Medical Marijuana: The Debate Rages On
The HWN Team | Heads or Tails
image by: O'Dea
Some countries, including Canada, Belgium, Austria, the Netherlands, the United Kingdom, Spain, Israel, and Finland have legalized the therapeutic use of marijuana under strict prescription control. So why not the United States?
Marijuana is known as pot, grass, weed but its formal name is actually cannabis. It comes from the leaves and flowers of the plant Cannabis sativa and is considered an illegal substance in many countries including the U.S. with possession of marijuana considered a crime punishable by law.
However, marijuana has been used as herbal medicine in some cultures going back thousands of years. And several countries including Canada, Belgium, Austria, the Netherlands, the United Kingdom, Spain, Israel, and Finland have already legalized the therapeutic use of marijuana under strict prescription control.
So, why not the United States? Expectedly, it is the drug regulators and legislators who are the biggest opponents to medical marijuana. The U.S. FDA continues to classify marijuana as a Schedule I drug, the most restrictive schedule of the Controlled Substances Act (CSA), substances which have a very high potential for abuse and have no proven medical use.1
According to a 2006 U.S. FDA advisory marijuana meets the three criteria for placement in Schedule I under 21 U.S.C. 812(b)(1)...marijuana has a high potential for abuse, has no currently accepted medical use in treatment in the United States, and has a lack of accepted safety for use under medical supervision.” 2
However, several studies have substantiated marijuana's medicinal use, especially in terminal diseases such as cancer and AIDS which has resulted in a fierce debate over the pros and cons of medical marijuana. To settle this debate, the Institute of Medicine (IOM) was requested by the Department of Health and Human Services (HHS) to evaluate the scientific evidence for benefits and risks of medical marijuana. The result is the infamous 1999 IOM report entitled “Marijuana and Medicine: Assessing the Science Base”. 3
The report was comprehensive but did not give a clear cut “yes” or “no” answer. The opposite camps of the medical marijuana issue often cite part of the report in their advocacy arguments. However, although the report clarified many things, it never settled the controversy once and for all, a controversy that is still raging years after its publication.4
So, here is what the two opposite camps have to say.
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Arguments for the medical use of marijuana: Marijuana is a naturally occurring herb. Marijuana has been used from South America to Asia and Africa as an herbal medicine for millennia. In this day and age when the “all natural” and “organic” are important health buzzwords, a naturally occurring herb like marijuana might be more appealing to and safer for the consumers than synthetic drugs. Marijuana has strong therapeutic potential The therapeutic potential of marijuana is its strongest point, as follows: • Several studies, as summarized in the IOM report, have observed that cannabis can be used as analgesic, e.g. to treat pain. A few studies showed that THC, a marijuana component is effective in treating chronic pain experienced by cancer patients. However, studies on acute pain such as those experienced during surgery and trauma have inconclusive reports. • A few studies, also summarized in the IOM report, have demonstrated that some marijuana components have antiemetic properties and are, therefore, effective against nausea and vomiting, which are common side effects of cancer chemotherapy and radiation therapy.5 • Some researchers are convinced that cannabis has some therapeutic potential against neurological diseases such as multiple sclerosis.6 • Specific compounds extracted from marijuana have strong therapeutic potential. Cannobidiol (CBD), a major component of marijuana, has been shown to have antipsychotic, anticancer and antioxidant properties.7-10 • Other cannabinoids have been shown to prevent high intraocular pressure (IOP), a major risk factor for glaucoma. • Drugs that contain active ingredients present in marijuana but have been synthetically produced in the laboratory have been approved by the U.S. FDA. One example is Marinol, an antiemetic agent indicated for nausea and vomiting associated with cancer chemotherapy. Its active ingredient is dronabinol, a synthetic delta-9- tetrahydrocannabinol (THC).11 Medical experts believe in medical marijuana One of the major proponents of medical marijuana is the Marijuana Policy Project (MPP), a U.S.-based organization. However, many medical professional societies and organizations have expressed their support for “controlled use” of medical marijuana.12 The American College of Physicians (ACP), for example, recommended a re-evaluation of the Schedule I classification of marijuana in their 2008 position paper. ACP also expresses its strong support for research into the therapeutic role of marijuana as well as “exemption from federal criminal prosecution; civil liability; or professional sanctioning…for physicians who prescribe or dispense medical marijuana in accordance with state law. Similarly, …protection from criminal or civil penalties for patients who use medical marijuana as permitted under state laws.” Medical marijuana is legally used in many developed countries The argument of “if they can do it, why not us” is another strong point. Some countries, including Canada, Belgium, Austria, the Netherlands, the United Kingdom, Spain, Israel, and Finland have legalized the therapeutic use of marijuana under strict prescription control. Some states in the U.S. are also allowing exemptions. |
Arguments against the medical use of marijuana: Lack of data on safety and efficacy Drug regulation is based on “safety first” policy. The safety of marijuana and its components still has to first be established. Efficacy only comes second. Even if marijuana has some beneficial health effects, the benefits should outweigh the risks for it to be considered for medical use. Unless marijuana is proven to be better (safer and more effective) than drugs currently available in the market, its approval for medical use may be a long shot. According to the testimony of Robert J. Meyer of the U.S. Department of Health and Human Services before the U.S. Congress “Having access to a drug or medical treatment, without knowing how to use it or even if it is effective, does not benefit anyone. Simply having access, without having safety, efficacy, and adequate use information does not help patients.” Unknown chemical components Medical marijuana can only be easily accessible and affordable in herbal form. Like other herbs, marijuana falls under the category of botanical products. Unpurified botanical products, however, face many problems including lot-to-lot consistency, dosage determination, potency, shelf-life, and toxicity. According to the IOM report “if there is any future of marijuana as a medicine, it lies in its isolated components, the cannabinoids and their synthetic derivatives.” The components of marijuana have not been fully identified and characterized. To fully characterize the different components of marijuana would cost so much time and money that the costs of the medications that will come out of it would be too high. Currently, no pharmaceutical company seems to be interested in investing money to isolate more therapeutic components from marijuana beyond what is already available in the market. Potential for abuse Marijuana or cannabis is addictive. It may not be as addictive as “hard drugs” such as cocaine; nevertheless it cannot be denied that there is a potential for substance abuse associated with marijuana. This has been demonstrated by a few studies as summarized in the IOM report. Lack of safe delivery system The most common form of delivery of marijuana is through smoking. Considering the current trends in anti-smoking legislations, this form of delivery will never be approved by health authorities. The IOM report “recommended that clinical trials should be conducted with the goal of developing safe delivery systems.” However, to date, according to drug regulators, no reliable and safe delivery systems in the form of vaporizers, nebulizers, or inhalers have been developed. New technologies have been developed but they are still at the testing stage.13 Symptom alleviation, not cure Even if marijuana has therapeutic effects, it is only addressing the symptoms of certain diseases. It does not treat or cure these illnesses. Given that it is effective against these symptoms, there are already medications available out there which work just as well or even better, without the side effects and risk of abuse associated with marijuana. |
The Hurdles of Settling the Issue
The 1999 IOM report could not settle the debate about medical marijuana with scientific evidence available at that time. The report definitely discouraged the use of smoked marijuana but gave a nod towards marijuana use through a medical inhaler or vaporizer. In addition, the report also recommended the “compassionate use of marijuana” under strict medical supervision. Furthermore, it urged more funding in the research of the safety and efficacy of cannabinoids.
So what stands in the way of clarifying the questions brought up by the IOM report?
- So much has happened since 1999. To date, no update of this report has been issued. The health authorities do not seem to be interested in having another review.
- There is limited data available and whatever is available is biased towards safety issues. A large part of data available is on the adverse effects of smoked (herbal) marijuana. Data available on efficacy mainly come from studies on synthetic cannabinoids (e.g. THC). This disparity in data makes an objective risk-benefit assessment difficult.
- Clinical studies on marijuana are few and difficult to conduct due to limited funding and strict regulations. Because of the complicated legalities (e.g. licensing, patents) involved, very few pharmaceutical companies are investing in cannabinoid research.
- In many cases, it is not clear how to define medical marijuana as advocated and opposed by many groups. Does it only refer to the use of “botanical product” marijuana or does it include synthetic cannabinoid components (e.g. THC and derivatives) as well? Synthetic cannabinoids (e.g. Marinol) available in the market are extremely expensive, pushing people towards the more affordable herbal cannabinoid in the form of marijuana. Of course, the issue is further clouded by conspiracy theories involving the pharmaceutical industry and drug regulators.
The Bottom Line
The future of medical marijuana and the settlement of the debate in the U.S. probably depends on more comprehensive and comparable scientific research or perhaps even an advocate in the White House.
Canada, Belgium, Austria, the Netherlands, the United Kingdom, Spain, Israel, and Finland have legalized the therapeutic use of marijuana under strict prescription control. Come on United States, isn't it time?
Published November 2, 2008, updated May 24, 2012
References
- Potential Merits of Cannabinoids for Medical Uses, Human Resources Committee on Government Reform, House of Representatives, April 1, 2004
- Inter-Agency Advisory Regarding Claims That Smoked Marijuana Is a Medicine, April 20, 2006
- Marijuana and Medicine: Assessing the Science Base, Institute of Medicine. The National Academies Press, 1999
- Watson S, Marijuana and medicine: assessing the science base: a summary of the 1999 Institute of Medicine report, Arch Gen Psychiatry. 2000 Jun;57(6):547-52
- Supporting research into the therapeutic role of marijuana: A Position Paper, American College of Physicians, 2008
- Baker D, The therapeutic potential of cannabis in multiple sclerosis, Expert Opin Investig Drugs, 2003 Apr;12(4):561-7
- Mechoulam R, Cannabidiol--recent advances, Chem Biodivers. 2007 Aug;4(8):1678-92
- Zuardi A, Cannabidiol, a Cannabis sativa constituent, as an antipsychotic drug, Brazilian J Med Biol Res. 2006 39: 421-429
- McAllister SD, Cannabidiol as a novel inhibitor of Id-1 gene expression in aggressive breast cancer cells, Mol Cancer Ther. 2007 Nov;6(11):2921-7
- Hampson AJ, Cannabidiol and (−)Δ9-tetrahydrocannabinol are neuroprotective antioxidants, Proc Natl Acad Sci U S A. 1998 July 7; 95(14): 8268–8273
- How does the cost of marijuana compare to the cost of Marinol? ProCon.org
- Marijuana Policy Project
- Gieringer D, Cannabis Vaporizer Combines Efficient Delivery of THC with Effective Suppression of Pyrolytic Compounds, Journal of Cannabis Therapeutics, Vol. 4(1) 2004
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