In the wake of our State’s dust-up over Medical Marijuana, I revisited a question I’ve had long simmering: Is pot a medicine?
Medicine, that is, in the sense that I think of a medicine as a physician: Is it demonstrably effective and safe at achieving some goal, preferably via a double-blind placebo controlled study. There is a paucity of such studies for pot; such studies are expensive. Neither of the two major funders of such studies—the pharmaceutical industry and the federal government of the United States—is particularly interested in knowing the answer. Further, the widespread availability of illegal pot makes running such studies difficult—people simply do not wish to participate in a study where they might receive a placebo.
Still, we have some rigorous studies of medical marijuana we can dig through.
The strongest data supporting the medical use of marijuana comes from those with HIV infection. The HIV virus—beyond attacking the T-cells of the immune system—attacks nerve cells in the body, frequently resulting in neuropathic pain—pain that is notoriously difficult to treat. (Chronic opiates are a poor treatment for nerve-originated pain; repurposed anti-seizure medicines like gapabentin, and repurposed
antidepressant meds like Nortriptyline are mainstays of traditional treatment.) A double-blinded, randomized and placebo controlled study of pot for this specific kind of pain (HIV-induced neuropathy) was published in 2007 by Abrams et al, showing decent pain control by smoking and few serious side effects.
Wallace et al, also publishing in 2007, randomized healthy volunteers to receive placebo or varying doses of THC via smoking, and then induced pain by injecting capsaicin (the chemical that makes hot peppers feel painfully hot) beneath the skin of the volunteers. Low to moderate doses of THC (intriguingly, not high doses) were significantly more analgesic than placebo.
Neuropathic pain is an important—and growing—problem, thanks to diabetes. A randomized, placebo controlled, double-blind study testing for this indication was unable to show any benefit of pot smoking over placebo for diabetic neuropathy.
In fact, a systematic review of the available double-blinded, placebo-controlled, randomized studies of pot cannot show a consistent benefit for pot, when used for neuropathic pain. Neuropathic pain is one—admittedly important and common—medical problem for which people in Washington State seek out medical marijuana.
Pharmaceutical companies have pounced on the potential here—devising an increasing variety of synthetic agonists and antagonists of the complex family of receptors that pot works through. These synthetic drugs are ‘cleaner’ by design—able to help with pain, cachectia, glaucoma and so on, with fewer side effects and more reliable efficacy than the complex, variable and often contradictory (in physiologic effects) from smoking the plant. You might feel ‘natural’ is better or safer. As a scientist, driven by data, I’m telling you this now: Pharma is going to win this one in the lab—legitimately. Eventually, for any medical indication pot might sometimes help, a pharmaceutical company will have devised a safer, more effective, related drug.
There is a nudge-nudge, wink-wink, aspect to medical marijuana. The secondary gain here—a plurality of us would be fine with recreational pot being legal, taxed and regulated—roils just below the surface of the medical marijuana ‘debate’. On that basis, it’s much easier to prove a few basic points. Smoking pot is pleasurable. It’s demonstrably safer than other, legal, recreational substances. Alcohol, comparatively, is a disaster of health concequences—mental and physical. Alcohol, despite being legal, is vastly more expensive socially as well.
If you want pot to be legal for recreation, ask for pot to be legal for recreation.
Thank you, Dr. Golob. From what I have known and what you stated, regarding the study of pot’s medicinal benefits– “Neither of the two major funders of such studies—the pharmaceutical industry and the federal government of the United States—is particularly interested in knowing the answer.”–I have wondered: Why are they not?
Whaa? So the clusterfuck of taking a good bill and having it go bad on its way through the legislature, but not too bad (except the Cannabis Defense Coalition says at the time no, it’s already bad, stop it altogether, please), and then it gets through the leg. and Slog says Demand the Governor Not Veto it (except the CDC says no, it’d be better if she vetoed it completely at this point) and then the gov vetoes only bits of it, thus exposing providers to danger for desperately trying to get patients – gravely ill ones who are going to live lives of misery thanks to the governor, says Slog – a safe supply of something…..
…research indicates does them no medical good?
All righty. Thanks, Dr. G, except you’ve made me dizzy and I have to lie down a sec.
Yes, but that will take ten times as long politically. By the way, how does it stand up to what they give people for chronic digestive ailments – are there any good studies on that?
As much as I loathe that alluring woman with the vinyl nurse’s outfit offering me ‘chronic haze’ and a happy ending, this seems like the most politically expedient way to go about jamming the door open, even if it does minimize the sometimes breathtaking pain I’ve lived with since I was 18.
I love your posts
I also love your posts.
How something that has never killed anyone can be made “safer” and a pharmaceutical company is supposed to do that is beyond me, especially when all of the cannabinoid compounds are not fully researched and understood (do some research on CBDs and CBNs).
I mean, GW Pharmaceutical wouldn’t have a high CBD content medication, Sativex, approved for prescription in Britain, more countries in the EU soon, and possibly the U.S. if there wasn’t any benefit from what is essentially an over-glorified tincture.
Because, you know, wink, wink, nudge, nudge.
Right.
@2: I want to make a subtlety clear here. There have been very few studies on pot as a medicine. The few that are out there have generally been outright positive or at least promising.
So, this is different than, say, whether vaccination causes autism–something that has been studied to death, with no connection drawn.
@8, thanks for that. Certainly every doctor I’ve ever had needed to tell me twice – appreciated.
Add me to the chorus of Doc Golob lovers.
And special thanks for this post. It really is time to just cut to the chase and legalize marijuana and other recreational drugs. The prohibitionist regime is an abject failure and creates far more public health and safety problems than it could ever solve. It deserves to die for this alone.
By trying to sneak in through the back door via medical marijuana we may be doing damage to the anti-prohibition movement if it turns out that pot really isn’t all that medical.
Let’s not “ask” for legal recreational pot, let’s demand it. We are the voters, after all. Hiding behind the medical claims of legit patients is pathetic and only maintains the furtive nature of recreational use. Make it legal, then call it medicine if you want. Booze can cure what ails you, too, right?
I think we should start just calling you the Doctor now.
Call “medical marijuana” what it is: legalization only for white and/or well-off people. The well-connected get to toke up in peace without having to let go of their real addiction: criminalizing the leisure habits of the poor and disenfranchised.
That’d be nice just to decriminalize it completely, but look how long it’s taken just to get medical marijuana partway there. The honest campaign would just say “it’s no one’s business but mine”, but will that really get more traction quicker? Dunno.
jt@14: the thing is, “decriminalization” is just as much a scam as “medical marijuana”. As long as possession and sale of marijuana is in any way illegal, it’s trivial for any cop (be it a good one who’s just being forced to make an arrest quota, or a bad one who likes hassling black kids) to roll you up from a ticket to a full-on arrest.
For instance, a fascinating little bit of trivia: simple marijuana possession has been a non-criminal offense in New York for well over twenty years now. And yet the leading cause of arrests in New York City is… marijuana possession. (And the vast majority of those arrests are of black and latino men caught up in “stop and frisk” operations.) The way it works is that the cops and courts interpret the law in the narrowest way possible: a joint in your pocket is simple possession (and thus a ticket), but if the joint is visible to a police officer, you are “openly consuming”, “disturbing the peace” or “soliciting to sell” depending on how badly the cop wants to fuck with you.
Full legalization or GTFO.
Oh right, I forgot the punchline: if a cop stops you and asks you to empty your pockets (which is SOP), and you pull out a joint… voila, the joint is visible! Instant arrest time. Wheee!
If you want pot to be legal for recreation, ask for pot to be legal for recreation.
The problem is that the authoritarians who believe that our bodies are collective property will ignore that request. It should be legal for recreation, of course, as should all drugs. The medication angle is appropriate, I think, as it appeals to what tiny shreds of decency still exist in most politicians.
As a doctor, I’d like you to actually visit a medical marijuana clinic or two in Seattle. There are actual, extremely sick, elderly, and injured people there who have the experience that marijuana helps them. If you’d like to dismiss and ban their safe treatment and instead give them free not-yet-invented “clean” miracle pharmaceuticals, that would be great. Since that’s impossible, what do you recommend these very ill people do while waiting for the DEA to dissolve? Euthanasia?
Thanks for this. Adding a rational context to the increasingly hysterical coverage of this is very much appreciated.
@18 did you… did you read the entire post?
It is indeed medicine – or at least it can be in a very narrow sense. Drawing smoke – any smoke – into one’s lungs is a health hazard. That has been proven beyond doubt. Smoke is an irritant, and continual irritation leads to other problems.
But…if you are wasting away due to loss of appetite or you are in enormous pain from the cancer that is consuming your body, then what’s a little smoke in the lungs? And although it’s very effective in relieving glaucoma, I don’t think it – or any other drug – should be used when there are better alternatives, and people claim weed is great for a panoply of minor-to-severe ailments.
I know that the big push for legalization comes from people who want to get legally high. I understand that. Why should someone with a joint or two be forever branded a felon and lose such things as access to the student loan program? I don’t really have an issue with that as long as people know the health risks. Grass may be natural, but lighting it up and drawing it into your lungs isn’t.
Chronic pain suffererer from muscluar auto immune disease damage reporting that marijuana helps a lot. I don’t need a study to tell me that my pain is better managed with marijuana than without. I also don’t expect anyone who doesn’t know what a life of chronic pain is like to understand or believe me for that matter.
It’s hard for people to believe that smoking a plant could really help. Easy to imagine it can get you high because that’s what they’ve been taught that’s all it’s good for. In addition to the fact that everyone is so used to pills and processed consumables that the thought of a weed being smoked for enormous benefits towards wellness sounds preposterous to them. It sounds like fucking voodoo to them.
Where are the It Gets Better style testimonials of medical marijuana patients so the average ignorant/misinformed American can see how good this medicine is and the positive impact it has on so many lives? Does something like that exist? Because if it doesn’t it should.
Thanks for posting this by the way.
Very nice dissertation, Doctor.
Perhaps next you could lay out for the Slog how
Life begins at Conception…..
isn’t the argument that by pushing for wider medical legalization, we bring marijuana use out into the open, and slowly over time society begins to unlearn all the bullshit it’s been fed about the evils of marijuana.
the only way that any kind of large-scale racial, gender, sexuality etc. change really happens is that more and more people get to know black/trans/gay people, and get to learn that the Other isn’t evil. it’s the same thing with weed.
that and all the people who are beyond rationality eventually die off. which is why it takes time. so we might as well speed things up with medical legalization. anything to get it out there.
@25–wait so, you’re saying that smoking marijuana is hazardous for your health? more hazardous than any number of other activities, all of which are legal? (i.e. drinking, cigarettes, driving a car, owning a firearm…)
“that has never killed anyone can be made “safer””
Really, putting smoke into your lungs is good for them? Never caused cancer?
Anyone else find it odd to treat symptoms of diabetes with a drug that gives you the munchies?
@29, that reasoning suggests that it would be the government’s business how often you exercise and how much red meat you eat. The government couldn’t possibly allow people to smoke cigarettes or drink more than a glass or two of wine a day. The government would have to limit how much recreational driving we do and the sports we enjoy.
It’s precisely this notion that conservatives pounce upon when opposing universal healthcare. The compassion of universal healthcare shouldn’t be sullied by the oppression of government intervention in our private lives.
We will ask for recreational pot to be legalized. There are steps we need to take before we can start on that however, and those steps include getting marijuana to the medical patients who need it and opening up the debate from there. Priorities, man.
@28 I was unaware that smoking was the only way to achieve the effects of marijuana.
When referring to Christine Gregoire, please use the formal and correct title:
“Ex-Governor”
thank you.
Obviously the FDA considers THC to be medicinal, since Marinol, the pharmaceutical formulation of THC, is Schedule III.
My autoimmune disease has gone into remission thanks to medical marijuana. In addition, it helps ease the effects of stronger painkillers when needed, eases my joint pain from rheumatoid arthritis, and makes the pain of the open sores that develop on my body bearable. Yup, I think I’m pretty convinced on the medical properties of marijuana.
Is Asprin medicine because it is packaged into little pills and sold in the medicine isle? If you make a tea out of the bark of a willow tree (where asprin comes from) and drink it, is that a medicine?
The question is this: is something a medicine because someone says or approves it as a medicine or is something a medicine because it WORKS for YOU?
How about pot instead of Viagra?
Aspirin is medicine because it’s been proven to be effective.
Marijuana hasn’t.
@40 I’ve smoked pot. It’s effective. Getting high can be and is a medical good.
Golob: We’re suing the Washington Department of Health over the Medical Quality Assurance Commission’s mishandling of our petition to add neuropathic pain to the list of qualifying conditions. Our case should be going to court sometime this month.
With our petition, we included three positive double blind, randomized, placebo-controlled clinical trials of cannabis in the treatment of neuropathic pain, and a review article for the treatment of neuropathic pain with cannabinoids. We also included a report from the University of California Center for Medical Cannabis Research of their most recent legislatively mandated research, which includes discussion of the evidence supporting the treatment of neuropathic pain with cannabis, to support our petition.
Please see cdc.coop/mqac for more detail and all of our supporting materials.
it’s just too bad that the messages of the “pot as medicine” and “pot is ok to use recreationally” movements get mixed. the latter discredits the former.
like when i see ads for medical cannabis that are on stranger pages right now…there’s one for “Left Coast Cannibis” with a bunch of scantily-clad women in very revealing nurse uniforms; the kind you would see on halloween. how on earth can one take the medical movement seriously with an ad like this?
and by the way Left Coast Cannabis…if it really IS just for medicine, why the hell direct it just towards hetero men?! medicine, right.
i am all for legalization of recreational use. but mixing messages is lame.
Do the tons of people using Viagra when they don’t have diagnosed erectile dysfunction somehow weaken the case for an easily accessible treatment for ED?
The synthetic cannabinoids in the ‘fake pot’ products K2, Spice, et al were first created in the research towards the pharmaceuticals that Golob envisions. Accomplia failed as a weight loss drug, and neither Marinol nor Sativex have quite the same ranges of benefits as marijuana itself seems to have. Perhaps they’ll figure out how to safely replicate the munchies in a lab with some mixture of substituted JWH molecules delivered as a lozenge, but that’s certainly years, if not decades, away. There are groups chomping at the bit to research marijuana on their own, but the DEA and NIDA are stopping them from growing it. The pot used to develop Sativex has to be grown in the UK.
Medical Marijuana is not a sham, in that there are actual people who find actual benefit to marijuana in treating specific problems. That there are people who are profiting off of that fact to sell mariuana to otherwise healthy adults is also obvious but doesn’t invalidate the first point.
I just checked out some of the links you posted.
Um, what the fuck, Jonathan?
The first, on diabetic neuropathic pain, was studying Sativex, not marijuana. It then conflated Sativex with cannabis and said it didn’t work for diabetic neuropathic pain. I think that’s more an argument against the efficacy of the state of the art in the pharmaceutical cannabinoids.
And did you actually just link to a pubmed article that lumped studies on marijuana in with MAGNETS to treat pain?
Dude, you can’t go looking at PubMed for 20 minutes and pass off this half-assedness as SCIENCE HAS SPOKEN.
As a physician who has clinical Cannabis (not pot) patients in my practice, and a researcher involved in the cannabinoid field for the last 7 years, I must concur with Na Fun above. Cannabis is a valuable botanical medicine for a myriad of scientifically explainable reasons for which we understand the precise molecular mechanisms. I would like to see Cannabis legalized for a host of reasons, particularly so that we (I) can move forward with the clinical science that could bring relief and restore quality of life to patients with quite a variety of ‘dis-eases’ that this fascinating ‘endo-cannabinoid’ biological system is involved in.
There’s also nuance to the data that epistemological orientations preclude.
“Pharma is going to win this one in the lab—legitimately.” No pharma will win it on the lunch date with the doctors or on their marketing tours. Also, I question pharma’s motivations in development all the time, especially if they can’t maximize profits.
@44 Nice catch. And to think one only needed to look at the abstract to find that those people weren’t smoking pot.
Let’s be clear, there are certain things that are controversial just because nobody wants to really know the truth. And there are certain things that we know are right because throughout the history of a particular therapeutic agent keep recurring, and this is the case for cannabis and pain. For thousands of years cannabis has been in the pharmacopeia of every society and culture in which it was available including the US pharmacopeia until 1942. It’s been helping humans with pain for thousands of years. Not only is it good medicine, it’s great medicine with an extremely low toxicity and multiple benefits other than just pain. And there’s substantial peer reviewed evidence to boot.
If we don’t cherry pick studies and examine the full scope of the literature, there is a continuous recurrence of analgesic action since the very inception of the studies on cannabis. It is my opinion that any claims on a lack of scientific evidence for medical cannabis are simply not founded in a proper understanding of the scope of the literature.
If we investigate the links in Dr. Golob’s article, a curious but common pattern emerges. The evidence he presents is skewed. For example, clicking on the link “a systematic review of the available double-blinded, placebo-controlled, randomized studies of pot cannot show a consistent benefit for pot” we find that this is really not a review of cannabis at all! Rather this study examines acupuncture, electrostimulation, herbal medicine, magnets, dietary supplements, imagery, and spiritual healing on nerve pain. So in my opinion, this is a rather poor example of a study relating to the dearth of the cannabis literature on neuropathic pain.
Also in my opinion, another link in the article is also very misleading. It states that cannabis is “unable to show any benefit of pot smoking over placebo for diabetic neuropathy”. While this statement is true in one sense, a closer examination sheds more light on the topic. To quote from the paper cited: “There was significant improvement in pain scores in both groups”. What’s also misleading is that this study was only the first in a series of many studies and the majority of which show benefit, including elegant double blind experiments with large numbers of patients. I’ve posted the link to several of these on my blog.
So I have been reading “Doctor” Golob’s opinions, and thought that I would raise a few points here. First, Jonathan is a “doctor” in the loosest sense. He was a PhD, and at the time of writing this article he was still in medical school and had not yet completed his medical education. In fact, he has only recently started his actual training towards being a physician. I do not mean to be harsh, but it seems that before anyone is entitled to give their “informed”opinion on an issue as controversial as medical marijuana, they should at least be upfront and honest about their qualifications and background. I agree with some of the comments above that Jonathan has been selective in his “review” of the literature. This is hardly surprising, as he has been selective in his description of his experience as a “doctor” as well. Had Jonathan actually had more experience as a physician (I myself actually have 5 years of training after completing my MD), he would realize that physicians have a social responsibility to become HONEST EXPERTS in a field before spouting a public opinion.
For those who do not think that Jonanthan Golob’s public comments are sometimes irresponsible, I need only remind everyone that it was a physician (Wakefield) who jump started the anti-vaccination nonsense. The difference is that Wakefield was a dishonest expert. Jonathan is a dishonest nonexpert.
What do I think about medical marijuana? I have my views, but (unless I were an pain specialist with a great deal of integrity) I would never use my “doctor” title to lend credence to them to the point that would publicly comment on the issue. Physicians should heal, and not use their training to publicly support their own personal views.