Blowing smoke: the medical cannabis debate
What’s really driving the push for medical marijuana – patients, politics or business?
AT the start of May, proponents of legalising marijuana for medicinal purposes scored another victory in the US, when Washington DC approved legislation allowing doctors to “recommend” the drug, though not actually prescribe it.
DC joins the 14 American states so far that have removed criminal penalties for the medical use of cannabis. Twelve more are considering it.
But while they ponder, it’s the patients who are losing out, say the writers of a New England Journal of Medicine editorial published last month.1
“Although state laws represent a political response to patients seeking relief from debilitating symptoms, they are inadequate to advance effective treatment,” the authors say.
“Medical experts emphasise the need to reclassify marijuana as a Schedule II drug to facilitate rigorous scientific evaluation of the potential therapeutic benefits of cannabinoids and to determine the optimal dose and delivery route for conditions in which efficacy is established.”
California was the first state to legalise medical marijuana in 1996. Colorado followed suit a decade ago. Both states have well-established infrastructure – and rapidly rising demand.
In April, USA Today reported that there is a six-month waiting period for the permission cards that allow the legal purchase of marijuana in Colorado – and 66,000 cards have already been issued. It stated that applications had gone from 270 per workday in August 2009 to about 1000 in February 2010.2
And it’s a multimillion dollar business, with dispensaries popping up like 'nail parlours', the paper reports.
As well, some states are taking the opportunity to earn much-needed sales tax revenue for their cash-strapped economies from the outlets.
However, there are no guidelines for best practice and no regulation of marijuana’s quality or potency – something that several key players, including the American Medical Association, the Institute of Medicine and the American College of Physicians, argue needs to change.
The American Medical Association has gone on the record saying it would support changing the classification of marijuana as a controlled substance if it makes research and development of cannabinoid-based medicine more likely.
The potential significance of cannabis as a medicine remains to be seen. Less than 20 small randomised controlled trials of short duration involving about 300 patients have been conducted over the last 35 years on smoked cannabis. Results so far show smoked cannabis reduces neuropathic pain, improves appetite and caloric intake, especially in patients with reduced muscle mass, and may relieve spasticity and pain in patients with multiple sclerosis.
The American Medical Association sites all this in its position statement released last year, but adds this important caveat: “the patchwork of state-based systems that have been established for ‘medical marijuana’ is woefully inadequate in establishing even rudimentary safeguards that normally would be applied to the appropriate clinical use of psychoactive substances." 3
Opinions on the matter vary widely, not only in the US, but also here in Australia, where public demand has been less brazen.
Dr Alex Wodak is director of the Alcohol and Drug Service at St Vincent’s Hospital in Sydney and an advocate of legalising cannabis for medical use. He points out that a two-volume independent review of the evidence published by the NSW Government back in 2001 listed a number of potential medical benefits for cannabis, and recommended more clinical trials of safety and efficacy, as well as more “flexibility in new medication registration by the TGA based on the clinical needs of special populations”.4
“However, no action was taken,” Dr Wodak says.
“The evidence for effectiveness and safety is now much stronger than it was in 2001.
“Cannabis seems to be a useful drug for selected patients with a range of conditions, including treatment-refractory cancer; chemotherapy-induced nausea and vomiting; symptoms of advanced HIV; disseminated sclerosis; and chronic non-cancer pain…
“Medicinal cannabis should be available in Australia for some patients with specific conditions where first-line drugs fail all too often.”
Some experts, however, believe that business lobbies and political motives may be playing a bigger role in the demand for cannabis than is warranted by the evidence.
University of Queensland public health policy professor Wayne Hall has researched the adverse effects of marijuana extensively and chaired the aforementioned committee for the NSW review.
The way Professor Hall sees it, cannabis has limited scope among the uses for which it has been trialled.
“There are now much more effective agents available than when cannabis was first trialled in the 1980s,” he says.
Much of the Australian push for legalised medicinal cannabis was originally driven by HIV patients, and that has dropped off as they now have access to effective antivirals, he adds.
“There are new indications for neuropathic pain, but the comparative studies have found that while there’s some effect, they’re not fabulously effective… It’s not looking like a great pharmaceutical, but it’s a convenient vehicle for liberalising laws around cannabis,” he says.
“All the indications it would be used for are second- or third-line treatment.”
While Dr Wodak has a different take on the potential for cannabis in medicine, he agrees that politics has no doubt influenced the evolving policy and the problems that go with it, especially in America.
“In the US, the medicinal use of cannabis cannot be separated from controversies regarding the recreational use,” he says.
“In a climate of often severe repression of recreational cannabis use, medicinal use of cannabis has seemed to be the only way out. This has inevitably led to some abuses.”
Those “abuses” have been highlighted most blatantly in California, where only a letter from a doctor stating that the patient has a condition that may benefit from marijuana is needed for access.
According to the US Drug Enforcement Administration’s (DEA) website, which publicly derides the Californian system, mood disorders are among the top three reasons for treatment.
The DEA also openly criticises the lack of regulations over how the marijuana should be cultivated or distributed as well as the state’s inability to distinguish between illegal and legal growers: “Many self-designated medical marijuana growers are, in fact, growing marijuana for illegal, ‘recreational’ use,” it says.
Moreover, it claims “large-scale drug traffickers hide behind” the scheme and “escape state prosecution because of bogus medical marijuana claims... Therefore, high-level traffickers posing as ‘care givers’ are able to sell illegal drugs with impunity.”
It’s those sorts of discrepancies that have many calling for change. And, amid the chaos, there is still a great unmet need for rigorous evaluation.
“Policymakers are grappling with questions that only scientific research can answer: For what conditions does marijuana provide medicinal benefits? Are there equally effective alternatives? What are the appropriate doses for various conditions? How can states ensure quality and purity?”
For now, answers are still pending.