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Debate Still Smoking

Baltimore RN, D.C. physician discuss pros, cons of medical marijuana

Monday November 3, 2008
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Few issues within the healthcare community are as controversial as medical marijuana. Proponents believe smoked cannabis is effective medicine for a wide range of conditions, including AIDS wasting syndrome, chemotherapy-induced nausea, and chronic pain.

Opponents say the science simply isn't there, that smoking is a flawed and potentially dangerous delivery system, and that conventional medicine offers equally effective or better alternatives.

For Lynn Billing, RN, BSN, CHPN, nurse coordinator in The Harry J. Duffey Pain and Palliative Care Service of The Sidney Kimmel Comprehensive Cancer Center at The Johns Hopkins Hospital in Baltimore, the issue is fairly straightforward. Under certain circumstances, she says, smoked cannabis can be good medicine. Billing has had several patients, both at the SKCCC and in her previous job as a hospice nurse, who turned to marijuana to relieve a variety of symptoms. In most cases, she reports, it was effective.

"I believe very strongly that if marijuana does help patients, they should use it," says Billing, who researched the issue for a college report. "But they should use it wisely and be honest with their caregivers about what they are doing."

Most of the patients under Billing's care who used marijuana had AIDS or cancer. One, she recalls, was a middle-aged professional male struggling with the side effects of chemotherapy. Billing suggested Marinol (dronabinol), a synthetic version of THC, the active ingredient in marijuana. The patient said he had tried Marinol but found it ineffective. Marijuana, he told Billing, provided more satisfactory relief for his nausea and vomiting.

"I think the [greatest] benefits of marijuana are as an appetite stimulant and nausea control," Billing says. "But I also see it helping patients with pain and anxiety."

The American Nurses Association has taken a progressive position on the issue of medical marijuana, recognizing "that patients should have safe access to therapeutic marijuana/cannabis." It also supports research in controlled investigational trials on the therapeutic efficacy of marijuana, legislation to remove criminal penalties for bona fide patients and prescribers of therapeutic marijuana, and federal and state legislation to exclude marijuana from classification as a Schedule I drug. But not all medical organizations agree.

The American Academy of Ophthalmology, The American Medical Association, The National Multiple Sclerosis Society, and the Institute on Medicine, for example, all have issued statements dismissing the idea marijuana is equal to, or more effective than, currently available conventional approaches.

"One of the most common misconceptions is that there is scientific evidence which proves marijuana can cure anything that ails you," says Andrea Barthwell, MD, president of EMGlobal, a consulting group based in Washington, D.C., and former deputy director for demand reduction at the Office of National Drug Control Policy in the nation's capitol.

It's true, Barthwell notes, that a handful of head-to-head clinical studies found smoked cannabis just as effective as approved appetite stimulants and antiemetics. But those studies are now decades old, and current treatments for nausea and appetite loss are far superior to those available at the time of the studies.

Barthwell also takes issue with the position held by many medical marijuana proponents that marijuana should be approved as medicine because, at the least, it does no harm. This belief, she says, skirts one of the most basic tenets of the drug approval process in the U.S.

"We don't approve medicines on the basis of them not being harmful," Barthwell says. "We approve them and allow them in general use because they are shown to be efficacious in clinical trials for a specific target. And that evidence is reproducible, not merely anecdotal."

Barthwell and others who oppose marijuana as medicine have other concerns, as well. Foremost, they warn, smoking marijuana has many side effects, including a potential for dependence, the risk of pulmonary disease, and illness from inhaling the smoke of contaminated products. The altered state that comes with smoking marijuana also can adversely affect the user's judgement.

Opponents of medical marijuana realize for people who have AIDS or advanced cancer, these potential side effects are not a primary concern. But the majority of people who smoke marijuana for medical reasons do so for chronic problems, Barthwell says, which means they may consume the drug for an extended period of time.

"Most people assume that marijuana doesn't have any negative effects on organ systems, but the evidence is very clear that it does," Barthwell says. "It's extremely variable, depending on how you use it, when you use it, how long you use it, and what you bring to it genetically. But there is a risk, just as there is a risk from taking anything into your body."

Advocates of medical marijuana would like to see more research into the effectiveness and potential use of cannabis, though the government's current position makes that unlikely any time soon. "Let's do more studies and get some data to prove this is a beneficial drug," Billing says. "Most pain medicines come from plants, such as poppies, and this is just another plant that has medicinal use. It's been abused in the past, but there obviously are some appropriate uses."

Barthwell says that money could be better used elsewhere. "We have a limited research budget, so I don't see the usefulness of going down a path that is not going to deliver a solution," she says. "That research money would be better spent looking at [new drugs] in a form that, at the end of the day, would pass the FDA approval process."

Don Vaughan is a freelance writer.

To comment, e-mail editorDC@nursingspectrum.com.

Medical Marijuana's History

Marijuana was made illegal in 1937, and its use, both as medicine and a recreational drug, was driven underground. The issue didn’t really hit the mainstream until the passage in 1996 of Proposition 215, a California initiative that removed criminal penalties for the medical use of marijuana with a doctor’s recommendation. Since then, an additional 12 states have enacted legislation that eases or eliminates penalties for the medical use of marijuana. In 2003, Maryland approved a law that reduces the penalty for marijuana possession if the person charged can prove its use is for medical purposes.
— By Don Vaughan