Marijuana has been used for thousands of years for a variety of things. It has been documented in ancient China and Egypt for example. There is, however, some disagreement and controversy as to what it may or may not be used for.
Colorado has had a medical marijuana program since 2000 and at that time it was very difficult for patients to obtain recommendations to use marijuana for their condition for a variety of reasons. Doctors were somewhat reluctant to recommend due to fear of legal recourse, and patients did not have the capacity to obtain their marijuana due to the lack of a place to go. Dispensaries simply did not exist 17 years ago.
In 2009, after a series of legal maneuvers at the state level, Colorado experienced de facto legalization and dispensaries appeared across the state. It has reached a point where there are more medical marijuana dispensaries in Colorado than the number of Starbucks and McDonalds combined. The total number of medical marijuana dispensaries rivals the total number of licensed pharmacies, where every other legal medication is dispensed in a controlled manner, supervised by a licensed pharmacist.
Licensed pharmacists are required to have a college bachelor’s degree, which typically takes four years to complete, followed by completion of a rigorous four-year Doctor of Pharmacology degree program. They are monitored by the state’s Department of Regulatory Agencies and have to have documented continuing education in order to continue to practice and maintain their license. On the other hand, anyone working in a medical marijuana dispensary needs to be 21 years of age, does not have to have any high school, college, or other higher education, and they don’t necessarily require knowledge of the pharmacology of one substance, compared to that of a licensed pharmacist.
In Colorado, a patient can obtain a recommendation for marijuana if they are certified by a licensed physician as having a “disabling medical condition.” Those conditions include pain, spasms, nausea, cancer, seizure, glaucoma, weight loss, and most recently PTSD. It is unfortunate that physicians who may not have the expertise for any of those conditions have the capacity to make recommendations for those conditions. For example, a radiologist can make a medical marijuana recommendation for a cancer patient under Colorado law. It would be improper for a general gynecologist to manage a patient’s chemotherapy regimen. In some instances, that would be considered malpractice. Also, under Colorado law, a bonafide patient-physician relationship is required and the physician is required to maintain medical records. In my experience, patients who have medical marijuana cards never know the name of the recommending physician and my office can never obtain medical records.
- El Paso County has the largest percentage of medical marijuana patients in the state.
- Over 20% of the state’s medical marijuana patients live there.
Regarding the chemistry of marijuana, there are components of the plant which may have medical use. The most common and well-known component is THC or tetrahydrocannabinol. It is also the component of the plant that gets you high. The other component of the plant which may have medical use is CBD, or cannabidiol, and does not get you high. The chemical system in the human body, called the endocannabinoid system, is where the components of the plant may work. The receptors where THC act are called the CB1 and CB2 receptors. CB1 receptors are mostly located in the central nervous system and CB2 receptors are mostly located on tissues which are involved in inflammation. THC works on these receptors primarily and it is important to understand that this is a substance that works primarily on the brain. How CBD works is less well understood but may work in patients with seizures, among other conditions.
The most common reason patients use marijuana is for pain
Pain is a broad diagnosis and can originate from a variety of sources and different types of pain will respond to different medications differently. In patients who go to the doctor, the most common pain conditions are back pain, joint pain, and abdominal pain. Unfortunately, the medical literature is completely absent in demonstrating benefit in these more common pain conditions. Most of the literature may show benefit in less common pain conditions, which include nerve-related and cancer pain. In these conditions, most of the studies used products which are purified, not available in the United States, or with synthetic products which mimic THC. It is also important to understand that dispensary cannabis is a generic substance and very different from cannabinoids which are purified products, absent of any contaminants.
A recent article from the respected medical journal, Annals of Internal Medicine, August 2017, reviewed the available medical literature and concluded that limited evidence suggests that cannabis may alleviate nerve-related pain in some patients, but insufficient evidence exists for other types of chronic pain. Another concern is the available products vary in potency and delivery systems. It can be smoked, vaped, ingested, rubbed, and some of the more potent products, dabbed, where a highly concentrated product is heated with a blow torch and the gases inhaled. There is no available literature on any of these variable and potent products and their medical benefits.
CBD is a product of the plant that will not get you high. How it works is not completely understood and is showing some promise in the management of pediatric seizures, which is very uncommon. The University of Alabama, Birmingham, is currently looking at potential benefit with the purified CBD product, Epidiolex. In Colorado, homemade preparations of this plant component run the risk of contaminants which include pesticides, fungicides, rodenticides, as well as particulate matter. At the University of Colorado, the pediatric seizure specialists have had to admit children using these homemade products who present with an increase in seizure, developmental regression, and in a few cases, the patient had to be placed in a coma to stop the seizures.
In summary, there is potential medical benefit from the components of the marijuana plant. There are currently many other plant-based medications used on a regular basis that have met the rigor of scientific study through the FDA, as patient safety is important. Marijuana has not met that rigor at this time. Per the American Pain Society’s position on the matter, there should be increased federal funding for: pain-related cannabis research; broadened pain conditions being studied; eased regulatory restrictions impeding appropriate research; improved access to high-quality plant cannabis for research; and states should be encouraged to collect and track data on patients receiving medical marijuana.
If physicians can be provided a plant-based medication that has met the rigor of scientific research, that data is widely available, and that product is proven in particular medical conditions, they would be satisfied. Marijuana has not yet met the definition of a medication, and science, not public opinion, should determine what is medicine.