Marijuana Law, Policy & Reform

Editor: Douglas A. Berman
Moritz College of Law

Wednesday, May 24, 2017

Encouraging new research about CBD as an effective treatment for Dravet syndrome

ImagesAs reported in this NBC News piece, headlined "Cannabis Drug Reduces Seizures in Severe Epilepsy Cases," some encouraging new research news was published in a major medical journal today. Here are the details:

A compound taken from marijuana greatly helped some children with a severe and often deadly form of epilepsy and completely stopped seizures in a very few, researchers reported Wednesday.  It's a rare success in a field suffused with more hope than facts — in which advocates clamor to have marijuana and compounds taken from the herb legalized for free use, while government rules limit use and researchers struggle to prove what works and what doesn't.

In this study, the researchers enrolled kids with Dravet syndrome, a very rare and often deadly form of epilepsy caused by a genetic mutation.  These kids have multiple, prolonged seizures that cause brain damage. There's no treatment. "It's hard to portray how serious and devastating this is," Dr. Orrin Devinsky, director of the New York University Comprehensive Epilepsy Center, told NBC News.

Devinsky and colleagues around the country tested a cannabis derivative called cannabidiol — CBD for short — on 120 Dravet syndrome patients.  Half took it for 14 weeks and half got a placebo.

"Seizure frequency dropped in the cannabidiol-treated group by 39 percent from nearly 12 convulsive seizures per month before the study to about six; three patients' seizures stopped entirely," the team wrote in the New England Journal of Medicine.  "In the placebo group, there was a 13 percent reduction in seizures from about 15 monthly seizures to 14," they added.

"Quite remarkably, 5 percent of the children in the active treatment group with CBD were completely seizure free during the 14 weeks of the trial," Devinsky said. "And these were kids who were often having dozens of seizures, if not many more than that per week."

The kids who got CBD were more likely to stop the trial because of side-effects. "Side-effects were generally mild or moderate in severity, with the most common being vomiting, fatigue and fever," Devinsky wrote.  But those who have been helped have been transformed, he added. "There's no doubt for some children this is just been an incredibly effective and game changing medication for them," Devinsky said.

"These are some of the children I care for [who] were in wheelchairs, were barely able to open their eyes in an office visit and really showed no emotion and … now they come in, they're walking, they're smiling, they're interactive. It's like a different human being in front of you."

He said it's not quite accurate to called CBD "medical marijuana."

"Cannabidiol is the major non-psychoactive compound present in cannabis or marijuana," Devinsky said.  "In this study, we were giving a compound CBD which has no high-producing or psychoactive properties."...

"The drug we gave was derived from cannabis or marijuana but it really should not be confused with the medical marijuana that would be obtained from dispensaries in the 44 U.S. states that have approved it. Those typically contain combinations of THC with CBD and many other compounds," Devinsky said.

It's not clear precisely how CBD works. It appears to attach to brain cells, he said. "The CBD binds with a novel receptor in the brain and thereby dampens down too much electrical activity," he said. "It seems to be a relatively unique mechanism of action that's not shared by any of the existing seizure medications."

Doctors are interested in trying CBD on autism, anxiety, inflammatory and autoimmune disorders, Devinsky said.  It may help people with other types of seizures, as well....

Australian epilepsy expert Dr. Samuel Berkovic said much more testing is needed. "This trial represents the beginning of solid evidence for the use of cannabinoids in epilepsy," Berkovic, who works at the University of Melbourne, wrote in a commentary.

May 24, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research | Permalink | Comments (0)

Friday, May 19, 2017

"New potential for marijuana: Treating drug addiction"

The title of this post is the headline of this lengthy CNN piece.  Here are excerpts:

Most European countries and Canada have embraced the idea of harm reduction, designing policies that help people with drug problems to live better, healthier lives rather than to punish them. On the front lines of addiction in the United States, some addiction specialists have also begun to work toward this end.

Joe Schrank, program director and founder of High Sobriety, is one of them. He says his Los Angeles-based treatment center uses medicinal cannabis as a detox and maintenance protocol for people who have more severe addictions, although it's effectiveness is not scientifically proven. "So it's a harm-reduction theory," he said. "With cannabis, there is no known lethal dose; it can be helpful for certain conditions."

"Some say it's hypocritical because, you know, you're supposed to go to rehab to get off drugs," said Schrank, who recently celebrated 20 years of sobriety from alcohol and all drugs. "And cessation of drug use can be a goal for some people, but pacing is also important." Some patients want to gradually move into abstinence, weaning themselves off drugs over time. Others want to maintain sobriety from a drug by using a less harsh drug, such as cannabis.

Others, including Todd Stumbo, CEO of Blue Ridge Mountain Recovery Center in Georgia, do not favor using marijuana as treatment for addiction. "I'm all about adding interventions and therapeutic techniques that have proven to be significantly profound in the changes to somebody's life and treatment. Unfortunately, I don't know that there's evidence to substantiate that marijuana's had that effect," says Stumbo. "Our take is abstinence based and we use every tool or intervention we can that's been proven effective in the past."

Still, harm reduction is gaining acceptance in the wider field of addiction specialists in the U.S. "In principle, what we have aimed for many years is to find interventions that would lead to complete abstinence," said Dr. Nora Volkow, director of the National Institute on Drug Abuse. Practically, though, that has been very difficult to achieve with relapsing addictions.

"One of the things is, we don't have any evidence-based medication that has proven to be efficacious for the treatment of cocaine addiction," Volkow said. "So we currently have no medicine to intervene, and it can be a very severe addiction and actually quite dangerous."...

"We have started to explore the extent to which interventions that can decrease the amount of drug consumed can have benefits to the individual," Volkow said, adding that she'd make this same argument for opioids and heroin. "It would be valuable to decrease the amount of drug consumed."...

Schrank, who readily concedes there are possible health and addiction risks with marijuana, says he offers his cannabis detox and maintenance protocol to people addicted to crack cocaine as well as those trying to kick opioids. Through the years, he says, he's treated about 50 people with this technique and expects to see "more people wanting to try to have a voice in their recovery rather than just plug into systems telling them what to do." Marijuana "can really help people with pain management and other health issues, or it can help them be safer," Schrank said.

Yasmin Hurd, director of the Addiction Institute at Mount Sinai School of Medicine, says generally, cannabidiol is the more important compound when it comes to marijuana as a treatment for addiction. It is one of the two primary cannabinoids, along with Δ9-tetrahydrocannabinol (THC), found in the cannabis plant. In terms of the wider scope of medical marijuana research, this is the "same cannabidiol being looked at for the kids with epilepsy," Hurd said.

May 19, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research | Permalink | Comments (0)

Thursday, May 18, 2017

Minnesota health department reports "perceptions of a high degree of benefit for most patients" in state's medical marijuana program

Rsz-minnesota-patients-with-chronic-pain-now-qualify-for-medical-marijuana-640x401Minnesota's medical marijuana program has garnered some headlines this week in part because of reports of big economic losses being suffered by industry players.   As this local article details, "Minnesota's medical marijuana manufacturing companies have lost $11 million in just two years of sales."  But the story emerging from the state this week that seems greater potential import and impact concerns a state study of patients noted this AP piece headlined  "Study: Minnesota medical marijuana patients report benefits."

The study comes from the Minnesota Department of Health and is titled "Minnesota Medical Cannabis Program: Patient Experiences from the First Program Year."  The complete report is due to to be released next month, but this Executive Summary was released this week and includes these passages:

Between July 1, 2015 and June 30, 2016 a total of 1660 patients enrolled in the program and 577 health care practitioners registered themselves in order to certify that patients have a medical condition that qualifies them for the program. The most common qualifying conditions were severe and persistent muscle spasms (43%), cancer (28%), and seizures (20%). Each of the remaining six qualifying conditions during the first year – Crohn’s Disease, Terminal illness, HIV/AIDS, Tourette Syndrome, glaucoma, and ALS – accounted for less than 10% of patients. Ten percent (167 patients) were certified for more than one qualifying condition. Most patients were middle-aged (56% between ages 36-64), 11% were <18, and 11% were ≥65. Distribution by race/ethnicity generally matched the state’s demographics, with 90% of patients describing themselves as white....

Information on patient benefits comes from the Patient Self-Evaluations (PSE) completed by patients prior to each medical cannabis purchase and from patient and health care practitioner surveys. Results of analysis of PSE and survey data indicate perceptions of a high degree of benefit for most patients....

Moderate to severe levels of non-disease-specific symptoms such as fatigue, anxiety, and sleep difficulties were common across all the medical conditions. And the reductions in these symptoms was often quite large. These findings support the understanding that some of the benefit perceived by patients is expressed as improved quality of life.

May 18, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms | Permalink | Comments (0)

Tuesday, April 25, 2017

"Marijuana may be a miracle treatment for children with autism"

Images (1)The title of this post is the headline of this notable new USA Today article.  I generally have a tendency to be skeptical of the tendency of some marijuana reform advocates to claim that marijuana is a "miracle plant" that can safely cure every possible ailment.  But I also generally have a tendency to believe there is a whole lot we still do not know about how the cannabis plant might impact brain functioning, and thus I do not wish to be immediately dismissive of serious research making serious claims about cannabis being helpful in dealing with a serious medical problem.   With that prelude, here are a few excerpts from the USA Today piece:

There is anecdotal evidence that marijuana’s main non-psychoactive compound — cannabidiol or CBD — helps children in ways no other medication has. Now this first-of-its-kind scientific study [in Israel] is trying to determine if the link is real.

Israel is a pioneer in this type of research. It permitted the use of medical marijuana in 1992, one of the first countries to do so. It's also one of just three countries with a government-sponsored medical cannabis program, along with Canada and the Netherlands. Conducting cannabis research is also less expensive here and easier under Israeli laws, particularly compared to the United States, which has many more legal restrictions.

Autism is one of the fastest-growing developmental disorders, affecting 1 in 68 children in the United States, according to the Centers for Disease Control and Prevention. Its debilitating symptoms include impaired communication and social skills, along with compulsive and repetitive behaviors. Autism typically emerges in infancy or early childhood. Advocates for combating the disorder are calling attention to it by declaring April National Autism Awareness Month....

Only two medications have been approved in the United States by the Food and Drug Administration to treat the symptoms of autism. Both are antipsychotic drugs that are not always effective and carry serious side effects....

Adi Aran, the pediatric neurologist leading the study, said nearly all the participants previously took antipsychotics and nearly half responded negatively. Yael desperately pushed Aran and other doctors to prescribe cannabis oil after a news report aired about a mother who illegally obtained it for her autistic son and said it was the only thing that helped him. “Many parents were asking for cannabis for their kids,” Aran said. “First I said, 'No, there’s no data to support cannabis for autism, so we can’t give it to you.'”

He said that changed about a year ago after studies in Israel showed that cannabis helped children with epilepsy by drastically reducing seizures and improving behavior for those who also have autism. Epilepsy afflicts about 30% of autistic children, Aran said. Mounting anecdotal reports of autistic children who benefited from cannabis also led Aran to pursue more scientific testing. After seeing positive results in 70 of his autistic patients in an observational study, Aran said, “OK we need to do a clinical trial so there will be data."...

Aran cautioned against premature conclusions about cannabis as a treatment for autism, but he said many children have shown significant improvements. Some no longer hurt themselves or throw tantrums. Some are more communicative. Others were able to return to classes after they had been suspended for behavioral problems....

Tamir Gedo, CEO of Breath of Life Pharma, which provides the cannabis oil for the study, said one mother reported, "My child is speaking relentlessly. … He never spoke before. And he's 12 years old.” One major concern is the long-term impact of prescribing cannabis to young patients, said Sarah Spence, co-director of the Autism Spectrum Center at Boston Children’s Hospital. “There certainly could be harm” to brain development, she said. But opioids and antipsychotic drugs currently prescribed to children are more harmful, said Gedo. “These families have no other hope.”

Notably, there is an advocacy group for treating autism with medical marijuana known as MAMMA, Mothers Advocating Medical Marijuana for Autism.

April 25, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate | Permalink | Comments (1)

Wednesday, March 29, 2017

Yet another serious study finds link between medical marijuana reforms and reduced opioid problems

Regular readers might be getting a bit bored by regular posts here highlighting research showing reductions in opioid use and problems in states that have legalized medical marijuana.  But, especially with the Trump Administration reportedly about to create a new commission to tackle opioid problems, I do not think the research in this arena can be given too much attention.  And, perhaps especially helpful for purposes of influencing the Trump Administration, FoxNews Health here is discussing the latest research under the headline "Would legalizing medical marijuana help curb the opioid epidemic?". The article starts this way:

In states that legalized medical marijuana, U.S. hospitals failed to see a predicted influx of pot smokers, but in an unexpected twist, they treated far fewer opioid users, a new study shows.

Hospitalization rates for opioid painkiller dependence and abuse dropped on average 23 percent in states after marijuana was permitted for medicinal purposes, the analysis found. Hospitalization rates for opioid overdoses dropped 13 percent on average.

At the same time, fears that legalization of medical marijuana would lead to an uptick in cannabis-related hospitalizations proved unfounded, according to the report in Drug and Alcohol Dependence.  "Instead, medical marijuana laws may have reduced hospitalizations related to opioid pain relievers," said study author Yuyan Shi, a public health professor at the University of California, San Diego.

"This study and a few others provided some evidence regarding the potential positive benefits of legalizing marijuana to reduce opioid use and abuse, but they are still preliminary," she said in an email.

Dr. Esther Choo, a professor of emergency medicine at Oregon Health and Science University in Portland, was intrigued by the study's suggestion that access to cannabis might reduce opioid misuse.  "It is becoming increasingly clear that battling the opioid epidemic will require a multi-pronged approach and a good deal of creativity," Choo, who was not involved in the study, said in an email.  

"Could increased liberalization of marijuana be part of the solution? It seems plausible." However, she said, "there is still much we need to understand about the mechanisms through which marijuana policy may affect opioid use and harms."...

Shi analyzed hospitalization records from 1997 through 2014 for 27 states, nine of which implemented medical marijuana policies. Her study was the fifth to show declines in opioid use or deaths in states that allow medical cannabis.

Previous studies reported associations between medical marijuana and reductions in opioid prescriptions, opioid-related vehicle accidents and opioid-overdose deaths. In a 2014 study, Dr. Marcus Bachhuber found deaths from opioid overdoses fell by 25 percent in states that legalized medical marijuana.

The study referenced in this press article is available at this link and is titled "Medical marijuana policies and hospitalizations related to marijuana and opioid pain reliever."

March 29, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research | Permalink | Comments (0)

Monday, March 27, 2017

Analyzing risks, restrictions, and barriers for those providing medical marijuana recommendations

As readers know from recent posts, my Marijuana Law, Policy & Reform seminar students deep into their class presentations. And a student this coming week is "analyzing and comparing the risks, restrictions, and barriers providers face for providing recommendations." Here are the materials this student has prepared for background on this topic:

CNN article about physician medical marijuana education

ABA article about Malpractice Liability

Nurse Practitioner article about APRN recommendations

ACP article about Marijuana Hospital Policies

Ohio Medical Marijuana Control Program - Advisory Committee - Physician Rule Presentation - Notice and Comment Review on Proposed Rule

Ohio's Proposed Rule for Physicians (draft as of 03/21)

March 27, 2017 in Business laws and regulatory issues, Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana State Laws and Reforms, Who decides | Permalink | Comments (0)

Friday, March 24, 2017

Terrific Harvard School of Public Health panel on "Marijuana: The Latest Scientific Findings and Legalization"

Marijuana-web-missed-1-636x358Though other commitments prevented me from watching the event live, I am grateful to have been able to find (and find the time) to watch an hour-long panel discussion on marijuana research and reform today as part of as The Harvard T.H. Chan School of Public Health.  I watched the full video via this page at The Huffington Post, which provides this "preview":

Twenty-eight states and the nation’s capital allow for the legal use of medical marijuana.  The drug is legal for recreational use in eight states and Washington, D.C. But with a new administration in office signaling a crackdown on recreational use, including an attorney general personally opposed to the drug, states are gearing up for a marijuana war.

While medical marijuana has been scientifically proved to ease pain, but the jury is still out on the drug’s other health benefits. A recent study conducted by the National Academies of Sciences, Engineering and Medicine, led by Harvard T.H. Chan School of Public Health professor Marie McCormick, found as much.  Ryan Grim, Washington bureau chief for The Huffington Post, will be joined by McCormick and other policy and research experts for a panel discussion on marijuana’s health benefits and legalization. 

This page at the Harvard School of Public Health indicates that the video will be posted there soon as well, and it provides this additional summary of the event:

California, Massachusetts, Maine, and Nevada became the latest states to legalize recreational marijuana, bringing to 28 the number of states that have okayed the drug for medicinal use, recreational use, or both. Even more states have rules that allow certain kinds of cannabis extracts to be used for medical purposes. At the same time that state legalization is increasing, the Trump administration is signaling that it may ramp up enforcement of federal drug laws, even when they come into conflict with state laws allowing recreational marijuana use. State and local governments may find themselves on uncertain legal ground. Meanwhile, policymakers navigating this new landscape are also working largely without the benefit of a solid foundation of scientific evidence on the drug’s risks and benefits. In fact, a new National Academy of Medicine report describes notable gaps in scientific data on the short- and long-term health effects of marijuana. What do we know about the health impacts of marijuana, and what do we still need to learn? This Forum brought together researchers studying marijuana’s health impacts with policymakers who are working to implement new laws in ways that will benefit and protect public health.

March 24, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Recreational Marijuana Commentary and Debate, Science | Permalink | Comments (0)

Monday, March 6, 2017

Examining studies on marijuana and THC in the treatment of psychiatric diseases and CBD in the treatment of neurological disorders

As recent posts highlight, my Marijuana Law, Policy & Reform seminar is now deep into the part of the semester in which student are making presentation based on their selected marijuana-related research issue. One student this coming week is exploring "the use of THC in the treatment of psychiatric diseases, in comparison to the use of CBD in the treatment of neurological disorders." Here are the studies the student plans to discuss:

Overarching Study:

National Academies of Science

——————————————————————————————————————————

Studies on the application of CBD to neurological disorders:

Cannabinoids in experimental stroke: a systematic review and meta-analysis

Cannabidiol and endogenous opioid peptide-mediated mechanisms modulate antinociception induced by transcutaneous electrostimulation of the peripheral nervous system

Medical Marijuana in Certain Neurological Disorders

——————————————————————————————————————————

Studies on the Application of THC to psychological disorders:

Cognitive and clinical outcomes associated with cannabis use in patients with bipolar I disorder.

Chronic Stress Impairs α1-Adrenoceptor-Induced Endocannabinoid-Dependent Synaptic Plasticity in the Dorsal Raphe Nucleus

Antidepressant-like and anxiolytic-like effects of cannabidiol: a chemical compound of Cannabis sativa (illustrating that anxiety, typically thought to be reduced by THC, may experience greater reduction thorough CBD)

March 6, 2017 in Assembled readings on specific topics, Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research | Permalink | Comments (0)

Sunday, March 5, 2017

Examining connections between marijuana reform and opioid epidemic

Friday, March 3, 2017

What might marijuana law look like if we really treated marijuana like a medicine?

The question in the title of this post is the question being raised by a student presentation in in my Marijuana Law, Policy & Reform seminar next week. The student addressing this issue has assembled the following background reading:

1.  Press article: "11 key findings from one of the most comprehensive reports ever on the health effects of marijuana"

2.  Information from the FDA: "What is the approval process for a new prescription drug?"

3.  More from the FDA: "FDA and Marijuana"

4.  Press article: "Most uses of medical marijuana wouldn't pass FDA review, study finds"

5.  Press article: "When Your State Says Yes To Medical Marijuana, But Your Insurer Says No"

March 3, 2017 in Assembled readings on specific topics, Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana State Laws and Reforms | Permalink | Comments (0)

Thursday, March 2, 2017

"Can we make cannabis safer?"

The title of this post is the title of this notable new piece from a group of doctors appearing in The Lancet Psychiatry.  Here is its summary:

Cannabis use and related problems are on the rise globally alongside an increase in the potency of cannabis sold on both black and legal markets.  Additionally, there has been a shift towards abandoning prohibition for a less punitive and more permissive legal stance on cannabis, such as decriminalisation and legalisation.  It is therefore crucial that we explore new and innovative ways to reduce harm.

Research has found cannabis with high concentrations of its main active ingredient, δ-9-tetrahydrocannabinol (THC), to be more harmful (in terms of causing the main risks associated with cannabis use, such as addiction, psychosis, and cognitive impairment) than cannabis with lower concentrations of THC.  By contrast, cannabidiol, which is a non-intoxicating and potentially therapeutic component of cannabis, has been found to reduce the negative effects of cannabis use.  Here, we briefly review findings from studies investigating various types of cannabis and discuss how future research can help to better understand and reduce the risks of cannabis use.

March 2, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Recreational Marijuana Commentary and Debate | Permalink | Comments (0)

Tuesday, February 21, 2017

"Can Marijuana Ease the Opioid Epidemic?"

The question in the title of this post is the headline of this new Stateline piece.  Regular readers may be tired of my repeated emphasis on the possible connections between the nation's opioid problems and marijuana reform, but I continue to consider the story very important and I am especially troubled to see so little attention seemingly given to these matters by those on the front-lines of the opioid epidemic.  Here are excerpts from the Stateline piece (which discusses medical marijuana more generally):

In the midst of an opioid crisis, some medical practitioners and researchers believe that greater use of marijuana for pain relief could result in fewer people using the highly addictive prescription painkillers that led to the epidemic.

A 2016 study by researchers at Johns Hopkins Bloomberg School of Public Health found that states with medical marijuana laws had 25 percent fewer opioid overdose deaths than states that do not have medical marijuana laws. And another study published in Health Affairs last year found that prescriptions for opioid painkillers such as OxyContin, Vicodin and Percocet paid for by Medicare dropped substantially in states that adopted medical marijuana laws.

In December, the New York Health Department said it would start allowing some patients with certain types of chronic pain to use marijuana as long as they have tried other therapies. The state’s original medical marijuana law, along with those in Connecticut, Illinois, New Hampshire and New Jersey, did not include chronic pain as an allowable condition for marijuana use, in part over concerns that such a broad category of symptoms could result in widespread and potentially inappropriate use of the controversial medicine.

Advocates for greater use of medical marijuana argue that including chronic pain as an allowable condition could result in even further reductions in dangerous opioid use. But some physicians remain cautious about recommending the botanical medicine as a pain management tool.

Dr. Jane Ballantyne, a pain specialist at the University of Washington and president of Physicians for Responsible Opioid Prescribing, which promotes the use of alternatives to opioids for chronic pain, said she does not recommend that her patients try marijuana. “There is no doubt marijuana is much safer than opiates. So we don’t discourage its use.” But in general, she said, “non-drug treatments are far more helpful than any drug treatment, and marijuana is a drug.”

At Mount Sinai Hospital here in the city, Dr. Houman Danesh, director of integrative pain management, suggests patients try physical therapy, yoga, acupuncture, stem cell therapy, nutrition counseling, hypnosis and behavioral health counseling before resorting to opioids or any other medications. He said lack of sufficient research to back up marijuana’s safety and efficacy has kept him from adding it to his pain management toolkit, but he doesn’t rule it out in the near future....

Dr. Howard Shapiro, started certifying patients for marijuana about a year ago and quickly became a believer. He’s one of only 371 doctors out of nearly 33,000 in [New York] City’s five boroughs registered to certify patients for medical marijuana. Statewide, only 863 out of roughly 96,000 physicians have signed up for the program....

As a primary care doctor who takes a holistic approach to medicine, Shapiro said trying medical marijuana was a natural for him. But he said he worried that “a bunch of druggies would start showing up.” Instead, he said the patients he began seeing were all very sick and none of them appeared to be seeking drugs for fun. The improvement he saw in those first patients was remarkable, he said. “I really think medical marijuana is the drug of the future,” Shapiro said. “We’re going to find out that it does a lot of things we already think it can do, but don’t have scientific studies to prove it.”

Out of 109 patients he’s seen over the past year, all but a handful reported substantial improvement in their pain and other symptoms within a month or two of using medical marijuana, he said. For Shapiro’s patients, the cost of marijuana treatment ranges from $300 to $400 a month, depending on their level of use.

February 21, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana State Laws and Reforms | Permalink | Comments (1)

Thursday, February 2, 2017

"Patients Are Ditching Opioid Pills for Weed"

The title of this post is the headline of this notable new Atlantic article, and here are excerpts:

James Feeney, a surgeon in Connecticut, heard it from his patients. A few actually turned down his prescription for oxycodone, the popular opioid painkiller that has also gained notoriety with the opioid epidemic. His patients, Feeney recalls, would say, “Listen, don’t give me any of that oxycodone garbage. … I’m just going to smoke weed.”

“And you know what?” says Feeney. “Every single one of those patients doesn’t have a lot of pain, and they do pretty well.” Marijuana has worked well enough, anecdotally at least, that Feeney is following his patients’ lead and conducting a trial at Saint Francis Hospital and Medical Center in Hartford, CT. The state-funded study will compare opioids and medical marijuana for treating acute pain, such as that from a broken rib.

That distinction — acute pain from an injury — is also an important one. A small body of evidence suggests that medical marijuana is effective for chronic pain, which persists even after an injury should have healed and for which opioids are already not a great treatment. But now Feeney wants to try medical marijuana for acute pain, where opioids have long been a go-to drug.

“The big focus from my standpoint is that this is an attempt to end the opioid epidemic,” he says. Overdoses from opioids, which includes heroin as well as prescription painkillers like oxycodone and morphine, killed more than 30,000 people in 2015.

Marijuana might have a bigger role in curbing this drug abuse than previously thought. Its potential uses are actually threefold: to treat chronic pain, to treat acute pain, and to alleviate the cravings from opioid withdrawal. And it has the advantages of being much less dangerous and addictive than opioids.... Yasmin Hurd, a neuroscientist at Mount Sinai who has a license to study marijuana and its derivatives...in a small pilot study ... has found that cannabidiol can reduce the cravings of people addicted to heroin. “They relapse because they are in conditions that induce craving,” says Hurd. By controlling their anxiety, cannabidiol also seems to be controlling their cravings.

Hurd is now running a larger trial to investigate if the substance could help people addicted to heroin, and she published a recent review on cannabidiol’s role in curbing substance abuse....

Interestingly, patients already seem to be replacing opioids with marijuana for chronic pain. A handful of observational studies have also found correlations between states legalizing medical marijuana and a drop in painkiller prescriptions, opioid use, and deaths from opioid overdose. And in 2016, Dan Clauw and his colleagues published a survey of patients with chronic pain who started patronizing a medical marijuana dispensary. They cut their previous opioid use by two-thirds....

Clauw, who runs a pain lab at University of Michigan, says he would to like understand how marijuana quells pain on a molecular level, but getting the license has proved too big a hurdle.

Meanwhile, Feeney’s hospital trial for acute pain is able to get around the logistics issue of marijuana as a scheduled substance. Medical marijuana is legal in the state of Connecticut, but neither Feeney nor his hospital provides it directly to patients. Rather, a doctor certifies a patient to use marijuana, and the patient then picks it up at a dispensary or pharmacy. “The strains I have to select from are so pure and so potent that the stuff they get from the University of Mississippi pales in comparison,” says Feeney.

The trial, which was just got started, will enroll 60 patients with rib injuries in total—30 on marijuana, 30 on opioids. The doctors chose rib injuries to study because the pain lasts a predictable six weeks. Because of the study’s design, patients get to choose whether they use opioids and marijuana to control pain. So far, the hospitals has enrolled a handful of patients. They’ve all chosen marijuana.

Some prior related posts:

February 2, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research | Permalink | Comments (0)

Tuesday, January 31, 2017

"Cannabis use disorder and suicide attempts in Iraq/Afghanistan-Era veterans"

The title of this post is the title of this notable new research appearing in the Journal of Psychiatric Research. Here is the abstract:

The objective of the present research was to examine the association between lifetime cannabis use disorder (CUD), current suicidal ideation, and lifetime history of suicide attempts in a large and diverse sample of Iraq/Afghanistan-era veterans (N = 3233) using a battery of well-validated instruments. As expected, CUD was associated with both current suicidal ideation (OR = 1.683, p = 0.008) and lifetime suicide attempts (OR = 2.306, p < 0.0001), even after accounting for the effects of sex, posttraumatic stress disorder, depression, alcohol use disorder, non-cannabis drug use disorder, history of childhood sexual abuse, and combat exposure. Thus, the findings from the present study suggest that CUD may be a unique predictor of suicide attempts among Iraq/Afghanistan-era veterans; however, a significant limitation of the present study was its cross-sectional design. Prospective research aimed at understanding the complex relationship between CUD, mental health problems, and suicidal behavior among veterans is clearly needed at the present time.

January 31, 2017 in Medical community perspectives, Race, Gender and Class Issues, Recreational Marijuana Data and Research | Permalink | Comments (0)

Wednesday, January 25, 2017

"Can medical marijuana be used to treat heroin addiction?"

Dt_150915_marijuana_leaf_pills_800x600The question in the title of this post is one that I wonder about a lot as more and more communities struggle for responses to the opioid epidemic.  The question is also the title of this new local article from New Hampshire, which discusses a legislative hearing about addiction and other conditions being added to the state's list of qualifying conditions for medical marijuana.  Here are excerpts: 

In the midst of a heroin and fentanyl crisis, New Hampshire lawmakers are considering a bill that would add opioid addiction to the list of qualifying conditions for the state’s therapeutic cannabis program.

That bill was one of five that could add chronic pain, opioid addiction, post-traumatic stress disorder, fibromyalgia and myelitis disorder to the list of conditions that qualify someone to use therapeutic cannabis in the state. New Hampshire lawmakers heard testimony on the bills Wednesday morning.

A number of patients testified in favor of the bills, but one doctor told legislators to proceed with caution on the bill that would allow doctors to treat drug addiction with marijuana.

Dr. Molly Rossignol, a family physician and addiction doctor at Concord Hospital, said there is not enough research to suggest cannabis is an effective treatment for addiction. “We’re going down a dark and potentially dangerous road,” Rossignol said. “In the past year, I’ve evaluated over 100 patients in our capital region. It is clear cannabis is not helping them stop or reduce their use of opioids.”

While medical marijuana is widely used in other states to treat chronic pain and other medical conditions, no state so far has approved therapeutic cannabis to treat addiction. However, at least one study showed a correlation between overdose deaths and medical marijuana laws. A 2014 study published in the Journal of the American Medical Association found opioid overdose deaths went down 25 percent in states that had medical marijuana laws.

State health officials in Maine considered the question of whether to add addiction as a qualifying condition last year, but ultimately their Department of Health and Human Services concluded there was not enough research or evidence to show it would be effective.

“Given the lack of rigorous human studies on the use of marijuana for the treatment of opioid addiction (only one clinical trial has been completed) and the lack of any safety or efficacy data, the Committee can not conclude that the use of medical marijuana for treatment of opioid addiction is safe,” wrote Dr. Siiri Bennett, the Maine state epidemiologist, and Dr. Christopher Pezzullo, the state health officer.

Rossignol said the issue of marijuana being used to treat addiction needed more time. “This has to be vetted, it has to be scientifically studied,” she said.

Rossignol said her experience with addicted patients has so far indicated marijuana is not helpful with addiction. She treats her addicted patients with Suboxone, a drug taken daily to keep cravings and withdrawal symptoms at bay. Suboxone, methadone and naltrexone are the three drugs approved by the Food and Drug Administration to treat addiction – Rossignol said when used with evidence-based therapies, many studies show they help with addiction.

She said she believed marijuana could do the opposite. “It is something that I see every day reducing their chances of getting into longterm recovery,” she said. “I think it is a very slippery slope.”

Several patients traveled to the State House to testify in favor of the five cannabis bills, including ones to add chronic pain and PTSD to the list of qualifying conditions. Stephen Boulter of North Conway told lawmakers that therapeutic cannabis had dramatically decreased his pain and increased his quality of life.

Boulter was able to qualify for medical marijuana due to a vertebrae injury. He said pain from that injury became debilitating. “It’s with you 24 hours a day, you always have pain,” he said. “The only thing that mitigated the pain were opiates, which I detested.”

When Boulter qualified for medical marijuana, he found it got rid of his pain and didn’t make him loopy. “It made a tremendous difference, it allows me to go to bed at night and go to sleep,” he said. “I firmly believe that anyone suffering with severe chronic pain working with a qualified provider can restore a normal, high quality standard of living.”

Former state Rep. Joe LaChance of Manchester, a disabled veteran, encouraged lawmakers to add PTSD to the list of qualifying conditions. “This is so important to us,” LaChance said. “This is near and dear to my heart.” LaChance briefly described his struggles with drugs and alcohol, crediting therapeutic cannabis with his recovery. “Cannabis saved my life,” he said. “The VA got me addicted to opioids. Add a bottle of Jack Daniels to that, I’m lucky to be here.”

Some prior related posts:

January 25, 2017 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Medical Marijuana State Laws and Reforms, Who decides | Permalink | Comments (0)

Thursday, January 12, 2017

National Academies of Sciences, Engineering, and Medicine releases massive new report on "Health Effects of Cannabis and Cannabinoids"

24625-0309453046-200I am very pleased to see that today, just in time for a long weekend, the National Academies of Sciences, Engineering, and Medicine has produced this massive new report titled "The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research."  The nearly 400-page report is available for download from this website, and here its the website's brief account of the report's coverage:

In one of the most comprehensive studies of recent research on the health effects of recreational and therapeutic cannabis use, a new report from the National Academies of Sciences, Engineering, and Medicine offers a rigorous review of relevant scientific research published since 1999. This report summarizes the current state of evidence regarding what is known about the health impacts of cannabis and cannabis-derived products, including effects related to therapeutic uses of cannabis and potential health risks related to certain cancers, diseases, mental health disorders, and injuries. Areas in need of additional research and current barriers to conducting cannabis research are also covered in this comprehensive report.

Helpfully, this new Business Insider article provides some of the substantive highlights of this important new report under the headline "11 key findings from one of the most comprehensive reports ever on the health effects of marijuana."  Here are excerpts from this press account:

A massive report released today by the National Academies of Sciences, Engineering, and Medicine gives one of the most comprehensive looks — and certainly the most up-to-date — at exactly what we know about the science of cannabis.  The committee behind the report, representing top universities around the country, considered more than 10,000 studies for its analysis, from which it was able to draw nearly 100 conclusions.

In large part, the report reveals how much we still have to learn, but it's still surprising to see how much we know about certain health effects of cannabis.  This summation was sorely needed, as is more research on the topic.... Before we dive into the findings, there are two quick things to keep in mind.

First, the language in the report is designed to say exactly how much we know — and don't know — about a certain effect. Terms like "conclusive evidence" mean we have enough data to make a firm conclusion; terms like "limited evidence" mean there's still significant uncertainty, even if there are good studies supporting an idea; and different degrees of certainty fall between these levels.  For many things, there's still insufficient data to really say anything positive or negative about cannabis.

Second, context is important. Many of these findings are meant as summations of fact, not endorsements or condemnations. For example, the report found evidence that driving while high increased the risk of an accident. But the report also notes that certain studies have found lower crash rates after the introduction of medical cannabis to an area. It's possible that cannabis makes driving more dangerous and that the number of crashes could decrease after introduction if people take proper precautions.

We'll work on providing context to these findings over the next few days but wanted to share some of the initial findings first. With that in mind, here are some of the most striking findings from the report:

• There was conclusive or substantial evidence (the most definitive levels) that cannabis or cannabinoids, found in the marijuana plant, can be an effective treatment for chronic pain, according to the report, which is "by far the most common" reason people request medical marijuana. With similar certainty, they found that cannabis can help treat muscle spasms related to multiple sclerosis and can help prevent or treat nausea and vomiting associated with chemotherapy.

• The authors found evidence that suggested that marijuana increased the risk of a driving crash.

• They also found evidence that in states with legal access to marijuana, children were more likely to accidentally consume cannabis.

We've looked at these numbers before and seen that the overall increases in risk are small — one study found that the rate of overall accidental ingestion among children went from 1.2 per 100,000 two years before legalization to 2.3 per 100,000 two years after legalization. There's still a far higher chance parents call poison control because of kids eating crayons or diaper cream, but it's still important to know that some increased risk could exist.

• Perhaps surprisingly, the authors found moderate evidence (a pretty decent level of certainty and an indication that good data exists) that cannabis was not connected to any increased risk of the lung cancers or head and neck cancers associated with smoking. However, they did find some limited evidence suggesting that chronic or frequent users may have higher rates of a certain type of testicular cancer.

• Connections to heart conditions were less clear. There's insufficient evidence to support or refute the idea that cannabis might increase the risk of a heart attack, though there was some limited evidence that smoking cannabis might be a trigger for a heart attack.

• There was substantial evidence that regular marijuana smokers are more likely to experience chronic bronchitis and that stopping smoking was likely to improve these conditions. There's not enough evidence to say that that cannabis does or doesn't increase the risk for respiratory conditions like asthma.

• There was limited evidence that smoking marijuana could have some anti-inflammatory effects.

• Substantial evidence suggests a link between prenatal cannabis exposure (when a pregnant woman uses marijuana) and lower birth weight, and there was limited evidence suggesting that this use could increase pregnancy complications and increase the risk that a baby would have to spend time in the neonatal intensive care unit.

• In terms of mental health, substantial evidence shows an increased risk of developing schizophrenia among frequent users, something that studies have shown is a particular concern for people at risk for schizophrenia in the first place. There was also moderate evidence that cannabis use is connected to a small increased risk for depression and an increased risk for social anxiety disorder.

• Limited evidence showed a connection between cannabis use and impaired academic achievement, something that has been shown to be especially true for people who begin smoking regularly during adolescence (which has also been shown to increase the risk for problematic use).

• One of the most interesting and perhaps most important conclusions of the report is that far more research on cannabis is needed. Importantly, in most cases, saying cannabis was connected to an increased risk doesn't mean marijuana use caused that risk.

And it's hard to conduct research on marijuana right now. The report says that's largely because of regulatory barriers, including marijuana's Schedule I classification by the Drug Enforcement Administration and the fact that researchers often can't access the same sorts of marijuana that people actually use. Even in states where it's legal to buy marijuana, federal regulations prevent researchers from using that same product.

Without the research, it's hard to say how policymakers should best support legalization efforts — to say how educational programs or mental health institutions should adapt to support any changes, for example. "If I had one wish, it would be that the policymakers really sat down with scientists and mental health practitioners" as they enact any of these new policies, Krista Lisdahl, an associate professor of psychology and director of the Brain Imaging and Neuropsychology Lab at the University of Wisconsin at Milwaukee, told Business Insider in an interview shortly before we could review this report.

It's important to know what works, what doesn't, and what needs to be studied more. This report does a lot to show what we've learned in recent years, but it also shows just how much more we need to learn.

January 12, 2017 in Medical community perspectives, Medical Marijuana Data and Research, Recreational Marijuana Data and Research, Science | Permalink | Comments (2)

Friday, December 16, 2016

Interesting results from early Ohio survey of state doctors concerning medical marijuana

This new local piece, headlined "Survey finds Ohio physicians not yet sold on medical marijuana," reports on the results of a notable poll taken of Buckeye state doctors concerning medical marijuana. Here are the details:

Only 3 in 10 Ohio doctors responding to a State Medical Board survey indicated they will be likely to recommend medical marijuana to patients under a new state law.

The board received responses from 3,000 of the state's 46,000 medical and osteopathic doctors during a survey in September. The results were announced at a meeting of the Ohio Medical Marijuana Advisory Committee on Thursday. About 40 percent of respondents say they would not be likely to recommend medical marijuana, 30 percent said they would be likely, and the remaining 30 percent were neutral or had no opinion.

Many physicians surveyed said they might change their mind if the federal Drug Enforcement Administration changed marijuana from a Schedule 1 drug, if they had more peer-reviewed research on the subject, or if they training and education.

The law effective Sept. 8 allows certified physicians to recommend, not prescribe, medical pot for patients with any of 21 qualifying diseases and medical conditions. The rules for the program are just now being proposed. Patients probably won't have access to the drug until Sept. 2018.

December 16, 2016 in Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana Data and Research, Who decides | Permalink | Comments (0)

Thursday, December 15, 2016

Outline of Ohio's medical marijuana regime emerges with release of proposed regulations

Images (3)This local article, headlined "Ohio medical marijuana dispensary, physician rules released," suggests that medical marijuana advocates might feel a bit warmer on a cold winter day in central Ohio due to the release of proposed details for the implementation of the state's medical marijuana law. Here are the basic details:

Up to 40 medical marijuana dispensaries would be licensed in Ohio under draft rules released Thursday morning. Would-be dispensary owners would have to pay a $5,000 application fee and an $80,000 license fee every other year. Applicants must show they have liquid assets totaling at least $250,000.

Dispensaries would have to hire a pharmacist, nurse, physician or physician's assistant to train employees, develop patient educational materials and be on-call or on the premises during operating hours. Dispensary employees would also have to, by law, report all medical marijuana purchases to the state controlled substances database, OARRS, within 5 minutes of dispensing a product.

A separate set of rules released Thursday requires doctors to take two hours of continuing education classes about medical marijuana as one of several requirements to become certified to recommend marijuana to patients. Certified physicians are barred from owning a dispensary or other medical marijuana business.

The Ohio Medical Marijuana Advisory Committee will review the rules at its meeting Thursday. Public comment will be collected on both physician and dispensary rules until Jan. 13, 2017.

Ohio's medical marijuana law allows patients with 20 medical conditions to buy and use marijuana if recommended by a doctor. The law prohibits smoking and growing marijuana at home. The law left most of the regulatory details, including how to license growers and register patients, to the Ohio Department of Commerce, Ohio State Board of Pharmacy and Ohio State Medical Board to decide over the next year.

The State of Ohio Board of Pharmacy drafted the dispensary rules, and the medical board developed the guidelines for physicians.

The proposed Ohio dispensary rules (which run 66 pages) are available at this link.

The proposed Ohio physician rules (which run 13 pages) are available at this link.

December 15, 2016 in Medical community perspectives, Medical Marijuana State Laws and Reforms, Who decides | Permalink | Comments (0)

Thursday, December 1, 2016

"The Case for Pot in the Age of Opioids: Legalizing medical marijuana could save lives that may otherwise be lost to opioid addiction."

ImrsThe title of this post is the headline of this U.S. News & World Report commentary on a topic that I hope continues to get more and more attention. Here is how the piece gets started (with links from the original):

Medical marijuana legalization won big this Election Day. Thanks to ballot initiatives in Arkansas, Florida and North Dakota, 26 states and Washington, D.C. now have medical marijuana laws. Four states also legalized recreational marijuana, adding to the national trend.

As states embrace pot, the federal government should follow suit and move toward legalizing medical marijuana nationwide to help save lives. In states where medical marijuana is legal, fewer lives are lost to opioid overdoses. Save lives by legally smoking weed? Yes.

Those in favor of marijuana legalization for medical use have strong evidence to support that marijuana is a useful treatment for many diseases. These include the treatment ofseizures, chronic pain and supportive care for those enduring cancer treatment.

Just as important, opioid overdose deaths dropped by approximately 25 percent in states that passed medical marijuana laws, compared to states that have not, according to Johns Hopkins' Center for Mental Health and Addiction Policy Research. That's something we can't overlook.

Yet pharmaceutical companies want us to ignore this data. In states where medical marijuana is legal, fewer opioid prescriptions are written compared to states where marijuana is illegal. This means that fewer people are buying the opioid drugs that are so profitable to the pharmaceutical companies.

The number of people dying from opioid abuse in the United States has been steadily rising. We can estimate now that approximately 43,000 people will die in the United States from accidental overdoses this year, a number that has grown in the past decade.

Legalizing medical marijuana probably will save lives that would otherwise be lost to opioid abuse and addiction. And as more states move to legalize recreational marijuana, providing even greater access to the drug, one could argue opioid use may drop more.

The states clearly understand that marijuana has medical benefits. Now, we need to look beyond the states to change laws on a national level. Failing to do so will end lives that we likely could save. Most notably, marijuana needs to be removed from Schedule 1, so that it can be prescribed and researched more thoroughly.

December 1, 2016 in History of Marijuana Laws in the United States, Medical community perspectives, Medical Marijuana Commentary and Debate | Permalink | Comments (0)

Saturday, November 26, 2016

"Where Marijuana Is the Doctor’s Orders, Will Insurers Pay?"

The question in the title of this post was the headline of this recent New York Times article, which included these excerpts:

For businesses and insurers, a string of ballot victories this month for marijuana advocates are adding to an intensifying conundrum about the drug and issues such as insurance coverage, employee drug testing and workplace safety.... “We are entering this conflict between a social policy decision and a workplace that is highly regulated,” said Alex Swedlow, the chief executive of the California Workers’ Compensation Institute, a research organization.

A major part of the predicament centers on unclear science about the benefits of marijuana or the dozens of compounds, known as cannabinoids, that are found in the plant. For its part, the Food and Drug Administration has approved only a synthetic version of a cannabinoid and a similar drug for narrow uses, such as to treat nausea in chemotherapy patients or to stimulate the appetites of patients with AIDS. Typically, health insurers will pay for marijuana-related drugs only for F.D.A.-approved uses.

But state medical marijuana laws usually give doctors permission to recommend marijuana to a patient with a “debilitating” condition, a phrase that can encompass problems including glaucoma, cancer and chronic pain. Usually, patients pay for the drug themselves and several states have explicitly exempted workplace compensation insurers for covering such costs.

But as a result of recent state court rulings in New Mexico, workplace insurers there are required to pay for marijuana-based treatments if they are recommended by a doctor. And lower courts in Connecticut, Maine, Massachusetts and Michigan have issued rulings directing workplace insurers to do so. The number of patients receiving such coverage is small. And because marijuana is illegal under federal law, insurers paying for the drug must use a financial workaround to avoid violations. One strategy is to reimburse patients for their costs rather than make a direct payment to a marijuana dispensary....

Despite the push toward legalization, few employers have dropped marijuana from the list of drugs for which employees are tested, compounds that typically include opioids, amphetamines and cocaine... As marijuana legalization expands, there are also concerns about its effect on workplace safety. Some studies suggest that marijuana use can impair a person’s judgment, though little data exists to compare the effect with that of other drugs like opioids.

In states where recreational use is allowed, the problem for employers becomes one of determining when an employee used marijuana, because detectable levels of it remain in the body for days afterward. As a result, employers must use more subjective observations to judge whether an employee has become impaired from using marijuana while at work, said Ethan Nadelmann, the executive director of the Drug Policy Alliance, a group that supports legalization.

As for Mr. Vialpando, the disabled worker in Santa Fe, he and his wife say they have all the evidence they need that medical marijuana works. Mr. Vialpando said that during the decade he used opioids, he withdrew from his family and friends, preferring to spend time by himself, watching television. He lost interest in food and developed sleep apnea — his wife used to wake up terrified at night because it appeared that he was dying.

These days, he smokes about four marijuana cigarettes daily. He said he had gained weight, enjoyed talking again and had resumed working on hobbies at home. His wife, Margaret, said that she hoped President-elect Donald J. Trump, when he takes office, will make marijuana a legal drug by changing how it is regulated. “I feel like I’ve gotten my husband back,” she said. “His personality has come back to the person that he used to be.”

November 26, 2016 in Employment and labor law issues, Medical community perspectives, Medical Marijuana Commentary and Debate, Medical Marijuana State Laws and Reforms, Who decides | Permalink | Comments (0)