Doug Boggs, PharmD, MS, BCPP
Clinical Pharmacy Specialist Psychiatry
VA Connecticut Healthcare System
During an informative, and often humorous, plenary session, Drs. Laura Borgelt and Abraham Nussbaum debated the use of marijuana as a medical drug. The debate focused on four specific issues. 1) Should marijuana remain a Schedule I substance? 2) Should physicians prescribe medical marijuana? 3) Should pharmacists dispense medical marijuana? 4) Is there future for medical marijuana? A review of the proceedings from this session are included below.
Cannabinoid-based pharmaceuticals are available (dronabiniol) or in clinical trials (nabiximols) within the United States, however many states are now legalizing cannabis sativa (street name: marijuana) as a medical plant. Currently 22 states have “medical marijuana” laws and two states have legalized recreational marijuana1(May 17, 2014). Also, for the first time in almost 45 years, a majority of Americans think marijuana should be legalized.2 This represents a substantial shift in public opinion about the risk/benefits of marijuana. Let the debate begin!
At the start of this section, CPNP attendees were split 50/50 as to whether marijuana should remain a schedule I substance.
Nussbaum started this section of the debate, stating marijuana should stay a schedule I drug, reviewing the criteria for Schedule I drugs as established by the 1970 Controlled Substance Act. A Schedule I substance has a high potential for abuse and no currently accepted use in medical treatment. Marijuana is the most commonly used illicit substance used in the United States.3 Among those who use marijuana, 10-20% of people develop dependence.3 While many clinical trials have been conducted they are often of small size, short duration, and have very subjective outcomes that are difficult to mask in a clinical trial. Dr. Nussbaum reported only 13 trials have used smoked cannabis as a comparator for indications such as HIV/AIDS, pain, chemotherapy induced nausea, glaucoma, Hepatitis C, and multiple sclerosis. He also pointed out that recent Cochrane Reviews found no evidence that marijuana was effective for many medical conditions.4-6 Finally Dr. Nussbaum argued that since there are more than 60 constituent compounds in marijuana7, the FDA could not regulate it as a medicine like other medications. In closing, Dr. Nussbaum suggested that while research should continue on purified constituents of marijuana, it should continue be a Scheduled I substance to prevent physicians from prescribing it until more evidence about its benefits are determined in a clinical research.
Dr. Borgelt argued that marijuana should not be a Schedule I drug by showing that for century’s-dating back to 3000 BC-marijuana has been used as a medication.8 It was not until 1937 that the United States classified marijuana as an illicit substance. Second, while cannabis does have an abuse potential, it also may have potential for the treatment of medical illnesses including pain, nausea, vomiting, and seizures. The addiction potential of cannabis is also is lower than nicotine, alcohol, cocaine, and heroin.9 Dr. Borgelt also reported that marijuana is much safer than many available FDA approved indications. Between 1997 thru half of 2005, although marijuana was linked to 279 fatalities, none were solely due to marijuana use. On the other hand, in the same time period 17 different FDA approved medications were responsible for 11,687 fatalities with 10,008 of the cases binging the primary contributing cause of the death. Finally, the vast number of strains of marijuana represents many medical opportunities for clinical study and restricting access could limit the availability of legitimate medicine. In closing Dr. Borgelt suggests that marijuana be moved to a Schedule II drug to acknowledge its potential medical use and similar to other Schedule II drugs. She also suggested it should be regulated similar to alcohol, limiting the age of use and imposing legal consequences for public impairment.
While no landslide change in opinion occurred after the presentations of each argument, Dr. Nussbaum was able to convince a small section of attendees that marijuana should remain a Schedule I substance, with 54% of attendees now agreeing with his position.
At the start of this section, CPNP attendees were again closely split 51%/49% favoring the idea that physicians should prescribe medical marijuana.
Dr. Borgelt started the discussion, physicians should prescribe medical marijuana, illustrating that ancient societies starting with the Chinese, in 2900 BC, gave marijuana for illness.8 The use of marijuana is also referenced by the Egyptians and Greeks, and was referenced in the US Pharmacopeia until 1942 AD. Furthermore, studies have reported smoked marijuana assists with the treatment of pain.10-13 Preliminary evidence also suggests strains of marijuana may help with seizures14, PTSD15, and irritable bowel syndrome.16,17 Dr. Borgelt finished her session by giving dosing recommendations for cannabis in the treatment of several conditions.
Dr. Nussbaum started his counter argument that physicians should not prescribe medical marijuana by illustrating 15 physicians in Colorado account for almost 50% of marijuana prescriptions18, suggesting this is not routine clinical practice but rather a small group profiting from the change in the law. Also the majority of sampled physicians in a study felt marijuana is harmful both physically and mentally.19 Then Dr. Nussbaum showed that the evidence for medical marijuana use in several medical conditions is small. The position from the Institute of Medicine is that studies involving smoked cannabis would only be useful to bring non-smoked rapid cannabinoid medications to the market.20 After mentioning the pharmacology of the endogenous cannabinoid system21, Dr. Nussbaum showed evidence that use of marijuana, especially during adolescence has been associated with developing a psychotic disorder22, long term cognitive decline23, depression, and suicide.24,25 Marijuana could also have a significant number of drug-drug interactions that have not been clarified making it difficult to monitor. Dr. Nussbaum also questioned the ethical dilemma of marijuana stemming from conflicts of interest due to potential financial rewards.
While not as close as previous questions, the results for this question were slim, 44% of participants felt pharmacists should dispense marijuana while 56% disagreed.
Dr. Borgelt started this discussion suggesting pharmacists should dispense medical marijuana by showing data that the majority of Americans want pharmacists to be responsible for dispensing marijuana.2 Adding that pharmacists are uniquely qualified to dispense marijuana due to our expert in drug knowledge, ability to identify drug interactions, and our ability to screen for misuse and diversion. Dr. Bogelt closed by suggesting the state of Connecticut (www.ct.gov) is the ideal model for setting up marijuana dispensaries with pharmacists overseeing the process.
Dr. Nussbaum countered by stating pharmacists do not dispense foxglove to treat atrial fibrillation, nor Pacific yew tree for cancer, rather digoxin and paclitaxel are dispensed, which are their extracted and refined chemical components. Pharmacists dispense medications, not plants, nor are they trained on the use of plants as medications; therefore the dispensing of marijuana is not appropriate.
Dr. Nussbaum was able to bring the majority of people to his side with 73% now reporting that pharmacists should not dispense marijuana.
The majority of participants were optimistic for the medical marijuana industry as 83% felt there is a future.
Dr. Bogelt also agreed that a future exists for medical marijuana fueled by the demand from the public, the revenue garnered from taxes (Colorado reported $5 million in the first 7 days), and the fact that the body has its own endogenous source of endocannabinoids (anandamide).
Dr. Nussbaum suggested that medical marijuana is a Trojan Horse with the ultimate goal to have full legalization or decriminalization of marijuana. While Dr. Nussbaum felt certain compounds from cannabis could be used for medication, medical marijuana would be something of the past.
While a small group of people changed their mind, the majority still agreed with Dr. Bogelt at the end of the session (75%) that medical marijuana is here to stay.