White Coat Underground

Why I won’t be prescribing medical marijuana

In November, the citizens of my home state approved a medical marijuana law. The very next day, I started getting calls from patients (often not may own) asking how they could get it. I’m not fan of draconian laws that imprison people for getting stoned, but when it comes to medical interventions (rather than legal ones) I have an informed opinion. The new law allows Michigan residents to grow weed for their own consumption if they have approval. The law does not allow doctors to prescribe marijuana, rather it allows them to certify that the patient has a condition designated by statue as qualifying them for the medical marijuana program.

When I prescribe a pharmacologic intervention, I usually have some data to back up my decision. My most commonly prescribed medications, such as metformin, ACE inhibitors, beta blockers, statins, and aspirin, have clear dosing options and have clear outcome data that support their use. Marijuana is not a clearly science-based treatment.

That is not to say it isn’t medically useful. There is a great deal of anecdotal data for its use in a variety of conditions, and there is scientific plausibility underlying this data. There are also data supporting the concept of cannabis dependence, and there is scientific plausibility to support the idea that smoking anything is probably bad for you. In other words, the available clinical data do not give a doctor a clear way to evaluate the risk/benefit ratio of pot.

In some circumstances, the decision is a bit more clear. In hospice patients or other patients with end-stage diseases, there is probably little harm in using cannabis, although we don’t have a lot of data here either.

With marijuana, we have a drug that is not standardized, and has no clear indications for which it has been well-studied. There is no other drug whose use I would recommend on such scant data. There may be considerable promise in cannabis and its derivatives, but until the government allows more study, I’m not writing it.

Comments

  1. #1 James Sweet
    November 19, 2009

    Agree totally, although it’s worth pointing out the reason why marijuana is coming in through the medical back door, so to speak: Those same draconian laws you mention, and the insanity surrounding their enforcement, have essentially torpedoed any chance of actually getting unbiased data any time soon… Which doesn’t change what your approach ought to be as a doctor, but it does give me sympathy for the medical marijuana initiatives. Unfortunately it is the only practical way in this political climate to follow up on the promising anecdotal data you refer to… which will just mean following it up with more anecdotes, grumble grumble.

    (of course, there’s also the problem that a double-blind study on marijuana is effectively impossible ;D )

  2. #2 Fletcher
    November 19, 2009

    I also think it’s worth pointing out that not all medical marijuana is smoked. Many cancer patients eat it, and many vaporize it. And marijuana’s long term side effects or addictive traits are of little concern to someone who would just like to keep their food down after chemo…. I would agree that cannabis as an effective treatment for many maladies is largely anecdotal, but the evidence of it’s effectiveness as an appetite stimulant is pretty solid, and it’s dangers, especially ingested, seem to be greatly outweighed by it’s benefits in that regard. Would you really tell a cancer patient that you won’t recommend that they try to eat a pot brownie because you think that….well, I can’t think of a good reason why you would say that…

  3. #3 Orac
    November 19, 2009

    I realize I may piss some people off by saying this, but the medical marijuana movement is a lot like the CAM movement. Minimal data, weak studies, no clear indications for its use. In fact, it reminds me of herbalism, in which magical thinking concludes that an herb with no standardization of active ingredient, many different chemical ingredients, and no rigorous evidence to support it must be better than those evil allopathic drugs.

    It really is woo at its core.

  4. #4 dan s
    November 19, 2009

    PalMD:

    There is more than merely “anecdotal data” indicating marijuana is effective for neuropathis pain (and nausea). Cannabinoids are approved for pain in Canada, for example. Also, see the studies below.

    I think your statements are not accurate, and your refusal to prescribe marijuana is not scientific. Are you sure you dont have a political bias against marijuana?

    Comment #2 is absolutely correct: vaporization is a safe and effective way to take marijuana. Tar and particulates are greatly reduced compared to smoking. Further, marijuana can be eaten (though this it is harder to dose properly like this). So, your objection to smoking is easily overcome.

    Neurology. 2005 Sep 27;65(6):812-9.
    Randomized, controlled trial of cannabis-based medicine in central pain in multiple sclerosis.

    Rog DJ, Nurmikko TJ, Friede T, Young CA.

    Walton Centre for Neurology and Neurosurgery, University of Liverpool, Liverpool, United Kingdom. djrdjr@doctors.org.uk

    BACKGROUND: Central pain in multiple sclerosis (MS) is common and often refractory to treatment. METHODS: We conducted a single-center, 5-week (1-week run-in, 4-week treatment), randomized, double-blind, placebo-controlled, parallel-group trial in 66 patients with MS and central pain states (59 dysesthetic, seven painful spasms) of a whole-plant cannabis-based medicine (CBM), containing delta-9-tetrahydrocannabinol:cannabidiol (THC:CBD) delivered via an oromucosal spray, as adjunctive analgesic treatment. Each spray delivered 2.7 mg of THC and 2.5 of CBD, and patients could gradually self-titrate to a maximum of 48 sprays in 24 hours. RESULTS: Sixty-four patients (97%) completed the trial, 34 received CBM. In week 4, the mean number of daily sprays taken of CBM (n = 32) was 9.6 (range 2 to 25, SD = 6.0) and of placebo (n = 31) was 19.1 (range 1 to 47, SD = 12.9). Pain and sleep disturbance were recorded daily on an 11-point numerical rating scale. CBM was superior to placebo in reducing the mean intensity of pain (CBM mean change -2.7, 95% CI: -3.4 to -2.0, placebo -1.4 95% CI: -2.0 to -0.8, comparison between groups, p = 0.005) and sleep disturbance (CBM mean change -2.5, 95% CI: -3.4 to -1.7, placebo -0.8, 95% CI: -1.5 to -0.1, comparison between groups, p = 0.003). CBM was generally well tolerated, although more patients on CBM than placebo reported dizziness, dry mouth, and somnolence. Cognitive side effects were limited to long-term memory storage. CONCLUSIONS: Cannabis-based medicine is effective in reducing pain and sleep disturbance in patients with multiple sclerosis related central neuropathic pain and is mostly well tolerated.

    Neuropsychopharmacology. 2009 Feb;34(3):672-80. Epub 2008 Aug 6.
    Smoked medicinal cannabis for neuropathic pain in HIV: a randomized, crossover clinical trial.

    Ellis RJ, Toperoff W, Vaida F, van den Brande G, Gonzales J, Gouaux B, Bentley H, Atkinson JH.

    Department of Neurosciences, University of California, San Diego, CA 92103, USA. roellis@ucsd.edu

    Despite management with opioids and other pain modifying therapies, neuropathic pain continues to reduce the quality of life and daily functioning in HIV-infected individuals. Cannabinoid receptors in the central and peripheral nervous systems have been shown to modulate pain perception. We conducted a clinical trial to assess the impact of smoked cannabis on neuropathic pain in HIV. This was a phase II, double-blind, placebo-controlled, crossover trial of analgesia with smoked cannabis in HIV-associated distal sensory predominant polyneuropathy (DSPN). Eligible subjects had neuropathic pain refractory to at least two previous analgesic classes; they continued on their prestudy analgesic regimens throughout the trial. Regulatory considerations dictated that subjects smoke under direct observation in a hospital setting. Treatments were placebo and active cannabis ranging in potency between 1 and 8% Delta-9-tetrahydrocannabinol, four times daily for 5 consecutive days during each of 2 treatment weeks, separated by a 2-week washout. The primary outcome was change in pain intensity as measured by the Descriptor Differential Scale (DDS) from a pretreatment baseline to the end of each treatment week. Secondary measures included assessments of mood and daily functioning. Of 127 volunteers screened, 34 eligible subjects enrolled and 28 completed both cannabis and placebo treatments. Among the completers, pain relief was greater with cannabis than placebo (median difference in DDS pain intensity change, 3.3 points, effect size=0.60; p=0.016). The proportions of subjects achieving at least 30% pain relief with cannabis versus placebo were 0.46 (95%CI 0.28, 0.65) and 0.18 (0.03, 0.32). Mood and daily functioning improved to a similar extent during both treatment periods. Although most side effects were mild and self-limited, two subjects experienced treatment-limiting toxicities. Smoked cannabis was generally well tolerated and effective when added to concomitant analgesic therapy in patients with medically refractory pain due to HIV DSPN.

    CNS Drugs. 2008;22(8):645-53.
    Role of cannabinoids in the management of neuropathic pain.

    Martín Fontelles MI, Goicoechea García C.

    School of Health Sciences, Pharmacology Unit, Rey Juan Carlos University, Madrid, Spain. isabel.martin@urjc.es

    The treatment of pain, particularly neuropathic pain, is one of the therapeutic applications of cannabis and cannabinoids that is currently under investigation and that stimulates interest among clinicians and basic researchers. Animal pain models, including models of acute, antinociceptive, inflammatory and neuropathic pain, have demonstrated the antinociceptive efficacy of cannabinoids without causing serious alterations in animal behaviour. These data, together with the historic and current empiric use of cannabinoids, support the interest in the analysis of their effectiveness in treating neuropathic pain. The evaluation of controlled trials that focus on the effect of cannabinoids on neuropathic pain reveals that this class of drugs is able to significantly reduce pain perception. Nevertheless, this effect is generally weak and clinical relevance remains under evaluation. Moreover, there is a lack of controlled trials and, in particular, comparisons with other drugs generally used in the treatment of neuropathic pain. Despite the fact that further research is required to achieve a definitive assessment, current data obtained from basic research and from analysis of the available controlled trials indicate that cannabinoids can be accepted as a useful option in the treatment of neuropathic pain.

    J Pain. 2008 Jun;9(6):506-21. Epub 2008 Apr 10.
    A randomized, placebo-controlled, crossover trial of cannabis cigarettes in neuropathic pain.

    Wilsey B, Marcotte T, Tsodikov A, Millman J, Bentley H, Gouaux B, Fishman S.

    VA Northern California Health Care System, Department of Anesthesiology and Pain Medicine, University of California, Davis Medical Center, Davis, California, USA. blwilsey@ucdavis.edu

    The Food and Drug Administration (FDA), Substance Abuse and Mental Health Services Administration (SAMHSA), and the National Institute for Drug Abuse (NIDA) report that no sound scientific studies support the medicinal use of cannabis. Despite this lack of scientific validation, many patients routinely use “medical marijuana,” and in many cases this use is for pain related to nerve injury. We conducted a double-blinded, placebo-controlled, crossover study evaluating the analgesic efficacy of smoking cannabis for neuropathic pain. Thirty-eight patients with central and peripheral neuropathic pain underwent a standardized procedure for smoking either high-dose (7%), low-dose (3.5%), or placebo cannabis. In addition to the primary outcome of pain intensity, secondary outcome measures included evoked pain using heat-pain threshold, sensitivity to light touch, psychoactive side effects, and neuropsychological performance. A mixed linear model demonstrated an analgesic response to smoking cannabis. No effect on evoked pain was seen. Psychoactive effects were minimal and well-tolerated, with some acute cognitive effects, particularly with memory, at higher doses. PERSPECTIVE: This study adds to a growing body of evidence that cannabis may be effective at ameliorating neuropathic pain, and may be an alternative for patients who do not respond to, or cannot tolerate, other drugs. However, the use of marijuana as medicine may be limited by its method of administration (smoking) and modest acute cognitive effects, particularly at higher doses.

    Phytother Res. 2009 May 13. [Epub ahead of print]
    Beneficial effects of a Cannabis sativa extract treatment on diabetes-induced neuropathy and oxidative stress.

    Comelli F, Bettoni I, Colleoni M, Giagnoni G, Costa B.

    Department of Biotechnology and Bioscience, University of Milano-Bicocca, Piazza della Scienza 2, 20126 Milano, Italy.

    Neuropathy is the most common complication of diabetes and it is still considered to be relatively refractory to most of the analgesics. The aim of the present study was to explore the antinociceptive effect of a controlled cannabis extract (eCBD) in attenuating diabetic neuropathic pain. Repeated treatment with cannabis extract significantly relieved mechanical allodynia and restored the physiological thermal pain perception in streptozotocin (STZ)-induced diabetic rats without affecting hyperglycemia. In addition, the results showed that eCBD increased the reduced glutathione (GSH) content in the liver leading to a restoration of the defence mechanism and significantly decreased the liver lipid peroxidation suggesting that eCBD provides protection against oxidative damage in STZ-induced diabetes that also strongly contributes to the development of neuropathy. Finally, the nerve growth factor content in the sciatic nerve of diabetic rats was restored to normal following the repeated treatment with eCBD, suggesting that the extract was able to prevent the nerve damage caused by the reduced support of this neurotrophin. These findings highlighted the beneficial effects of cannabis extract treatment in attenuating diabetic neuropathic pain, possibly through a strong antioxidant activity and a specific action upon nerve growth factor. Copyright (c) 2009 John Wiley & Sons, Ltd.

  5. #5 JustaTech
    November 19, 2009

    Orac: I would suggest that there are a few small differences between MM and CAM: a) the MM people would love some nice rigorous studies, b) it’s know to be psychoactive, which indicates pharmoactivity, if not the exact nature of said activity, c) thus far there isn’t much money to be made.

    That said, there is a lot of “herbalism” to this and the whole thing needs a lot more study. (Hey FDA: let’s do some science!)

  6. #6 dan s
    November 19, 2009

    There has ALREADY been a significant amount of science done-more than what is necessary to get approval for conventional patented drugs. The studies I posted above are a small sampling of what is available on pubmed. So where do people get this idea that it hasnt been studied?

    I expect that this is what the FDA and big pharma companies like to tell people, to protect their market share for medications. Cannabinoids have many uses, so its a big threat to a multbillion dollar market of pharmaceutical drugs. Thats the reason why the FDA has been slow to act, why many doctors are pressured not to prescribe, and why the NIDA is still stonewalling more studies.

    The whole thing is very political.

  7. #7 DrugMonkey
    November 19, 2009

    There’s no reason to be hesitant Orac. They are *exactly* the same. Just, as with some of the herbal woo, there is the potential that there is something real there. a natural product that has medical benefit..i think the extant knowledge supports this possibility quite well.

    Current clinical reality is different of course. In the present case of arguing that MJ is different than oral delta9THC we have at least two hypotheses to test. One, that other cannabinoids in the plant material may be modifying the effects of delta9THC or conveying independent effects. Worth evaluating. Second, could be a dose control issue. smoking is an exquisitely titratable way to go relative to a ballistic event like oral capsule swallowing. it is possible this is one of the issues.

  8. #8 Dianne
    November 19, 2009

    I’ve had a certain amount of success prescribing marinol for cancer related anorexia. I’m not sure what, if any, advantage marijuana would have, though I can imagine at least two, maybe three, possibilities:
    1. The inhaled version is more effective because it gets into the circulation quicker and bypasses the problematic GI route. If so, inhaled marinol (maybe in something analogous to an albuterol inhaler) might be a worthwhile thing to test.
    2. THC is not the only active ingredient in marijuana. Also potentially worth testing.
    3. Maybe the placebo effect of taking a hit of marijuana is greater than that of taking a drug. It’s natural and naughty, both of which might appeal to some percentage of the population.

  9. #9 dan s
    November 19, 2009

    drugmonkey and orac-

    Care to comment on the abstracts I posted? They would seem to contradict your statements. I think these studies indicate more than mere “potential”.

  10. #10 Denbee
    November 19, 2009

    I developed a brain tumor (pinealoma) shortly after I came home from Vietnam and as it was inoperable (1971)I had a shunt placed and recieved 5 weeks of radiation treatments. I was told I must take an anti-sezure (dilantan?) the rest of my life. I tried for a month but the medication dorked me out to where I could not function, I had to quit. I had stopped my cannabis use during all this but started again after stopping the anti-sezure meds. I have had two sezures in 39 years and they both happened during a period when I could not purchase any cannabis. I wonder?…I also cut 3 fingers off on a saw 20 years ago and the phantom pain during those dry periods almost drove me insane, cannabus seems to help that very much also. So study it some more and then discuss it until the cows come home, it does not matter to me, I’m a believer! I have used cannabis for many, many years.
    There is also a bonus of my cannabis use that goes beyond what we are discussing today. I was raised by alcoholic parents. Many of my friends I grew up with are alcoholics and I served in Vietnam with alcoholics. I have seen alocholics shoot each other in Vietnam. The loss of control and the violence associated with drinking has never been a part of my life, except for my youth, because of cannabis. I am 60 years old, I am a 30 year runner, I have been employed by the same employer for 37 years and have never missed a day of work or been late except for a gall bladder surgery and my fingers amputated. My marriage and family are very solid also. I doubt very much that I could say all that if I had been a drinker. Tell me, what crime or harm to society or to myself have I committed by consuming cannabis?

  11. #11 HP
    November 19, 2009

    I don’t have a strong opinion one way or the other about medical marijuana, but I do take Metformin daily (500 mg ER). IIRC, Metformin is a derivative of European Lilac, prescribed since the time of Galen for diabetes.

    (When I was first diagnosed, and had to take mandatory education classes, the instructor said I was the only person in 15 years of teaching the class who raised his hand when she asked how they diagnosed diabetes in “Bible times” [her words].)

    Now Metformin’s in a form that is calculable, controllable, inexpensive, and widely prescribed. What will it take to get marijuana to that point for the disorders where its indicated? Lilacs are pretty innocuous; marijuana not so much. So what’s needed?

    (Speaking of Metformin, I understand that certain extracts of European poppy can control diarrhea. Can you get me a prescription? [itch, itch, itch])

  12. #12 mike d
    November 19, 2009

    PalMD:

    There is more than merely “anecdotal data” indicating marijuana is effective for neuropathis pain (and nausea). Cannabinoids are approved for pain in Canada, for example. Also, see the studies below.

    I think your statements are not accurate, and your refusal to prescribe marijuana is not scientific. Are you sure you dont have a political bias against marijuana?

    Comment #2 is absolutely correct: vaporization is a safe and effective way to take marijuana. Tar and particulates are greatly reduced compared to smoking. Further, marijuana can be eaten (though this it is harder to dose properly like this). So, your objection to smoking is easily overcome.

    Neurology. 2005 Sep 27;65(6):812-9.
    Randomized, controlled trial of cannabis-based medicine in central pain in multiple sclerosis.

    Rog DJ, Nurmikko TJ, Friede T, Young CA.

    Walton Centre for Neurology and Neurosurgery, University of Liverpool, Liverpool, United Kingdom. djrdjr@doctors.org.uk

    BACKGROUND: Central pain in multiple sclerosis (MS) is common and often refractory to treatment. METHODS: We conducted a single-center, 5-week (1-week run-in, 4-week treatment), randomized, double-blind, placebo-controlled, parallel-group trial in 66 patients with MS and central pain states (59 dysesthetic, seven painful spasms) of a whole-plant cannabis-based medicine (CBM), containing delta-9-tetrahydrocannabinol:cannabidiol (THC:CBD) delivered via an oromucosal spray, as adjunctive analgesic treatment. Each spray delivered 2.7 mg of THC and 2.5 of CBD, and patients could gradually self-titrate to a maximum of 48 sprays in 24 hours. RESULTS: Sixty-four patients (97%) completed the trial, 34 received CBM. In week 4, the mean number of daily sprays taken of CBM (n = 32) was 9.6 (range 2 to 25, SD = 6.0) and of placebo (n = 31) was 19.1 (range 1 to 47, SD = 12.9). Pain and sleep disturbance were recorded daily on an 11-point numerical rating scale. CBM was superior to placebo in reducing the mean intensity of pain (CBM mean change -2.7, 95% CI: -3.4 to -2.0, placebo -1.4 95% CI: -2.0 to -0.8, comparison between groups, p = 0.005) and sleep disturbance (CBM mean change -2.5, 95% CI: -3.4 to -1.7, placebo -0.8, 95% CI: -1.5 to -0.1, comparison between groups, p = 0.003). CBM was generally well tolerated, although more patients on CBM than placebo reported dizziness, dry mouth, and somnolence. Cognitive side effects were limited to long-term memory storage. CONCLUSIONS: Cannabis-based medicine is effective in reducing pain and sleep disturbance in patients with multiple sclerosis related central neuropathic pain and is mostly well tolerated.

    Neuropsychopharmacology. 2009 Feb;34(3):672-80. Epub 2008 Aug 6.
    Smoked medicinal cannabis for neuropathic pain in HIV: a randomized, crossover clinical trial.

    Ellis RJ, Toperoff W, Vaida F, van den Brande G, Gonzales J, Gouaux B, Bentley H, Atkinson JH.

    Department of Neurosciences, University of California, San Diego, CA 92103, USA. roellis@ucsd.edu

    Despite management with opioids and other pain modifying therapies, neuropathic pain continues to reduce the quality of life and daily functioning in HIV-infected individuals. Cannabinoid receptors in the central and peripheral nervous systems have been shown to modulate pain perception. We conducted a clinical trial to assess the impact of smoked cannabis on neuropathic pain in HIV. This was a phase II, double-blind, placebo-controlled, crossover trial of analgesia with smoked cannabis in HIV-associated distal sensory predominant polyneuropathy (DSPN). Eligible subjects had neuropathic pain refractory to at least two previous analgesic classes; they continued on their prestudy analgesic regimens throughout the trial. Regulatory considerations dictated that subjects smoke under direct observation in a hospital setting. Treatments were placebo and active cannabis ranging in potency between 1 and 8% Delta-9-tetrahydrocannabinol, four times daily for 5 consecutive days during each of 2 treatment weeks, separated by a 2-week washout. The primary outcome was change in pain intensity as measured by the Descriptor Differential Scale (DDS) from a pretreatment baseline to the end of each treatment week. Secondary measures included assessments of mood and daily functioning. Of 127 volunteers screened, 34 eligible subjects enrolled and 28 completed both cannabis and placebo treatments. Among the completers, pain relief was greater with cannabis than placebo (median difference in DDS pain intensity change, 3.3 points, effect size=0.60; p=0.016). The proportions of subjects achieving at least 30% pain relief with cannabis versus placebo were 0.46 (95%CI 0.28, 0.65) and 0.18 (0.03, 0.32). Mood and daily functioning improved to a similar extent during both treatment periods. Although most side effects were mild and self-limited, two subjects experienced treatment-limiting toxicities. Smoked cannabis was generally well tolerated and effective when added to concomitant analgesic therapy in patients with medically refractory pain due to HIV DSPN.

    CNS Drugs. 2008;22(8):645-53.
    Role of cannabinoids in the management of neuropathic pain.

    Martín Fontelles MI, Goicoechea García C.

    School of Health Sciences, Pharmacology Unit, Rey Juan Carlos University, Madrid, Spain. isabel.martin@urjc.es

    The treatment of pain, particularly neuropathic pain, is one of the therapeutic applications of cannabis and cannabinoids that is currently under investigation and that stimulates interest among clinicians and basic researchers. Animal pain models, including models of acute, antinociceptive, inflammatory and neuropathic pain, have demonstrated the antinociceptive efficacy of cannabinoids without causing serious alterations in animal behaviour. These data, together with the historic and current empiric use of cannabinoids, support the interest in the analysis of their effectiveness in treating neuropathic pain. The evaluation of controlled trials that focus on the effect of cannabinoids on neuropathic pain reveals that this class of drugs is able to significantly reduce pain perception. Nevertheless, this effect is generally weak and clinical relevance remains under evaluation. Moreover, there is a lack of controlled trials and, in particular, comparisons with other drugs generally used in the treatment of neuropathic pain. Despite the fact that further research is required to achieve a definitive assessment, current data obtained from basic research and from analysis of the available controlled trials indicate that cannabinoids can be accepted as a useful option in the treatment of neuropathic pain.

    J Pain. 2008 Jun;9(6):506-21. Epub 2008 Apr 10.
    A randomized, placebo-controlled, crossover trial of cannabis cigarettes in neuropathic pain.

    Wilsey B, Marcotte T, Tsodikov A, Millman J, Bentley H, Gouaux B, Fishman S.

    VA Northern California Health Care System, Department of Anesthesiology and Pain Medicine, University of California, Davis Medical Center, Davis, California, USA. blwilsey@ucdavis.edu

    The Food and Drug Administration (FDA), Substance Abuse and Mental Health Services Administration (SAMHSA), and the National Institute for Drug Abuse (NIDA) report that no sound scientific studies support the medicinal use of cannabis. Despite this lack of scientific validation, many patients routinely use “medical marijuana,” and in many cases this use is for pain related to nerve injury. We conducted a double-blinded, placebo-controlled, crossover study evaluating the analgesic efficacy of smoking cannabis for neuropathic pain. Thirty-eight patients with central and peripheral neuropathic pain underwent a standardized procedure for smoking either high-dose (7%), low-dose (3.5%), or placebo cannabis. In addition to the primary outcome of pain intensity, secondary outcome measures included evoked pain using heat-pain threshold, sensitivity to light touch, psychoactive side effects, and neuropsychological performance. A mixed linear model demonstrated an analgesic response to smoking cannabis. No effect on evoked pain was seen. Psychoactive effects were minimal and well-tolerated, with some acute cognitive effects, particularly with memory, at higher doses. PERSPECTIVE: This study adds to a growing body of evidence that cannabis may be effective at ameliorating neuropathic pain, and may be an alternative for patients who do not respond to, or cannot tolerate, other drugs. However, the use of marijuana as medicine may be limited by its method of administration (smoking) and modest acute cognitive effects, particularly at higher doses.

    Phytother Res. 2009 May 13. [Epub ahead of print]
    Beneficial effects of a Cannabis sativa extract treatment on diabetes-induced neuropathy and oxidative stress.

    Comelli F, Bettoni I, Colleoni M, Giagnoni G, Costa B.

    Department of Biotechnology and Bioscience, University of Milano-Bicocca, Piazza della Scienza 2, 20126 Milano, Italy.

    Neuropathy is the most common complication of diabetes and it is still considered to be relatively refractory to most of the analgesics. The aim of the present study was to explore the antinociceptive effect of a controlled cannabis extract (eCBD) in attenuating diabetic neuropathic pain. Repeated treatment with cannabis extract significantly relieved mechanical allodynia and restored the physiological thermal pain perception in streptozotocin (STZ)-induced diabetic rats without affecting hyperglycemia. In addition, the results showed that eCBD increased the reduced glutathione (GSH) content in the liver leading to a restoration of the defence mechanism and significantly decreased the liver lipid peroxidation suggesting that eCBD provides protection against oxidative damage in STZ-induced diabetes that also strongly contributes to the development of neuropathy. Finally, the nerve growth factor content in the sciatic nerve of diabetic rats was restored to normal following the repeated treatment with eCBD, suggesting that the extract was able to prevent the nerve damage caused by the reduced support of this neurotrophin. These findings highlighted the beneficial effects of cannabis extract treatment in attenuating diabetic neuropathic pain, possibly through a strong antioxidant activity and a specific action upon nerve growth factor. Copyright (c) 2009 John Wiley & Sons, Ltd.

  13. #13 Bentham
    November 19, 2009

    dan s…
    How many of these studies have you actually read yourself? It seems a little bit unfair to post a list of 5 studies and then expect comment on them 23 minutes later. It is not possible to critically evaluate one study in 23 minutes.

    If you pick out one of these studies that you have already evaluated yourself and feel to be well-designed and conducted, I’ll be happy to take a look at it and give you an opinion about the study.

    You might not be guilty of this, but be aware of the impression you might be giving people. It is a frequent tactic to post a bunch of abstracts of studies that you personally have never even read much less critically evaluated and then complain that nobody is addressing them. The most frequent result I have found when trying to address this sort of situation is that I do a metric $%#^ ton of work evaluating the studies and then get no response or merely an assertion that I’m a Big Pharma shill. Once again, I have no idea whether or not this is a fair characterization in this case.

    If you haven’t read any of these studies yourself, then what you’ve done here is extremely arrogant.

    By the way, I do have a personal horse in this fight. I’m a practicing hospice doctor. I would love to have useful data on this drug and another arrow in my quiver. I’ve discussed marijuana with multiple patients and have passed along a recipe for a tincture to two of them. [There is approximately zero chance that I'll be recommending a smoked form for anyone.] In this n=2 sample, I’ve got positive reports for treating anorexia in an AIDS patient and nausea in a cancer patient.

  14. #14 dan s
    November 19, 2009

    Benthan

    Wow. You need to chill. I expected comment within 23 minutes? Where was that stated or implied? Nowhere! I was just posting more thoughts. I wasnt harrassing. Honest.

    I havent read the studies-just the sbstracts. The abstracts alone clearly contradict the statements in the blog post that there is only “anecdotal data” and “scientific plausibility” for MM. There is much more (according to the abstracts): placebo-controlled studies with significant results that have been replicated by different research groups. In science, thats considered the gold standard of proof, right?

    This isnt my blog. This is (I think) your blog. I’d say that you have a responsibility to fact-check your writing before you publish. You made incorrect statements about a lack of scientific data on medical marijuana. Pointing out your mistake, and why you are wrong-with references- does not make me “extremely arrogant”. It makes me a fact-checker.

    And BTW, there are a bunch of other such MM studies available on pubmed. This is what I found in about 15 minutes. Maybe next time you could spend a few minutes on pubmed vetting your blog posts before publishing?

    I look forward to reading your comments. If you’re too busy, I understand. Its not a big deal. But at least correct your blog post or whatever.

  15. #15 Bentham
    November 19, 2009

    dan s–
    This is not my blog. I am posting this under a different pseudonym than I normally use on the internet, but I am neither PalMD nor Orac.

    You posted the abstracts of five studies.
    You accused the blog owner of being inaccurate and unscientific as well as insinuating a political bias based on studies that you haven’t actually actually even evaluated yourself. This is really offensive.

    23 minutes later, you posted again to ask for comment on these studies. Even if someone started looking at one of these studies right after you posted, it wouldn’t be possible to actually evaluate one of them in that amount of time. (Well, a study could be so transparently bad that it would be possible to dismiss it in that amount of time.)

    After insulting him, you then asked him to do your work for you. (PalMD may be to polite to call you out for insulting him, but I’m not. I sincerely believe that you owe him an apology.)

    Abstracts are not terribly useful for evaluating a study (except possibly to tell you that a study isn’t worth your time looking at).

    If you believe that it is easy to critically evaluate studies, then you shouldn’t find it too difficult to critically evaluate the ones that you posted and then tell us which one you feel makes the strongest case.

    There is currently no error for PalMD to correct.

  16. #16 bob
    November 19, 2009

    Also, the same thing got posted again under a different name (“mike d”). It sure seems like someone just has a google alert for “medical marijuana” set up, and a text document armed and ready to copy-paste as a comment.

  17. #17 dan s
    November 20, 2009

    Bentham

    I’m not asking you or anyone else to do any work or evaluate studies for me. I expected PalMD to do that before publishing. I guess I expected PalMD to run a responsible science blog.

    There appear to be some good quality controlled studies, which have been replicated, that contradict the statements made by PalMD. Deal with it.

    I thought this was a “science-based medicine” blog. Yet, PalMD provides absolutely no references for his statements about MM. And then he goes on to make statements that are clearly wrong in view of the studies I cited.

    While I have not read the particular studies I cited, I have followed the science in this area for a while, and the regulatory decisions in Canada etc. There is far more than mere anecdotal data and scientific plausability. How come PalMD didnt mention anything about controlled studies-good or bad? Could it be because he didnt even know they exist?

    PalMD obviously knows little about the subject of MM. Its irresponsible for him to spread misleading information on this “science based medicine” blog.

  18. #18 inverse_agonist
    November 20, 2009

    There’s being reasonably conservative and then there’s being a stick in the mud. As noted by other commenters, clinical data regarding the efficacy of marijuana exists. Citing the dearth of such evidence as an argument against medical marijuana is highly disingenuous, given that the government maintains a monopoly on the supply of marijuana that can be used in clinical studies. Apparently the people at the existing facility are incapable of producing better marijuana than a bunch of gangsters in the forest.

    Others have been correct to point out that marijuana can be eaten or vaporized, and that it’s not that complicated for people to smoke until they’re done. The dose standardization thing is silly. I’m sure you’d tell your patients to eat fruits and vegetables. The chemical composition of those is unstandardized, and may vary significantly with growing and storage conditions. You can hurt yourself by taking too many fat-soluble vitamins, so we better be careful about telling people to eat carrots!

    There’s also data regarding the harmfulness of marijuana smoke, and it’s not harmful compared to tobacco smoke. It might even reduce the risk of certain cancers.

    Cannabis dependence is…not that bad. Dependence is not bad just because it’s dependence. It wouldn’t surprise me if you yourself were caffeine-dependent, yet perfectly capable of doing a good job as a doctor. People can become dependent on OTC headache medication. The whole POINT of taking antidepressants is that becoming dependent on them is BENEFICIAL to the patient.

    Marijuana is so physically benign that it’s wrong to deny it to someone if they want to use it for a medical condition, even if it only works as a placebo. There’s potential benefit and no serious medical danger. There’s lots of evidence that opiates are good pain medications, and you’d presumably prescribe those, but handing someone a bottle of Vicodin is in no way less dangerous than handing them some cannabis. Driving to your office to ask you for marijuana is more dangerous than marijuana, for that matter.

    And what is the difference between a hospice patient and a typical healthy person, really? The only difference is HOW SOON they’re going to die. They’re both going to die with 100% certainty. Where do you draw the line?

    I think there is entirely too much regulation about dispensing drugs. A grown man or woman should not need anyone else’s permission to put something in his or her body. Period. People wouldn’t even be asking you if the government didn’t enforce its policy of treating people like children by locking people in cages.

  19. #19 another pseudonym
    November 20, 2009

    just after a glance:

    n=30something is not particularly mindblowing clinical evidence, however it lends plausibility. the studies you cite use different cannabis preparations, making them difficult to compare, and the last abstract used rats. you can’t use preclinical animal model research to justify a compound for clinical use. that’s why we call it preclinical.

    that second abstract is a review article. if you even read it, you’d see that they admit right in there that the effect is generally weak and clinical relevance is questionable.

    looking at the very articles you cite, the efficacy is not great and the side effects are significant. if this were something coming out a drug company, i’d be willing to bet the herbal med/altmed folks would cite the poor qualities of this new compound as more reason to believe big pharma is evil. just another double standard.

    so. where’s all that definitive evidence again?

  20. #20 dan s
    November 20, 2009

    I made no claim about having “definitive” evidence-only controlled studies. The mere existence of these studies indicates PalMD has no idea what he is talking about.

    Its starting to feel like this place is not the so-called “science based medicine” blog its advertised to be. its just a home for more of the same old closed-minded hyperconservative medical politics.

    Bentham/anotherp/PalMD: get a clue.

  21. #21 Eric
    November 20, 2009

    Dan S>
    Rather than the incoherent mass of text you’ve posted of primary sourcing with zero interperetation, read the Institute of Medicine’s report on medical marijuana. While published in 1999, it’s still relatively current and applicable. There’s been nothing spectacular published since then to overturn their conclusions:

    http://www.iom.edu/en/Reports/2003/Marijuana-and-Medicine-Assessing-the-Science-Base.aspx

    You can buy a copy or just follow the link and read the online version. It basically supports everything Pal said, and while somewhat dated, is still quite definitive. The studies that have been done are a smattering of relatively weak studies (primarily limited due to size), that give ambigous, contradictory results that in some cases are profoundly negative (glaucoma for instance), others that are weakly promising (Multiple sclerosis), and in some cases profoundly inferior to existing treatments (nausea related to chemotherapy). Much of this is somewhat limited by study size. There’s also very significant side effects with in most cases little benefit.

    There’s also the problem that raw plant material is not suitable for use as a drug. This is a surmountable problem, Canadian Sativex is an example of this, but otherwise little effort has been expended on the problem.

    Inverse> I agree. Dependence is not a problem. Patients with anxiety disorders frequently are dependent on their benzos, depressed patients on their antidepressants, hell diabetics are dependent on their insulin. There is however, a profound difference between dependence, and genuine addiction. Take a gander at the ASAM consensus statement to emphasize that: http://www.painmed.org/pdf/definition.pdf
    And shove any comments about marijuana not being addictive up where the sun doesn’t shine. It’s a very heavily discussed topic with a rather large amount of literature published. However, just like not everyone who has ever had a glass of alcohol becomes an alcoholic, not everyone who uses marijuana becomes addicted to that. It’s only a portion with a set of risk factors that lean in that direction – but that doesn’t mean it’s not a problem.

    There are also individuals for whom the substance can be profoundly harmful. People with Bipolar Disorder and Schizophrenia or a particular mutation in COMT. Leweke and Koethe in Addic. Biology, 2008 is the definitive review on that.

  22. #22 Joel
    November 20, 2009

    Orac: as a psychoactive and potentially addictive substance, marijuana clearly has some physiological effect – whether it has a beneficial effect is entirely another question. Now, the primary (positive) “evidence” for both medical marijuana and herbal medicine is anecdotal – whether there’s sufficient in either case to justify properly studying them I don’t know. Let’s assume there is.

    Many herbal medicines have been studied, again and again, mostly without positive results (and generally without the negative results affecting people’s willingness to buy or sell them). MM has not been studied extensively, due to prohibition – I think it’s worth giving it the opportunity to try (and potentially fail).

    Of course, probably a huge chunk of the motivation for MM is probably a result of people being frustrated at its prohibition, and I don’t think the data supports that (would you be happier with recreational rather than medical marijuana?).

  23. #23 Igor
    November 20, 2009

    Ultimately, in additional to inconclusive effects of MJ on the variety of medical conditions, we are ignoring legal and social realities. First, in my experience, a minor people often engage in doctor shopping and like, so most people I met from CA, for example, do not have an underlying medical condition to support their prescription of medical MJ. Of course, that is also a problem with recreationally used painkillers. Second, Gonzales v. Reich sets the precedent for MJ grown for medical use. Growing MJ, even if legal in your state and pursuant to a prescription, will still subject you to federal criminal prosecution if caught.

  24. #24 History Punk
    November 20, 2009

    “I expect that this is what the FDA and big pharma companies like to tell people, to protect their market share for medications. Cannabinoids have many uses, so its a big threat to a multibillion dollar market of pharmaceutical drugs. That’s the reason why the FDA has been slow to act, why many doctors are pressured not to prescribe, and why the NIDA is still stonewalling more studies. ”

    Once upon a time, syphilis was treatable, but only through a very expensive, very time-consuming regime than involved the use of arsenic and other highly toxic substances. Most doctors did not want to risk arsenic poisoning, so the treatment of syphilis became a specialty practiced by syphologists. These doctors became rich, powerful- Hitler’s physician Dr. Morrell was a syphologist.

    Then someone figured out that syphilis can be cured with a simple injection of penicillin into the butt. Did the AMA suppress this cheap, easy, and if one possess the fortitude to stab a medal object into one’s ass, self-treatment? I’ve checked the phone book and it appears that in fact, syphologists have gone the way of the dodo. I am willing to bet that Dr. PALmed has treated patients with this treatment. See, for all the babbling about “Big Pharma” it is often forgotten that “Big Insurance” would rather not spend vast sums of their money on patient care, particularly when there are cheaper options that allow them to look good.

  25. #25 dan s
    November 20, 2009

    eric

    The ION report of 1999 is severely outdated. There has been 10 years of research since then.

    Also, did you even read the IOM report?

    The IOM report points out the effectiveness of MM for treating pain. See below. One of the main reasons the IOM report is not enthusiastic about MM is because they assume its always smoked. But this concern is easily obviated because it can be delivered as a spray, or vaporized or eaten. Sprays can even be made at home by patients.

    Also, the existence of drugs that are more effective for SOME PEOPLE is not a reason to prohibit the availability of a drug for all people. There are many drugs available for most indications. For example, there are many statin drugs ( a class of drugs more dangerous than MM) that are FDA approved, even though some are more effective than others for most people. Why is that? Your criticism along these lines is irrelevant/illogical. The IOM agrees.

    Raw plant material may not be suitable as a conventional, mass market drug. But this is not how MM has been implemented. There are different strains available, always locally, and patients can choose and grow a strain themselves, or choose one they like from a grower. It works. I dont see why MM should be forced to fit into the manufacturing model used for pure chemical compounds. Its never going to be a pure chemical compound, and there is anecdotal evidence indicating it works BETTER as a mixture of natural compounds. Sativex deals with this issue by using a single, very consistent strain. The problem with this is that a single strain is better for some indications than others.

    Your objections are illogical and outdated. Why are the so called “science based” medicine people so biased against MM? Could it be because it does not have a big pharmaceutical company sponsor?

    Igor: The Obama administration has declared they will be allowing use of medical marijuana in states where it is legal. The pointless raids and arrests of sick patients of the Bush years are over.

    In my view, the objections to MM are anything but scientific. They are rooted in a desire by the FDA and regulatory agencies to protect their clients: the pharmaceutical industry. Ignorance of the available science doesnt help, either.

    The IOM report states:
    “The accumulated data indicate a potential therapeutic value for cannabinoid drugs,
    particularly for symptoms such as pain relief, control of nausea and vomiting, and appetite
    stimulation. The therapeutic effects of cannabinoids are best established for THC, which is
    generally one of the two most abundant of the cannabinoids in marijuana. (Cannabidiol, the
    precursor of THC, is generally the other most abundant cannabinoid.)
    The effects of cannabinoids on the symptoms studied are generally modest, and in most
    cases, there are more effective medications. However, people vary in their responses to
    medications and there will likely always be a subpopulation of patients who do not respond well
    to other medications. The combination of cannabinoid drug effects (anxiety reduction, appetite
    stimulation, nausea reduction, and pain relief) suggests that cannabinoids would be moderately
    well suited for certain conditions, such as chemotherapy-induced nausea and vomiting and AIDS
    wasting. ”

  26. #26 James Sweet
    November 20, 2009

    JustATech at #5 outlines very nicely why MM is, at present, different from CAM. I think the claims of the most outspoken MM advocates are, indeed, pure woo. But unlike most herbalism, this one has not been sufficiently debunked yet, and as others have pointed out, we KNOW there is some kind of pharmacological effect.

    Frankly, I’d be rather surprised if rigorous studies didn’t at least support its palliative use as an appetite booster for terminal cancer patients. As far as pain, it clearly “works”, but how the cost/benefit stacks up against other methods of pain management is unclear. I’m far more skeptical about its use in glaucoma and other conditions.

    But it’s still different from CAM. Most CAM can’t work from a plausibility standpoint, and has been proven not to work by evidence. “Mainstream” medicine is plausible and (usually at least somewhat) proven. MM lies in a murky middle ground, where it is plausible-with-caveats, and largely unproven either way.

  27. #27 PalMD
    November 20, 2009

    Many clinical claims for MJ pass the plausibility test. Now if we just had useful data…

  28. #28 James Sweet
    November 20, 2009

    Oh yeah, one more HUGE difference between CAM and MM: CAM has managed to lobby the federal government to take down virtually all barriers to marketing their product, requiring no testing, no responsible labeling, only just the Quack Miranda, and financing a whole research arm to study it (NCCAM); while the federal government fights against MM at every opportunity, to the extent of even thwarting state laws, and mostly refuses to finance studies into its efficacy.

    The deck is stacked heavily in favor of CAM, and it still can’t prove a damn thing. Conversely, the deck is stacked heavily against MM.

    If hypothetically, echinacea let’s say was banned by the federal government, and despite anecdotal reports of it helping with colds there had never been a rigorous study, I might in theory support a Medical Echinacea initiative, to get the government to stop with their obstinacy… And then if it turns out to have no effect, or a deleterious effect, so be it.

  29. #29 Calli Arcale
    November 20, 2009

    dan s, perhaps I can help explain the problem folks are having.

    First off, you criticize PalMD for failing to read the literature. You follow this with evidence that you have not read the literature yourself. Surely you can see why this comes across as a little disingenous. At the very least, you give the impression that you have started with the conclusion that medical marijuana is beneficial and then sought studies to support your idea. This is the reverse of science.

    Second, you misunderstand what PalMD says when he indicates there is no clinical data for him to base his prescribing on. He’s not saying marijuana has not been studied. It *has* been studied. It’s just that the studies have not yielded clinically useful information. Interesting information, certainly. But it doesn’t tell him enough to know how to apply that information to his patients. Which is a pity; so far, marijuana hasn’t gotten much beyond the basic science level. What clinical research there is has been mixed. It really needs to be studied in a more concerted manner, culminating in actual clinical trials, so that doctors can make a recommendation more useful than “some people in your situation report positive experiences with marijuana”.

    Unfortunately, I don’t think that’s likely to happen soon. It seems that only small studies are able to fly under the radar enough to get funded, and they are often saddled with restrictions which limit their clinical relevance. The blame for that isn’t with modern medicine, nor with big pharmaceutical companies. It’s with marijuana prohibition, and the social and political stigma associated with it.

    Truthfully, if marijuana were legalized, I bet Big Pharma would be all over it (though they would probably have to race Big Tobacco for it). Right now, the only reason they’re reluctant is because they see it as a business risk to be associated with marijuana. And they’re right. Keeping their noses clean on what is still technically an illegal drug is a good way of making sure they stay in business. But if marijuana were legalized, that risk would be gone. They’d be all over like . . . well, like they’re already all over opium. Opium is illegal, but derivatives of its active ingredient are quite legal, and extremely popular. (It also ties in to what I think should be the strategy for combating poppy growing in Afghanistan: do what they did in Turkey and arrange for them to sell their crop to pharmaceutical companies. Make it a force for good. Give them a *legal* market, and outcompete Al Quaeda.) Morphine and codeine are the best-known derivatives. They are heavily prescribed, but have unpleasant side effects. In particular, they cause constipation and drowsiness (sometimes extreme drowsiness) and are *definitely* addictive.

    If marijuana turned out to be a viable alternative to those drugs, and were made legal, Big Pharma would be thrilled. They’d probably be even happier if it didn’t have the restrictions that opiates have (which are only legal under certain narrowly-defined conditions, in a way which makes them inconvenient for legitimate customers). They’d be happiest of all if they could sell them over the counter.

    Big Pharma is no more opposed to cheap treatments than Big Insurance is, especially if it’s something with high demand. They know they can make more money selling a billion doses for $0.10 apiece than they can selling ten thousand doses for $200 apiece. They also know they can sell more of those $0.10 doses if patients are alive to buy them, so it is actually in their interests for patients to live long and retain significant buying power. Especially since one of the highest demand items is cheap pain relief.

  30. #30 dan s
    November 20, 2009

    PalMD:

    Have you searched the literature for any “useful data”? Or are you repeating this as opinion from someone else?

    Were you aware of the existence of the type of studies I cited above before I posted them? Did you consider them before you wrote this blog post?

  31. #31 another pseudonym
    November 20, 2009

    In my view, the objections to MM are anything but scientific. They are rooted in a desire by the FDA and regulatory agencies to protect their clients: the pharmaceutical industry. Ignorance of the available science doesnt help, either.

    the available clinical science is inconclusive and weak, even the best things you could dig up yourself showed little effect which may or may not even be worthwhile in regular clinical practice. the claimed ignorance of the science is yours.

    so far the evidence shows that MM is at best a last-ditch course of action when all other attempts (using demonstrated effective drugs) have failed.

    you can cite out of context bits and pieces of anything you like, but that doesn’t make it real. the cannabinoids referred to in your handy IOM quote above are cannabinoid based drugs. you apparently skipped over the part you didn’t like, where they recommended against pursuit of smoked cannabis plant material in favor of development of synthetic or purified chemicals that target the endogenous cannabinoid system.

    cannabinoid drugs: not the same as medical marijuana.

  32. #32 James Sweet
    November 20, 2009

    BTW, one quick point to Dan S… I am not entirely convinced that vaporization might not have similar lung disease issues to smoking. This would need to be more carefully studied. Also, many people find consuming it to be unpleasant (the high is much more powerful), so that is not an option for everyone.

    So the cost/benefit on MM as a pain reliever is still unclear. Then again, the reduction in addictiveness over opiates might balance some of those costs… who freakin’ knows, eh?

  33. #33 dan s
    November 20, 2009

    One more thing for the CAM bashers to consider:

    CAM practices (scientific and unscientific alike) are common because of the failings and corruption of “science based” medicine. Big money medicine promoted by big pharma has had some spectacular failures in recent years. Vioxx comes to mind. Does anyone here remember Vioxx? Now, why should a patient trust the FDA and so called “science based medicine” in view of the Vioxx disaster?

    I respect good science and I want to see more of it. But something has to be done about the rampant corruption of the medical journals and big pharma companies before I will ever trust the FDA or conventional medicine again.

  34. #34 James Sweet
    November 20, 2009

    Funny, I see Vioxx as ultimately a triumph of science-based medicine. Here we have a pharmaceutical company trying their damnedest to conceal a problem with their product, but because science is, you know, actually evidence-based, they got caught. This does not diminish the tragedy of all those people who died… but when’s the last time you heard of the CAM community determining that one of their practices was wrongheaded and dangerous? Answer: NEVER. And don’t believe for a second that people aren’t dying out there because of CAM.

    For all of it’s problems, real medicine is kept in check by science. There will always be corruption problems (though I would argue those pale in comparison to the lying and cheating practiced by woomeisters of all stripes) and there will always be difficulty interpreting the science… but the alternative is so much worse.

    You ask, “why should a patient trust the FDA and so called ‘science based medicine’ in view of the Vioxx disaster?” Because the problem was eventually fixed. Why should a patient trust the CAM community in view of the homeopathy disaster? How many cancer patients have to die from forgoing effective treatments in favor of homeopathic bullshit before the CAM community fixes the fucking problem? Answer: Infinity. The CAM community will kill and kill again without remorse. Vioxx at least got pulled from the market. Why should a patient trust CAM practitioners? They shouldn’t.

    Your argument is analogous to: Gee, that guy didn’t intentionally jump off a skyscraper, yet he fell to his death anyway. I guess the only way to avoid falling to my death is to intentionally jump off a skyscraper…

    Idiot.

  35. #35 another pseudonym
    November 20, 2009

    ah, now we’ve reached the typical pattern: if your first choice of logical fallacy fails, move to another.

  36. #36 dan s
    November 20, 2009

    Hahahaha!

    Vioxx is a “triumph” of science based medicine that killed 30,000 people. If thats your definition of success, then what would failure look like? If your revered system of FDA science based medicine actually worked, then this whole sad story would never have happened in the fist place.

    James sweet: The Cam community will kill and kill again? This is ironic in view of the Vioxx scandal, and other medical disasters I could point to. Levoquin is another (commonly prescribed for minor infections like urinary tract infections).

    Also, your analogy is nonsensical. If jumping off a skyscraper=taking a deadly drug, then my arguments and vies (not all expressed here) are more akin to not climbing up a skyscraper in the first place. Or even going near one.

    The problem with vioxx was fixed, eventually, because a whistleblwoer at the FDA defied his superiors and was later fired. Nothing at the FDA was fixed in terms of conflicts of interest or post approval monitoring. The story of how it all went down does not give one confidence in the FDA or the so called “science based” system we supposedly have.

    I dont defend all CAM, and I think a lot of it is woo as well. Homeopathy is a good example and I dont use homeopathics.

    The best CAM practices are nutrition-based. There is little risk to these treatments and there is decent science supporting them (e.g. coq10 and magnesium for heart disease etc).

    The studies I cited would certainly be better if they had larger sample sizes. However, big studies cost big bucks and the government is reluctant to fund this stuff, and big pharma has no interest in it either (they want it to go away). When it comes to pain treatments, the more options there are available, the better. And patients can determine for themselves if its working or not (unlike drugs like statins etc, where scientific proof is absolutely critical and the whole point). So, I just dont get this stubborn refusal to accept that MM is a reasonable treatment option for pain that should be made available.

    PalMDs refusal to comment on the merits of the science are indicative of a decidedly nonscientific and political bias.

  37. #37 James Sweet
    November 20, 2009

    If thats your definition of success, then what would failure look like?

    Easy: CAM killing just as many people and then never fixing the problem.

  38. #38 igor
    November 20, 2009

    “The studies I cited would certainly be better if they had larger sample sizes. However, big studies cost big bucks and the government is reluctant to fund this stuff, and big pharma has no interest in it either (they want it to go away)”

    Once again, if something worked why wouldn’t big farma want to use it and make even more money. You consistently fail to address that argument that if something is effective and cheap to make, why would “Big Pharma” not want to get into it? In fact, some of the pharmaceutical companies are already getting into supplements and other CAM stuff simply because they don;’t have to do expensive research or comply with stringent (and expensive) regulations while still making a good buck. You are naive to claim that pharmaceuticals are the only thing driven by profit (as if that automatically makes something invalid or evil)

  39. #39 catgirl
    November 20, 2009

    I think it’s reasonable to conclude that medical marijuana is helpful for some conditions. What I’d really like to see are studies on dosing. Even if you know it can help your patient, you need to know what the right amount is for you to use. If they’re allowed to just grow it for their own use, the concentrations of the helpful ingredients will vary. I’d love to see lots of research done on which ingredients are helpful, which doses are optimal for relieving symptoms and minimizing risks, and even the biological mechanisms. All of these things are perfectly reasonable to demand in a medical situation, but some people are so invested in the greatness of medical marijuana, that they think we should bypass all this research and start prescribing it.

    FWIW, I think that marijuana should be legal for recreational use, with restrictions. That would really help with the medical aspect, because you’d separate the two different issues (legality/ vs. effectiveness).

  40. #40 WMDKitty
    November 20, 2009

    I have Cerebral Palsy, and I find that cannabis helps with the spasticity and chronic pain.

  41. #41 Calli Arcale
    November 20, 2009

    PalMDs refusal to comment on the merits of the science are indicative of a decidedly nonscientific and political bias.

    He didn’t refuse to comment on the merits of the science; nice strawman you’ve got there, dan s. It is his opinion that the clinical evidence is inadequate for him to make appropriate recommendations. That’s not refusing to comment. That’s just an opinion contrary to yours. Considering that you have admitted you haven’t read the evidence yourself, I’m not at all convinced that your opinion is any better than his.

    The problem is that there is a difference between clinical evidence and *any* evidence. I’ve seen both positive and negative studies looking into the possible benefits of medical marijuana. There’s clearly a lot of work to be done before there will be useful information for actual primary care physicians to make concrete recommendations to their patients, unless they feel comfortable making recommendations on preliminary studies only. And many do. PalMD just isn’t one of them. He has his standards, and he sticks them. That seems fair to me. Different doctors do have different standards, and to a certain extent, that’s to be expected — many of these decisions are value judgments, not black-and-white pronouncements. If they happen to disagree with you, this does not mean they are paid disinformation agents or anything like that.

    Regarding Vioxx, I think it’s a great example of why we cannot trust *any* company selling us stuff for our health. The only reason I’m more likely to take a product from “Big Pharma” than “Big Herbal”* is because at least there’s *some* oversight of the former. The latter does whatever it pleases, and largely gets away with it.

    *Note: Big Pharma and Big Herbal have a significant overlap. Some of the biggest supplement manufacturers are also pharmaceutical manufacturers.

  42. #42 Kim
    November 20, 2009

    OK, just a practical question: you say in the original post that your state does not allow prescription, but instead allows doctors to certify a patient as having a qualifying condition. I can understand your reticence to say to a patient “oh sure, go forth and use this random plant with no clear dosing standards (and a variety of delivery methods), about which I am neither capable nor permitted to provide instruction” — it sounds like the absolutely correct ethical position, IMO — but if all you’re asked (and permitted) to do is provide the patient with information about his condition as contained in his own medical records the situation seems a bit different to me, somehow. Or is there more to the certification process than this?

  43. #43 Kim
    November 20, 2009

    Dan S: Y’know, medical marijuana advocates objecting to any doctor who doesn’t agree with them is tiresome. There will be doctors who certify patients easily out of compassion (or more cynical motives) regardless of the state of the evidence, why jump on PalMD for stating that he won’t be one of them?

  44. #44 PalMD
    November 20, 2009

    Kim, the problem with “certification” is the second part of the language:

    a physician must state in writing that the patient has a qualifying debilitating medical condition and that medical marihuana may mitigate the symptoms or effects of that condition.

    The first part is easy, but the second part requires me to say something I’m not fairly certain is true. This system does not absolve me of my ethical responsibilities. If it were simply a matter of writing a note that says my patient has glaucoma, then I’m not even a part of the equation, and the whole conversation is moot.

    As an aside, I’ve never understood the glaucoma thing. We have very effective medical treatments for glaucoma, and I’m not sure what pot could add to them.

  45. #45 Rogue Epidemiologist
    November 20, 2009

    I’m on board with Pal and Orac’s opinions. I see the potential for using THC for alleviating certain symptoms and conditions. But I don’t think it’s medically prudent to offer the medicine in some uncontrolled or smoked form (sorry, you can’t convince me that smoking a substance is the safest way to deliver it into the system).

    If we want to study THC as a therapeutic, why not purify it, control the dosage and find a safe means of delivery? I’m going to guess ingestion is not a problem. Run a trial, test it out, evaluate results. If it works, then find some appropriate way to market the drug in a pure, controlled form.

    Anecdotally, I know a lot of stoners. I have heard their arguments. And even within the cannabis advocacy movements, they’re pretty aware that they’re thinly veiling their real motives (to go out and get stoned) under a cloak of medical purpose. If stoners want to legalize getting stoned, then you might as well be blunt about it (I pun, therefore I am). I think it’s disingenuous to call it medical if you’re only toking to enjoy Pink Floyd’s ‘The Wall’ (which is plenty enjoyable even when viewed with complete sobriety).

  46. #46 another pseudonym
    November 21, 2009

    If we want to study THC as a therapeutic, why not purify it, control the dosage and find a safe means of delivery?

    we have! d9-THC has been purified, put in an oral capsule form, and even approved by the FDA for use in certain conditions.
    http://www.nlm.nih.gov/medlineplus/druginfo/meds/a607054.html

    but it’s not plant material, so the MM advocates remain dissatisfied.

  47. #47 ZenMonkey
    November 21, 2009

    “Another pseudonym,” your implication about “MM advocates remain[ing] dissatisfied” is unhelpfully dismissive. As has been mentioned, there is more than one helpful cannabinoid in marijuana (aside from just THC). Pill forms such as Marinol often have good results in people who are using cannabis only to control nausea. There are many other medical benefits of cannabis besides nausea control (easing pain, spasticity, etc.), and people who find relief from those symptoms often do not benefit from the narrowly targeted pharmaceutical version.

    That’s why advocates aren’t happy, not just because “it isn’t plant material.”

  48. #48 ZenMonkey
    November 21, 2009

    Sorry, one more thing.

    “Smoking isn’t healthy” is, I’m afraid to tell you, not a valid argument here. It’s been said before but many “real” patients do not smoke — they ingest, vaporize, use tinctures or sprays, or even topical lotions. If all you have is “smoking’s bad for you mmkay?” then find another argument, please.

  49. #49 Bill
    November 22, 2009

    “In my view, the objections to MM are anything but scientific.”

    We are talking about a psychoactive drug with a high potential for abuse, as evidenced by the large number of purely recreational users.

    Given the above, ANY doctor would be reluctant to prescribe MM without exhausting all alternatives, including purified & standardized cannabinoid drugs (e.g. Marinol) derived from the plant itself.

  50. #50 becca
    November 24, 2009

    ‘You can hurt yourself by taking too many fat-soluble vitamins, so we better be careful about telling people to eat carrots!”
    Actually, yes (sort of- actually the carrots are fine, it’s the carotene and retinol that’ll do you in). See the Caret trial debacle.
    And DM, I mean, “another psudeonym” – read up on that trial to understand why people *should* be skeptical of purified known-dose compounds vs. dietary mixtures.

    “People wouldn’t even be asking you if the government didn’t enforce its policy of treating people like children by locking people in cages.”
    LOL cause locking children in cages is good parenting!!

  51. #51 another pseudonym
    November 26, 2009

    whoa. i am not DM, just to clarify.

  52. #52 Frank Fuentes
    November 29, 2009

    Sigh. I agree that I never understood the glaucoma thing, but I can personally attest to the anti-nausea and appetite-enhancing properties.

    I would dearly love to see some studies with real power, but politics really gets in the way. Large-scale studies are hard enough to organize without the ONDCP breathing down your neck; if we could just get it out of the hands of the DEA and let the FDA apply the same rules as it does to all investigational drugs, we could actually collect some significant data.

    While I agree that the whole “god-given natural herb” business is used in a lot of woo claims, the presence of woo is only grounds for suspicion; it doesn’t in and of itself constitute evidence for ineffectiveness. The shortage of clinical data is much more troubling, but in this case there’s a glaringly obvious reason for the dearth of solid clinical data.

    Even if it’s not uniformly better than other anti-nausea drugs, if it works reasonably well with reasonable side effects, it’s another arrow in the quiver. Different drugs react differently with different people, and the usually-best drug can have unacceptable side effects or interactions. So it’s always good to have a backup.

    Not that the FDA is perfect, either; one major complaint I have with the FDA is that it loads the costs on the NDA applicant, on the assumption that they can reclaim those costs via a patent monopoly. Even with the orphan drug procedure, it’s still extraordinarily expensive.

    (In defense of the FDA, this is due to legislative mandate and not something that they can fix administratively. But it really hurts research into finding new applications for off-patent drugs.)

    Oh, yes, Bill, as for Marinol/dronabinol, the main complaint I hear about it is that it has too many side effects; Δ-9-THC is the most psychoactive component, but for medical applications getting stoned out of your mind is an unwanted side effect. We’d all feel a lot happier about standardized extracts, but there’s this catch-22 problem…

    And I’m afraid that I don’t see how large numbers of recreational users constitutes evidence of potential for abuse. (I’m not disagreeing with your conclusion, just your logic.) How is being popular evidence of abuse potential? Does the large number of recreational consumers of Coca-Cola constitute evidence of its potential for abuse? How about the large number of purely recreational players of golf?

    Again, trustworthy numbers are hard to come by, but there’s hardly a shortage of occasional MJ users who don’t dive into an addictive spiral. It’s not obviously more destructive than beer.

  53. #53 Prometheus
    December 16, 2009

    Every analgesic introduced into human society from aqua vitae to Lyrica has been hailed as a panacea except marijuana which was vilified from square one. Every one of these introductions and popularizations has led to horrific consequences and draconian regulation. In working backwards with marijuana it’s medical use advocates are pursuing precisely the all-purpose non-addictive no-side-effects anecdotal line that put a bottle of heroin cough syrup in every medicine cabinet in America a century ago.

    I certainly think it should be decriminalized because whether it is lawn darts, fireworks switchblades or sodomy, prohibition does not work on your off the shelf citizen of these united states….ever.

    That being said there is too loaded an agenda which the commentary proves and too little clinical study . I would no more trust a doctor who prescribed marijuana than I would trust one that prescribed any other herbal remedy or for that matter intercessory prayer and coffee enemas. I support PalMD in his decision not to treat reports from the Amsterdam coffee shops as a clinical trials just as I hope he does not recommend the red light district as an established treatment for erectile dysfunction.

    I think using people in chronic pain to identity politic past government, a legal way to get your smoke on, is pretty gross but what the hell. My grandmother and every nurse during the twenties hustled gin prescriptions for their “nerves” so who am I to judge.

  54. #54 some guy in california
    December 16, 2009

    I am a card carrying medical cannabis user. Being a science junkie, I can tell you that Orac and PalMD are correct as far as I can tell. It is generally woo. But who cares? Millions of people use it, and it’s addictive properties are pretty small compared to almost any other drug, legal or illegal. If MM is how we stop prosecuting Americans, and stop sending billions of dollars to violent cartels, then I think it is worth it. The fact is, it does more harm than good being illegal.

  55. #55 PalMD
    December 16, 2009

    Legalization is an entirely different issue thankfully. Whether the data is adequate to make good recommendations is where my role starts and ends.