You know someone who takes it legally. With their doctor's approval, they obtain cannabis from a dispensary, and--theoretically--they use it to treat various ailments, perhaps muscle spasms caused by multiple sclerosis, nausea from cancer chemotherapy, poor appetite caused by chronic diseases, seizure disorders, or Crohn's disease. States have been climbing onboard the medical cannabis train since California legalized it in 1996, but over 20 years later, the tale of medical cannabis still lies in murky waters. Let's begin.
A brief overview of marijuana
Cannabis, also known as marijuana, is a psychoactive drug from the Cannabis plant. It has been used medically and recreationally since the B.C. era, and society has related a negative stigma against its users and the drug itself. The United States federal government listed cannabis as a Schedule I substance in 1970, next to powerful drugs such as heroin, LSD, and MDMA. This designation prohibits its use for any purpose. On paper, cannabis still remains a Schedule I drug, even though many state governments became more progressive and the medical community at large accepts some aspects of cannabis use.
Medical cannabis is awfully confusing. It refers to the whole, unprocessed plant. Someone who has a "medical marijuana card" and goes to a dispensary receives marijuana in a form that can be smoked, vaporized, eaten, or taken as a liquid extract. However, according to drugabuse.gov, the Food and Drug Administration does not approve of medical cannabis because researchers "haven't conducted enough large-scale clinical trials that show that the benefits of the marijuana plant. . . outweigh its risks in patients it's meant to treat." However, the FDA currently approves of two drugs, dronabinol and nabilone, that contain the psychoactive cannabinoid, tetrahydrocannabinol (THC), which can treat "nausea caused by chemotherapy and increase appetite in patients with extreme weight loss caused by AIDS." The FDA also approves of a Cannabidiol (CBD)-based liquid medication called Epidiolex®, which can "treat two forms of severe childhood epilepsy, Dravet syndrome and Lennox-Gastaut syndrome." Outside these drugs, the FDA considers THC and CBD illegal, which is notable because Hemp-based CBD has become increasingly popular, especially when it is infused in consumable products.
Historically, its medical use was in some sense medically, legally, and socially outsourced.
Marijuana was used quite seriously as a painkiller in the United States up until the 1850s. Around this time, there was a growing romanticism surrounding synthetic drugs, like opium. A striking medical invention also transformed healthcare: the syringe. If you are catching my drift here, I appreciate it. Marijuana's active components are not water-soluble, so they are ineffective (and probably dangerous) if injected. Physicians now had a more reliable drug in opium, which is easier to measure and elicits a quicker physiological response over orally-administered marijuana.
A startling law, the Marihuana Tax Act in 1937, required "all manufacturers, importers, dealers, and medical practitioners dealing with marijuana to register with the federal government and to pay a special occupational tax" (Boire and Feeney). In response to a growing sentiment that likened the "marihuana" used by despised minorities to the cannabis used by respected physicians, this tax law served as a de facto prohibition on all uses of marijuana. Thus, cannabis' medical use took a big hit, and by the looks of it, it never recovered very well.
Clinical education does not thoroughly cover medical marijuana.
If medical marijuana is going to have a significant effect on American healthcare, the industry needs better clinical education surrounding it. A paper out of Drug and Alcohol Dependence, found that "only 9% of medical schools have medical marijuana documented in their curriculum." Over 25% of medical school deans reported that their graduates would probably not be able to field questions about medical marijuana. That is unacceptable. Chronic pain is one of the country's leading health complaints, and medical marijuana is a high profile drug that comes to mind in the chronic pain management conversation. As we venture off further into the 21st century, we must improve clinical education.
The federal government provides little-to-no incentive to research medical marijuana.
I'm trying to think of a good analogy to describe the predicament scientists face when it comes to researching medical marijuana. It's legal in some states but not at the federal government. It's something we know we should learn more about, yet the federal government provides minimal research dollars towards it. And the FDA doesn't accept medical marijuana because there have not been large enough randomized clinical studies. That is a Catch-22, my friends.
NPR reports that the government only funds marijuana growth through a sole contractor that produces a micronized powder form, which lacks the potency found in the marijuana products offered at dispensaries. Additionally, researchers report that they must overcome lengthy and costly hurdles in the application process for carrying out long term clinical trials. If it is not financially sensible to research pressing issues, scientists will lose faith and move on.
And let me get a little edgier here and say that Big Pharma is, as the name suggests, BIG! Medical marijuana is a potential threat to opioid manufacturers, and pharmaceutical companies will certainly raise hell and lobby the federal government if they perceive medical marijuana as a viable competitor.
The Wrap Up
This is certainly a contested issue and a multi-faceted one. I definitely do not predict a major breakthrough in medical marijuana anytime soon---majorly based off its Schedule I designation. As someone entering the medical field, I enjoy seeing how THC and CBD are playing practical roles in medicine. I look forward to watching the journey of a drug that was formerly stigmatized to obscene extremes into a moderately supported medicine that can be used to help people.
Sources:
Boire, Richard Glen, and Kevin Feeney. Medical Marijuana Law. Ronin, 2007. Burgard, Sarah. “Health, Mental Health, and the Great Recession.” Health, Mental Health, and the Great Recession, Oct. 2012. DeCambre, Mark. “The Stock Market Just Booked Its Ugliest Christmas Eve Plunge - Ever.” MarketWatch, MarketWatch, 24 Dec. 2018, www.marketwatch.com/story/the-sp-500-is-on-the-verge-of-tumbling-by-the-most-it-has-ever-fallen-on-christmas-eve-2018-12-24. Evanoff, Anastasia. “Physicians-in-Training Are Not Prepared to Prescribe Medical Marijuana.” NeuroImage, Academic Press, 4 Sept. 2017, www.sciencedirect.com/science/article/pii/S0376871617304416. Hanson, Karmen, and Alise Garcia. Affirmative Action | Overview, www.ncsl.org/research/health/state-medical-marijuana-laws.aspx. Harding, Anne. “Medical Marijuana Treatment Uses and How It Works.” WebMD, WebMD, www.webmd.com/pain-management/features/medical-marijuana-uses. “Healthcare Jobs and the Great Recession : Monthly Labor Review.” U.S. Bureau of Labor Statistics, U.S. Bureau of Labor Statistics, 1 June 2018, www.bls.gov/opub/mlr/2018/article/healthcare-jobs-and-the-great-recession.htm. Holahan, John. “The 2007–09 Recession And Health Insurance Coverage.” The Physician Payments Sunshine Act, www.healthaffairs.org/doi/10.1377/hlthaff.2010.1003. National Institute on Drug Abuse. “Marijuana as Medicine.” NIDA, www.drugabuse.gov/publications/drugfacts/marijuana-medicine.
Ezra Guttmann is a medical student at the Touro College of Osteopathic Medicine. There is no medical advice on this website.
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