Peering Throughthe Smoke: Marijuana as Medicine
by Ken Rude, PT
I told some of my patients that I'm preparing an article on medical uses of marijuana. Arjuna, who has two chronic medical conditions, surprised me. "I tried it once and it took away my pain. Nothing else has helped me at all." Arjuna (not her real name) suffers a lot. She's middle-aged, poor and clearly unable to work. "I had a ten-dollar bag that lasted me two days. A joint would stop the pain for about three hours."
Interestingly California, which passed a law legalizing medicinal use of marijuana in 1996, was not the first state to do so: it was New York. In 1980 the legislature in Albany passed the Antonio G. Olivieri Controlled Substances Therapeutic Research Program, enacted as a means of supplying marijuana to seriously ill cancer patients. (New York City Councilman and State Assemblyman Olivieri died of brain cancer in 1980.) Only a handful of patients were ever beneficiaries of the program, which is still on the books but was inactivated in the late 80s through bureaucratic maneuvering. The author of the law? None other than Alan Hevesi, our current State Comptroller.
Taking away medication from dying cancer sufferers is a result more of emotion-laden politics than of reasonable discussion. And in fact there is enough scientific knowledge about marijuana today that it's possible to talk about its medical use on a more rational plane. After spending some time researching this topic, it's become clear to me that Nature, with its artful symmetry, prepared our bodies in advance for a plant like marijuana. At the same time, marijuana, like many medicines, has harmful side effects. My main question then is whether marijuana, as a medicine, is beneficial to certain patients in ways that outweigh its harm. In other words, can our bodies use its substances wisely?
The Cannabinoid Receptors
There are more than 200 chemical substances in marijuana smoke. Over sixty of these are cannabinoids, the active substances unique to cannabis (marijuana's genus name). The most abundant cannabinoid and main active ingredient is delta-9-tetrahydrocannabinol, or THC. The scientific basis for medical marijuana got a big boost in the late 1980s with the discovery of the cannabinoid receptor system—a system which, when activated, has widespread effects throughout our bodies. These receptors are found in large numbers in parts of the brain that influence pain and pleasure, balance and our sense of time. They are also found in our nerves and the cells of our immune system. Cannabinoids bind to these receptor sites, to produce marijuana's effects.
As my patient Arjuna found out, marijuana uses the cannabinoid receptor system to modify pain. No other available medicine activates these particular pain-control pathways. At the present time, narcotics—let's call them "medical opium"—are the strongest painkillers medicine has. They act by binding to so-called opioid receptors, activating the body's most effective pain-control system. But narcotics have their limitations. They appear less effective, and sometimes completely ineffective, in controlling chronic pain—something the cannabinoid system appears to control more effectively. In other words a marijuana derivative, while not a one-stop pain reliever, may someday have an important supplementary role in pain control—one that may permit doctors to control pain with less narcotics than we now need. This would be a delicious irony: For years it's been said that marijuana leads to harder drugs; medically, someday the reverse may be true.
Other Properties of Marijuana
Marijuana also has a reasonably clear role in relieving nausea. Among its staunchest medical proponents are persons undergoing cancer chemotherapy, some of whom esteem it for its ability to control nausea and vomiting, even if for most people other anti-nausea drugs work as well or better. Still marijuana, when smoked, has one great advantage: it acts almost instantaneously, so the user can take the precise dose needed, while a pill can take two hours or more to work.
A somewhat related property is marijuana's ability to control loss of appetite and wasting. Wasting—the severe loss of body mass—is a serious consequence of such illnesses as cancer and AIDS. It makes victims frail and hastens death. While getting "the munchies"—the craving to eat—is a mild vice and a source of humor among stoners, it is a positive blessing for those who have lost their appetites. The skinny on pot is that it can keep the sickest people a little bulkier and a little stronger.
In the early 1970s marijuana gained some medical respect for controlling glaucoma, a condition in which fluid pressure within the eye leads to blindness. Since that time, however, other drugs have been developed that are more effective than marijuana at relieving these effects. Marijuana has also been used by some who suffer multiple sclerosis to relieve the spasticity in their limbs. It must be stressed that, even if it can help treat symptoms, no one claims that marijuana can cure MS.
Finally, mention should be made that marijuana has some anti-depressive properties. Recreational users take it to feel good. There are much more effective antidepressants, and getting intoxicated to battle your depression (and maybe tossed in the slammer) is very far from wise. But seriously ill persons face a more complicated situation. Isn't it a good thing if your medicine not only keeps you healthier, but allows you to feel something other than the icy hand of despair?
Looking back at the list of marijuana's users, we see human beings who suffer from cancer, AIDS, multiple sclerosis, blindness and chronic pain. These conditions are very serious, and sometimes fatal. Persons with these diagnoses are heavy users of the medical system, and consumers of many expensive medications. The potential benefits of marijuana, or marijuana derivatives, may lie in how well they treat multiple symptoms. Consider that marijuana appears to have some effectiveness in relieving pain, nausea and depression, and in stimulating the appetite. These conditions certainly occur among sufferers of cancer and AIDS. If one substance can do all this at very low cost, then perhaps it meets the test of doing more good than harm. Do some very expensive pills work better? Yes, they do—but not if they're vomited out before they have a chance to work. Clearly, there is a large and growing public demand for medical marijuana, despite its side effects and the sometimes unsavory characters who flock to illicit drugs.
Negative Side Effects of Marijuana
The side effects certainly are not trivial. If a marijuana cigarette is medicine, then it is unique in being the only medicine that is smoked. Like tobacco, it contains carcinogens and other substances that are harmful for your lungs. Breathing problems are widespread and getting worse as we pollute our air, and there would seem to be something grossly irresponsible about a doctor prescribing someone with breathing difficulties—or any of the rest of us—a medicine that could cause lung cancer.
Because cannabinoid receptor sites are abundant in the immune system, it should be no surprise that marijuana also tends to suppress our immune response. Studies show that both animal and human pot smokers are more prone to illnesses than abstainers. Other pharmaceuticals also can act as immunosuppressors, so in this respect marijuana is not unique.
"Pot is not addictive!" goes an old joke: "And I should know, I've been smoking it for decades." The reality is that some users are unable to quit without help. Contrary to what I learned as a kid, marijuana use can become addictive, although in a manner different from heroin. Pot smokers who quit show withdrawal symptoms, although these are milder than with narcotics. Over twenty percent of residents of drug rehab programs cite marijuana as their primary substance of abuse. Good medicine shouldn't come with a monkey on your back.
Any pot-fighter will cite these and other undesirable effects, and many will throw in the dubious, sometimes laughable scare stories we all heard as kids. Widespread use of alcohol and tobacco illustrate the social harm of making dangerous substances widely available. The most concrete indication of the anti-marijuana lobby's "muscle" shows up in the 1970 Controlled Substances Act. This act creates a series of five categories of restriction based on a substance's medical usefulness and potential for abuse. Along with heroin and LSD, marijuana is classified as a Schedule 1 substance—a substance considered to have a high potential for abuse and no medical use. Cocaine, by comparison, is a less-restricted Schedule 2. Even plutonium, if it were to be listed, could not be in a more restricted category than marijuana. Repeated attempts over the years to have marijuana reclassified have been unsuccessful.
The claim that marijuana has no medicinal use seems almost comical in light of documented medicinal use stretching back several millennia. And it seems puzzling when you consider that in 1937, when marijuana was first prohibited in America, the only significant opposition to outlawing it came from the American Medical Association, which felt the plant had medical potential.
Legalized Medical Marijuana
Let's jump forward to 1996 and California's Proposition 215, approved by that state's voters, allowing seriously ill patients to buy and use marijuana if prescribed by a doctor. The California initiative allowed establishment of Cannabis Buyers' Clubs for the purpose of providing legal marijuana to the ailing. Although the intentions are good, there is little doubt that some have used legally-obtained marijuana for purposes more recreational than medicinal. Nonetheless, and despite several highly-publicized federal raids of Cannabis Buyers' Clubs in California, at least eight states now have statutes permitting medical marijuana use under certain circumstances. In New York State, Assemblyman Richard Gottfried has introduced a medical marijuana bill every year since 1998. In 2003, Gottfried's bill passed three assembly committees by wide margins before the law stalled in the Rules Committee. The bill was endorsed by over 1200 doctors as well as several state health organizations. Growing support mirrors public surveys in New York State, where big majorities support medical use of marijuana under certain circumstances. Still, although Gottfried plans another attempt in the Assembly this year, there is no sponsor in the State Senate, and Governor Pataki is on record as opposing the measure.
The United States Government, meanwhile, vigorously opposes any relaxation of marijuana laws, even to aid the sick. Don't expect this to change by the end of next week.
Since you've read this far, I'll let you know my opinions. First, I think we need to let go of the myth that this plant has no medicinal value and get rid of its Schedule 1 classification. Indeed, there is already a medicine on the market—Marinol—whose active ingredient, THC, is the main active substance in marijuana. Failure to re-classify amounts to de facto government suppression of research and development of new, cannabis-based medicines. Drug development is extremely costly, and drug makers won't develop drugs if doctors fear increased scrutiny for prescribing them.
Second, and just as importantly, recommendations on when and how to use marijuana or its derivatives medically must come from doctors. Right now, the tens of thousands of people who need the medicine in marijuana have to associate with drug dealers. This is stigmatizing and, what's worse, the advice of sellers or recreational users is a very poor substitute for the informed knowledge base of an MD. But as long as marijuana use is tainted with criminality, doctors won't touch it even when it's the best medical choice.
Marijuana has a medical past of several thousand years, and I think its future has great potential if only governments will permit and encourage research. A large number of patients will likely benefit once cannabis-based therapies hit the markets. Smoked marijuana hardly looks like an ideal medicine—who wants to spend all their time stoned? But those therapies have yet to be developed, so right now, what real choice do a lot of really sick people have?
I asked Arjuna if she had told her doctor that marijuana was the only thing that controlled her pain. "Hell, no," she told me. "He's a doctor. He won't listen to that. He's gonna think I'm nuts."
