Marijuana use in the U.S. is on the rise, and it no longer is just for recreational use. A growing number of clinical studies has found marijuana to be a viable treatment for a multitude of medical conditions, including chronic symptoms associated with rheumatic diseases, nerve damage, glaucoma and movement disorders. It also has been shown to be effective as an appetite stimulant for those with HIV.
Several states have decriminalized its recreational use, and more states now are legalizing and overseeing the dispensing of medical marijuana. Researchers are looking beyond the traditional smoking of marijuana and are invested in creating viable medicines in other forms. But is it the right treatment for your pain?
Cannabis, now known by its Mexican slang term as marijuana, was first described in a Chinese medical reference dated to 2700 BC. The Spanish brought marijuana to the New World in the mid-1500s; the English introduced it in 1611 to Jamestown, where it became a major commercial crop alongside tobacco. Grown as hemp, it was a source of fiber until the late 1800s, when it was replaced by cotton as a major cash crop in the southern U.S. In the 1920s, marijuana emerged as a recreational drug for achieving euphoria, this time as an intoxicant and an alternative to alcohol during Prohibition.
As a medical agent, from 1850 until 1943, marijuana was included in the United States Pharmopeia, a publication containing legally recognized standards of identity, strength, quality, purity, packaging and labeling for drug substances, dosage forms and other therapeutic products. It listed marijuana as a prescription for various conditions, including labor pains, nausea and rheumatism. However, because of its recreational use in the Roaring ’20s, the U.S. Federal Bureau of Narcotics mounted a campaign that portrayed marijuana as a powerful substance that would lead users to narcotics addiction. Marijuana was cast as an evil substance that could cause ‘reefer madness.’
Many authorities still consider marijuana a gateway drug. The Controlled Substance Act of 1970 formally classified it, along with heroin and LSD, as a Schedule I drug, i.e., having the relatively highest abuse potential and no accepted medical use. Until the early ’70s, most marijuana came from Mexico, but in 1975, the Mexican government agreed to eradicate the crop by spraying it with the herbicide paraquat, which raised public fears about toxic side effects. Colombia then became the main supplier. The zero tolerance climate of the Reagan and Bush administrations resulted in passage of stricter laws and mandatory sentences for marijuana possession, heightening vigilance against smuggling at the southern borders. The war on drugs brought a shift from reliance on imported supplies to domestic cultivation. Beginning in 1982, the Drug Enforcement Administration increased its attention to marijuana farms in the U.S., and a shift to the indoor growing of plants specifically developed for small size and high yield resulted. After a decade of decreasing use, smoking marijuana for recreational use began an upward trend again in the early 1990s.
Currently, the U.S. outlaws all cannabis use, but 20 states and the District of Columbia no longer prosecute for the possession or sale of marijuana as long as the individual is in compliance with the state’s marijuana sales regulations (known as decriminalization laws). And several states also have introduced legislation and passed laws to regulate licensed, legal medical marijuana dispensaries. However, an appeals court ruled in January 2014 that a 2007 Ninth Circuit ruling remains binding in relationship to the ongoing illegality, in federal legislative terms, of California cannabis dispensaries. This ruling reaffirmed the national impact of the federal Controlled Substances Act. The political battle continues to be waged.
As the public debate is fought, research into the medical value of marijuana proceeds. To date, approximately 22,000 published studies and reviews in the scientific literature reference the cannabis plant and its cannabinoids, nearly half of which have been published in the last decade. The scientific conclusions of much of the research directly conflict with the federal government’s stance that cannabis is a highly dangerous substance worthy of absolute criminalization. However, there is a good deal of professional debate about the quality of the research produced and promoted to the general public.
Recent research suggests cannabis is a valuable aid in treating a wide range of conditions, including pain—particularly pain from nerve damage, called neuropathic pain, and spasticity, glaucoma and movement disorders. Marijuana also is a powerful appetite stimulant, specifically helping patients suffering from HIV, the AIDS wasting syndrome. The chemicals in marijuana, called cannabinoids, are being studied and prescribed to treat other various symptoms and diseases.
Researchers know the human body produces its own cannabinoid chemicals. They play a role in regulating pleasure, memory, thinking, concentration, body movement, awareness of time, appetite, pain and the five senses. This is of great interest to biologists and medical researchers. However, even with the quantity of research being produced, the use of cannabis as a medicine widely endorsed and prescribed is questioned because of inconsistent scientific rigor, due primarily to restrictions on the production of the drug.
As recently as November 2015, a group of researchers from McGill University published a study in the journal Arthritis Care and Research that found scant evidence supporting the use of cannabinoids in rheumatic diseases. According to Yoram Shir, director of the Alan Edwards Pain Management Unit of the McGill University Health Centre in Montreal and one of the study’s authors, “Much of the research on marijuana is anecdotal, with results based on personal information and biased information sources. We conducted an extensive and comprehensive study focusing specifically on patients with rheumatic diseases, probably the most prevalent etiology for marijuana use among those with chronic non-cancer pain. We determined that, because of the quality of the research, there can be no conclusions drawn regarding the efficacy or side effects—especially long-term side effects—associated with cannabinoid therapy. While we found that those studies provide limited information, the results are not relevant to other chronic pain conditions and our results should not be extrapolated for other diagnoses.”
Mark Weiner, M.D., a Massachusetts physician board certified in neurology and sleep medicine, is a respected patient advocate for the use of medical marijuana. He agrees with the quality of research and its limited application. “There is little money coming in from the U.S. federal government and none from the big pharmaceutical companies for researching the medicinal properties of marijuana. If the federal government would say, ‘We want to know,’ there would be significant funding,” said Weiner, who also is a brain cancer patient. “The research material is uncomplicated: You can take a seed, throw it in the ground and a plant pops up, so the product is available and inexpensive for study. The true reason for the lack of research—that marijuana will not be a money maker for big pharma—is clouded in the U.S. by the ‘slippery slope’ argument, that marijuana is a gateway drug and leads to substance abuse and addiction. The research in Europe, Israel and Japan is much more advanced because of the support of their government institutions.”
High-quality research is needed, because the plant, while inexpensive to produce, is complex. Of the 400 chemicals found in its biological makeup, 60 are defined as unique and classified as cannabinoids. In the 1990s, scientists identified cannabis receptors within the human body. When those receptors are stimulated by the cannabinoids in marijuana, the effects can be seen through neural pathways at a cellular level. A 2014 review paper published in the Journal of the American Medical Association (JAMA) said clinical research into the therapeutic value of cannabinoids is expanding, particularly as it is being explored to modify disease. Of particular interest are trials to moderate autoimmune disorders such as multiple sclerosis, rheumatoid arthritis and inflammatory bowel disease, as well as their role in the treatment of neurological disorders such as Alzheimer’s disease and amyotrophic lateral sclerosis (ALS). Other studies are demonstrating that cannabinoids have antioxidant properties, can kill cancer cells and may act as a neuroprotectant to help ward off dementia.
“There is a good deal of interesting study dealing with the genetics and breeding of the marijuana plant to make more effective cannabinoids,” said Daniel Macris, CEO of Halcyon Organics, an Atlanta-based company growing cannabis to meet the current and future trends of what he calls ‘cannabinoid medicine.’ “Medical research is far behind proving hypotheses and anecdotal stories that there are significant medicinal properties associated with marijuana. We believe that when the results are in, they will be conclusive and significantly helpful for treating many diseases.” He focuses on two main cannabinoids from the marijuana plant of medical interest: THC and CBD.
THC increases appetite and reduces nausea. The FDA recently approved THC-based medications for these purposes. THC decreases pain, inflammation and muscle control problems. CBD is a cannabinoid that does not affect the mind or behavior and is used to treat a laundry list of conditions, including reducing pain and inflammation, controlling epileptic seizures and possibly treating mental illness and addiction. However, because of the limited and early research, the safety and efficacy of its widespread medical applications have not sufficiently been proven. Recently, the Senate recommended $800,000 for an Institute of Medicine study on medical marijuana and has encouraged the National Institutes of Health (NIH) to support more research on CBD.
Many questions remain about the long-term effects of marijuana. What’s clear is that marijuana’s signature high, caused by the psychoactive cannabinoid THC, is not risk-free. Although there are no deaths directly linked to marijuana overdose, studies have shown that smoking marijuana alters the brain development of teenagers and can induce panic or paranoia, increase heart rate and, for approximately 9% of users, can become addictive. A growing body of literature points in the same direction: Starting young and using marijuana frequently may disrupt brain development.
In short-term recreational usage, marijuana has been shown to impair attention, memory, learning and decision-making. Those effects can last for days after the high wears off. For teenagers and young adults, heavy marijuana use has been associated with a dismal set of life outcomes, including poor school performance, higher dropout rates, increased welfare dependence, greater unemployment and lower life satisfaction. There are clinical reasons to think adolescents may be uniquely susceptible to lasting damage from marijuana use. At least until the early to mid-20s, the brain is still developing and is particularly sensitive to damage from drug exposure.
However, many of the research results are frustratingly mixed. According to a 2015 report by the American Psychological Association, while some studies found increased risk for mood disorders and psychotic symptoms among marijuana users, others found chronic use among teenagers did not raise the risk of later depression, lung cancer, asthma or psychotic symptoms. Fortunately, the research is broadening. In hopes of painting a clearer picture of marijuana’s potential risks to youth, the National Institute on Drug Abuse plans to launch a large longitudinal study later this year to examine what children look like before they start using substances and then follow over time what happens to their brains. This research will explore the long-term cognitive effects of cannabis and will examine the question, “Is there a safe level of use?”
It’s Not the ’60s Anymore
Advocates for medical marijuana use say the drug has come a long way from its image as a recreational drug smoked to get high. Macris said smoking marijuana is the least effective way to see its medical benefits. In fact, he strenuously objects to the recreational use of marijuana.
“None of the current research on cannabinoid medicine is designed to make or keep an individual ‘high.’ We are looking at its value as a natural immunosuppressant,” he said. “Stoned out hippies smoking ‘dope’ is the outdated image that most people have when thinking of marijuana use. Smoking causes the lowest transfer of the right chemicals in the correct dosage into a person’s system; it does not allow for proper ingestion of the medical properties of cannabinoids. We are learning how to tincture oils, make lozenges and compound skin balms infused with cannabinoids to administer the drug safely and effectively.”
Weiner agrees that marijuana is nothing to play with. “As a physician, I highly object to recreational use of any drug, particularly a psychoactive one that will change brain function. Those current advocates of medical marijuana who base its value on the recreational experience of users in the ’60s and ’70s are ill-informed and totally wrong. What may have produced euphoria in an otherwise healthy teenager 40 or 50 years ago has no relevance or basis for effectiveness or success in an older adult experiencing a chronically disabling, diagnosable medical condition. Marijuana as recreation has absolutely no place in this discussion.”
Marijuana’s potency has risen dramatically in recent years. Thirty years ago, THC concentrations typically were well below 10%. But a recent analysis of marijuana samples bred and sold in Colorado found THC potency approaching 30%, according to results presented at the 2015 meeting of the American Chemical Society.
Macris and his colleagues at Halcyon Organics also are working with genetics and breeding. “Marijuana is entirely organic and has been grown throughout history as an agricultural product,” he said. “It is new to think of it as medicinal and to consider it being developed for the quality of its different cannabinoids while eliminating focus on the high caused by THC.”
He said medical research is 10 to 15 years from effectively examining the effect of cannabinoid medicine on the central nervous system and as an anti-inflammatory, a natural immunosuppressant and an aid for neuropathic pain. “While we can speculate now about what constitutes a reasonable ‘dose,’ there is still a subjective element to the prescription that requires greater clarity and predictability,” he said. “What is clearly lacking and sorely needed are studies to look at the effect of increased potency and different modes and methods of use on brain-related measures.”
Access and Attitudes
“The political zeitgeist about marijuana as medicine is convoluted and confusing,” said Weiner, in his role as patient advocate. “As a physician treating a patient, I prescribe a drug by writing a note that directs what and how much to take of certain medication. Legal and ethical regulations guiding the physician and pharmacist provide excellent oversight to ensure proper usage of the prescription. In Massachusetts, though, marijuana is seen differently. I can certify only that a patient meets the legal criteria for the need for marijuana based on disabling symptoms and diagnosis.
“Massachusetts has established a list of diagnoses that are permissible for certification,” he added. “The list was created on decisions that were only partially considered based on the proven or emerging value of marijuana. Other than that, the state has adopted a ‘don’t ask, don’t tell’ attitude toward the medicinal use of marijuana. I fully believe and advocate for the approach that if an individual has symptoms potentially relieved by marijuana—noted through research ranging from qualitative to anecdotal to experimentally validated findings—that medical marijuana should be considered as a first line of treatment, not after a failure of other treatments, such as narcotics.”
Macris agrees. “There has been a tremendous political agenda to prove marijuana’s ‘badness.’ If more energy were spent on education, regulation and loosening the laws restricting the production of marijuana, the drug could be studied more effectively. It has the potential to make a tremendous impact on the quality of life of people living with different chronic diseases.”
“The scientific community must call for further urgent research to determine the true role of cannabinoids in disease intervention,” added Shir.
There has been great interest from the scientific community on medical marijuana over the last decade. Physicians, biologists and their peers agree the politics of continuing to promote fear of marijuana as a dreadful, recreational gateway drug has produced bad legislation.
“There needs to be a focus on in-state growing, so that better research can be produced locally and regionally. The trend toward medical marijuana is now in the mainstream of society, and research findings ultimately will result in widespread prescription and availability of a variety of forms of medical cannabinoids for different diseases,” said Macris. “The political pushback only slows the research for an inexpensive, first-line treatment.”