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    Smoked marijuana is not good medicine

    Larry LaBenneLarry LaBenneThe cannabis plant has a long history of medical use dating back many centuries, and extractives from the plant currently show strong potential for the treatment of a variety of medical conditions.

    Smoked marijuana, however, does not meet today's criteria for use as a legitimate medicine. Decades of ongoing research have demonstrated that the risks associated with smoking marijuana far outweigh any potential medical benefits.

    In spite of the established risks, the emerging legalization of smoked marijuana is resulting in its increased use for both medical and nonmedical purposes.

    Along with more frequent use of this form of the drug, the incidence of adverse events is on the rise, yet the overall perception of risk is decreasing. Among the many factors that contribute to this decreased perception of risk is the campaign waged by healthcare practitioners who advocate for expanded medical use of smoked marijuana.

    Healthcare practitioners, if informed of the risks, are in a key position to significantly contribute to public health by educating people on the risks of smoked marijuana, while advocating for the development of safe and effective alternative dosage forms.  

    Next: The DEA position

     

    The DEA position

    The DEA publication titled "The DEA Position on Marijuana" makes a strong case for the continued classification of smoked marijuana as a schedule 1 controlled substance with no legitimate medical purpose.

    The evidence-based publication cites more than 300 references to validate the arguments that the weight of scientific evidence overwhelmingly shows that marijuana is unsafe, regardless of the medical condition being treated; and that the DEA's position against smoked marijuana is not one of self-interest, but is formed by what independent scientific studies have been telling us for decades.

    According to the publication, the DEA is not alone in opposing the use of smoked marijuana as a medicine. Many medical organizations, including the American Medical Association, the American Cancer Society, the National Multiple Sclerosis Society, and the American Glaucoma Society, agree that smoke is a very poor drug-delivery system, even as they and the DEA acknowledge the therapeutic potential of extractives and alternative dosage forms.

    Next: The double standard

     

    When is smoking anything okay?

    It is difficult to imagine why any health professional would endorse the use of smoke as a drug-delivery system. Many of the same pharmacists who advocate for the elimination of tobacco products from pharmacies do not object to dispensing smokable marijuana.

    It just does not make sense. When something is smoldering and producing smoke, most people would not dispute that inhaling the smoke would be harmful. Smoke is a product of combustion, and combustion produces carcinogenic hydrocarbons and hundreds of other known toxins, and marijuana smoke is no different.

    In fact, according to a study published in 2008 by The American Chemical Society, there are significantly higher levels of ammonia, hydrogen cyanide, and aromatic amines in marijuana smoke than there are in tobacco smoke.

    So why is there such a pervasive double standard when it comes to smoking medical marijuana?  

    Next: Justified fun

     

    Medicalized recreation

    Perhaps the double standard has arisen because people who wish to take advantage of the law are using the concept of medical marijuana to justify their use marijuana for recreational purposes.

    This assertion is not too difficult to believe. For example, in the opinion of Scott T. Imler, the co-author of California Proposition 215 (the 1996 ballot initiative that legalized medical marijuana in California), the medical marijuana program is "a joke.”

    “We created Prop. 215 so patients would not have to deal with black-market profiteers," he has said. Now, however, "it has turned into a joke." He also stated, "Most of the dispensaries in California are little more than drug dealers with store fronts." And he added, "I think a lot of people have medicalized their recreational use." 

    Next: In what universe?

     

    Harmless? Really?

    Many who argue that the recreational use of medical marijuana is not important base their position on the assumption that smoked marijuana is harmless. However, decades of research have clearly shown otherwise.  

    Addiction. First off, contrary to popular belief, marijuana is addictive. According to the National Institute on Drug Abuse, as many as 50% of daily users become addicted and report withdrawal symptoms upon cessation of marijuana use.

    AEs and the ED. Second, citing many studies published in JAMA, Archives of Internal Medicine, Respirology and elsewhere, the "DEA Position on Marijuana" points out that, in addition to its addictive potential, use of smoked marijuana is also implicated in numerous adverse health issues.

    Acute health issues often result in emergency department (ED) visits. According to the Drug Abuse Warning Network (DAWN), smoked marijuana accounts for nearly half of all emergency department visits involving an illicit drug, second only to cocaine! Among the most common reasons that marijuana smokers end up in the ED are panic attacks, depersonalization, delusions, tachycardia, severe stomach pain, and intractable hyperemesis. 

    Next: Just the body and the mind

     

    Mental health. The "DEA Position on Medical Marijuana" also refers to many studies that describe chronic mental health issues resulting from use of smoked marijuana. Among the many well-documented issues are:

    · The triggering or worsening of depression and anxiety disorders;

    · Irreversible neuropsychological and neurocognitive deficits, especially memory loss, and impaired thinking and concentration;

    · The triggering of schizophrenia and ongoing issues with paranoid delusions and hallucinations as a result of structural changes to the brain.

    Physical health. Also described and referenced in the publication are many of the chronic physical health issues associated with smoked marijuana that are thought to result ultimately from the high level of tar and toxins produced by its combustion.

    One of the studies cited concluded that just three marijuana cigarettes, on average, contain as much tar as an entire pack of nicotine cigarettes. In light of the level of tar and toxins a joint contains, it is no surprise that disorders involving destruction of lung tissue are among the most well-documented issues relating to physical health.

    Another study concluded that bullous lung diseases occur up to 20 years earlier in marijuana smokers than they do in tobacco smokers. Pulmonary fibrosis, COPD, and precancerous lung conditions are also very well-documented consequences of smoking marijuana.

    Beyond lung issues are increased risks of cancers of the bladder, reproductive organs, and head and neck, as well as heart/cardiovascular disorders.

    Next: Nonsmoking casualties

     

    Secondary targets

    Unfortunately, the many adverse consequences associated with marijuana extend beyond the end user.

    One example of a commonly occurring and very alarming scenario is unintentional ingestion by children. In just one study published in JAMA Pediatrics, titled "Pediatric marijuana exposures in a medical marijuana state," 1,378 patients younger than 12 years of age presented exposures to just one emergency department in the state of Colorado over a six-year period.

    That is just one of many examples of how expanded access to marijuana is having a negative impact on innocent people.

    Bottom line

    Smoked marijuana is largely illegal because it is unsafe to use as a medication and its negative impact stretches far beyond the end user. For the protection of innocent people, it should remain illegal.

    As pharmacists, who are known to be the most accessible and trusted of healthcare professionals, we have significant opportunity and responsibility to protect people by:

    · Educating our patients on the facts about the established risks with using smoked marijuana as medicine;

    · Applying our unique skill sets to advocate for the development of safe and effective alternative dosage forms and delivery-systems;

    · Keeping smokable marijuana out of pharmacies.

    The last point is most important. It is bad enough that most of us are already dispensing products on a daily basis that are only said to be safe and effective, when we know the opposite to be true.

    Even worse, we often find ourselves in situations where we dispense pursuant to questionable prescriptions.

    We need to get off of this slippery slope before it is too late. If smokable marijuana becomes uniformly legalized for dispensing in pharmacies, what will come next?

    Let’s not find out.

    Larry Labenne is staff pharmacist with Martin's Pharmacy in DuBois, Penn. Contact him at larrylabenne.rx@gmail.com.

     

    Larry LaBenne, PharmD, CDE
    Larry LaBenne practices pharmacy in DuBois, Penn. Contact him at larrylabenne.rx@gmail.com.

    16 Comments

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    • DanicaBrown
      Nice article. Marijuana has been shown to alleviate symptoms of a huge variety of serious medical conditions including cancer, AIDS, and glaucoma, and is often an effective alternative to synthetic painkillers. A bipartisan group of 18 legislators, such as Barney Frank and Ron Paul, released a bill that is intended to supply a legal protection for customers of legal medical marijuana, in case of prosecution produced by the dichotomy between federal and state laws. The Drug Policy Alliance is committed to increasing the number of states with medical marijuana laws, supporting and improving existing state medical marijuana programs, protecting medical marijuana patients, and ending the federal ban on medical marijuana so that all patients within the United States have safe access to quality medicine and research into marijuana’s medicinal benefits can move forward.
    • JOANKHARPER
      Totally agree. Its benefits is astounding. Many people have testify ( http://getwhitepalm.com ) how powerful this herb is.
    • GeorgeYeager
      Great article! It's about time someone says this. It scares me how many doctors and pharmacists are refuse to acknowledge the risks and are OK with their patients smoking marijuana.
    • Mike Brown
      George and Larry, I suggest you read the book, Marijuana, Gateway to Health by Clint Werner. Take a look at his references please. Thank you. Mike
    • Anonymous
      Larry, did you really read the list of 320 evidence-based" references" at the end of DEA report? If you did you would see virtually nothing in the way of real science, in other words placebo-controlled, double-blind studies published in peer-reviewed journals. What's there is nothing but a listing of newspaper articles and television reports! I'm a scientist; don't show me anecdotes and opinion pieces. From personal experience, that of long-time friends who've smoked marijuana for up to 40 years, and from patients, I know of no adverse effects other than the urge to overeat. Smoked marijuana is without question more efficacious than any prescription medication to combat nausea and to increase appetite! If you can find another delivery system other than inhaled smoke, I'm all for it. Until then, at the very least, don't prevent needy patients from obtaining a safe and effective substance based on decades-old paranoia and hysteria, and most importantly intentional ignorance.
    • Mike Brown
      Thanks Anonymous. Don't try to convince Larry and millions of others that are lost in the propaganda bubble over the last 5 decades courtesy of Uncle Sam's bs. It's a waste of your valuable time. If you look at the studies from Israel rather than the negative biased information from the US, vaporization is the way to go. My opinion is that in the next decade, studies will show that even smoking is more protective for disease benefits than placebo smoking. Thanks again Anonymous. Mike
    • LarryLaBenne
      Mike Brown- You should try reading the studies conducted in Israel. Here is one example: http://www.ncbi.nlm.nih.gov/pubmed/24483000. You should ask yourself: what evidence do you have to support your position?
    • LarryLaBenne
      Yes. I read and researched every reference as well as numerous other articles referenced elsewhere. Some of the references are opinion pieces as you said, but many others do make reference to factual data. Some of the opinions are relevant such as the opinion of the author of prop 215. Correct me if I am wrong, but I did not realize that institutional reporting of adverse event data required double-blind, randomized controlled trials published in peer reviewed journals??? Following through with that argument, RCT's would be needed for the reporting of any adverse event data including APAP toxicity, opiate overdose, etc. I am glad you are in favor of an alternative delivery system! One of the goals of my article was to raise awareness that smoke is not a suitable delivery system. Being the scientist that you are: strongly supporting the scientific method, and against opinion pieces and anecdotes, it is interesting that you use anecdotes to form the basis of your position. Can you provide any references to any RCT's supporting your position? Thank you.
    • Anonymous
      Maybe I live in LaLa Land but MJ users that I see/hear from/know don't smoke MJ any longer. They EAT it. They VAPORIZE it. They make BUTTER out of it. They make ALCOHOLIC and GLYCERITE extracts of it. They make TEAS out of it. Yes, inhaling burning ANYTHING (even burning cooking oil left on the burner too long) is not a good idea [ask the Iraq War veterans reporting constrictive bronchiolitis 'cause their boneheaded command had them burning EVERYTHING a short distance from where they slept every night ... Camp Victory(!?)] So this whole, "smoking MJ is not a good idea" is moot. Well, it's not, really moot because smoking it WILL deliver active drug and the user can titrate it to effect. Instead of worrying/spending time on MJ smoking, our time would be better spent fixing this problem: My stepdaughter's first, First Grade class :: 1/2 of all the children have ASTHMA and they don't smoke MJ. THIS is where we need to focus.
    • Anonymous
      How many of you advocates would like to fly from LA to NYC in a plane captained by a regular MJ user??
    • LeoLawless
      98 of US studies in the Library of Medicine on marijuana have been geared to show its harm and dangers. Show a valid study performed to openly determine its effectiveness or lack thereof before criticizing it.
    • Anonymous
      Do you know how to use Pub Med/NCBI? It's almost as simple as searching Google.I will be happy to post some study examples if you can't find any. I don't think the author of this piece concluded ineffectiveness. There are many studies that show effectiveness, but most conclude that smoke is a terrible delivery method.
    • Anonymous
      Do you know how to use Pub Med/NCBI? It's almost as simple as searching Google.I will be happy to post some study examples if you can't find any. I don't think the author of this piece concluded ineffectiveness. There are many studies that show effectiveness, but most conclude that smoke is a terrible delivery method.
    • Anonymous
      "Smoked marijuana is largely illegal because it is unsafe to use as a medication and its negative impact stretches far beyond the end user." You're wrong on two counts: First, it's illegal largely because of unjustified hysteria and federal drug policy over reaction and overreach. Second, its negative impact beyond the user is largely the result of the criminal enterprises that formed as a result of making it illegal. While I would prefer that my patients used a method of ingestion that does not include the inhalation of agents other than the active ingredient (THC), the fact is, marijuana is effective and inhalation is the fastest and most easily titratable formulation. We should be working to improve the delivery system and dosage formulations, not rehashing tired chestnuts from the "Reefer Madness" era and unfounded vilification by the DEA which, by the way, is hardly a source of credible information on this issue.
    • Anonymous
      There is a form of MJ other than inhalation. It's called Marinol (Dronabinol).
    • Anonymous
      Perhaps you should try actually reading the article. First off, the ultimate source of information is not from the DEA, but they reference independent sources of information. You said: """""First, it's illegal largely because of unjustified hysteria and federal drug policy over reaction and overreach. Second, its negative impact beyond the user is largely the result of the criminal enterprises that formed as a result of making it illegal"""" It would be interesting to see some references for these statements. On the other hand, the author of this article has no such problem. You seem to be suggesting that it should be uniformly legalized for medical as well as recreational use. In this case most people compare it to alcohol(which by the way is a fallacy). But we have ways of measuring "impaired" when it comes to alcohol. There are no such standards in place for MJ. Until there is a way of measuring effectively whether the dude doing a surgery is impaired from this substance... or the big rig driver on the road in front of me, it needs to remain illegal. Furthermore, as much as you would like to think the cognitive (and other) health issues a part of some grand government conspiracy, they are very real and independently studied and have been for decades. So imagine, the decline in productivity in our society if everyone that wants to freely smoke has access to the drug. Do you seriously think uniform legalization or decriminalization will yield any positive results? As a health professional, does the perspective of accidental ingestion by children not concern you? It should. Again if you read the article, you would realize that it already happens way too much, and it will happen even more with increased access to the drug which you are obviously in favor of. It is encouraging that you are in favor of improving delivery systems, but it frightening that you are comfortable with you patients inhaling smoke for present lacking of a better dosage form. Smoke is toxic, and it an irresponsible way to practice medicine. If you want a better dosage form, then speak up and try to do something about it instead of sitting back and letting your patients smoke MJ while you wait for big money and big power to develop an alternative dosage form. Like I said, read the article, and evaluate the 300+ references that are used to formulate the DEA's position. It sounds like you would benefit from the reading to get yourself caught up to date with the latest scientific information information on the subject. No "reefer madness" here like you put it. It just happens that the latest information corroborates what other studies have already been saying for decades.
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