Posts Tagged ‘marijuana controversy’

Marijuana controversies: Part 2, state laws, health issues and DUI

Wednesday, March 6th, 2013

When I was a Veterans Administration Research and Education fellow (1970-1972) working inTorrance, CA, at Harbor General Hospital, I volunteered at the Long Beach Free Clinic once or twice a week to keep up my clinical skills. One evening I made an emergency "house call" across the street from the clinic at the headquarters of the "Peace and Freedom Party." I didn't know anything about that group, but as I attended to the ill member of the Party, I realized that many of those in the rooms I passed through were smoking pot.

It was clearly an illegal drug then, even in California, but my role there was that of a physician, not a policeman, so I just took care of my patient, eventually calling an ambulance to take him to a local hospital.

Fast forward to the 21st century.

Should this be legal for adults? Voters in Washington state and Colorado said, "yes."

Should this be legal for adults? Voters in Washington state and Colorado said, "yes."

Now a Colorado state amendment has legalized the drug as of December 10, 2012 with 55% of voters approving use, possession, cultivation and distribution by anyone 21 and older. A group called "Sensible Colorado" has outlined the development of Colorado laws regarding pot. As of March 1, 2013  a state task force on recreational marijuana has recommended special sales and excise taxes on it as well as rulings barring smoking it in bars, restaurant and social clubs. The group also said the plant should only be grown indoors, but could be sold to those visiting from out of state and given away, an ounce, at a time to adults.

In late February the Colorado House Judiciary Committee unanimously passed a Marijuana DUI bill, setting a 5 nanograms (ng) per milliliter of blood as the THC level as which a person could be ticketed for driving while impaired.

In past legislation, the 5 ng limit was considered a “per se” limit, which meant that if a driver’s blood level is 5 ng per milliliter of whole blood, the driver is assumed to not be in a fit state to drive safely. Similarly a driver's blood alcohol content (BAC) of .08 per milliliter is sufficient to issue a DUI ticket.

HB 1114 states that in a marijuana DUI prosecution , a jury may "infer" that a defendant was under the influence with a 5 ng level, but that defendant has the opportunity to prove that he/she was not impaired.

The 5 ng limit is based on the amount of active THC (delta 9 THC) in whole blood,  This form of THC functions for a short period of time following ingestion, typically from two to four hours. Latent THC, the kind that remains in the blood after active THC has dissipated, can remain in the blood for days after ingestion, according to a toxicology expert who testified in the Colorado hearings on the subject.

In early December, 2012 the state of Washington also legalized recreational marijuana for adults over 21. An article in the Huffington Post online said that there would be state licensing for those who grow pot, process it or sell it in a retail setting. Although smoking it in public is still illegal, much like drinking in public places, the Seattle Police Department told its officers not to issue citations for those who do so...pending further notice. Instead police officers will advise people to smoke pot at home. Washington's Initiative 502, much like Colorado's Amendment 64, allows the state to regulate and tax the drug's sale and sets limits for DUI.

The website of the Office of National Drug Control Policy says the Justice Department is reviewing these state initiatives and has no further comment at present. Federal law currently doesn't permit even medical marijuana, much less recreational pot use.

Gallup polls, as reported in a December 10, 2012 online review, show nearly two-thirds of Americans surveyed (64%) believe the federal government should not take active steps to enforce its policy on marijuana in states that have legalized its use.  Amazingly forty percent of those who oppose the legalization of pot still think this should be a state by state decision, decided by voters. Overall 48% of those surveyed were in favor of the drug being legal and 50% were against it. This is a marked change from the 1969 poll where only 12% wanted it to be legal or even 2005  when about one-third favored legalization.

As I would have expected, the survey results varied by age. Sixty percent of those under 30 are pro-marijuana; those in the 30 to 64 age range are equally divided into pro- and anti-pot camps and sixty percent of those 65 and old are against the new state laws.

A number of studies conclude that heroin, cocaine, alcohol and cigarettes are more dangerous to those who use them than marijuana. That by no means implies there aren't potential major issues with smoking pot. One of the physicians who commented on the New England Journal of Medicine discussion on medical marijuana had a mid-twenties patient with a 10-year history of smoking marijuana frequently and now needed a tracheotomy for cancer of the larynx. An online review of the medical dangers of marijuana focused on negative effects on the immune system, potential for carcinogenesis, and effects on memory and brain function, but some of its conclusions have been denied by other scientists.
DUI is DUI, but maybe we need to develop a better test.

DUI is DUI, but maybe we need to develop a better test.

A High Intensity Drug  Trafficking Areas (HIDTA) website comments that 9% of Washington eighth grade students, a fifth of 10th graders and over a quarter of seniors in high school are current marijuana users. Teen drivers are involved in motor vehicle accidents (MVAs) disproportionally and  data strongly suggest that marijuana users who drive have significantly increased rates of increased rates of MVAs. The combination of teens smoking pot and then driving is scary.

Are we at a tipping point concerning marijuana? It seems like that may be true.

If so, what will the next few years show about the risks of recreational pot use?

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.