A hot topic of debate in many circles surrounds the use of medical marijuana. It is a complicated matter due to conflicting rulings about its legality and accessibility. The Drug Policy Alliance, which refers to itself as “the nation’s leading organization promoting drug policies that are grounded in science, compassion, health and human rights,” has reported that “23 states and the District of Columbia have passed medical marijuana laws legalizing the use and production of medical marijuana for qualifying patients under state law.” Marijuana is identified in the U.S. Controlled Substances Act as a Schedule I drug, which falls into the category of “high potential for abuse, no currently accepted medical use in treatment in the United States, as well as a lack of accepted safety for use of the drug or other substance under medical supervision.” The FDA has approved the use of medical marijuana to treat pain, which is the main reason people ask for a prescription, according to Barth Wilsey, MD, a pain medicine specialist at the University of California Davis Medical Center. The pain could be as a result of headaches related to cancer, HIV, hepatitis C, glaucoma or neurological damage. Medical marijuana is considered an option when all other traditionally accepted means of treatment have been exhausted. While it may be acquired through a written or oral recommendation from a physician that a patient would benefit from medical marijuana, an actual prescription may not be written. It is ingested in several ways:
- Smoked
- Vaporized (heated until active ingredients are released, but no smoke is formed)
- Eaten (usually in the form of cookies or candy)
- Taken as a liquid extract
Medical marijuana is acquired via dispensaries in the states where it is legal. In order to purchase marijuana in this way, a state issued ID card is required. An article in the New England Journal of Medicine titled, “Medicinal Use of Marijuana — Polling Results,” Jonathan N. Adler, MD, and James A. Colbert, MD, described a poll of 1,446 medical professionals from around the world. They were asked to consider the case of a 68-year-old woman with a diagnosis of metastatic breast cancer. The outcome indicated that, “76% of all votes were in favor of the use of marijuana for medicinal purposes.” Those who opposed it were concerned that there was a lack of clinical evidence that it was effective, that monitoring the dosage was challenging and that side effects could ensue. Doctors who supported the use of medical marijuana for this particular patient were influenced by their belief in pain management and the diminishing of suffering.
Palliative Care and Medical Marijuana Use
David J. Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania Perelman School of Medicine and director of hospice and palliative care at the University of Pennsylvania Health System, has written a book called Stoned: A Doctor’s Case for Medical Marijuana. In it he describes an initial belief that such treatment was not to be taken seriously — until he began to explore the practical application for many of his patients. “There’s a fair amount of science behind it,” Casarett said. “Those are medical benefits that people in the medical marijuana world — including advocates and patients — really take seriously.” In an effort to relieve severe back pain, Casarett became his own test subject, but he wasn’t familiar with the appropriate dose. As a result, he experienced the side of effects of confusion and temporary psychosis. He heard “air traffic controllers vectoring flights into and out of the Phoenix airport — those voices were coming from my living room, where there really weren’t any air traffic controllers.”
Considering Cannabinoids
Cannabinoids are “organic substances present in cannabis sativa, having a variety of pharmacologic properties.” Casarett shared that, “There are dozens that are naturally occurring in marijuana, as well as hundreds of synthetics. Two that we know most about are tetrahydrocannabinol — THC and cannabidiol — CBD.” The former is what brings about the euphoric and relaxed state that those who use marijuana recreationally or habitually seek out. The latter has the pain relieving effects in the absence of the high. One researcher whom Casarett encountered is testing the efficacy and the correct balance of a low THC/high CBD blend of marijuana.
Not Your Typical Pot Brownies
When the subject of edibles arises, so too does a concern about varying degrees of potency. Casarett explained that, “the absorption time can be widely variable” so that one person might “eat a square of marijuana-infused chocolate at the same time but — because of differences in the way that our GI tracts work, differences in the degree that our livers metabolize the main forms of cannabinoids that are occurring in medical marijuana (CBD and THC) — you may feel the effects within 15 minutes, and I may not feel those effects for an hour or more. Or I may never feel those effects, or vice-versa.” Casarett added that it sometimes takes “half an hour to an hour — before people begin to feel the full effects. And a common problem that many first-time users experience is eating a brownie or a square of chocolate or a gummy bear, waiting for 15, 20 minutes, not feeling any effect. And so they try another one and another one and another one, all the while those doses are stacking up, so when they begin to feel an effect in an hour or hour and a half, they’ve taken too much.”
