Archive for the ‘medical marijuana’ 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.








Marijuana controversies: Part 1, background and medical use

Friday, March 1st, 2013
Now physicians can prescribe marijuana in some states

Now physicians can prescribe marijuana in some states

Last evening I glanced at the table of contents of the New England Journal of Medicine and was somewhat surprised to find there was an article online on medical marijuana.It discussed a hypothetical patient with metastatic breast cancer who had considerable pain issues and had asked her primary care physician if she could use pot to relieve her pain, nausea and fatigue. There were pro and con discussants with a psychiatrist from the Mayo Clinic in favor of "thoughtful prescription of medicinal marijuana,"  but wanting those to occur within established doctor-patient relationships.

That latter comment made sense to me; if medical marijuana (AKA Cannabis) is recommended by a physician, it should be by a doctor who knows that particular patient well, not someone who writes Rx's for dozens of people a day in a "pain mill."

On the other side of the issue were a Clinical Professor of Psychiatry at Georgetown University (a former White House Drug Czar) teamed with the Chief of the Pain Management Services at a Florida University. They noted that most of the research efforts have focused on specific chemicals from the marijuana plant and that there is limited, but high-quality, data supporting relief of some kinds of pain by smoking pot, but not the type of pain the patient being discussed had. They mentioned two prescription "cannabinoids" that are currently FDA-approved as oral agents specifically for the treatment of nausea/vomiting secondary to chemotherapy.

There have been over a hundred comments to date in the online discussion of the article. One was from a Colorado anesthesiologist/acute pain specialist who commented that patients who use marijuana on a daily basis may become cross-tolerant to opiate drugs, therefore requiring much higher and more dangerous doses of them to have a desired effect in pain control.

A major issue remains the 1970 classification of marijuana as a Controlled Substance Schedule 1 drug, therefore, putting it into the company of heroin, LSD and mescaline, chemicals that have a high potential for abuse and a lack of any medical value.

To date eighteen states have legalized physicians to prescribe the drug, but Federal policy lags far behind and, in theory, docs who write Rx's for marijuana could face legal action. In Israel, on the other hand, over 10,000 patients use marijuana under government license  according to a July, 2012 NPR article.

I found an online article titled "How Marijuana Works." This comes from one of the HowStuffWorks websites, not a medical publication, but seems fairly well balanced. It mentions that cultivation of marijuana is not at all new, with written reports in China dating back over 2,000 years. The plant apparently came from India where it can grow to heights over 13 feet. It contains an enormous number of chemicals, over 400 of them with 60 falling into the cannabinoid group. The National Cancer Institute's webpage on Cannabis and Cannabinoids define these as chemicals that activate specific receptors found throughout the body to produce drug-like effects.

So what's a receptor? I read a superb analogy in Discover magazine with science writer Gary Taubes comparing them to miniature locks on the surface of cells, locks that can only be opened with the correct chemical key.

Cells, including those involved in immunity and the central nervous system, have receptors that bind with substances such as hormones, antigens, drugs, or neurotransmitters (brain chemicals that communicate information from nerve cells). Two different kinds of receptors, termed CB1 and CB2, bind with cannabinoids. The CB1 receptor, when triggered, causes the drug high; THC (the full chemical name is delta-9-tetrahydrocannabinol) is primarily the cannabinoid that leads to this effect. A March, 2012 study from the Mount Sinai School of Medicine focused on the CB2 receptor after research showed that a medication that triggered only CB2 might prove a significant adjunctive treatment to standard anti HIV therapy in late-stage disease.

Other articles in the medical literature discuss the use of marijuana versus cannabinoids in glaucoma therapy. Smoking marijuana lowers intraocular pressure in roughly two-thirds of glaucoma patients. One issue, however, is smoking marijuana is smoking and in end-of-life care probably poses acceptable risks, but done in other situations it may cause a host of problems. Other means of administration include drinking raw cannabis juice, the use of inhalers or administering only specific active cannabinnoids.

In my state, Colorado, there's an organization, headed by an attorney and calling itself Sensible Colorado, that has advocated for medial marijuana. One of their websites outlines the "History of Colorado's Medical Marijuana Laws." Over thirteen years ago our voters passed Amendment 20 to the state constitution, legalizing limited amounts of marijuana for patients and their primary caregivers.

Checking for high intraocular pressure, a precursor of glaucoma

Checking for high intraocular pressure, a precursor of glaucoma

The statute listed the diseases for which a person could be prescribed marijuana/cannabinoids. The first group included cancer, HIV/AIDS and Glaucoma. As I read background articles I could see some reason behind those choices. I'm less impressed with data on most of the other reasons to give the drug  to patients.

In 2000, Colorado voters support the legalization of medical marijuana. In our city and around the state there followed a proliferation of "pot shops," without a great deal of unified regulation. Some cities were stricter in their approach toward the sale of marijuana than others.

All this may have been overcome by events; I'll write about the recent changes in the law in my next post.