Pot as Medicine
A considerable amount of attention is being paid to the the Los Angeles City Council's recent decision to ban medical marijuana dispensaries in the city, while at the same time, in Oakland, a federal crackdown closed the nation's largest cannabis dispensary. Much of the attention stems from the fact that prior to these events, California had long been a medical marijuana stronghold. Strangely, somewhat lost in the highly politicized hullabaloo is the one question we should really be asking about medical marijuana: Is it good medicine?
There is a great deal of anecdotal evidence suggesting marijuana can be used to effectively treat any number of ailments, and there is equal anecdotal evidence to the contrary. Neither conglomeration of "information" helps to answer the question at hand. Instead, as a medical community, we need to see results from controlled clinical studies before reaching conclusions about the safety and/or efficacy of medical marijuana -- and we rely on the FDA to gather and evaluate this evidence, if and when it exists.
The FDA subjects all drugs to rigorous scrutiny, only approving them for widespread use when they:
1. Are standardized by identity, purity, potency and quality
2. Are accompanied by adequate directions for use in the approved medical indication, and
3. Have risk/benefit profiles that have been well-defined in well-controlled clinical trials
This stringent FDA approval process is necessary because it safeguards patients from potentially dangerous drugs. Not surprisingly, all major medical organizations support the FDA process. Furthermore, the AMA, the American College of Physicians and the Institute of Medicine have issued public statements decrying the ability of state legislatures and/or ballot initiatives to determine whether certain drugs should be made available without FDA approval -- which is how medical marijuana has been "legalized." These organizations wisely believe that cannabis should be subjected to the same critical analysis as every other potential medication.
Basically, marijuana scores zero out of three in the FDA approval test. Starting with the final criteria, we see that nowhere near the necessary number of studies on cannabinoid medications has been conducted. There are indications in a few of the studies that do exist that marijuana can effectively treat neuropathic pain, and that it may improve appetite and reduce nausea in cancer and AIDS patients. However, its efficacy as a treatment for glaucoma -- anecdotally one of the biggest "uses" for medical marijuana -- is disputed by no less an authority than the Glaucoma Research Foundation, whose website reads, in part, "The high dose of marijuana necessary to produce a clinically relevant effect makes it a poor choice for the treatment of glaucoma, especially given 'significant side effects' and the availability of safer effective drugs." Furthermore, those using marijuana to treat mental health symptoms such as anxiety and psychosis might be surprised to learn that studies show cannabis may actually exacerbate or even cause rather than alleviate those symptoms.
To examine medical marijuana in terms of the first two FDA criteria, all we need do is travel to the nearest pot dispensary. Most of these facilities have shelves lined with jars of creatively-named pot varieties along with various other cannabis-infused products (teas, cookies, candies, etc.) Nowhere is there any guarantee of purity, potency or quality. In fact, independent labs have found mold, synthetic insecticides and numerous other toxins in medical marijuana. (Some of the molds can be quite dangerous to immune-compromised patients.) Furthermore, there are no specific directions for use, leaving doctors and patients uncertain as to what a proper dose of dispensary pot might be. The general instruction seems to be something along the lines of smoke it until you feel better.
Could you imagine a drug like Ambien, for example, being sold in various sized pills, with varying degrees of potency, with the only instruction to the patient being "keep taking pills until you're no longer awake?" The FDA would never sign off on that, nor would any self-respecting doctor prescribe such a medication. That doesn't mean this mythical drug is without potential, only that its manufacture, dosage and medical indications need to be standardized to protect patients before it gains approval for widespread use.
Natural is Not Necessarily Safe
Sometimes proponents of medical marijuana respond to the above arguments by stating: "Marijuana is natural, it's a plant that grows wild, and therefore it's safe." Well, poison ivy is also natural, and also a plant that grows wild, but I don't recommend rolling around in it. In other words, "natural" is hardly the benchmark for declaring anything, especially a drug, safe and effective. Also important, especially for baby-boomers, is to understand that today's marijuana is not the same stuff we had in the 1960s and '70s. Pot has been genetically engineered over the years and it is now much stronger than the "weed" we grew up with. Whereas popping a couple of 250 mg aspirin is the same experience today as in 1970, smoking a joint is vastly different, which can be disconcerting, if not downright dangerous, for an unsuspecting user. High-potency marijuana, which is the norm today due to modern cultivation techniques, has been shown to impair executive function and inhibit motor control.
It is also important to note that, besides not meeting FDA criteria for medical approval, marijuana is far from a neutral substance, and its use has been linked to a number of health problems. Short-term side effects include: sleepiness, difficulty keeping track of time, impaired memory, reduced ability to perform tasks requiring concentration and coordination (such as driving), increased heart rate, bloodshot eyes, dry mouth and throat, food cravings, decreased social inhibitions, impaired cognition, distorted perception (sight, sound, touch) and occasionally paranoia, anxiety and even hallucinations. Longer-term side effects include coughing, wheezing, chest colds and increased susceptibility to serious lung infections such as pneumonia. Of particular concern to marijuana users over 50 years of age are the neurocognitive effects of marijuana use. Marijuana also contains many of the same carcinogens as cigarettes, often in more concentrated quantities, which may increase the risk of cancer and other serious health problems.
First Do No Harm!
Traditionally, all drugs in the United States are vetted and evaluated for safety and efficacy through a comprehensive series of double-blind studies using thousands of participants. Until the full amount necessary research on medical marijuana is conducted and analyzed, the Hippocratic Oath should prevent physicians from recommending it, regardless of what state legislatures and ballot initiativesmight say. After all, the fact that a drug is legal to prescribe doesn't necessarily mean it should be prescribed. Nevertheless, certain less-than-ethical doctors currently hand out medical marijuana recommendations like candied tongue depressors -- essentially selling "get out of jail free" cards to their patients who want to get high.
Like it or not, we are entering an era in which cannabinoid products are becoming part of a physician's arsenal. Perhaps some of the cannabinoid medications currently in development will prove to be safe and useful drugs. However, as of now, a significant amount of rigorous research is needed to better understand the effects of different formulations, methods of administration, and dose-response relationships. And until we fully and comprehensively understand the risk/benefit profile of cannabinoids, the medical community needs to accept that these "medications" do not meet FDA standardsand should therefore not be "prescribed," except perhaps in extreme circumstances where all pertinent FDA-approved drugs have failed.
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David Sack, M.D., is board certified in Addiction Psychiatry and Addiction Medicine. He is CEO of Elements Behavioral Health, a network of addiction treatment centers that includes Promises, The Ranch, The Recovery Place, and The Sexual Recovery Institute. You can follow Dr. Sack on Twitter.
Follow David Sack, M.D. on Twitter: www.twitter.com/drdavidsack