Medical Marihuana Controversy with comments by Dr. Rotchford

MEDICAL MARIJUANA CONTROVERSY
BY: DR. STEPHEN F.GRINSTEAD
     Although we have entered a new millennium many old controversies are still raging. One of these issues is the use of marijuana as a legitimate medication. There are two polarized camps fueling this debate. One side preaches the evils of using this herb and the other side extols the virtues. Over the past 17 years I have listened to both sides of this issue and have seen the impact
of this controversy on my clients. Unfortunately, there is an important piece missing; reliable double-blind studies designed to test how effective marijuana really is as a legitimate medication. Also, because of the way in which the Drug Enforcement Agency (DBA) rates or "Schedules" drugs, there are legality issues to consider. For Schedule I substances, the criteria that need to be considered are whether the substance 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. While Schedule I drugs cannot be used medically, the law does allow supervised research. For substances to be rated as Schedule II, the DEA considers its high potential for abuse, whether it has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions and whether abuse of the substances may lead to severe psychological or physical dependence. While legal for medical use, doctors need to go through additional legal steps when prescribing these drugs. A substance is placed on Schedule III based on its potential for abuse relative to substances in other schedules, whether it has a currently accepted medical use in treatment in the United States, and its relative potential to produce physical or psychological dependence is less.
     What has been available for several years as a legitimate medication is Marinol (dronabinol), a synthetic THC (delta-9-tetrahydrocannabinol, the active psychoactive chemical in marijuana). While marijuana is still listed as a Schedule I drug by the DEA and illegal for medical use, Marinol the synthetic form of THC has finally been reduced from Schedule II to a Schedule III Drug.
Marinol has been used in treating Glaucoma, people undergoing chemotherapy, and for people with AIDS. Again sides are split on the effectiveness of this medication. One side says Marinol works great therefore there is no need to legalize the medical use of marijuana. The other side states that Marinol is not nearly as effective as smoked marijuana.
After working with many individuals who have used Marinol and also smoked marijuana, I see that both sides have good points. For example, after helping some of my clients work through denial issues surrounding marijuana abuse, they become honest and share that the Marinol did work as well for controlling nausea or increasing appetite, but they didn't get high. On the other hand, several clients who needed help for nausea caused by chemotherapy treatment were not able to ingest the Marinol tablets and found smoking marijuana to be a better option for them.
     There are many risks associated with marijuana, especially smoked marijuana, 0that must be considered not only in terms of immediate adverse effects on the lung; e.g., bronchi and alveoli, but also long-term effects in people with chronic diseases and those with a poor immune status. The major problems I have with someone smoking marijuana as a medicine is the inability to regulate the dosage and, even more important the delivery system. The level of THC varies so greatly in the marijuana that is currently available, that coming up with a therapeutic dose is extremely difficult. In addition, marijuana has other ingredients that may have problematic side effects. Then there is the dangerous delivery system-the issue of smoking it. The components of the smoke are hazardous, especially in the immuno-compromised patient. No other medication we have is administered that way because of the potential dangers.
Because of the lack of research there has been no exploration of a safer delivery system for the active ingredient of marijuana (THC). There have been suggestions that an aerosol delivery system for the THC or Marinol would eliminate the dosage and the unsafe smoking problems. Why is this not being given due consideration?
One of the reasons may be that there is not enough profit for drug companies, but I believe the main reason is the stigma that has historically surrounded marijuana. I think that marijuana is a serious drug of abuse that leads to dependency (addiction), but this is also true of many legal prescription medications. For example Vicodan and OxyContin have both been increasingly abused in the past several years and Valium and Xanax have been a serious abuse problem for at least the past decade.
     Another problem with medical marijuana is that it is often prescribed for conditions that may not be medially indicated. In fact, several of my clients received medical marijuana prescriptions for stress management and chronic pain management. I am not aware of any legitimate research that indicates marijuana is a medically sound treatment for either of these conditions. That is why quality research needs to be undertaken to prove once and for all the legitimacy of using marijuana-or at least its active ingredient THC-to treat specific medical conditions.
In 1999 a study Marijuana and Medicine: Assessing the Science Base by Janet E. Joy, Stanley J. Watson, Jr., and John A. Benson, Jr., Editors was published. This study was supported under contract No. DC7C02 from the Executive Office of the President, Office of the National Drug Control Policy. One major important finding of this study was that although marijuana smoke delivers THC and other cannabinoids to the body, it also delivers harmful substances, including most of those found in tobacco smoke. In addition, plants contain a variable mixture of biologically-active compounds and cannot be expected to provide a precisely defined drug effect. For those reasons, the report concludes that the future ofcannabinoid drugs lies not in smoked marijuana, but in chemically-defined drugs that act on the cannabinoid systems that are a natural component of human physiology. Until such drugs can be developed and made available for medical use, the report recommends interim solutions. The development of these appropriate drugs depends upon thorough double-blind clinical trials.
     I understand this is a controversial issue. While I am not in favor of legalizing "street drugs" I do advocate utilizing a potentially effective medication after it has undergone the same level of testing as the other medications we currently use. However, I believe that in addition to verifying the effectiveness, the delivery system and dosage problems need to be resolved before I would feel comfortable endorsing the use of medicinal marijuana for any of my clients.

Steve Grinstead specializes in training and consultation for addiction and coexisting personality and mental health problems. He is an author and nationally recognized expert in preventing relapse related to chronic pain disorders and is the developer of the Addiction-Free Pain Management System. Steve has also co-authored several books with Terence Gorski on Addiction-Free Pain Management, Food Addiction, and Denial Management as well as conducting Gorski-CENAPS® workshops and skills trainings nationally. Steve can be reached at his office in Sacramento California at (916) 419-1674, by email at sgrinstead@addiction-free.com or through his web site www.addiction-free.com.

Dr. Rotchford's Comments:
     I respect Dr. Grinstead a great deal and appreciate the work he has done in promoting non-medicinal approaches to effective pain management. He is also very knowledgeable in the field of addiction. I must disagree with him, however, on the primacy he puts on clinical trials for determining the role of marihuana or cannabis. I know for a fact that many of his interventions have not been shown to be effective based on sound clinical trials. I also provide medical acupuncture and know that through it I have helped countless individuals. This is despite the lack of "clinical trials" demonstrating benefit.
Nonetheless, it is clear that smoking cannabis is more dangerous than acupuncture or cognitive therapy. Besides the effects on the lungs and the appetite it clearly has behavioral complications and can be psychologically addicting. Because the management of chronic pain often involves helping patients find new and natural ways to deal with the stresses and emotional upheavals of life, anything which interferes with the brain's natural regulatory mechanisms, as does cannabis, is clearly a risk for delaying if not outright preventing recovery in chronic pain disorders. There is no evidence to support these concerns but my observation along with others is that patients who smoke marihuana, and are dealing with chronic pain disorders are less likely to see progress in their pain management. If a patient tells me that marihuana helps with their pain I have no reason to disbelieve them. After all, pain is a subjective phenomenon and as such I am not able to question a patient's subjective response. Nonetheless, as a physician I can observe behavior and reports of pain levels over time. If a patient isn't having less pain or experiencing better quality of life over time I must ask, as a physician, whether it is because of their current treatment approaches and/or a lack of other effective adjunctive therapies.
     In conclusion, based on a whole set of contextual issues unique to each individual's presentation I make a clinical decision whether the benefits of marihuana use outweigh the risks. Furthermore, I convince myself that the patient is consenting to use marihuana after full disclosure and understanding of marihuana's risks and other therapeutic alternatives . It is only then that I agree to sign the Washington State waiver for Medical use of marihuana.