Archive for the ‘THC’ Category

Medical Marijuana 2: immingrants to Colorado

Sunday, December 8th, 2013
Smokeable pot or marijuana  brownies is what most officials feared.

Smokeable pot or marijuana brownies is what most officials feared.

This morning's edition of The New York Times had an interesting article on marijuana migrants to Colorado. These aren't people looking for recreational pot, they're parents of kids with intractable seizures. In August, Dr. Sanjay Gupta, a neurosurgeon who was President Obama's initial choice as U.S. Surgeon General in 2009 (he's now CNN's chief medical correspondent), published a bombshell article in CNN Health with the title, "Why I changed my mind on weed." Gupta had previously published a 2009 Time magazine article, "Why I would vote No on Pot", but then undertook an extensive review of past efforts pro and con marijuana. He discovered that the 1970 decision to make the drug a Schedule 1 substance was not based on solid evidence of addictive properties and lack of medical efficacy, but rather on the absence of studies and, presumably therefore, was a political choice, not a scientific one.

The problem, of course, is by making pot Schedule 1, those studies could not be easily done, if at all.

Gupta refers back to a 1943 study in New York City under Mayor LaGuardia. The medical arm of that research concluded smoking pot neither led to addiction nor was it a "gateway drug,"

Gupta also reviewed a huge number of relatively recent U.S. studies of the drug; interestingly, 94% of them were designed to show the dangers of marijuana and only 6% looked at its benefits.

I did find a 2009 article in The Journal of Clinical Investigation, a premier research journal, with the arcane title "Cannabinoid action induces autophagy-mediated cell death through stimulation of ER stress in human glioma cells," Like most JCI articles it was quite complex, but the bottom line was the scientists involved (from Spain and from Harvard) concluded THC, one of the major chemicals in marijuana, may be useful in fighting cancer. They did not suggest cancer patients should smoke pot!!!! Rather, a chemical pathway uncovered in the study could lead eventually to anti-tumor therapies.

A recent review of research studies on the use of cannabinoids (marijuana contains over 500 of these chemicals with THC and CBD being the most significant) for seizure disorders was titled "Slim Evidence for Cannabinoids for Epilepsy." It noted that marijuana appears to have an anti-epileptic effect in animal studies, but we don't know yet if that's true in people. The extensive literature review only found four human studies, none of high quality, and concluded no reliable conclusions could be drawn at the present time. But CBD appeared to be safe for the relatively short time it was given in these projects.

High quality studies clearly need to be done in this arena.

So why did Dr. Gupta change his mind?

In the first place he felt Americans had been misled by the 1970 decision to classify marijuana as a Schedule 1 drug. And then there is Charlotte's Web, an oil said to be low in THC (the chemical which leads to a pot "high') and chock-filled with CBD which has no psychotropic effects, but appears to have a variety of positive medical effects.

In 2006 a Colorado woman gave birth to twins, one of each gender. When they were only 3 months old, the girl started having seizures, first one, then many. The doctors said her scans and blood tests were normal, but eventually, when she was two and a half, a neurologist at Denver Children's Hospital she had found a rare genetic mutation associated with an intractable type of epilepsy. Another specialist put the child, Charlotte, on a special diet sometimes useful in drug-resistant epilepsy.

A plethora of side effects and, two years later, the return of multiple seizures, drove her parents to a relentless hunt for something that could stop her convulsions. Eventually they heard of a California boy being treated with a cannabis product for the same rare syndrome as their child.

Colorado law demanded two doctors approve her application for a medical marijuana card. Charlotte's mom found a Stanford-trained MD, PhD and a Harvard-trained internist who had significant reservations because of Charlotte's age, but felt all other treatment options had been tried. Both signed the card.

An initial dose of a low-THC, high-CBD product in oil form from a Denver dispensary gave incredible results…no seizures for the first week of treatment. But the oil was in short supply and expensive.

And it's not the optimal form for medical use.

This is not the optimal form for medical use; the high CBD oil may be.

Enter the Stanley brothers, six men who owned a large marijuana dispensary and grew their own plants. They had developed another marijuana-derived oil that was low in THC, while containing lots of CBD. They had also started a nonprofit, the Realm of Caring Foundation, to provide cannabis and its derivatives to those who had major diseases (cancer, MS, seizures, Parkinson's), but were unable to pay market prices for the substances.

Fast forward to Charlotte at age six, having seizures in her sleep only two to three times a month (versus up to 300 a week). Her neurologic status has markedly improved and the oil she takes has been named after her. Dr. Gupta visited her and other patients who have had similar results.

Not all find their panacea in Colorado medical marijuana derivatives, but one of the two physicians who signed Charlotte's card, working with Dr. Edward Maa, an assistant professor of neurology at the University of Colorado School of Medicine, has accumulated a series of eleven such children with drug-resistant major seizure disorders and eight had a decline in seizure frequency of 98-100%. The data is about to be presented at an American Epilepsy Society meeting.

There's another side to the Colorado story, a familiar and sordid one. An August, 2013 article in The Denver Post was titled "Oversight of Colorado medical marijuana doctors remains spotty." It detailed a sting operation which led to a conviction of a Loveland physician who prescribed marijuana for an ankle sprain ten years past and for back pain even the patient said wasn't present. The two state governmental agencies who should be providing oversight of those doctors who provide medical marijuana prescriptions have largely been inactive.

The Colorado State Health Department has referred the names to the board of medicine of a very small number of physicians who account for an inordinate percentage of medical marijuana recommendations . They say these are the outliers, implying the vast majority who prescribe the drug are doing in an ethical and appropriate manner. I'm not so sure that is true and a law enforcement officer has been quoted as saying, "Very little has occurred to any of these physicians until now."

To complicate matters, Colorado voters (and those in the state of Washington) in November, 2012, approved the use of recreational marijuana for anyone over 21 years old. The Justice Department response is captured in an online article "Tolerating Pot With a Frown."

I think medical marijuana is here to stay; we'll see how many careful studies get done to determine who should get actually it.








Medical Marijuana: Politics versus Science

Wednesday, November 27th, 2013
Marijuana in its raw form.

Marijuana in its raw form.

I recently read a New York Times article by Jane Brody titled "Tapping Medical Marijuana's Potential" in which she notes the long history of medical, spiritual and recreational use of the drug and mentions it contains  a multitude of chemicals (400 plus) in its raw form.  She confirmed my thought that if people are to use the drug for medical reasons, a joint or a pipe certainly isn't the optimal modality for administering it, When smoked, the number of compounds released multiplies by a factor of five (over 2,000 chemicals) and some are felt to lead to risks similar to those of tobacco.

As of November, 2013, twenty states and the District of Columbia have medical marijuana clinics; two states have even legalized its recreational use and a Gallup poll in October reported fifty-eight percent of Americans support legalizing marijuana for non-medical purposes. That's way up from the 12% in 1969 and roughly a third at the start of the 2000s who favored changing the laws concerning marijuana. Subgroups in this survey that still opposed legalization were those sixty-five and older and those who identified themselves as Republicans ( 62% of Democrats and 65% of Independents {up 12% since 2011} favored the change). Even the over sixty-five group had a considerable (+14%) increase in the last two years of those who are in favor of loosening the laws on the drug.

I'm going to stick to comments on medical marijuana, and not get into a discussion of recreational use.

Cornell University Law School's Legal Information Institute website details 21 USC § 812 Schedules of Controlled Substances. There are five levels of these drugs (or substances) and the most tightly controlled is Schedule I, drugs/substances (D/S) with a high potential for abuse and no currently accepted medical use in treatment in the United States. Additionally there is a lack of accepted safety for those D/S even if they are given under medical supervision. There's a long list of  Schedule I drugs including heroin, LSD, mescaline and GHB (the date rape drug). But marijuana is right alongside those, mostly for political, as opposed to scientific reasons.

Schedule II D/S  have a high potential for abuse, but do have a currently accepted  medical use in this country, some with and others without severe restrictions. Abuse can lead to severe psychological or physical dependence. Opium and cocaine are in Schedule II. Schedule III D/Ss have less potential for abuse, a currently accepted medical use and abuse can lead to moderate or low dependence. Amphetamine and its derivatives are in Schedule III. As you would expect, Schedule IV and V D/S have lower potential for abuse and habituation.

In 2005, the U.S. Supreme Court, discussing California's medical marijuana regulation (voted in under the 1996 Proposition 215) in  a case titled Gonzales v. Raich, issued a majority opinion that Congress had the power to prohibit local cultivation and use of marijuana in that state. They did so by case precedent under the Commerce Clause referring back to a 1942 decision about wheat farming. Justice O'Connor, Chief Justice Rehnquist and Justice Thomas dissented with Justice O'Connor writing that the Court's decision was sweeping overreach. She noted the two women who had sued the US Attorney General and the DEA were, in one case, raising a very small number of marijuana plants and, in the other case, relying on locally grown plants. Neither one was engaged in interstate commerce nor even conceivably had enough of the drug to substantially affect such. Both were acting in accordance with California law.

In 2008, an article in CMAJ, the Canadian equivalent of JAMA, reviewed safety studies on marijuana used medically and noted that short-term usage of the then existing forms of medical cannabinoids "appeared to increase the risk of non-serious adverse effects (the most common being dizziness), but not serious ones. The problem was the risks in longer-term use weren't well defined, even in that country which had been the pioneer in 2001 by legalizing medical usage of the drug.

2009 Department of Justice memorandum, directed at "Selected United States Attorneys," discussed "Investigations and Prosecutions in States Authorizing the Medical Use Of Marijuana." It firmly held to the DOJ being committed to enforcing the Controlled Substances Act (CSA) in all states, saying Congress still felt marijuana was a dangerous drug; its illegal distribution and sale was a serious crime and its sale provided gangs and cartels with oodles of money. While adhering to the CSA was still a clear priority, DOJ felt federal resources should not be expended in the pursuit of individuals who use marijuana medically in compliance of state laws.

An April, 2010 article in NEJM, written by two attorneys from the University of Maryland School of Law, mentions that the American Medical Association had recently voted for reviewing marijuana's status as a Schedule I drug. At that time, fourteen states had passed laws to allow the medical uses of the drug and over a dozen more were considering the idea. But there was very little if anything being done to "advance the development of standards" concerning dosing, packaging, potency, quality or purity issues. Experts in this country had urged reclassification to Schedule II as a means to allow rigorous testing of possible benefits, dosing and delivery means.

In early 2012, Mayo Clinic Proceedings published two articles and an editorial on Cannabis. The first article reported a case series of 98 patients with "Cannabinoid Hyperemesis." The first term meant chemicals found in marijuana and the second implies severe, persistent vomiting. The more common use of the medical term refers to the one to two percent of women who have continued, severe, nausea and vomiting during pregnancy…a condition termed hyperemesis gravidarum (gravid means pregnant).

How much THC is in this joint? Who knows?

How much THC is in this joint? Who knows?

A superb, long and detailed review by J. Michael Bostwick, MD of Mayo's Department of Psychiatry and Psychology has the intriguing title, "Blurred Boundaries: The Therapeutics and Politics of Medical Marijuana." and is available on an NIH website. It is well balanced and covers many facets of the history and pharmacology of the drug with caveats on its use in young individuals, an association with psychosis (marijuana may or may not be causative, but its use appears to have a distinctly negative effect on those already psychotic), the pros and cons of using it medically, and the currently available pharmaceutical cannabinoids.

The New York Daily News, on January 22, 2012, had an article titled "Marijuana-based drug Sativex may get FDA approval." A followup published August 14, 2013 in an industry online news source, Fierce Pharma, said the European pharmaceutical firm GW now had an American partner company working with the FDA on a Phase III trial for the drug in treating cancer pain and spasticity in multiple sclerosis patients. The oral spray has already been approved for patient use in the U.K., Canada, Denmark, Poland, Austria and Sweden. It has a mixture of THC, the psychoactive component, and cannabidiol, a non-psychoactive cannabinoid that can lessen the negative effects of THC while, potentially, offering reduced anxiety and anti-seizure effects of its own.

An October 3, 2013 article in Time Magazine's World section was titled "Canada Rolls Out a '$1 Billion" Privatized Medical Marijuana Industry." Medical marijuana has been legal in Canada for more than a decade but was strictly regulated. In a country whose population as of July, 2013, was estimated to be just over thirty-five million (versus the United States's November, 2013 estimate of 317 million), there are almost 40,000 registered medical marijuana users. The Canadian government thinks that there will be over eleven times that number by 2024 and has recently voted to shift to private companies, as opposed to Health Canada, controlling the drug's distribution by mail-order, but still under tight restrictions.

What next in the sweeping changes concerning marijuana? I'd like to see well-controlled prospective medical studies, but those can't happen until (and unless) it becomes a Schedule II drug.