Illegal Medicine? Doctor’s Interview

How did the Institute of Medicine’s study regarding the use of marijuana for medical purposes came about?

Dr. Joy: It came about because the ONDCP, the Office of National Drug Control Policy, otherwise known as drug czars office came to the Institute of Medicine and asked if we’d do a study. The reason they came to anyone at all in the first place was because of the passage of medical marijuana ballet initiatives in first California and then Arizona. They were concerned about a domino effect, about it spreading through the country. What they said is they wanted to see what the real science was.

What were the findings regarding addictive potential of marijuana when used for medicinal purposes?

Dr. Joy: There is a lot of research on marijuana abuse and the addictive nature of marijuana, but that’s on marijuana as a drug of abuse, as a recreational drug. That’s the huge difference between the abuse potential for marijuana as a medicine. There is no research on that because there’s really no legally allowed, at least at the federal level, medical use of marijuana. So there’s no research on that question.

We did look at what was known about the addictive potential of marijuana, and I have to admit coming into this study I was a little surprised to find out that yes indeed it is an addictive drug. One big factor though is a lot of people they think as something as being addictive and they think of those movies they say, the heroin and the horrible withdrawal symptoms. That’s not what addiction is necessarily. The definition of addiction is far more, if you will, white than most people realize. There is a standard definition and it includes things like, do you think about the drug a lot, does it influence your life. And for many people that qualities that qualify somebody as being addicted to a drug they wouldn’t realize that, that means addiction. So people get confused about addiction.

What symptoms does marijuana relieve?

Dr. Joy: I get asked a lot about what symptoms marijuana relieves. Before I say that I always want to explain it’s not just marijuana per se it’s the active ingredient in marijuana and that is THC. THC is part of a larger family of chemicals that act in the same way in the brain and that family is called cannabinoids. There are cannabinoids that naturally occur in the brain and they all seem to have very similar effects … there are some differences in the margin which I won’t go into. But so this family of THC-like molecules relieves certain symptoms most reliably pain, nausea and it’s an appetite stimulant. Again these are moderate to mild effects — they’re not the world’s best pain reliever probably. There are a lot of interesting twists about the way cannabinoids might relieve pain in ways that available medications don’t. Opiates are classic pain relievers but they have a nasty side effect that causes nausea in a lot of patients. Also people become tolerant to opiates so they have to take more and more and that’s not a good thing. The interesting thing about the cannabinoids and that’s the THC family is that they act on different biochemical pathways than the opiates and as I mentioned before it reduces nausea. So here you have a drug that can act together with a drug, it can reduce the amount you might need of that opiate and at the same time reduce the nasty side affect. None of this has been clinically tested by the way. This is rational speculation based on what the basic science has taught us.

Are there other drugs that have the same benefit that marijuana has shown to have?

Dr. Joy: Yes and no. There is no other drug that is exactly the same as marijuana. I mentioned the key active ingredient in marijuana is THC, there is a legally available drug on the market called Marinol and that is THC in a little capsule of sesame oil. That’s very different than weed because of the way it’s delivered into the body. But the other half of the answer is that there’s no family of chemicals that has the same range of effects that THC does because I mentioned before sitting on the outside of a whole bunch of cells is this grabber molecule called the receptor. And that receptor is unique to the cannabinoid families.

If you’re looking to place the argument about why marijuana is sort of the choice here what would the argument be?

Dr. Joy: Well there are two answers. Now I’m going to go back to the Marinol, that’s the THC pill. People who argue against the need for having medical marijuana will say what’s the point you’ve already got it, it’s right here in pill form. The key to consider is the way it gets into the body. Most people smoke marijuana, and that means the THC gets into the body really quickly, within three minutes you get the peak effect and it drops off quickly. When you swallow a pill it goes in through the stomach of course and then into the bloodstream and it takes a lot longer to take effect — 30 minutes. Now imagine you’re severely nauseous, severe vomiting, obviously you want the quick action.

Also, people complain that the feeling, the high feeling is different on Marinol than it is on the smoke. We didn’t study that. There’s some data on that, but not a lot. The main point is the difference between the legal pill and the illegal weed is a rapid onset of drug effect and a sharp effect. A lot of people who spoke to the study committee talked about being able to titrate the effect of the weed. We didn’t analyze that in broad detail although I will say that there are some studies that show that people don’t titrate it as well as they might think. But the point is you can stop it quickly.

If the greatest difference between the use of marijuana and Marinol has to do with the onset of the benefits, is there a correlation then between the duration of the benefits?

Dr. Joy: The Marinol pill effects stay around much longer, so people do complain that they feel high for a really long time, they also say they don’t like the high. The effect does last longer. However, people feel like they’re not feeling the effects of marijuana after they’ve smoked it and yet studies show that 24-hours later when they take a driving simulation test they’re still impaired. People don’t feel that. So to say how long the effects last there are different components of the effect so marijuana does lots of things. Some of it has medicine you really want, you want pain relief, nausea relief. You don’t necessarily want impaired short-term memory.

Is there any correlation between a person who might be taking the marijuana as smoking it, they see an immediate peak in their ability or their pain. But are there lasting issues, do you see a great drop off in those other types of issues or is it really just a feeling of high and a lack of pain?

Dr. Joy: It does stimulate appetite. It’s not a long-term effect. The effects of THC in marijuana are short term it’s not like a week later they’re still eating more.

Other than the potential of impairing the driving, what dangers are associated with using marijuana for medical reasons?

Dr. Joy: There are individual dangers and then there are social dangers. I’m going to say the social dangers cause they’re quick and easy. A lot of the people who are adamantly opposed to medical use of marijuana say they are because they’re afraid it’s going to send a message to children it’s going to increase recreational use of drugs. So that’s a social danger. An individual danger would be I mentioned it before, it’s an immunosuppressive drug. The report did conclude that, and I’ll describe those harms in a minute, that yes there are harms associated with using cannabinoid drugs. However they’re well within the range of harms that we tolerate for other approved medications. So it’s not perfect but the vast majority of prescribable medicines are likewise not perfect. So the most serious acute side affects for an individual physiology is likely to be the psychological effects, impaired judgment. The word is really still out on the immune system.

The one thing I didn’t say, the glaring absence of what I said about acute harms is smoking. Smoking is generally considered bad for you and smoking a joint is not drastically different than smoking a tobacco cigarette. So any harms that would come from cigarette smoking you can imagine that they would come from marijuana.

Societaly speaking, anti-support for medical use of marijuana would be what?

Dr. Joy: Would be that it would encourage the abuse of marijuana and encourage the abuse of other drugs in general. Because there’s the fear that people who use marijuana are more likely to go on to use more dangerous drugs, and especially for kids.

Is there anyway to deliver the medication that may get more approval or less friction?

Dr. Joy: We are advocating that. One of the recommendations of the report is for the development of what we call a rapid onset cannabinoid drug delivery system. Something like an inhaler that you take for asthma. And again we said cannabinoid, it doesn’t have to be THC, we improve on natures molecules all the time.

In the terms of the true findings of the study, can you give me the bullet point on why we set out to do this and you found what?

Dr. Joy: We were asked to evaluate the scientific evidence for the medical value of marijuana — what does the science tell us? What we found that was despite this enormous political controversy that there was a really high level on the science. And the scientific evidence indicates that there is a modest clinical benefit from the active ingredients in marijuana. Insofar as the data are there smoking marijuana is not a healthy delivery system for THC. And then we recommended developing if you will a clean delivery system and perhaps the more controversial part of the recommendation was we describe some really limited situations under which we recommended that people be allowed to smoke marijuana for medical purposes. And this is under medical supervision and all sorts of things. And the rational behind that was that even in the ideal world that a rapid onset cannabinoid, that the THC family of drugs, delivery system can be developed there will still be people out there who have symptoms that are not being relieved by the other wise wonderful medications that exist.

Is that the key, the real core of what marijuana succeeds at that other don’t?

Dr. Joy: You might call it a little niche, there are always people who aren’t well served or adequately served by the available medications. Pain relief is just a great example because pain is so very difficult to treat. And the best pain reliever for some things anyway, opiates, people become tolerate to it, it makes them nauseous and they get addicted.

Is there anything else you want to mention?

Dr. Joy: Smoking is bad for you.

Smoking is bad for you but this is a controversial treatment that there’s scientific proof to support it’s need?

Dr. Joy: Yes, but I would qualify and say that there’s no evidence that this would be a blockbuster, that this fills a huge gap. It would always be a small gap, it would always only work for a few people. In the few clinical trials a number of people who tried it in the early cancer trials as relieving nausea hated it. They really didn’t like the psychological effects if you will. They didn’t like the high. You know I mentioned there’s a small subset of people for whom the great medications don’t work. There’s also a small subset of people who when they take marijuana it’s not euphoria, it’s a panic attack. So just like we’re all different we’re all different in lots of ways. So for the most part there are better medications out there but the point is it’s for the most part.

Source: Ivanhoe @2001