Monday, July 3, 2017

Medical Marijuana

So Pennsylvania's medical marijuana supply chain is getting up and running. Licenses have been awarded. A list of diseases has been approved--you must have an approved diagnosis to qualify for a prescription. Here's a link to the list. Soon, growers in PA will begin producing the product, and I suppose some physicians will apply to become registered prescribers of marijuana as well.

Samples of THC and CBD in a lab.
The state's law is restrictive. Only "CBD oil" products can be used. CBD, or cannabidiol (kanna-bid-DI-ol), is one psychoactive component of the plant, and mainly it is calming and sedative. It's also said to regulate how THC acts in the brain--THC being the psychoactive component that makes people high. Smokeable products won't be legal.

A lot of the drive for legalization of medical cannabis in Pennsylvania was from a group of parents of children with various seizure disorders, some parents of children with autism, and so forth. Of course there were other advocates, but really, even the hardest of conservative legislators has difficulty telling sick kids they can't have a medicine that works. This link to Family Practice News shares conference coverage during which one physician in California reports seeing deep changes in some children with autism who use marijuana. It's not stated how they use it (I doubt it is smoked!) and the article also discusses other novel uses of nutritionals and drugs in these children.

Why Medical Marijuana?

People ask me--colleagues, patients--what I think of medical marijuana. There's a lot to unpack in that question.

The drug is still illegal in a large number of states. The federal government still lists it as a Schedule 1 drug (no medical use and highly addictive--of course, neither of these is true, but I won't get into the racist and protectionist mindset in the early 20th century that led to this designation).

Like many herbals, it's not just one drug. Dronabinol has been commercial available for prescription for over 20 years. I used to prescribe a lot of it when I treated AIDS patients. But patients using cannabis say that it isn't the same. Chemically, dronabinol is in fact THC, but again, when you are using the weed, you're getting dozens of other substances. The medical effects of these have barely been studied.

Marijuana makes people high. What does it mean to be "high"? Is it wrong to enjoy a pleasant sensation while you are also addressing your pain, anxiety, depression, stiffness, or other symptoms that you say are treated by smoking (or eating) pot? My students struggle with this. Is it a professional prejudice that we don't want people to feel "good" when they feel better from the medication?

Is "medical marijuana" an excuse to get high? If so, what's wrong with that? Do we have to medicalize experience in order to allow adults to enjoy things that they like? If a professional believes people should be sober at all times (which is a legitimate point of view), do they have the right to impose that on their patients?

Marijuana is among the safest of mind-altering substances. There's never been a fatal overdose. Yet alcohol and tobacco cause many deaths, and are nonetheless legal. Many prescription drugs are known to cause fatalities. Of course, one ought not drive or operate power tools when one is high..., but then isn't that the warning on a bottle of Oxycontin too?

I don't have a problem with marijuana being used for symptom relief, but I think its proponents overstate its effectiveness. It's not for everybody; especially because in many places it is still a black market product, you don't know what you're getting. But if one likes to get high, maybe that's not super important. After all, once the beer and wine start to flow at a party, doesn't everybody (who drinks) feel "better"? To most folks, it matters not that Rolling Rock is being served instead of Bud Lite--it's still alcohol!

I have a big problem with people who think this shouldn't be an option for patients. To me that is just imposing one's own beliefs on others. I'm not against some of the concerns, such as how should we approach this in children? Where does inhaled (smoked) cannabis fit in, when we're talking about health? How regulated should it be? These are all legitimate questions.

From a safety standpoint, I have little to say against its use by patients (mine or anyone else's). I recall warning some of my AIDS and hepatitis patients that their existing criminal records would make buying weed on the street a hazard to their freedom! It's said to interfere with homeopathic remedies, yet I have observed this effect is variable: for some, pot antidotes the remedy, for most it just tends to cause a premature remedy failure, and repeating the remedy works in both cases, except those in which the cannabis use is pathological. (Here I would define "pathological" use as daily, heavy use, perhaps exceeding 1-2 grams/day, or use multiple times a day. This is my definition as there is no consensus on what constitutes "heavy" use. It also exempts those who use cannabis strictly for symptom control. As you can see, these "definitions" are slippery!)

There's good evidence that recreational cannabis use in younger people can affect both coping skill development and maturation of the brain's frontal lobes, which govern impulse control and executive function. But then lots of kids who smoked dope in high school are successful and intelligent citizens.

So when I'm asked about this, I have to frame it in terms of who is asking. Is it a patient asking about trying it for symptom control? If so, that requires an answer tailored to their medical circumstances, but unfettered by my own biases (for or against use). If it's a patient asking about recreational use, the same condition applies: There's just no evidence that modest drug use is terribly hazardous, but I might add "Don't operate your chain saw while you're high!" (And this applies whether you're high on Afghan Kush or Bud Lite.) If it's someone who just wants my opinion, I am freer to admit that I think marijuana should be fully legal for both medical and recreational use.

It's safer than tobacco, alcohol, and to some extent safer than other prescription drugs that are often used to medicate symptoms. There are times when it should be avoided, but this shouldn't be imposed by government, except in the case of children. It should be studied, but studied in ways that account for all of its complexities--and this should obtain when we study any herbal medicine! Legalization, where it has happened, has invited all sorts of improvements, including research, but also including safety: buying correctly labelled, unadulterated cannabis in a store or dispensary is much safer than buying God-knows-what from a guy with a backpack who may or may not be armed!

Pennsylvania is pretty conservative, so it doesn't surprise me that we're late to the table and joining that table oh-so-slowly. I hope that the parochial, racist, oppressive rationales that have driven the Drug War and have maintained prohibition on this herb are dying off. I predict that the changes are going to come faster, and that in a few more years (and election cycles), politicians won't find it convenient to maintain the status quo. I only hope that when that happens, cannabis--medical or recreational--won't end up completely captive to either the pharmaceutical industry or the multinational corporations that produce and market alcohol and tobacco.

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