Medical Marijuana“Take a deep breath”

Dr. Stu HolzerDr. Nefthi Sandeep

The Controversy

• In 1970 marijuana was placed in Schedule 1 of the US Controlled Substances Act as the government considered it to have “no accepted medical use in treatment in the United States.”

• Currently 14 of 50 states have approved the medical use of marijuana for qualified patients. (an additional 14 states have pending legislation including New York).

“The evidence is overwhelming that marijuana can relieve certain types of pain, nausea, vomiting and other symptoms caused by such illnesses as multiple sclerosis, cancer and AIDS -- or by the harsh drugs sometimes used to treat them. And it can do so with remarkable safety. Indeed, marijuana is less toxic than many of the drugs that physicians prescribe every day.” – Jocelyn Elders, MD (Former US Surgeon General 3/26/04)

"Although I understand many believe marijuana is the most effective drug in combating their medical ailments, I would caution against this assumption due to the lack of consistent, repeatable scientific data available to prove marijuana's medical benefits. Based on current evidence, I believe that marijuana is a dangerous drug and that there are less dangerous medicines offering the same relief from pain and other medical symptoms."

– Bill Frist, MD (Former US Senator (R-TN) 10/20/03)

“Mr. President?..”

• http://www.youtube.com/watch?v=LvUziSfMwAw

States Legalizing Medical MarijuanaState Year Passed Possession Limit

Alaska 1998 1 oz, 6 plants

California 1996 8 oz, 18 plants

Colorado 2000 2 oz, 6 plants

Hawaii 2000 3 oz, 7 plants

Maine 1999 2.5 oz, 6 plants

Michigan 2008 2.5 oz, 12 plants

Montana 2004 1 oz, 6 plants

Nevada 2000 1 oz, 7 plants

New Jersey 2010 2 oz, NO plants

New Mexico 2007 6 oz, 16 plants

Oregon 1998 24 oz, 24 plants

Rhode Island 2006 2.5 oz, 12 plants

Vermont 2004 2 oz, 9 plants

Washington 1998 24 oz, 15 plants

http://medicalmarijuana.procon.org/

Drug Scheduling

• US Controlled Substances Act (Title 21 United States Code, Subchapter I, Part B Section 812)

• Schedules 1-5 (1 is most restrictive)• 3 criteria for classification

– Potential for abuse– Acceptable medical Use– Safety & potential for psychological and/or

physical addiction

Schedule 1• Tetrahydrocannabinols* • Heroin• Codeine derivatives• Morphine derivatives

Schedule 2• Opium and derivatives • Coca leaves and extracts• Fentanyl• Methadone

Schedule 3• Amphetamine/Methylphenidate• Barbituric acid• Lysergic acid• Phencyclidine

*Marijuana has remained in schedule 1 since 1970.*Federal law prohibits prescribing schedule 1 drugs

Schedule 4• Phenobarbital• Paraldehyde

Schedule 5• Specific mixtures of narcotics with non-narcotics

Drug Scheduling

Historical Timeline Five children with epilepsy respond to cannabinol therapy, 2 almost completely seizure-free. (Davis & Ramsey)

Czech scientists find cannabis most effective against many Gram+ and 1 Gram- microorganisms compared to 2000 other herbs’ antibacterial action(Kapelikovi)

Cannabis may be useful in treating pathological loss of appetite, i.e. anorexia nervosa (Grinspoon)

US Controlled Substances Act deletes Marijuana Tax act of 1937 and makes marijuana Schedule 1 drug.

Oral marijuana increases appetite and food intake in healthy individuals (Hollister)

Cannabis reduces intraocular pressure by 30% thus helping glaucoma pts. (Hepley & Frank)

1949 1952 1969 1970 1972

Historical TimelineTHC slowed the growth of lung cx, breast cx & virus-induced leukemia in mice (Munson et al)

Scientists at NIDA meeting conclude that given therapeutic potential, govt. should invest tax dollars into more marijuana research.

THC has antiemetic properties superior to compazine and placebo. (Sallan et al)

Impressive array of enzymes (amylase, lipase maltase, urease, etc.) may account for medicinal activity of cannabis

Robert Randall uses Doctrine of Necessity to defend himself against charges of marijuana cultivation. (Washington, D.C.)

Smoked marijuana reversed bronchospasm as well as beta-agonist in experimentally induced asthma (Tashkin et al)

1975 1976

Historical Timeline NIDA continues to grow cannabis for biomedical research (contamination-free, with 3 predictable levels of potency)

Conservative DEA Judge Francis Young concludes “Marijuana is one of the safest therapeutically active substances known to man.”

Cannabinoid receptor is discovered prompting search for its endogenous ligand.

Court of appeals overturns a couple’s criminal conviction for marijuana cultivation ruling their use as a “medical necessity” in treatment of AIDS(Florida)

Jim Montgomery, a paraplegic, is sentenced to life for using marijuana to treat muscle spasms(Oklahoma)

1978 1988 1990 1991 1992

Historical TimelineSmoking marijuana exerts field cancerization effects on bronchial epithelium increasing risk for lung cancer(Barsky et al)

AMA supports “free exchange…disclosure of information between patients and physicians…even if the effectiveness of a potential treatment…is not fully understood.”

Arizona and California become 1st states to legalize marijuana use under MD supervision. Clinton Administration plans to criminally prosecute MDs who prescribe marijuana.

U.S. District Court Judge Fern Smith rules that federal officials may not sanction California doctors who recommend marijuana in compliance with state law

NIH report concludes marijuana “looks promising enough to recommend that there be new controlled studies done.”

8-year study concludes long-term cannabis smokers don’t experience greater annual decline in lung function than non-smokers (Tashkin et al)

1996 1997

Historical TimelineFrequent marijuana use can cause airway injury, lung inflammation and impaired pulmonary defense…which could be life-threatening in seriously immunocompromised patients. (Tashkin et al)

Heavy chronic marijuana use causes memory loss and attention problems (Solowij et al)

Medical marijuana patients may be able to protect themselves from harmful toxins by…using an electric vaporizer (Multidisciplinary Assoc. for Psychedelic Studies)

U.S. 9th Circuit Court of Appeals rules govt. may not revoke a doctor’s license to dispense medication or investigate a physician for recommending marijuana to sick patients.

Japanese study finds similarities between the brain dysfunctions of schizophrenic patients and the disruptions in brain activity caused by marijuana use. (Ujike et al)

AMA rejects report urging consideration of compassionate use of marijuana by cancer patients and others

2001 2002

Historical TimelineHouse of Rep’s votes to allow DEA to raid and arrest medical marijuana patients and caregivers in the 10 states legalizing medical marijuana (Bush administration)

Supreme Court rules that state medical marijuana laws (in 10 states) do not protect users from federal prosecution/federal ban on the drug).(Justice John Paul Stevens)

CA-Gov Grey Davis signs law, S.B. 420, for voluntary ID card to show law enforcement officers to protect legitimate users.

One week later, the House voted down an amendment that would have stopped the Justice department from hearing such cases.

No association between heavy regular smoking of marijuana and lung cancer…a suggestion of some protective effect. (Hashibe & Tashkin et al).

Confidential poll of Deans of 126 AAMC medical schools shows over 60% support physician’s legal right to prescribe smoking marijuana to relieve sxs.

2003 2005 2006

CONFUSED?

Unanswered Questions

• What is the therapeutic dose• Age-restrictions• Safety and long-term consequences• Form of delivery• Conflicting results between researchers

What’s happening in New York?

New York State Legislation

• What’s proposed? o Bill: "Legalizes the possession, manufacture, use,

delivery, transfer, transport or administration of marihuana by a certified patient or designated caregiver for a certified medical use.” (Possession is limited to 2.5 oz and 12 plants).

• What’s the status?o Passed the NYS-Committee on Health and referred to

the Senate Codes Committee again (as of Feb. 23, 2010)

Percent Use in States Changes in Teen Use in States with Legal Medical Marijuana (1999 vs. 2006)

State Percentage Change

Alaska -2.14

California -1.19

Colorado -2.86

Hawaii -1.26

Maine +3.79

Montana -0.84

Nevada -4.03

Oregon -1.24

Vermont +1.68

Washington -2.2

Net -10.29http://medicalmarijuana.procon.org/

Teen Marijuana Use in States with Legal Medical Marijuana vs. States Without It

http://medicalmarijuana.procon.org/

AMA Policy: Medical Marijuana• 1) Calls for further adequate and well-controlled studies of

marijuana and related cannabinoids in patients who have serious conditions for which preclinical, anecdotal, or controlled evidence suggests possible efficacy and the application of such results to the understanding and treatment of disease.

• 2) Urges that marijuana’s status as a federal Schedule I controlled substance be reviewed with the goal of facilitating the conduct of clinical research and development of cannabinoid-based medicines, and alternate delivery methods. This should not be viewed as an endorsement of state-based medical cannabis programs, the legalization of marijuana, or that scientific evidence on the therapeutic use of cannabis meets the current standards for a prescription drug product. (New HOD Policy)

AAP and Legalization of Marijuana

1. The American Academy of Pediatrics opposes the legalization of marijuana.

2. The American Academy of Pediatrics supports rigorous scientific research regarding the use of cannabinoids for the relief of symptoms not currently ameliorated by existing legal drug formulations.

Marijuana and Autism?

• http://www.youtube.com/watch?v=wodlyntXERs

Impact on Society• Will legalization of medical marijuana spur the use

of recreational use among teenagers/children?• Potential for illegal use/abuse of prescribed

marijuana from patients or caregivers.• Potential for backlash against medical community

(e.g. abortion)• Should physicians be held responsible for abuses of

Rx made in good faith?• Should physicians be held responsible for long-term

adverse effects?• Practicality of current regulations

References1. Hunger and appetite after single doses of marihuana, alcohol, and dextroamphetamine. Hollister L

Journal of Clinical Pharmacology and Therapeutics Vol 12, No. 1 Clin Pharmacol Ther. 1971 Jan-Feb;12(1):44-9. 2. Marihuana smoking and intraocular pressure. Hepler RS, Frank IR. JAMA. 1971 Sep 6;217(10):13923. Antineoplastic activity of cannabinoids. Munson AE, Harris LS, Friedman MA, Dewey WL, Carchman RA. J Natl Cancer Inst.

1975 Sep;55(3):597-602.4. Antiemetics in patients receiving chemotherapy for cancer: a randomized comparison of delta-9-tetrahydrocannabinol and

prochlorperazine. Sallan SE, Cronin C, Zelen M, Zinberg NE. N Engl J Med. 1980 Jan 17;302(3):135-8.5. Effects of smoked marijuana in experimentally induced asthma. Tashkin DP, Shapiro BJ, Lee YE, Harper CE. Am Rev Respir

Dis. 1975 Sep;112(3):377-86.6. ”The Religious and Medicinal Uses of Cannabis in China, India and Tibet.” Mia Touw Journal of Psychoactive Drugs,,Jan-Mar,

1981 Vol. 13(1).7. Histopathologic and molecular alterations in bronchial epithelium in habitual smokers of marijuana, cocaine, and/or

tobacco. Barsky SH, Roth MD, Kleerup EC, Simmons M, Tashkin DP. J Natl Cancer Inst. 1998 Aug 19;90(16):1198-205.8. Heavy habitual marijuana smoking does not cause an accelerated decline in FEV1 with age. Tashkin DP, Simmons MS,

Sherrill DL, Coulson AH.Am J Respir Crit Care Med. 1997 Jan;155(1):141-8.2002 9. " Effects of Smoked Marijuana on the Lung and Its Immune Defenses: Implications for Medicinal Use in HIV-Infected

Patients.” June 2001 Journal of Cannabis Therapeutics. Vol. 1, Issue 3/4, Pages 87-102). Donald P. Tashkin et al.10. Cognitive functioning of long-term heavy cannabis users seeking treatment. Solowij N, Stephens RS, Roffman RA, Babor T,

Kadden R, Miller M, Christiansen K, McRee B, Vendetti J; Marijuana Treatment Project Research Group.JAMA. 2002 Mar 6;287(9):1123-31.

11. New perspectives in the studies on endocannabinoid and cannabis: cannabinoid receptors and schizophrenia. Ujike H, Morita Y. J Pharmacol Sci. 2004 Dec;96(4):376-81.

12. Marijuana use and the risk of lung and upper aerodigestive tract cancers: results of a population-based case-control study. Hashibe M, Morgenstern H, Cui Y, Tashkin DP, Zhang ZF, Cozen W, Mack TM, Greenland S. Cancer Epidemiol Biomarkers Prev. 2006 Oct;15(10):1829-34.

13. http://medicalmarijuana.procon.org/

The EndOr is it the beginning….