None Of These “medicines” Were Smoked

Marijuana was used as a medicinal for thousands of years and perhaps longer. The earliest written reports of marijuana use come from Chinese writings in the 27th century BC.

Until the early 1940s in the United States, marijuana was found in more than 20 medications for a variety of ailments. It continued to be included in the US Pharmacopoeia, the predecessor of the Physician's Desk Reference, five years after the Marijuana Stamp Act was passed.

Prior medical use of marijuana was restricted to extracts of the cannabis plant combined with various other ingredients and sold in a variety of patent medicines advertised and marketed as cure-alls. None of these “medicines” were smoked.

In states where medical marijuana is currently available, it is almost exclusively sold in drug emporiums in a raw state meant to be smoked. In Hawai‘i, individuals with medical marijuana cards were initially allowed to cultivate three plants for personal use; this later increased to seven plants.

The vast majority of medical marijuana users claim chronic pain and smoke the raw plant. (A small group use marinol, a legal medical form of tetrahydocannibol, prescribed in a 5mg tablet, which has a little or no euphoric properties.)

The scheduling by the Drug Enforcement Agency of marijuana and other drugs (heroin, Lysergic Acid Diethylamide, Gamma-Hydroxybutyrate, and various mephadrones in “bath salts”) automatically eliminates valid research on the drugs, which is never a good idea from an academic, research, or public policy perspective.

Marijuana should be removed from Schedule I. This would allow research to determine possible medical applications of marijuana extracts and develop acceptable delivery methods other than smoking the raw plant.

In Hawai‘i, the Hawai‘i Medical Association (HMA) took a stance against the first medical marijuana bill passed in 2000. One main sticking point is that medical marijuana would need to be provided in a non-smoking form in order to have support from the medical profession. Authorizing use by inhalation of a drug with an unknown number of co-drugs contained in the same raw form is not supportable.

The United States has experienced a century of terrible adverse medical consequences of cigarette smoking and nicotine addiction. Over 400,000 lives lost each year are directly and indirectly attributable to the adverse effects of smoking cigarettes. We endured as a nation, and as a medical profession, the falsification of data from the US tobacco industry regarding the problems of nicotine use and, specifically, the problems related to chronic inhalation of a raw drug which contained nicotine and multiple other identified tars and carcinogens. How can physicians or medical associations support any medical marijuana law that involves smoking an unrefined drug after this experience with cigarette smoking?

Marijuana's ingredients are available in a pill form. The approval of Marinol, a non mind-altering form of delta 9 tetrahydrocannabinol for general use, is a case in point. This is a marijuana extract that has been available by physician prescription for use for a variety of anecdotally acceptable treatments, especially the nausea associated with chemotherapy, anorexia associated with HIV infection, and some reported forms of pain relief. Other ingredients from the cannabis plant have been isolated. Found to be anecdotally useful in treating certain childhood seizure disorders.

Supporting the use of medical marijuana by inhalation solely because users prefer it would be akin to supporting the inhalation of any other drug meant to be taken by mouth. Addicts in our treatment program often crumble pills. Nasally inhale or inject them intravenously to obtain a faster high. We would never say, “OK, go ahead and inject yourself if that's what you prefer.”

The primary reason for medical marijuana use is control of chronic pain. Medical users descriptions of chronic pain are often vague. May relate to some distant injury or surgery to rationalize the need for a marijuana card in Hawai‘i.

Some practicing physicians in Hawai‘i who formerly prescribed the marijuana card have ceased doing so (anonymous, personal communication). A few physicians travel within the state for the purpose of writing marijuana prescriptions. Many neither examine the patient nor take a detailed history.

Marijuana card holders who seek addiction treatment in our program for marijuana dependence indicate that at the time of prescription, they in fact had very little pain. They told the prescribing physician what was necessary to obtain a medical card. They also report minimal history taking or physical examination by the physician. Rarely were they required to show some evidence that indicated pathology. It is difficult to support that approach to prescribing any medication.

Most pain medicine specialists emphasize the importance of understanding the pathophysiology, severity, and origin of the patient's pain which correlate with the stated symptoms. While pain is subjective and some are more tolerant to chronic pain than others, an approach to pain management needs to be based on the body's ability to heal, as well as the pathophysiological understanding of its etiology. Our bodies usually heal rapidly from surgery and most forms of trauma.6

Opiate prescribing practices of individual physicians are being scrutinized. There is obvious over prescribing of opiates by some physicians. There are opiate-prescribing mills operating as legitimate pain management clinics. State and federal efforts are underway to close these prescription mills which are legalized drug-dealing businesses. In some cases, unscrupulous physicians are doing the same thing in their individual practices.

Continuing medical education training on analysis of chronic pain, pathophysiology, and severity are being provided to educate physicians on evidence based methods of treating chronic pain. The same approach needs to be applied to medical marijuana.

There is no current rationale to support that prescribing marijuana would be preferable to other approaches to pain management. Unfortunately, medical marijuana laws are passed as a means to bypass the illegality of marijuana. Medicine has often been an unwilling participant in this process.