Archive for the ‘marijuana’ Category

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.





Marijuana and Schizophrenia: What's the association?

Saturday, July 6th, 2013

My wife called my attention to an editorial page piece in the July 2, 2013 edition of The Wall Street Journal linking marijuana use to schizophrenia. I at first wondered who the paper had chosen as a distinguished medical figure to write on his or her research study of the association between use of this drug and the most severe mental illness, but read the commentary and realized it was written, not by a professor, but by a Yale psychiatry resident in training.

Having been a Duke resident more than 45 years ago, I was aware that young physicians at major teaching centers might, as I did, see a particular spectrum of the general patient population, in many cases the most ill portion of it.  Therefore I was less than certain of the strength of the basis for his viewpoint, but felt it was a highly significant topic and it was well worth perusing the literature pro and con.

Does this cause mental illness?

Does this cause mental illness?

In 2010 Time magazine published a well-balanced article titled "The Link between Marijuana and Schizophrenia." That led me to several medical research reports, but the lay press article itself was interesting.

It commented that studies showed those who were diagnosed with schizophrenia were approximately twice as likely to be marijuana smokers than groups who didn't have this dire diagnosis. Some studies, viewing things prospectively, suggested (note the word, please) that pot smokers were at double the risk of developing schizophrenia as those who never smoked the drug.

But, as the Time article noted  the portion of our US population diagnosed with this debilitating illness has remained constant at roughly 1%, and the current National Institute of Mental Health (NIMH) web-based discussion of schizophrenia agrees with this figure. It mentions that some drug abusers exhibit symptoms like those of patents with schizophrenia, but NIMH states that most researchers do not think that drug abuse is the cause of this mental illness.

A short piece from the CDC on childhood mental disorders in JAMA  for July 3, 2013, confirmed that schizophrenia is way down the list of mental disorders in US children. On the other hand, ADHD, behavioral/conduct disorders, anxiety, depression, use of illicit drugs or alcohol or cigarette, autism spectrum disorders and even Tourette syndrome (a neurologic disorder characterized by tics {repetitive involuntary movements and vocalizations} are listed as affecting multitudes of our youth.

In any given year, according to the CDC article, up to one fifth of our kids and adolescents have a mental disorder, while inpatient admissions have sharply increased for both mental health and substance abuse problems, especially for "mood disorders," e.g., anxiety and depression.

But there may be a subset of marijuana-using/abusing youngsters that merits special attention.

A 2011 Harvard Health Publications (HHP) blog piece by the then editor of the series, a woman whose bachelors degree was not in a medical field, but had a brother who developed schizophrenia, is titled "Teens who smoke pot at risk for later schizophrenia, psychosis."

I was concerned that she might have a biased slant on the disease, but impressed, as I read her blog piece by the articles she cited.

But then I went back to the articles themselves, as I routinely do. The first was in the British Medical Journal in 20111 and was a population based cohort study, a comparison of two different groups. The outcome was the "incidence and persistence of sub-threshold psychotic symptoms after adolescence." The verbiage used was that the use (and especially the continued use) of cannabis was a risk factor for developing severe mental illness.

I'd read the study as showing kids who end up psychotic often have smoked (or otherwise used) marijuana.

The second article cited was from the Archives of General Psychiatry, again a 2011 publication and was a meta-analysis (a study of a number of articles). The authors reviewed a large number of published research studies, picked 83 of them which met their standards for inclusion and pooled the results for statistical purposes.

That's a common way to look at data in order to have enough of it to reach a significant conclusion, which in this case was that the age of onset of psychosis was 2.7 years younger in the group who used cannabis.

Once again, that's only an association, but not a proof of causation.

The third article came from Lancet (in 1987) and was the result of  long-term followup of 45,550 Swedish military conscripts. Those who had smoked pot more than fifty times had a much higher rate of developing serious mental illness.

I want to go back to the blog in Harvard Health Publication, because here's where I have to differ with the author. Her statement that, "So far, this research shows only an association between smoking pot and developing psychosis or schizophrenia later on" makes sense; she admits the data don't prove marijuana causes psychosis.

But in the very next paragraph, she compares this research to that on cigarette smoking first being noted to be associated with lung cancer and later found to be a major cause of that disease.

Do troubled youngsters choice to smoke pot or does smoking it cause later troubles?

Do troubled youngsters choice to smoke pot or does smoking it cause later troubles?

Don't get me wrong; today's marijuana is reputed to be much stronger than that which was around when I was a young research fellow and volunteered time at the Long Beach Free Clinic. And some of the studies I've read in the last week would certainly make me want to caution a teenager with a family history of schizophrenia that pot smoking is really risky for them.

Maybe we're going to see an epidemic of the disease in those of our younger generation who smoke marijuana and don't any family history of schizophrenia or other major mental illness.

But I sure haven't see any data yet that convinces me that's going to happen.