Marijuana as Medicine, Loren L. Friedman, MD

VCS Practice Blog

July 26, 2018
Virginia Cancer Specialists » VCS Practice News » Physicians » VCS Practice News » Loren Friedman MD FAAHPM » Marijuana as Medicine, Loren L. Friedman, MD

Marijuana has been cultivated and used for medical purposes for thousands of years.

In recent decades there has been increased interest in the benefits of marijuana in the treatment of a multitude of conditions.  Marijuana is advocated by many for the treatment of chronic inflammatory pain, cancer pain, nerve pain, nausea, decreased appetite, muscle spasm in multiple sclerosis, epilepsy, anxiety, insomnia, depression, glaucoma, opioid dependence, and even as a treatment for cancer.

Discussion of the beneficial properties of marijuana has been subjected to biases from enthusiastic supporters and from detractors.  But what is the science?

The beneficial effects of marijuana are primarily related to chemical compounds called cannabinoids.  The most discussed cannabinoids are THC—an abbreviation for tetrahydrocannabinol, and CBD oil—an abbreviation for cannabidiol.  THC is the chemical that provides the intoxicating “high” when it attaches to receptors in our brains.  CBD oil does not cause this euphoria and has been effective in the treatment of some rare forms of childhood epilepsy.

Previously the cannabis plant was thought to have less than a dozen different cannabinoids.  Currently, over 100 different cannabinoids have been identified in different strains of marijuana.  It also turns out that our bodies make types of cannabinoids, called endogenous cannabinoids, or, endocannabinoids. And cannabinoid receptors have been identified in our bodies.  When cannabinoids attach to these receptors, a variety of effects are triggered.

Evidence

The tremendous success of modern medicine is founded on the scientific method.  Specifically, this means an emphasis on providing solid evidence that treatments are effective.  The gold standard of evidence is the randomized, controlled, double-blind clinical trial.  A double-blind trial compares treatments with neither the researcher nor the patient knowing which treatment is being given.  Hundreds of clinical studies on the use of marijuana have been published.  Many of these trials have small numbers of patients, are not blinded and have biases.

For example, a drug called Sativex (nabiximols) which combines two major cannabinoids, THC and CBD, in an oral spray was initially approved in Great Britain in 2010 for use in managing muscle spasticity in patients with multiple sclerosis.  It has also received approval in Canada both for use in patients with multiple sclerosis and for patients with cancer pain.  When larger double-blind clinical trials were performed as a step toward FDA approval in the United States, Sativex was shown to reduce cancer pain and muscle spasm; however, it was no more effective than placebo (pretend medicine).  FDA approval of Sativex may occur in the future but, based on current evidence, it is not currently available in the United States.

One place for consumers to look for evidence-based reviews on cannabis and other medications is in the Cochrane Library.  This is a non-profit organization which provides health information.  This may be accessed for free at www.cochrane.org

Cochrane published a review of the medical literature on cannabis for the management of nerve (neuropathic) pain in March 2018.  They looked at 16 studies which examined both medical cannabinoid products and marijuana and which comprised 1,750 patients.  While there is some evidence that patients experienced relief from nerve pain with cannabis products, Cochrane concluded that there is a lack of good evidence.  So, it is difficult to know how effective cannabis is for nerve pain.

There is evidence that cannabinoids may be useful in the management of nausea.  However, we do not have evidence that marijuana products are as effective as currently used anti-nausea medications.

Marijuana has also been discussed as a treatment for cancer.  Indeed, in the laboratory cancer cells have been killed by cannabinoids.  A drug can kill cancer in a lab, however, and have no effect in a living person.  There are no human studies to indicate that cannabinoids are useful as a treatment for cancer.

Laws and Regulations

The U.S. government labeled marijuana as a Class 1 Controlled Substance in 1942 and, despite the recommendations of federal commissions dating back to the 1970s to change this designation, this current classification persists.  The Class 1 designation is for drugs that are deemed unsafe with no currently accepted medical use.  However, marijuana does have medicinal benefits and its safety and risks for abuse are much lower than drugs like opioids or benzodiazepines (alprazolam, diazepam, etc.)  No one stops breathing from a massive overdose of marijuana, for example; however, respiratory arrest from a massive overdose of opioids is common.  Marijuana does have risks.  It impairs memory, judgement, and motor coordination.

As of June 2018, 29 states and D.C. have made medical marijuana legal.  Of these 29 states, 9 states along with D.C. have made marijuana legal for recreational purposes.  Medical marijuana is not legal in Virginia.

There are currently two FDA approved—and therefore legal in all 50 states—cannabinoid products.  Marinol and Syndros are brand names for dronabinol which is a synthetic THC.  It comes in capsules and liquid. Cesamet is the brand name for nabilone, which is also a manufactured cannabinoid, synthesized in the laboratory (rather than derived from the marijuana plant.) These medicines are prescribed for nausea and as appetite stimulants.  They are sometimes prescribed “off-label,” which means they are sometimes prescribed for conditions for which they have not been specifically approved, for help with pain management.  Some patients feel helped by these medications.  Again, the evidence we have suggests that

they are mildly effective.  They are less effective than other medicines available to treat these symptoms.

In June 2018, the FDA did finally grant approval to Epidiolex, a brand name cannabidiol (CBD oil) for use in patients with two rare and severe forms of epilepsy, Lennox-Gastaut syndrome and Dravet syndrome.  Epidiolex is expected to be available in the U.S at the end of 2018.  This will be the first medicine approved by the FDA actually derived from the marijuana plant.

Marijuana State Laws as of July 2018

Federal laws would take precedence over state laws if the federal authorities chose to intervene. And federal law states that marijuana is illegal.  However, the U.S. government has not overstepped state jurisdiction.


Here is the current status of Marijuana State Laws laws for Virginia, D.C., and Maryland:

Virginia

District of Columbia

  • Possession of marijuana
    • Personal use, possession, and home cultivation of marijuana was legalized in DC in 2014.  However, Congress has blocked plans to further regulate and tax the legal sale of recreational marijuana
    • Small amounts of marijuana may be “gifted,” but not sold
  • Medical marijuana
    • Physicians who have registered for the marijuana program have been able to recommend medical marijuana to DC residents since 2013.  The plan is to enable DC licensed Nurse Practitioners, Physician Assistants, Dentists, and Naturopaths to be able to recommend marijuana for patients later in 2018 if legislation is approved.
    • 5 Dispensaries around the city, with plans to open more, can sell marijuana to DC residents, and to residents of 16 (of 29) states currently with medical marijuana laws.  Maryland residents are eligible to buy marijuana from DC dispensaries.  Virginia residents are not.

Maryland

  • Possession of marijuana
    • Possession of small amounts of marijuana was decriminalized in Maryland in 2014.  Possession is a civil offense punishable by a fine.
  • Medical marijuana
    • Available for registered Maryland residents with a physician recommendation
    • As of July 2018, more than 30 of over 100 licensed Maryland dispensaries are open and selling marijuana to registered patients with a recommendation from a physician
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                            [post_content] => Dr. Friedman’s increased interest in Palliative Medicine began early in his career when, while working as a family physician, he began to address the unique needs of patients coping with cancer diagnoses. Subsequently, he further developed his skills in pain and symptom management. In 2004, he founded the first hospital-based palliative medicine program in Northern Virginia at the Virginia Hospital Center. He served as the medical director of that award-winning program for the next decade until leaving to join Virginia Cancer Specialists.

Locally, Dr. Friedman’s leadership roles have included mentoring many young palliative medicine physicians, chairing the Virginia Hospital Center Ethics Committee, and speaking frequently on pain management. Nationally, he has had the honor of serving as one of only ten physicians from across the country on the initial test writing Committee for the American Board of Internal Medicine, developing the board examination for palliative medicine. Throughout his distinguished career, Dr. Friedman has received multiple awards and honors, including the Haynes Rice Community Service Award and the CareFirst Blue Cross Blue Shield Outstanding Palliative Care Program Award at Virginia Hospital Center. He has served as a volunteer physician in programs such as the Arlington Free Clinic and the D.C. Partnership to Improve End of Life Care. His current focus is on improving quality of life for patients and families faced with serious illness.

In his free time, Dr. Friedman spends time at the beach with his wife. He enjoys learning about music production from his teenage son and social entrepreneurship from his 20-something daughter.

 

 


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