Potential Objections to Medical Marijuana SAFETY,…

         Potential Objections to Medical Marijuana
SAFETY, EFFECTIVENESS, THERAPEUTIC AND PALLIATIVE BENEFITS:

Objection: There is little trustworthy evidence that smoked marijuana
actually works.
Reply: In a White House-commissioned 1999 report, the National Academy
of Sciences' Institute of Medicine, in a review of the current science at the
time, found extensive scientific evidence verifying that marijuana has
medical value for patients suffering from pain, nausea, appetite loss, and
other symptoms of illnesses such as cancer, multiple sclerosis, and
HIV/AIDS. The IOM report stated, "Nausea, appetite loss, pain, and anxiety
are all afflictions of wasting and all can be mitigated by marijuana ... there
are patients with debilitating symptoms for whom smoked marijuana might
provide relief." Subsequent studies since the 1999 Institute of Medicine
report, including randomized, double-blind, placebo-controlled clinical trials,
continue to show the therapeutic value of marijuana in treating a wide array
of debilitating medical conditions, including relieving medication side effects
and thus improving the likelihood that patients will adhere to life-prolonging
treatments for HIV/AIDS and Hepatitis C. Marijuana was also shown to be
effective at alleviating HIV/AIDS neuropathy, a painful condition for which
there are no FDA-approved treatments. That is why, in January 2008, the
American College of Physicians ­ the second-largest physician group in the
country ­ called for marijuana to be reclassified under federal law to allow
physician prescriptions, citing "marijuana's proven efficacy at treating certain
symptoms and its relatively low toxicity."

Objection: Marijuana is an addictive drug that poses significant health
consequences to its users.
Reply: Marijuana and cannabinoids have a generally excellent safety profile.
Unlike many medicines, acute lethal overdoses of marijuana have not been
reported, and research has not documented increased mortality attributable
to chronic use. Concerns about immunological impairment have not been
borne out in research with AIDS patients. No medications are without risk;
however, medical marijuana is relatively benign compared to many routinely
prescribed drugs. The American College of Physicians noted marijuana's
"relatively low toxicity" in its January 2008 statement. Further, the American
Public Health Association's official position statement on medical marijuana
states, "[M]arijuana has an extremely wide acute margin of safety for use
under physician supervision and cannot cause lethal reactions ... greater
harm is caused by the legal consequences of its prohibition than possible
risks of medicinal use." And, in its 1999 study, the Institute of Medicine
concluded that "Compared to most other drugs ... dependence among
marijuana users is relatively rare."

Objection: Smoked marijuana is a known carcinogen with hundreds of well-
documented negative effects.
Reply: In fact, the largest and most well-controlled studies have consistently
found that marijuana smokers don't have higher rates of lung cancer or other
typically tobacco-related cancers. A 2006 NIDA-funded case-control study co-
authored by Dr. Donald Tashkin -- one of the world's foremost experts on the
respiratory effects of illicit drugs -- found no increased risk of lung cancer
among even the heaviest marijuana smokers. Indeed, there was a trend
toward lower lung cancer risk among even heavy marijuana smokers as
compared to non-smokers, though the difference did not reach statistical
significance. One possible explanation for this is the growing body of
evidence documenting the anti-tumor actions of cannabinoids. Also, a 1997
Kaiser Permanente epidemiological study of 65,000 subjects showed no
increase in lung or other tobacco-related cancers due to marijuana smoking,
suggesting the potential of a favorable risk/benefit ratio for smoked medical
marijuana in some chronic and/or painful conditions.

It is worth noting in this context that the phrase "smoked marijuana" is a red
herring. Marijuana need not be administered by smoking: It can be taken in
food, tea, or through a smokeless vaporizer. Vaporization technology,
discussed in the American College of Physicians' position paper, has been
shown to achieve the drug delivery benefits of inhalation -- rapid action and
ease of dose titration -- without the harmful combustion products contained
in smoke.

Objection: Marijuana can cause schizophrenia.
Reply: Concerns have been raised in recent years regarding associations
between marijuana use and acute psychosis and schizophrenia. While
marijuana users have higher rates of psychotic symptoms or diagnosed
psychosis than non-users, the relative risk remains modest, and increased
rates of marijuana use in the U.S. and Australia during the 1970s and 1980s
did not lead to increased incidence of schizophrenia. Overall, the evidence
suggests that marijuana use can precipitate psychosis in vulnerable
individuals but is unlikely to cause the illness in otherwise normal persons.
Use of cannabinoids in patients with a family or personal history of psychosis
should generally be avoided until more is known.


PROTECTING DOCTORS AND PATIENTS:

Objection: The mere existence of medical marijuana access laws puts both
patient and physician in harm's way.
Reply: Medical marijuana access promotes physician autonomy to
recommend the evidence-based medical treatment that is best for a patient,
without legal punishment. Organized medicine should recognize the
difference between licensing a drug for marketing and simply exempting
patients using marijuana in state-sanctioned programs under the advice and
supervision of a physician from criminal prosecution. Federal courts have
upheld the right of physicians to recommend marijuana to patients, and
physicians in the 12 medical marijuana states who follow appropriate
standards of care when recommending marijuana have not experienced
difficulties.

Objection: There is no clear reason why the American Medical Association
and other physician groups should support patient protection for legitimate
medical marijuana users in the 12 state-sanctioned programs.
Reply: Existing AMA policy already affirms the protection of physicians
practicing in medical marijuana states from federal prosecution for discussing
and recommending medical marijuana to their patients. It does not,
however, extend protection to the patients themselves in medical marijuana
states, an important omission that warrants addressing by the AMA. In
addition to arrest, fines, and confiscation of property and legally obtained
supplies of medical marijuana, patients and their families have been
subjected to DEA "SWAT team" style invasions of their homes and the
sudden discontinuation of their medical marijuana treatment. This can lead to
exacerbation of chronic pain, wasting, and other serious medical conditions
previously controlled by medical marijuana. Subjecting seriously ill patients
to arrest and prosecution constitutes cruel and unusual punishment, which is
why the editor-in-chief of the New England Journal of Medicine called the
federal ban on the medical use of marijuana "misguided, heavy-handed, and
inhumane."

Federal law makes no distinction between those who possess or grow
marijuana for medical purposes and those who are using it recreationally:
the same penalties apply. The possession of a single marijuana cigarette can
result in a sentence of up to one year, while the cultivation of a single
marijuana plant can produce a sentence of up to five years.
[http://www.justice.gov/dea/agency/penalties.htm]

Objection: We don't know what the general physician sentiment on this
issue is.
Reply: In a 2005 poll conducted by HCD Research and the Muhlenberg
College Institute of Public Opinion of 922 U.S. office-based physicians
weighted by specialty and geography, 74% disagreed that "the federal
government should be able to prosecute those who use, grow, or obtain
marijuana prescribed or recommended by their doctor for chronic pain within
the guidelines of state law."

Objection: Supporting any form of medical marijuana access is politically
risky for physician organizations.
Reply: Across the country and with increasing frequency, public opinion polls
-- and actual votes at the ballot box -- show that support for medical
marijuana is overwhelming, steadily rising, and cuts across demographic and
party lines. A 2004 AARP poll showed that 72% of seniors support medical
marijuana, and a 2005 Gallup poll found that 78% of Americans support
"making marijuana legally available for doctors to prescribe in order to
reduce pain and suffering."

Not one of the state medical marijuana laws passed since 1996 has been
repealed. Indeed, when legislatures have made changes to these laws, it has
generally been to extend and expand them. For example, in 2002, Maine
increased the amount of medical marijuana that patients are allowed to
possess. In 2007, Vermont expanded the list of conditions covered under the
program and increased the number of marijuana plants that patients could
legally grow. These are not the sorts of actions that legislators take when a
law is unpopular.

Objection: The American Medical Association is a leader in organized
medicine and their policy on medical marijuana is clear, consistent, and
sufficient at this time.
Reply: The Connecticut newspaper Guilford Courier interviewed AMA
spokesperson Robert Mills (Office of Media Relations) and reported on July
15, 2005, that "the AMA recommends keeping marijuana [unchanged] as a
controlled substance 'pending the outcomes of studies to prove the
application and efficacy of marijuana and other related cannabinoids'" but, in
contrast, Mills and an American Cancer Society spokesman "both mentioned
that patients afflicted with cancer and other painful medical conditions should
not be prosecuted for trying to alleviate their suffering."

Furthermore, the AMA is a member organization of the Accreditation Council
for Continuing Medical Education (ACCME). Medical colleges and hospitals
accredited by the ACCME have awarded AMA PRA Category 1 Credits to
physicians attending conferences and CME events focusing on medical
marijuana clinical therapeutics and research. The AMA defines the content of
CME as "the body of knowledge and skills generally recognized and accepted
by the profession as within the basic medical sciences, the discipline of
clinical medicine, and the provision of health care to the public."

Objection: Marijuana use can cause psychosis in some people and, if a
patient who had a recommendation from a physician commits a violent act,
that physician could be subject to criminal prosecution.
Reply: Thousands of physicians have recommended medical marijuana to
tens of thousands of patients in the 12 states where it is sanctioned by law.
There have been no recorded cases of a psychotic reaction by a patient to
marijuana that have resulted in a physician being put at legal or criminal risk
for issuing such a recommendation. A great many prescription medicines can
cause adverse psychiatric reactions, some much more commonly than the
putative link between marijuana and psychosis. This is the sort of risk that
physicians manage every day by appropriately evaluating, screening, and
monitoring patients.

Objection: If wider access were allowed to medical marijuana for legitimate
patients, there would be an increase in the amount of marijuana-related car
crashes and fatalities.
Reply: As with the use of any medication, common sense and personal
responsibility must prevail. Literally hundreds of prescription and over-the-
counter drugs -- taken every day by millions of Americans -- can cause
drowsiness or slowed reactions and should not be used while driving. We do
not deny patients who need these medicines the relief they need because
driving while taking them is contraindicated; instead, we expect them to use
common sense. Medical marijuana patients should be held accountable to the
same standards and laws as those who take any medicine with the potential
to impair coordination and decision-making. One-fifth of the U.S. population
now lives in states with medical marijuana laws, but there is no published
evidence indicating that the medical use of marijuana has led to an increase
in motor vehicle accidents in any of these states.

Objection: Increased medical marijuana access would lead to decreases in
workplace productivity.
Reply: There is no reason to believe that this is the case, and some reason
to believe that the opposite is true. No medical marijuana law requires
employers to accommodate marijuana use in the workplace. Many patients,
however, report that marijuana, by providing improved relief of nausea, pain,
loss of sleep, and other symptoms, allows them to work more productively
than they could before beginning a medical marijuana regimen. And some
have found that their marijuana regimen actually allowed them to return to
work, when without using marijuana they had been too ill to do so.

CHILDREN, GATEWAYS, AND DIVERSION:

Objection: Affirmative positions supporting medical marijuana endanger our
children and encourage abuse of the drug.
Reply: Of the 12 medical marijuana states, 10 now have data on teen
marijuana use from both before and after the medical marijuana laws were
passed. Adolescent marijuana use has not risen in a single one of these
states [http://www.mediafire.com/?lujnxibnvgf]. Instead, it has declined
since medical marijuana became legal. For example, in California -- the state
where tales of abuse appear to be most common -- the state-sponsored
California Student Survey found that 34.2 percent of ninth graders reported
having used marijuana in the past six months in 1995-96, the last survey
before California's medical marijuana law, Proposition 215, passed. This
represented a near-doubling from the 1991-92 survey. Teen marijuana use
began to decline in the 1997-98 survey, the first conducted after Prop. 215
passed. By 1999-2000, past-six-months marijuana use by ninth graders had
plunged to 19.2 percent, and it has declined even further since then.
[http://safestate.org/documents/CSS_11_Tables.pdf]

The American College of Physicians notes, "Opiates are highly addictive yet
medically effective substances and are classified as Schedule II substances,"
but "there is no evidence to suggest that medical use of opiates has
increased perception that their illicit use is safe or acceptable."

Objection: Marijuana is a gateway drug to harder substances, and therefore
medical marijuana use will lead to dangerous drug use.
Reply: In science, the distinction between correlation and causation is
crucial. The "gateway theory" has been roundly debunked by many credible
sources. According to a 2006 study commissioned by the British Parliament,
"the gateway theory has little evidence to support it despite copious
research." The Institute of Medicine has concluded, "There is no evidence
that marijuana serves as a stepping stone [to other drugs] on the basis of its
particular physiological effect." The American College of Physicians noted in
February 2008, "Marijuana has not been proven to be the cause or even the
most serious predictor of serious drug abuse. It is also important to note that
the data on marijuana's role in illicit drug use progression only pertains to its
non-medical use." In any case, it is absurd on its face to cite a supposed
"gateway effect" for patients who are already routinely prescribed opiates
and other highly addictive, potentially deadly narcotics. Medical marijuana is
a safe alternative for patients whose other options are not as reliable or
effective.

Objection: Medical marijuana laws create opportunities for diversion to
illegal markets.
Reply: Recent press reports have indicated that the DEA is continuing to
close down medical marijuana dispensaries ("buyers' clubs"). Reports
emphasize the large volume of marijuana being cultivated by some
dispensaries and the risk of diversion to illegal sales outside of the medical
marijuana patient community. While these risks are not trivial, neither is the
ongoing problem of diversion of prescription drugs to illicit uses-- and yet we
do not deny patients who need these drugs appropriate relief because of
such abuse. The best way to ensure that medical marijuana is not diverted to
illicit uses is through appropriate regulation and control, but federal law
enforcement efforts have actually hampered and interfered with attempts by
state and local governments to implement such controls. The AMA could
encourage state and local governments to develop stronger systems of
licensing and oversight of medical marijuana production. It could also call
upon the federal government either to participate constructively in such
regulation or get out of the way of state efforts to do so.

THE DIFFICULTIES AND OBSTACLES OF DOING RESEARCH:

Objection: The American Medical Association and others already have pro-
research positions on medical marijuana.
Reply: The current research climate for marijuana has created a significant
chilling effect for researchers wanting to pursue FDA-approved clinical and
basic research on the safety and efficacy of medical marijuana. While existing
AMA policy recommends that NIDA should provide medical marijuana for all
FDA-approved clinical and basic research studies in the U.S., this
recommendation has gone unheeded by NIDA, which has refused to supply
medical marijuana to several privately-funded, FDA-approved research
projects and has delayed initiation of other projects (including those
approved and funded by NIDA) for several years. A more strongly worded
position that specifically recommends marijuana's reclassification under
federal law and/or the licensing of private medical marijuana production
facilities that meet all regulatory requirements to produce pharmaceutical-
grade marijuana for use exclusively in federally-approved research would
provide a solution to the current no-win situation. It is entirely appropriate
for organized medicine to respond to the current legal limbo to help create a
positive climate for increased research.

Objection: There have been many federally-sanctioned studies on the
medical use of marijuana in the past decade. These studies are continuing
today, and they will continue in the future.
Reply: On the contrary, only a handful of medical marijuana studies have
been allowed to proceed, and only one is presently underway. These have
been small pilot studies, and while they have been consistently successful,
the federal government is actively obstructing the type of medical marijuana
studies that would be needed to obtain FDA approval. Most notably, a group
of researchers at the University of Massachusetts at Amherst has been
seeking to conduct formal trials for years, but the Drug Enforcement
Administration is blocking their efforts. The researchers are trying to create a
facility to grow specific marijuana strains under controlled, reproducible
conditions to test marijuana's efficacy for various indications. Such research
is essential for FDA approval, but the DEA has refused to approve such a
facility.

Objection: There haven't been any double-blind, placebo-controlled studies
proving marijuana's effectiveness.
Reply: Despite the many difficulties in acquiring marijuana for research, in
2007, Dr. Donald Abrams of the University of California, San Francisco,
published just such a study that found marijuana to be safe and effective at
treating peripheral neuropathy, which causes great suffering to HIV/AIDS
patients. There are no FDA-approved treatments for peripheral neuropathy,
which is notoriously resistant to treatment with conventional pain
medications. In the UCSF study, marijuana was clearly shown to give relief.
In this randomized, double-blind, placebo-controlled trial, a majority of
patients had a greater than 30 percent reduction in pain after smoking
marijuana. In another randomized, double-blind, placebo-controlled study
published in April 2008 by the Journal of Pain, marijuana was found to be
effective at relieving neuropathic pain from a variety of causes, including
diabetes, multiple sclerosis, and spinal injury.

Objection: There has been no research on non-smoked delivery systems for
marijuana.
Reply: The IOM expressed concern about the health risks of smoking and
urged development of a "nonsmoked, rapid-onset cannabinoid drug delivery
system," but noted that in the meantime, "we acknowledge that there is no
clear alternative for people suffering from chronic conditions that might be
relieved by smoking marijuana, such as pain or AIDS wasting." The answer
to the IOM's concerns about smoking is vaporizers, which take advantage of
the fact that cannabinoids vaporize at a temperature well below that at which
marijuana burns. Vaporizers allow patients to inhale cannabinoid vapors
without smoking, achieving the same rapid action and easy dose titration
without the tars and other irritants found in smoke. Several studies of such
devices have now been published. In a study of one such device, the
Volcano, researchers confirmed that the device works as intended, stating,
"What is currently needed for optimal use of medicinal cannabinoids is a
feasible, nonsmoked rapid-onset delivery system. With the Volcano, a safe
and effective delivery system appears to be available to patients."
[www.cmcr.ucsd.edu/geninfo/abrams_vap_abs_1.pdf]

Objection: Sativex® will be approved soon.
Reply: Sativex® is a concentrated extract of the components of natural
marijuana that has been developed for sublingual use to counter pain
associated with advanced cancer and pain/spasticity associated with multiple
sclerosis. An FDA-approved clinical study for advanced cancer pain is
underway. Additional studies will likely be needed prior to approval by the
FDA, making it likely that Sativex® would not be available in the U.S. for at
least three more years. Meanwhile, many thousands of people are already
obtaining significant symptom relief with medical marijuana in the 12 states
with medical marijuana programs, but they are still subject to federal
prosecution and intimidation.

Sativex may well prove to be a useful product, but it has been shown to have
drawbacks. It takes far longer to reach peak blood levels than inhaled
marijuana, and the alcohol-based spray has been associated with oral
lesions.