Medical cannabis

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Medical cannabis refers to the use of the drug cannabis as a physician-recommended herbal therapy, most notably as an antiemetic.

There are many studies regarding the use of cannabis in a medicinal context.[1][2][3][4] Cannabis was listed in the United States Pharmacopeia from 1850 until 1942.[citation needed] The United States federal government does not currently recognize any legitimate medical use, although there are currently seven patients receiving cannabis for their various illnesses through the Compassionate Investigational New Drug program that was closed to new patients by President George H. W. Bush. Francis L. Young, an administrative law judge with the US Drug Enforcement Agency, in 1988, declared that "in its natural form, (cannabis) is one of the safest therapeutically active substances known."[5] However, smoked cannabis is today not approved by the U.S. Food and Drug Administration (FDA) [6] It has medicinal uses throughout recorded history of Homo sapiens. Specifically to the United States, it was used legally for medicinal use for many things including birth-giving, chronic pain, and some other known conditions before 1942, when its use was essentially outlawed from The Marihuana Tax Act of 1937. [7] Currently in 12 states it is medically available to conditions it has been shown effective to treat through recent studies.

The term medical marijuana post-dates the U.S. Marijuana Tax Act of 1937, the effect of which made cannabis prescriptions illegal in the United States.

Due to widespread illegality of cannabis as a recreational drug its legal or licensed use in medicine is a controversial issue.

[8]

Contents

Cannabis plant
Cannabis plant

Cannabis has been used for medicinal purposes for over 4,800 years.[9] Surviving texts from Ancient India confirm that its psychoactive properties were recognized, and doctors used it for a variety of illnesses and ailments. These included a whole host of gastrointestinal disorders, insomnia, headaches and as a pain reliever, frequently used in childbirth. The ancient Egyptians even used hemp (cannabis) in suppositories for relieving the pain of hemorrhoids.[15]

Cannabis as a medicine was common throughout most of the world in the 1800s. It was used as the primary pain reliever until the invention of aspirin.[10] Modern medical and scientific inquiry began with doctors like O'Shaughnessy and Moreau de Tours, who used it to treat melancholia, migraines, and as a sleeping aid, analgesic and anticonvulsant.

By the time the United States banned cannabis (the third country to do so) with the 1937 Marijuana Tax Act, the plant was no longer extremely popular. Skepticism about marijuana arose in response to the bill. One of the main opponents to the bill was the representative of the American Medical Association.[11]

Later in the century, researchers investigating methods of detecting cannabis intoxication discovered that smoking the drug reduced intraocular pressure.[12] High intraocular pressure causes blindness in glaucoma patients, so many believed that using the drug could prevent blindness in patients. Many Vietnam War veterans also believed that the drug prevented muscle spasms caused by battle-induced spinal injuries. Later medical use has focused primarily on its role in preventing the wasting syndromes and chronic loss of appetite associated with chemotherapy and AIDS, along with a variety of rare muscular and skeletal disorders. Less commonly, cannabis has been used in the treatment of alcoholism and addiction to other drugs such as heroin and the prevention of migraines. In recent years, studies have shown or researchers have speculated that the main chemical in the drug, THC, might help prevent atherosclerosis.

In 1972 Tod H. Mikuriya, M.D. reignited the debate concerning marijuana as medicine when he published "Marijuana Medical Papers 1839-1972".

Later, in the 1970s, a synthetic version of THC, the primary active ingredient in cannabis, was synthesized to make the drug Marinol. Users reported several problems with Marinol, however, that led many to abandon the pill and resume smoking the plant. Patients complained that the violent nausea associated with chemotherapy made swallowing pills difficult. The effects of smoked cannabis are felt almost immediately, and is therefore easily dosed.[13] Marinol (Jojel), like ingested cannabis, is very psychoactive, and is harder to titrate than smoked cannabis.[14] Marinol has also consistently been more expensive than herbal cannabis.[15] Some studies have indicated that other chemicals in the plant may have a synergistic effect with THC.[16]

In addition, during the 1970s and 1980s, six US states' health departments performed studies on the use of medical marijuana. These are widely considered some of the most useful and pioneering studies on the subject,[citation needed]

In May 2001, "The Chronic Cannabis Use in the Compassionate Investigational New Drug Program: An Examination of Benefits and Adverse Effects of Legal Clinical Cannabis" (Russo, Mathre, Byrne et al) was completed. This three-day examination of major body functions of four of the five living US federal cannabis patients found "mild pulmonary changes" in two patients.[17]

Potential health benefits aside, marijuana remains a US Federally controlled substance, making transport across state lines illegal. It has been estimated that an average "marijuana clinic" consumes a pound of cannabis per day[citation needed], making acquisition a critical challenge. This acquisition may have to resort to illegitimate (i.e., illegal) sources, contributing to crime in communities. This point was illustrated in early 2007, with the tragic murder of Denver area medical cannabis activist Ken Gorman [18].

Researchers face similar challenges in obtaining medical cannabis for research trial. Recently, the US FDA has approved a number of cannabis research clinical trials, but the Drug Enforcement Agency has not granted licenses to the researchers in these studies.

A study included 250 patients and compared smoked cannabis to oral THC, under the auspices of the Food and Drug Administration. All participants were evaluated by a medical doctor and had vomiting uncontrolled using at least three alternative antiemetics. Patients chose smoking cannabis or taking an oral THC pill. Multiple objective and subjective standards were used to determine the effectiveness.[citation needed]

  • Conclusion: Cannabis was far superior to the best available drug at the time of testing, Compazine, and smoked cannabis is clearly superior to oral THC. "More than ninety percent of the patients who received cannabis... reported significant or total relief from nausea and vomiting." No major side effects were reported, though three patients reported adverse reactions that did not involve cannabis alone. The report, dated November 6, 1988, can be read here, though no publication in the peer-reviewed medical literature has been made.

27 patients had failed on other antiemetics therapies, including oral THC.

  • Conclusion: 90.4% success for smoked cannabis; 66.7% for oral THC. "We found both marijuana smoking and THC capsules to be effective antiemetics. We found an approximate 23% higher success rate among those patients administered smoked marijuana. We found no significant differences in success rates by age group. The major reason for THC capsule failure was nausea and vomiting so severe that the patient could not retain the capsule."[citation needed]

A series of studies throughout the 1980s involved 90–100 patients a year. The study was designed to make it easier for patients to enter the oral THC part of the study. Patients who wanted to smoke cannabis had to be over 15 years old (oral THC patients had to be over 5) and use the drug only in the hospital and not at home. Smoked cannabis patients also had to be receiving rare and painful forms of chemotherapy to qualify.

  • Conclusion: Despite the bias towards oral THC, the California study concluded that smoked cannabis was more effective and established a safe dosage regimen that minimized adverse side effects. The full text of the study can be seen here.[citation needed]
A Vapor-Bong for use with medicinal herbs prescribed by a physician.
A Vapor-Bong for use with medicinal herbs prescribed by a physician.

119 patients that had failed using other antiemetics were randomly assigned to oral THC pills and either standardized or patient-controlled smoking of cannabis.

  • Conclusion: All three categories were successful — patient controlled smokers at 72.2%; standardized smokers at 65.4%; oral THC at 76%. Failure of oral THC patients was due to adverse reaction (6 out of 18) or failure to improve (9 out of 18); failure of smoking cannabis was due to intolerance for smoking (6 out of 14) or failure to improve (3 out of 14).[citation needed]

Many medical cannabis opponents note that smoked cannabis is harmful to the respiratory system. However, this harm can be minimalized or eliminated by the use of a vaporizer or ingesting the drug in an edible form or other non-smoking modes of delivery like tinctures. Vaporizers are devices that vaporize the active constituents (cannabinoids) and the fragrant aromatic substances in the preparation without combusting the plant material and thus preventing the formation of toxic substances. Studies have shown that vaporizers can dramatically reduce[19] or even eliminate[20] the release of irritants and toxic compounds.

According to a survey on the recommendation of cannabis in California[21], cannabis is indicated for over 250 conditions. Cannabis is most importantly indicated as an antiemetic for the treatment of nausea and anorexia associated with treatments for cancer, AIDS, and hepatitis. Cannabis also acts as an antispasmodic and anticonvulsant and is indicated for neurological conditions such as epilepsy, multiple sclerosis, and spasms. As an analgesic and an immunomodulator it is indicated for conditions such as migraine, arthritis, spinal and skeletal disorders. As a bronchodilator it is beneficial for asthma. It also reduces the intraocular pressure and is indicated for glaucoma. Recent studies have shown the drug to be efficacious in treating mood disorders and mental health issues such as depression, post traumatic stress disorder, clinical depression, obsessive-compulsive disorder, panic disorder, and bipolar disorder.[16] It is also indicated for premenstrual syndrome, hypertension, and insomnia.

In the United States, the Federal Food, Drug, and Cosmetic Act makes the Food and Drug Administration (FDA) the sole government entity responsible for ensuring the safety and efficacy of new prescription and over-the-counter drugs, overseeing the labeling and marketing of drugs, and regulating the manufacturing and packaging of drugs.[22] The FDA defines a drug as safe and effective for a specific indication if the clinical benefits to the patient are felt to outweigh any health risks the drug might pose. FDA and comparable authorities in Western Europe in including the Netherlands, have not approved smoked marijuana for any condition or disease. [23] [24] Cannabis remains illegal throughout the United States and is not approved for prescription as medicine, although 12 states - Alaska, California, Colorado, Hawaii, Maine, Montana, Nevada, New Mexico, Oregon, Rhode Island, Vermont and Washington - approve and regulate its medical use. (The federal government continues to enforce its prohibition in these states.) However, there are also 2 states, Arizona and Maryland, whose drug laws are favourable towards the medicinal use of marijuana,[clarify] but which still explicitly ban it.

Pro-cannabis demonstrators in Los Angeles, California, August 2007.
Pro-cannabis demonstrators in Los Angeles, California, August 2007.

Dozens of medical organizations have endorsed allowing patients access to medical marijuana with their physicians' approval. These include, but are not limited to, the following:

John Walters is a prominent opponent of medical use of cannabis
John Walters is a prominent opponent of medical use of cannabis

In the USA, the FDA has approved two cannabinoids for use as medical therapies: dronabinol and nabilone. It is important to note that these medicines are not smoked. Dronabinol is a synthetic THC medication[48], while nabilone is a synthetic cannabinoid marketed under the brand name Cesamet.

Medication Year approved Licensed indications
Nabilone 1985 Nausea of cancer chemotherapy that has failed to respond adequately to other antiemetics
Marinol 1992 Nausea of cancer chemotherapy that has failed to respond adequately to other antiemetics, AIDS wasting

These medications are usually used when first line treatments for nausea fail to work. In extremely high doses and in rare cases there is a possibility of "psychotomimetic" side effects. The other commonly-used antiemetic drugs are not associated with these side effects.

The prescription drug Sativex, an extract of cannabis administered as a sublingual spray, has been approved in Canada for the treatment of multiple sclerosis;[49] this medication may now be legally imported into the United Kingdom and Spain on prescription.[50] Dr. William Notcutt is one of the chief researchers that has developed Sativex, he has been working with GW and founder Geoffrey Guy since the company's inception in 1998. Notcutt states that the use of MS as the disease to study "had everything to do with politics."[51]

See also: Health issues and the effects of cannabis

On 20 April 2006, The United States Food and Drug Administration (FDA) issued an advisory against medical marijuana stating that, "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. Furthermore, there is currently sound evidence that smoked marijuana is harmful." [18]. Some prominent American societies have been reluctant to endorse medicinal cannabis. For example: [19], the National Multiple Sclerosis Society [20] , the American Academy of Ophthalmology [21] and the American Cancer Society [22]. (Federal Register, 1992).

On June 6, 2005, the U.S. Supreme Court handed down a decision which approved the Federal Government's position that federal law permits the prosecution of persons possessing cannabis regardless of the defense that they are medicinal cannabis patients, even in states that exempt its prohibition for medicinal purposes.. [23]

The Institute of Medicine, run by the United States National Academy of Sciences and funded by the United States federal government, conducted a comprehensive study in 1999 to assess the potential health benefits of cannabis and its constituent cannabinoids. The study concluded that smoking cannabis is not recommended for the treatment of any disease condition, but did conclude that nausea, appetite loss, pain and anxiety can all be mitigated by marijuana. While the study expressed reservations about smoked marijuana due to the health risks associated with smoking, the study team concluded that until another mode of ingestion was perfected that could provide the same relief as smoked marijuana, there was no alternative. In addition, the study pointed out the inherent difficulty in marketing a non patentable herb. Pharmaceutical companies will not substantially profit unless there is a patent. For those reasons, the Institute of Medicine concluded that there is little future in smoked cannabis as a medically approved medication. The report also concluded for certain patients, such as the terminally ill or those with debilitating symptoms, the long-term risks are not of great concern.[52]

In an unpublished 2001 study by the Mayo Clinic, Marinol was shown to be less effective than megestrol acetate in helping cancer patients regain lost appetites.[53]

In 2003, the American Academy of Ophthalmology released a position statement asserting that "no scientific evidence has been found that demonstrates increased benefits and/or diminished risks of marijuana use to treat glaucoma compared with the wide variety of pharmaceutical agents now available." [54]

World laws on cannabis possession (small amount). Data is from multiple sources detailed on the full source list
World laws on cannabis possession (small amount). Data is from multiple sources detailed on the full source list
European laws on cannabis possession (small amount).  Data is from multiple sources detailed on the full source list
European laws on cannabis possession (small amount). Data is from multiple sources detailed on the full source list

Cannabis is in Schedule IV of the Single Convention on Narcotic Drugs, making it subject to special restrictions. Article 2 provides for the following, in reference to Schedule IV drugs:

A Party shall, if in its opinion the prevailing conditions in its country render it the most appropriate means of protecting the public health and welfare, prohibit the production, manufacture, export and import of, trade in, possession or use of any such drug except for amounts which may be necessary for medical and scientific research only, including clinical trials therewith to be conducted under or subject to the direct supervision and control of the Party.

This provision, while apparently providing for the limitation of cannabis to research purposes only, also seems to allow some latitude for nations to make their own judgments. The official Commentary on the Single Convention indicates that Parties are expected to make that judgment in good faith.

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