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Medical Marijuana: are we ready?

Cannabis has been used recreationally and medically for centuries. Despite long experience, relatively little is known about the risks and benefits of its use as a medication. A considerable portion of our ignorance can be attributed to government discouragement of cannabis research. Searching the NIH website brings up many studies of both cannabis abuse and cannabis as a therapeutic agent, but most of the general information available is about cannabis as a drug of abuse.

And there is no doubt about the abuse potential and withdrawal potential of marijuana except among hard core denialists. The data is clear: marijuana discontinuation is associated with a withdrawal syndrome in many users, with some experts likening it in symptoms and severity to nicotine withdrawal.

As with any pharmacologically active substance, there are no “side effects”, only effects which we desire and those we do not. Given that cannabis is clearly a powerful pharmacologic agent, that there is a great deal of anecdotal evidence supporting its use, and that there is scientific plausibility to these claims, its potential use as a therapeutic drug should be investigated seriously.

As marijuana becomes increasingly available for medical use, practitioners of science-based medicine need to evaluate the evidence for the use of this drug. In evaluating a new drug, we must ask a number of questions, including those of safety, efficacy, and perhaps redundancy. Claims for the efficacy of marijuana tend to be hyperbolic, with no condition being exempt from its benefits. The state of Michigan passed a law last year allowing the use of medical marijuana. The statue requires a doctor to attest to the following:

It is my professional opinion that the applicant has been diagnosed with a debilitating medical condition as indicated above. The medical use of marihuana is likely to be palliative or provide therapeutic benefits for the symptoms or effects of applicant’s condition.

Once a patient has this certification, they are allowed to grow a small amount of pot for their own use.

What conditions does this apply to?

  • Cancer �
  • Glaucoma �
  • HIV or AIDS Positive (sic)
  • Hepatitis C
  • Amyotrophic Lateral Sclerosis
  • Crohn’s Disease
  • Agitation of Alzheimer’s Disease
  • Nail Patella

OR a medical condition or treatment that produces, for this patient, one or more of the following and which, in the physician’s professional opinion, may be alleviated by the medical use of medical marihuana.

  • Cachexia or Wasting Syndrome
  • Severe Chronic Pain
  • Severe Nausea
  • Seizures (Including but not limited to those characteristic of Epilepsy)
  • Severe and Persistent Muscle Spasms (Including but not limited to those characteristic of Multiple Sclerosis.)

“Cancer” means so many different things as to be nearly meaningless.  What if in my professional opinion the patient’s basal cell cancer might be improved with a toke?  Leaving this aside, what evidence do we have that marijuana is safe and effective in the listed conditions, and that it has a better risk/benefit profile than extant treatments?

For example, a recent review of marijuana for for the use of muscle spasticity in multiple sclerosis found little objective evidence for its benefit.   Glaucoma, one of the original “indications” for medical marijuana, is a condition for which many sophisticated and effective interventions exist, but the literature for the use of cannabis for this disorder is anemic to say the least.

The use for marijuana for many of these indications barely passes the plausibility test.  Of what possible use could pot be in the treatment of hepatitis C or Crohn’s disease?  The agitation of Alzheimer’s could just as plausibly be exacerbated by pot as palliated, and a recent review found no benefit.

Some areas with better plausibility include cachexia (weight loss due to chronic disease) and nausea, although the development of drugs such as ondansetron, with its minimal side-effects and excellent anti-emetic activity makes pot look redundant at best.

Dronabinol, a synthetic and legal marijuana-based drug has been used for a number of years for nausea and appetite loss, but the data have not been all that encouraging.

Marijuana offers many promising avenues of investigation, although there will be little advancement without a change in US government policy.  But for a physician, the reason for the lack of data is not nearly as important as the lack of data itself.  As physicians, we cannot ethically prescribe or recommend a powerful pharmaceutical whose effects are not at least reasonably well-known.  In fact, it’s hard to envision any situation in which prescribing marijuana would be ethical.  If there were a condition with a lot of anecdotal data and no other effective treatment, and the risks of the condition were such that they outweighed the health risks and dependence potential of marijuana, we would maybe—maybe—have something to work with.  But for now, people who want to take cannabis should not count on a doctor to approve it for them.

Posted in: Science and Medicine

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34 thoughts on “Medical Marijuana: are we ready?

  1. Kausik Datta says:

    As if in response to your post today, NY Times brought out this thought-provoking report today:
    Medical Marijuana – No longer just for adults
    A summary of the report in a couple of paragraphs from the report –

    Dr. Jean Talleyrand, who founded MediCann, a network in Oakland of 20 clinics who authorize patients to use the drug, said his staff members had treated as many as 50 patients ages 14 to 18 who had A.D.H.D. Bay Area doctors have been at the forefront of the fierce debate about medical marijuana, winning tolerance for people with grave illnesses like terminal cancer and AIDS. Yet as these doctors use their discretion more liberally, such support — even here — may be harder to muster, especially when it comes to using marijuana to treat adolescents with A.D.H.D.
    “How many ways can one say ‘one of the worst ideas of all time?’ ” asked Stephen Hinshaw, the chairman of the psychology department at the University of California, Berkeley. He cited studies showing that tetrahydrocannabinol, or THC, the active ingredient in cannabis, disrupts attention, memory and concentration — functions already compromised in people with the attention-deficit disorder.
    Advocates are just as adamant, though they are in a distinct minority. “It’s safer than aspirin,” Dr. Talleyrand said. He and other marijuana advocates maintain that it is also safer than methylphenidate (Ritalin), the stimulant prescription drug most often used to treat A.D.H.D.

    California has already gone to pot. Will America follow suit – to the detriment of its younger generation? I have seen and worked with pot-addicted young people, and noticed from close quarters how the pot kept an otherwise bright young man from achieving anything that he could.

  2. riley290 says:

    Although not legal in my home state, my step-father occassionally uses marijuana to relieve the pain of hepatitis C induced end-stage liver disease. He has been on painkillers from demerol to fentanyl for 15 years and now is prescribed 350 tablets of morphine sulfate a month. His useper day drops dramatically when he “tokes up” once or twice a week.

    Although a lot of his pain is brought on by other mitigating factors (irremovable gallstone, vasculature problems) that have been brought on or are untreatable due to his hepatitis I was just responding specifically to the hepatitis C claim.

    And yes, there is a little in the way of research to back this claim up, it is anecdotal and a single point in what should be a huge study but it makes it nice to see him at ease from his pain and not in a morphine induced stupor a few times a week.

    Although the science is little, there are no doubt benefits for many conditions, absence of evidence isn’t evidence of absence, as you and Steve like to say.

    This should really be an indictment of the NIH and those in charge of the research monies that we are willing to put patients on long term opiate treatments because we have been unwilling to conduct studies on another naturally occuring substance. Resveratrol has been more highly vetted in the search for heart and aging mitigators, it’s time that we dissociate the stigma of marijuana and begin actively pushing for treatments with its active ingredients.

  3. wlondon says:

    I’ve been outspoken for years in suggesting marijuana ought to be legalized and that it has medical utility (at least in appetite stimulation, as an anti-emetic, and for various palliative care uses). It would be nice if an inexpensive smoke-free cannabinoid inhaler were on the market (as NAS suggested years ago), but it still appears that marijuana offers medicinal benefits for many patients that far exceed the risks of its smoke.

    My support for medical marijuana doesn’t blind me to the dark side of relying on medical authority to decide who gets medical marijuana in at least some areas of California. It’s disturbing that marijuana has become the primary focus of the medical practice of some physicians, even when such physicians do their job responsibly. I see no point in relying on medical authority, especially if many physicians are indiscriminate in prescribing or prescribe marijuana for questionable medical purposes. (Legalization would do away with farcical medical marijuana activities.)

    The criticism in this column of one particular physician rings true:

    http://www.latimes.com/news/local/la-me-lopez18-2009nov18,0,3168645.column

  4. Basiorana says:

    While I avoid it like the plague, I believe recreational marijuana should be legal– while it is certainly a drug of abuse, it has been repeatedly shown to be safer than cigarettes and causes less impairment and long-term brain damage than alcohol abuse. Honestly, the only reason you can buy cigarettes at the grocery store and have to go to a dealer for pot is the strength of the tobacco lobby– there’s no MEDICAL or SAFETY reason it should be illegal for adults who aren’t driving or caring for a child or otherwise endangering others (ie, same rules as for alcohol use).

    And I will say, and I’m sure anyone who has looked at the studies will agree, that marijuana use is FAR safer than using strong opiates for pain relief, particularly in patients who cannot swallow well (like cancer patients) and require IV lines. Marijuana use could mean the difference between having a person spend their final days on a hospital IV line, or using a nebulizer.

    Obviously marijuana shouldn’t be prescribed if there is an alternative that is safer, but the reason medical marijuana has been legalized is because often the alternative is Fentanyl– or they’ve become immune to even that.

    I don’t think there’s enough evidence for any use other than pain relief as an alternative to powerful opiates or in patients who suffer from severe nausea as well as pain. I’m not sure about things like glaucoma or anything, I agree the data’s not really there yet– but the pain relief connection is clear, and if the only functional alternative is powerful opiates, doctors should absolutely try it.

  5. Lukas says:

    I think it’s important not to overstate the case against Marijuana. While there is a legitimate question as to whether it should be used in a medical context, and what it would be good for in that context, some of the quotes seem a bit extreme.

    “And there is no doubt about the abuse potential and withdrawal potential of marijuana except among hard core denialists. The data is clear: marijuana discontinuation is associated with a withdrawal syndrome in many users, with some experts likening it in symptoms and severity to nicotine withdrawal.”

    I live in a country where Marijuana is essentially legal. Many of my friends have smoked it regularly and extensively during a part of their lives – between several times a day and a few times a week over a period of roughly 8 years. They have all gone on to study and to lead normal, successful lives. Furthermore, none of my friends smoke dope anymore, except for one. He’s also working as a successful miocrobiologist, with many published papers, so it clearly hasn’t kept him “from achieving anything that he could”. I don’t know of a single case of any of my friends having had any issues quitting smoking dope, although some of them have been unable to stop smoking cigarettes.

    This, of course, is anecdotal. At most, it shows that the withdrawal symptoms don’t occur in every case. However, my own experience seems to be in line with most studies I’ve read on the topic, and with the scientific consensus at least in my own country.

    Is there abuse potential in Marijuana? Sure, as with every other substance. Is there withdrawal potential? Probably some, although it seems to be far less severe than that of nicotine. Does it occur with “many users”? I doubt it.

  6. Robin says:

    Linking your last two posts, a mom treats her son’s autism with weed:

    http://www.cbsnews.com/stories/2009/11/23/earlyshow/health/main5748637.shtml

  7. For an article from Science-based medicine I expected it to be a little more factual. It says that Ondansetron (Zofran) makes marijuana appear redundant with it’s minimal side-effects. I checked it out and Ondansetron can kill you amongst many other things, I don’t see how that is minimal.

    http://www.druglib.com/adverse-reactions_side-effects/zofran/

    And of course Marijuana doesn’t kill you

    http://medicalmarijuana.procon.org/viewresource.asp?resourceID=000145

    Also the article says that a recent study holds that there is currently no objective info about the effects of cannabinoids on MS, but doesn’t mention the fact that the same study noticed differences in the objective and subjective reports that raised doubts as to the tests objectivity and warranted further investigation. I didn’t expect Science Based Medicine to twist that study in their articles favor so blatantly. Once again anti-spasmodics used to treat MS kill people, and once again marijuana doesn’t.

  8. wertys says:

    Prof Andrew Rice at University College London is an expert on cannabinoids in pain management and he is of the opinion having reviewed the literature on the topic that even though there is some modest benefit from some forms of cannabinoid the current formulation have an unacceptably high risk of causing psychosis and lack specificity for analgesic effects. He would like to see basic science continue but believes that clinical trials should be postponed until better targeted agents become available from the basic scientists. Despite being a leading proponent of cannabinoids for analgesia, he feels they are still quite a way off being safe and effective enough for clinical use, compared to opioids and other antineuropathic pain drugs.

    The above is a summary from my notes of 2 conferences he addressed in London last year and Australia in May of this year.

  9. Grinch says:

    Basiorana,
    “it has been repeatedly shown to be safer than cigarettes and causes less impairment and long-term brain damage than alcohol abuse. Honestly, the only reason you can buy cigarettes at the grocery store and have to go to a dealer for pot is the strength of the tobacco lobby– there’s no MEDICAL or SAFETY reason it should be illegal for adults who aren’t driving or caring for a child or otherwise endangering others (ie, same rules as for alcohol use).”

    Let’s say that this argument is not devoid of logic and accept your premise that marijuana should be legal because because cigarettes are bad. The reason is not because of the big tobacco lobby (although that may have some role). The reason that pot is illegal, is Harrison prohibition acts of 1914, 1915, 1927, 1937, 1950, 1956, 1958, etc.
    No medical or safety reasons? Well, how about marijuana induced psychosis, increased morbidity, “Marijuana smoke contains some of the same cancer-causing compounds as tobacco, sometimes in higher concentrations.Studies show that someone who smokes five joints per week may be taking in as many cancer-causing chemicals as someone who smokes a full pack of cigarettes every day.”

    Your argument that marijuana should be legal because cigarettes are bad is both immature and insulting to the intelligence of the experts. I think, also, that you mean alcohol can cause liver damage.

  10. TKayzer says:

    It seems to be there has been much study of cannabis, and the various claims for and against debated ad nauseum. The following site may help dispel many of the disputed claims:
    http://www.drugpolicy.org/marijuana/factsmyths/

  11. tmac57 says:

    Peter, while ondansetron is a great anti-emetic, the cost of it at $20+ per tablet, can be cost prohibitive for many. A woman who was in a cancer support group that I attend, said that her insurance company would only approve 10 pills a month for her while she was undergoing chemo. Needless to say that is totally inadequate. Some insurance won’t pay for it at all.

  12. tcw says:

    We have a bad enough problem with drunk drivers, so I would not like to open the door to more high drivers by legitimizing dope. The pot lobby wants to legitimize pot to get it on a different DEA class so that legal ramifications are not as difficult for self centered potheads (I know, I know, your grandpa used it for his ALS, but he’s not the majority of users). The medicalization of it is a doorway for enabling addicts. Rather, we shoud isolate the pharmaceutically relevant and therapeutic compounds and do research on those, otherwise it is another red rice yeast vs. statin situation.

  13. DevoutCatalyst says:

    Wish Carl Sagan was here to comment.

  14. TKayzer says:

    To TWC: There are already many over-the-counter drugs that have more serious ramifications than cannabis. How is it dealt with now?

    To DevoutCatalyst: And a host of others, many of whom are doctors.

  15. TKayzer says:

    To TWC: There are already many over-the-counter drugs that have more serious ramifications for driving than cannabis. How is it dealt with now?

    To DevoutCatalyst: And a host of others, many of whom are doctors.

  16. penguinsix says:

    Some of the things that concern me with legalization is the interaction with the rest of our society that hasn’t been fully explored. For example, drunk / ‘stoned’ driving was mentioned, and there will also need to be some guidelines set for things like heavy equipment operators who use casually or heavily.

    But I also wonder about some medical issues, for example:

    1) Drug Interactions: What about the side-effects of marijuana with prescription medicine? I can’t image that has been fully researched such that the FDA can speak authoritatively on which common medications are safe and which have a dangerous side-effect when used with a regular marijuana smoker.

    It would seem that introducing a new chemical into the system of many recipients of public health medicines would lead to some massive unexpected consequences, from the primary treatments being rendered ineffective or less effective to the potential for death (hypothetically speaking–I know of no studies). Could be quite messy, possibly even litigious.

    2) Fetal Drug effects: Apparently there are some studies on this
    http://www.dss.mo.gov/cd/info/cwmanual/section7/ch1_33/sec7ch8.htm

    Marijuana is used by an estimated 28% of adults between the ages of 18 and 25. Ten percent of those users are women. One study reports that infants born to mothers smoking five joints a day, showed decreased visual response to light, and more tremors, startles, and shrill cries. Chasnoff reports several infants whose mothers used marijuana showed hypotonia and severe developmental delay, but says urine tests showed some marijuana is contaminated with PCP.

    I think as this debate moves forward there are a whole slew of issues that have to be discussed, beyond the political catch-phrases and social acceptance or lack thereof. There’s quite a bit of science that needs to be done on this.

  17. And a host of others, many of whom are doctors.

    OK, here’s one doctor’s mostly non-scientific point of view:

    Hemp should be legalized for numerous reasons that can be summarized as follows: the damage caused by its being illegal is enormous and not justifiable. I believe that this damage far outweighs any benefits, but that is beside the point. The default mode in an ostensibly free society should be NOT to ban.

    Hemp’s potential medical benefits have almost certainly been overstated, as is the case with other ‘herbs.’ These have not been investigated to any substantial extent, mainly because the plant is illegal.

    Potential medical benefits are relevant to arguments for making it legal ONLY because doing so would hasten useful investigations.

    Doctors should NOT be the designated gatekeepers for legal access to hemp, both because it encourages corruption and quackery and because doctors should not be expected to act as policemen. This also applies to narcotics.

    Essential links and reading:

    http://www.drugpolicy.org/homepage.cfm

    AIN’T NOBODY’S BUSINESS IF YOU DO
    The Absurdity of Consensual Crimes in a Free Country
    (see: http://www.mcwilliams.com/books/aint/f01.htm )

    Various articles by Jacob Sullum:

    http://reason.com/people/jacob-sullum/all

    Several of my colleagues and readers will undoubtedly be shocked to read these apparently libertarian positions, but so be it.

  18. Dacks says:

    One the one hand, I’m very much in favor of decriminalizing pot, and maybe all street drugs. What has outlawing drugs done except create a job for nasty criminals and punish the people who are victims of these dealers, instead of helping them?

    On the other hand, using marijuana as medicine is a really bad way to go about legitimizing the drug, especially without strong science to back it up. It’s almost as if we want to go from demonizing pot to glorifying it without ever looking directly at the drug and finding out what it is.

    On the third hand, if someone with end-stage liver disease finds comfort in smoking pot, it seems to me that it might be ethical for a doctor to honor that request, even with the current paucity of knowledge about the drug’s effect. The (perceived) benefit would outweigh the risk in this case.

  19. Basiorana says:

    Grinch– Alcohol abuse can cause brain damage as well as liver damage.

    My point was that it’s illogical to say that marijuana is worse than alcohol or cigarettes, and illogical to ban marijuana when those are legal. Now, there are a lot of reasons to ban both of those, and if the law was consistent and alcohol and tobacco were ALSO banned, I might think it was too restrictive but it would not be a bad law, particularly. However, the current system is not reflective of actual health and safety concerns, and instead is reflective of cultural concerns (alcohol was common in Western culture at the time of the prohibition acts, while marijuana was less common and associated with immigrants and the poor, especially poor Africans) and financial concerns (there was no powerful organized lobby against banning marijuana as there was against cigarettes– remember that it’s only recently that tobacco stopped being THE major cash crop of the Southern states.

    For every concern of marijuana– and there are concerns, I don’t use it for a reason– you can find a worse problem with cigarettes or with alcohol. Overall, in areas where marijuana is legal and accessible, alcohol and cigarettes cause far more deaths and healthcare costs per users.

    Now, yes, there are reasons not to use marijuana; there are reasons why all drugs ought to be restricted; but there is no practical reason why tobacco and alcohol should be legal and accessible and yet marijuana is not. It reveals a bias in the law based on cultural and financial concerns in the country, not an actual desire to improve health and safety.

  20. Fifi says:

    Of course people prone to addiction can get addicted to marijuana, or sugar, coffee, alcohol, cocaine, coca-cola, exercise or any other substance or activity that quickly changes their physical/emotional/psychological state. There’s a reason why an addiction is called a “habit”. Essentially, addiction’s about wanting to feel differently – better – than one feels right now. Or being able to feel or do something that isn’t normally accessible and is only accessible on the drug of choice. Most hardcore addicts of any drug – and this does include food if we’re talking about the many people who use sugars and fats to change their mood or thinking, even though their consumption is killing them – have something underlying the addiction. It can be neuranatomical/cognitive or it can be emotional, or a combination of both (since the first usually causes emotional/psychological distress). That’s a poor argument against legalizing marijuana or medical use and it ignores dealing with why some people are addicts in favor of an often hidden or unrecognized “moral” argument against addiction that isn’t evidence based. A lot of people can use even highly addictive drugs – such as cocaine – for recreation without becoming addicts. Just as a lot of people can use oxycontin for pain without becoming addicts, even though it’s a physically addictive substance that has found a huge black market.

    Certainly the moral hysteria in the US regarding means that there isn’t much study of Cannabis for medicinal use in the US but research has been going ahead in other countries for a while now. (Incidentally, it was the cotton farmers who waged the big war against hemp and marijuana to get it prohibited – often using racism and moral hysteria to do so. It was less about health and safety and more about commercial competition. It’s interesting to see how the propaganda and the memes it spawned endure even to this day in the “moral” argument against the social dangers of cannabis, particularly when compared to the very real social costs of alcohol consumption, both recreational and as an addiction.) We recognize that alcohol addiction is about the individual and environment, and that some people aren’t prone to alcohol addiction. Why people thinks this functions differently in regard to other drugs probably has more to do with liking to have a few drinks for fun and relaxation every once in a while so they have a personal/social relationship with alcohol they don’t with other drugs.

  21. Kausik Datta says:

    More on this issue in breaking news…
    First signs of a great country going to pot… Personal pot use for medicinal purposes with a scrip is fine, but a lounge?
    Medical marijuana users socialize, smoke at Oregon cafe
    Fourteen states allow cannabis to be cultivated and used for medical reasons, and Maine this month became the fifth to allow retail pot dispensaries, joining California, Colorado, New Mexico and Rhode Island. Only Oregon has a place where any medical marijuana cardholder can socialize and use free, over-the-counter cannabis.

    Will this remain restricted to only users using for medicinal purposes? Remains to be seen. If my experience in Baltimore is any indication (admittedly anecdotal), it will not.

  22. Geekoid says:

    While more scientific study is certainly needed, and the number of anecdotes and sues now seem to warrant more studies, may poeple ehre seem to be addressing other issues.

    Those people seem to forget that as adults we should be able to choose. It is so available, that if I chose to get some pot and light up, it would be trivial to do. I choose not to. Why people think all of a sudden people like me would become pot heads only shows there ignorance on the matter.

    Everything can be abused, and bringing in the ‘potential’ some one could have accomplished is a logical fallacy. You have no way of knowing if those people would have accomplished jack.

    This is becoming the typical ‘we don’t have enough information to make a judgment so lets argue over poor anecdotes’ discussion it always becomes on all boards.

    In my opinion with the limited data we do have, I say if someone suffering from a chronic pain or is having appetite issues let them have there pot; which is usually steamed or eaten or applied as a butter.

  23. neurosnap says:

    I have a lot to comment about this article, but I’m going to just point out a few snippets that I found interesting.

    “And there is no doubt about the abuse potential and withdrawal potential of marijuana except among hard core denialists. The data is clear: marijuana discontinuation is associated with a withdrawal syndrome in many users, with some experts likening it in symptoms and severity to nicotine withdrawal.”

    Actually, there is a lot of doubt about the withdrawal potential of cannabis. I’m a cannabis user and speaking strictly of anecdotal evidence, the withdrawals are specifically psychological. I have started and quit cold-turkey many times with no problems at all; the same could also be said about virtually every single cannabis user I know of. Unless there is a serious mental addiction–which can be attributed to any chemical, pleasurable fixation–I cannot imagine that slumping cannabis withdrawal with nicotine withdrawal in scientifically valid, especially since you have even claimed yourself that the literature on the subject is sparse.

    “For example, a recent review of marijuana for for the use of muscle spasticity in multiple sclerosis found little objective evidence for its benefit.”

    I suggest you read this great article about the CB2 receptor, here (http://www3.interscience.wiley.com/journal/118687471/abstract?CRETRY=1&SRETRY=0). There were a lot of interesting ideas addressed in this paper. One thing I found interesting was, “The elevated expression of CB2 receptor mRNA by activated versus resting microglial cells is the first direct evidence that CB2 is up-regulated as a consequence of microglial cell activation during CNS autoimmunity.”

    This article also references other studies found on the CB2 receptor and they lead to the conclusion that when the CB2 receptor is activated, it could potentially help reduce the symptoms of Multiple Sclerosis, Experimental Autoimmune Encephalomyelitis (EAE), and Alzheimer’s Disease; basically, common auto-immune diseases that have been tested thus far. Although, the conclusion that their experiment came to was that CB2 receptors increased in microglial cells and macrophages when there was an auto-immune disease present.

    I have also seen anecdotal evidence of cannabis alleviating the symptoms of Parkinson’s Disease as well.

    This little snippet was also very interesting–from the article cited above:

    Microglial cells and the CB system have also been implicated in inflammation in the CNS associated with MS. MS is characterized by microglial activation and neurological deficits including sensory deficits, motor weakness, tremor and ataxia (Compston and Coles 2002). Clinical studies have suggested beneficial effects of cannabinoids in MS (Pertwee 2002). In EAE, Δ9-tetrahydrocannabinol (THC), a plant-derived cannabinoid that binds to both CB1 and CB2 receptors, delayed the onset of disease when administered prior to disease induction (Lyman et al. 1989). Administration of synthetic cannabinoids to mice with chronic, relapsing EAE resulted in a reduction in spasticity and tremors (Baker et al. 2001). Mice with Theiler’s murine encephalomyelitis administered cannabinoids exhibited a significant improvement in neurological deficits, decreased microglial activation and decreased numbers of infiltrating T cells in the CNS (Arévalo-Martín et al. 2003). Taken together, these studies suggest that CB receptor activation could have a beneficial role in the progression of EAE.

    “Dronabinol, a synthetic and legal marijuana-based drug has been used for a number of years for nausea and appetite loss, but the data have not been all that encouraging.”

    I just want to say that I have never seen a study that has actually compared cannabis and drabinol (marinol) and tested their efficacy side-by-side. This leads me to believe that the synthetic form might not be as effective as cannabis.

    Also, I recently read this study that suggests cannabinoids could increase neuronal growth in the hippocampus. The study can be found here (http://www.jci.org/articles/view/25509/version/1).

    Not only that, but cannabis could have anticancer effects (http://www.ncbi.nlm.nih.gov/pubmed/14570037?dopt=Abstract) (http://www.ncbi.nlm.nih.gov/pubmed/12182964?dopt=Abstract). Although, I would like to point out that a study in 2004 stated that the right concentration of THC was important for either cell apoptosis or the opposite, cell proliferation:

    “In the light of these results, the use of cannabinoids in cancer therapy has to be reconsidered, because relatively high concentrations of THC induce apoptosis in cancer cells, whereas nanomolar concentrations enhance tumor cell proliferation and may, therefore, accelerate cancer progression in patients.” (http://cancerres.aacrjournals.org/cgi/content/full/64/6/1943)

    Now, obviously some of my “evidence” is strictly anecdotal, but I have also been reading the literature on cannabis as well. This article would lead some to believe that the medical benefits are minimal. While that may be true, we should also state that every person reacts differently to medications and having those alternatives are just as vital. I also agree that more studies need to be conducted on cannabis and legalizing or at the very least, removing the ridiculous stigma behind cannabis would inevitably lead us to a greater understanding.

  24. Dacks says:

    “applied as a butter.”
    People are using marijuana topically? Or are they applying the butter to their toast?

  25. S says:

    penguinsix: “For example, drunk / ’stoned’ driving was mentioned, and there will also need to be some guidelines set for things like heavy equipment operators who use casually or heavily.”

    I’m not a medical professional, just a former blue-collar worker. Truckers in the U.S. are currently subjected to regular physical examinations and random mandatory piss testing under DOT regulations. At my former workplace, random drug testing was a condition of our insurance coverage; we were also required to submit ourselves for testing after any accident involving vehicles or equipment. Again, not an expert, but would it really be that difficult for OSHA to mandate drug testing for workers who operate heavy machinery?

  26. yeahsurewhatever says:

    As in favor of cannabis legalization as I am, I’ve always thought it was kind of stupid to hinge the argument on its medicinal value.

    A physician who is prepared to prescribe it to, say, a terminal cancer patient, ought (logically) to be equally prepared to prescribe tobacco — or crack? — if the patient genuinely believes it helps them, right? Because this is all about the patient’s perception, isn’t it? Palliative care for someone who is dying. Making the process of dying somewhat more comfortable.

    One must concede that smoking crack is comfortable, and one must concede that the patient is going to die anyway. So the cannabis argument in this scenario can be generalized to quite nearly any recreational drug, and it’s absurd to think of crack prescriptions. So why is it less absurd to think of cannabis prescriptions?

    Not to mention the point that inhaling any burning organic matter is inherently bad for your lungs.

    I think anyone serious about cannabis legalization should keep medicine out of it. It’s purely a question of constitutional law, in my view.

  27. Lawrence C. says:

    “As physicians, we cannot ethically prescribe or recommend a powerful pharmaceutical whose effects are not at least reasonably well-known.”

    This seems reasonable, but at what point is it determined that “effects” are “reasonably well-known?” There are a host of “well known” drugs that were widely prescribed for many years but were later withdrawn after it was determined that they were in fact lethal. (Just a few examples: fenfluramine hydrochloride, dexfenfluramine hydrochloride, terfenadine, mibefradil dihydrochloride, astemizole, troglitazone, cisapride monohydrate, and alosetron hydrochloride.) Was it unethical to prescribe these drugs then because they were not really as well known as they should have been? Can the ethics of an act be changed retroactively based on new knowledge?

    “In fact, it’s hard to envision any situation in which prescribing marijuana would be ethical.”

    The parochial myopia here is startling and suggests that continuing education in a state with a longer standing medical marijuana system is advisable. There are thousands of doctors who will be glad to bring you up to speed on not only the ethics but also their observed clinical results over the past decade. There is plenty of data to go around but for reasons stated in the article, the Feds also discourage publishing such things. Before SBM takes on this topic again it would be advisable to get better educated on the subject. (As it stands this article sounds like it was written in the 50′s right after a showing of “Reefer Madness.”)

  28. gidoc says:

    To all patients with IBD that use cannabis/marijuana!

    Dear Patient,
    reports from patients suggest that use of cannabis/marijuana reduces symptoms associated with inflammatory bowel disease (IBD). In order to bring this to a scientific level more detailed information from patients is needed.
    We are conducting a study that is assessing the use, the benefits and the side effects of cannabis/marijuana for the self-treatment of inflammatory bowel disease (Crohn’s disease and ulcerative colitis). This questionnaire is directed to all patients with IBD that use cannabis/marijuana for their IBD.
    We are asking you to complete the internet based questionnaire. Please make sure that you respond to all questions which may take you approximately 10 minutes.
    This research study has been approved by the University of Calgary, Canada, Conjoint Health Research Ethics Board. You are under no obligation to complete this questionnaire. Your responses to this questionnaire will be kept strictly anonymous.
    Thank you for taking the time to read this material and fully respond to the questionnaire.
    If you have any questions, please contact the administrator for this study: Cannabis_use_in_IBD@gmx.com
    Please, support this research initiative by following the link and answering a 10 min (3 pages of questions) questionnaire.

    To start the study:

    http://ibd-cannabis-survey.limequery.com/index.php?sid=34989&lang=en

  29. Uther says:

    Just some observations about various antiemetics vs. cannabis. I have given ondansetron to patients on a surgical floor and it is less effective than promethazine in controlling nausea. Promethazine is a great drug but the risk of vascular damage is a bit scary to me and it knocks people out (which may partly explain why it works better than ondansetron). I think an vaporized version of cannabis in something like an albuterol inhaler could be a useful adjunct to these drugs that we use a lot on the surgical floor. Less sedation than promethazine, rapid onset, no risk of vascular damage. For some ondansetron works just fine but when that doesn’t work, it’s nice to have a range of alternatives.

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