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Pharmaceutical or Illegal Drug: The Bizarre Case of Marijuana

by Craig Klugman, Ph.D.

After gay marriage, one of the most controversial issues in the United States today is the issue of marijuana. Twenty-one states have passed laws or referendums legalizing the use of marijuana for medical purposes. Two states (Washington and Colorado) have legalized small amounts of marijuana for recreational use. Sixteen other states have pending legislation. Some of these states allow physicians to prescribe it while others permit physicians to recommend it by certifying that a patient has a qualifying condition.

This is a far cry from the 1970s when marijuana was classified as a Schedule I drug meaning it has no medicinal use and is highly addictive. Even through the 1980s and 1990s youth were told to “Just Say No” and to be wary because marijuana was a gateway drug to harder drugs.  As we have learned in the time since, Just Say No was a failure and marijuana is not a gateway drug. In a 2014 Pew Research Center poll (n=1821 U.S. subjects), 75% of respondents said that marijuana would eventually be legal, 44% said it should only be legal for medicinal use, and 16% would keep it illegal. In a separate Pew poll, 54% supported legalization. Compare that number to the 12% who supported legalization in 1969, 31% in 2000, and 41% in 2010.

Despite public opinion and state law, federal law still criminalizes the growth, distribution, and use of marijuana even for most medical purposes. In U.S. v. Oakland Buyer’s Cooperative (2001), the U.S. Supreme Court ruled that buyers’ clubs cannot grown and dispense marijuana because it violates federal law. A year later, the Court left standing a 9th Circuit ruling that doctors had a first amendment right to discuss medical marijuana. And in Gonazlez v. Raich (2005), the Court found that the federal government can prosecute marijuana users and suppliers even when operating under state law.

U.S. Attorney General Eric Holder in several statements announced an end to the Drug Enforcement Agency raids on medical marijuana clinics, an intent to not prosecute patients for medical marijuana use, and in 2013 that the Department of Justice would not challenge state laws in this area. Of course the next Attorney General and the next President could easily and capriciously change these rules.

Marijuana has been at the center of the failed war on drugs for a number of deliberate reasons. During Prohibition, the use of marijuana increased. Soldiers in the military in World War II and Vietnam used marijuana because it was widely available overseas. Public health and marketing campaigns began against this “killer weed” that was the source of “reefer madness.” Insanity was viewed as a byproduct of smoking weed. In 1937, the Marijuana Tax Act placed marijuana in the same category as cocaine and opium, a connection that survives even today.

There are many reasons offered for marijuana’s bad image. One of the major factors is that throughout the early and mid-Twentieth Century, it was the drug of choice among “undesirable” populations including immigrants from South of the border and jazz musicians. In the campy 1930s film, “Reefer Madness,” dancing is considered an evil action caused by smoking pot.  A second reason is that marijuana hemp was a competitor to cotton, and thus it was outlawed in many states as an attempt to protect that industry. A third reason is that its popularity during Prohibition was a threat to both the alcohol and tobacco lobbies and their economic interests.

In 1999, the Institute of Medicine Published “Marijuana Medicine” which stated that there was enough anecdotal evidence that clinical trials should take place to investigate the risks and benefits, and the delivery methods. Clinical trials have been slow in happening. There is currently only 1 legal growth source of marijuana in the U.S., at the University of Mississippi, where the federal government grows the plant for constant levels of THC. It is, however, very difficult to get permission to access this farm for research and funding has been tight, only $14 million from 2007-2011. Allegations have surfaced that the federal government makes it easier for researchers to have access if they are investigating the harm of marijuana rather than any benefits. A PubMed search reveals that only 101 articles of cannabis or its extracts have ever been published and this includes studies of derivative drugs such as Sativex, Marinol (Dronabinol), and Cesamet (Nabilone).

The IOM proposed that the drug could be useful as an antiemetic, anti-anxiety, as well as for pain control and enhancing appetite. The most recent medical marijuana law, Illinois, lists over 35 conditions for which the weed may provide benefit. A new Utah law [and a proposed bill in Illinois that would] permits an oil of marijuana to be used in children suffering from epilepsy.

There are legitimate concerns about more widespread use of marijuana. Some laws expressly prohibit driving under the influence. There is a psychological addiction. The delivery method of smoking can cause cancer. And 4 deaths have been reported worldwide as possible caused by marijuana (2 men who had undiagnosed heart conditions, a student who leaped to his death after ingesting a marijuana cookie, and a woman who had half a joint before she died).

On the other hand, marijuana has not been found to be physically addicting and beyond 4 case studies, death from marijuana toxicity is difficult. According to the DEA, you would need to smoke 40,000 joints in a short time to reach a toxic dose of THC.

For health care providers and institutions, a host of ethical issues are raised: Should patients with a legal referral be permitted to smoke pot in the hospital (or in the smoking area)? Should marijuana be on the hospital formulary? Should use be in the record? Should patients be encouraged to take FDA approved derivative drugs instead? How should hospital employees be handled who use marijuana under a doctor’s supervision when drug and alcohol policies expressly forbid it? If a physician refuses to recommend or write a reference for marijuana, is she or he required to refer to a colleague who will? Should the drug be declassified from being a controlled substance (HR 499 would do this)? Lacking a lot of scientific studies, should an evidence-based medicine even recommend this plant as a treatment?

The potential of a safe, inexpensive treatment for the symptoms of many diseases is attractive. The lack of research is worrying. History and politics makes the conversation challenging. But the opportunity to potentially help millions of patients requires that we make the difficult decisions.

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