your replies and I hope I am not a bother with my constant back and forths.

    I agree that the gold standard type study would be great, but also agree its unlikely. Unfortunately, science isn’t always value neutral. NIDA is very picky about what studies it will allow on various controlled substances. This applies mainly for the cannabis issue, but also the opiates and mood disorders thing. Thankfully, there is something in the works that may be even better than the sub-optimal pharmaco-stopgap of off label sub. A few Enkephalinase inhibitors are in Phase I and II trials for anxiety and depression. These meds would lead to indirect mu and delta opiate receptor agonism, with less/or no abuse potential and improved efficacy/reduced side-effects.

    Reply

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