“What should physicians consider before recommending the use of medical marijuana to their patients?”
In 1967, out of concern over the rapidly growing use of marijuana, then considered a dangerous drug, I began to review the scientific and medical literature, looking for a reasonably objective summary of the data supporting the drug’s prohibition. To my surprise, I found no credible scientific basis for its prohibition.
The assertion that marijuana is a toxic drug is based on old and new myths. In fact, one of the exceptional features of this drug is its remarkably limited toxicity. Compared to aspirin, which people are free to purchase and use without the advice of or a prescription from a physician, cannabis is much safer: There are well over 1,000 deaths annually from aspirin in the United States alone, whereas there has never been a death anywhere from marijuana. By the time cannabis regains its place in pharmacopoeias around the world, it will be regarded as one of the safest drugs in those compendiums. Moreover, I believe it will eventually be hailed as a “wonder drug,” just as penicillin was in the 1940s.
It may not be surprising to learn, therefore, that marijuana’s use as a medicine, legally or illegally, with or without the recommendation of a physician, is growing exponentially worldwide. In the United States, with the recent addition of Massachusetts, 20 states and the District of Columbia have established legislation that makes it possible for patients suffering from a variety of disorders to use the drug legally with a physician’s recommendation.
Unfortunately, because each state arrogates to itself the right to define which conditions may be lawfully treated with cannabis, many patients with legitimate claims to the therapeutic usefulness of this plant must continue to use it illegally—and endure additional anxiety as a result. California and Colorado allow its legal use for the widest number of medical conditions. New Jersey is the most restrictive;
I would guess that in that state only a small number of patients who would find marijuana to be as or more useful as other, invariably more toxic, conventional drugs are allowed legal access to it.
Perhaps because so many patients have discovered for themselves that marijuana is both relatively benign and remarkably useful, the consensus that cannabis is evil is being undermined. The only workable way of realizing the full potential of this remarkable substance, including its full medical potential, is to free it from the present dual set of regulations—those that control prescription drugs in general and the special criminal laws that control psychoactive substances. These mutually reinforcing laws establish a set of social categories that strangle its uniquely multifaceted potential. The only way out is to cut the knot by giving marijuana the same status as alcohol—legalizing it for adults for all uses and removing it entirely from the medical and criminal control systems.
Lester Grinspoon ’55 is an HMS associate professor of psychiatry emeritus, and author of Marihuana Reconsidered, and, with James B. Bakalar, of Marijuana, the Forbidden Medicine.
Kevin P. Hill:
In November 2012, residents of the Commonwealth of Massachusetts voted overwhelmingly in favor of medical marijuana. Their sentiments echoed those of voters in the rest of the country; as of October 2013, 20 states and the District of Columbia had enacted medical marijuana laws. The genie is out of the bottle, and there is no turning back.
In 2008, Massachusetts decriminalized possession of less than one ounce of marijuana—an amount sufficient to roll 80 joints. The new medical marijuana regulations stipulate that those with medical marijuana cards can possess up to 10 ounces of marijuana as a 60-day supply, an incredibly large amount. And it is important to note that marijuana is more potent than ever. If you recall marijuana from the sixties and seventies, today’s marijuana is more than 10 times as strong.
It must also be noted that most people who use marijuana occasionally do not become addicted to it, but 9 percent of adults and 17 percent of young people who use it develop addiction problems. Marijuana is not a harmless drug; like alcohol, it is a substance that some can use without difficulty while others have problems that affect school, work, and relationships.
Medical marijuana has been available in Massachusetts since January 1, 2013. Patients may obtain a certification—not a prescription—from a doctor and that certification allows them to possess medical marijuana. Patients can get medical marijuana for “debilitating conditions,” such as cancer, multiple sclerosis, or any other condition for which their physician sees fit to recommend it. This is another potential problem. While I can accept patients with such conditions using medical marijuana, my concern is that most people who receive recommendations will have conditions other than the ones specified in the laws.
Physicians are in a difficult position due to the demand for a treatment that is both federally illegal and lacking strong scientific evidence supporting its medical use. Marijuana and other cannabinoids have been studied as treatments for a large number of medical conditions without much luck. Cannabinoids have been found to be effective in treating nausea and vomiting associated with cancer chemotherapy, and poor appetite associated with certain illnesses. There are, however, FDA-approved cannabinoid medications (dronabinol and nabilone) for these problems, so it is difficult to explain the need for the marijuana plant as medicine.
Physicians must weigh the risks and potential benefits of medical marijuana on a case-by-case basis. Oncologists or neurologists treating patients for the debilitating illnesses specified in the medical marijuana regulations may wish to recommend it as a treatment, particularly if multiple medication trials have not produced relief. Many other physicians, including psychiatrists like me, will probably find that patients requesting medical marijuana have such illnesses as mood disorders or addiction that make them poor candidates for its use. So far, the non-FDA-approved status of marijuana—and the lack of support by any major medical organization—has made most physicians reluctant to recommend it to their patients.
Kevin P. Hill is an HMS assistant professor of psychiatry at McLean Hospital and director of the Substance Abuse Consultation Service in the hospital’s Division of Alcohol and Drug Abuse.
The opinions presented are those of the contributors and do not necessarily reflect those of the President and Fellows of Harvard University or the publishers of Harvard Medicine magazine.