From Pot to Prescription: The Long, Strange Trip of Medical Marijuana

Abstract

When people think of marijuana, they may picture Cheech and Chong, embodying the stereotypical image of stoners high on drugs who are mostly interested in chips and chilling out. However, as medical marijuana has become legal in 29 states and the District of Columbia, practitioners and patients are seeing the health and palliative benefits of controlled forms and dosages of the substance. Nonetheless, even in states where medical marijuana can be used legally, there are still some barriers, questions, and concerns that limit its popularity. The term “medical marijuana” generally refers to using the whole, unprocessed marijuana plant or its basic extracts to treat symptoms of illness and other conditions. The Food and Drug Administration has not recognized or approved the marijuana plant as medicine. However, the scientific study of cannabinoids, compounds that are contained in marijuana, has led to two FDA-approved medications that contain cannabinoid chemicals: drobinol (Marinol, AbbVie; Schedule III) and nabilone (Cesamet, Meda Pharmaceuticals; Schedule II). The two main cannabinoids that are currently of greatest medical use are tetrahydrocannabinol (THC) and cannabidiol (CBD). THC — the compound that creates the “high” feeling associated with marijuana — can increase appetite and reduce nausea, and it also may help decrease pain, inflammation, and muscle control problems. Unlike THC, CBD doesn’t elicit euphoria, but it has been used to reduce pain and inflammation, and control epileptic seizures. CBD may have potential uses for treating mental illness and addictions as well. Cannabinoids can be administered in a variety of forms. The patch form is not recommended for dementia patients, as they are more likely to peel them off; for those patients, the lotion or oil forms can be rubbed on the skin. There also are vape juices and edibles such as cookies, candies, and brownies, as well as oils that can be added to food or drinks. Although more study on the clinical benefits of medical marijuana is needed, for now there is a general consensus that medical marijuana may be helpful in treating some medical issues. In 1999, for instance, the Institute of Medicine concluded that marijuana may produce modest results for relieving pain, stimulating appetite in people with AIDS wasting syndrome, and controlling chemotherapy-related nausea and vomiting. The FDA has conducted clinical trials with thousands of participant to determine the benefits and risks of medical marijuana. However, the studies to date are insufficient to show that the benefits of the marijuana plant — as opposed to its cannabinoid ingredients — outweigh the risks. There is some evidence to suggest medical marijuana may reduce costs and produce positive outcomes. One recent study showed, for example, that Medicare saved more than $165 million in 2013 on prescription drugs in the District of Columbia and 17 states that allowed cannabis to be used as medicine (Health Aff 2016;35:1230–1236). Researchers analyzed Medicare data from 2010 through 2013 for drugs approved by the FDA to treat several common ailments — including pain, glaucoma, depression, and nausea — for which marijuana is considered a potential remedy. Researchers found that except for glaucoma, prescribers wrote fewer prescriptions for all ailments after medical marijuana became legal. The number of Medicare prescriptions dropped most significantly for drugs that treat pain, depression, anxiety, nausea, psychoses, seizures, and sleep disorders. “It’s not hard to extrapolate that lives that might have been lost to opioid addiction and overdose were saved by medical marijuana,” Alan C. Horowitz, RN, JD, a partner with Arnall Golden Gregory LLP in Atlanta, GA, said of the study. “While much research is needed, there is a growing body of evidence that supports the efficacy of medical marijuana.” Another study found that opioid overdose death rates were an average of about 25% lower in states where medical marijuana was legal, compared with states that hadn’t legalized the substance (JAMA Intern Med 2014;174:1668–1673). The significance of this statistic is unknown, though. Practitioners are starting to see benefits of medical cannabis with geriatric patients, including lower levels of anxiety and improved sleep. According to Cari Levy, MD, PhD, CMD, associate professor of medicine at the University of Colorado School of Medicine, “Many argue that marijuana is safer than opioids. It’s nearly impossible to overuse. It would require a dose of 15 grams or more, which is much higher than even heavy users consume in a day. Patients might get ‘goofy,’ but we won’t see any respiratory depression.” One study, although only conducted in mice to date, suggests that marijuana also may be good for memory, especially in the elderly, and may actually prevent brain aging and restore learning ability (Nat Med 2017;23:782–787). Other recent animal studies have shown that marijuana extracts may help kill certain cancer cells and reduce the size of others. The research isn’t all good news for marijuana users, however. Recently, results from a study on respondents to the 2005 U.S. National Health and Nutrition Examination Survey suggested that marijuana users had a threefold increase in the risk of death from hypertension compared with nonusers [Eur J Prev Cardiol, Aug. 8, 2017; doi: 10.1177/2047487317723212]. Although Dr. Levy acknowledged there have been deaths associated with marijuana (for example, a young man jumped to his death after eating a marijuana-laced cookie, and another man killed his wife after eating candy containing marijuana), she stressed the difference between drug-associated deaths such as these and drug-induced deaths, such as an overdose. Particularly for younger people, there are risks of dependence, psychosis, altered neurologic development, poorer educational outcomes, progression to other illicit drugs, and amotivational syndrome. Other possible risks include hepatitis C progression due to steatosis, cannabinoid hyperemesis syndrome (characterized by recurrent nausea, vomiting, and abdominal pain), orthostatic hypotension (directly toxic to blood vessels), visceral adiposity/insulin resistance, and nasopharyngeal carcinoma. Dr. Levy noted that there also is evidence that medical marijuana can cause increased heart attacks. There remain many barriers and ambiguities to medical marijuana use that are likely to prevent its growth, at least in the short term. However, Mr. Horowitz noted that the U.S. government is trying to move forward. “Realizing the growing trend in medical marijuana and the increasing body of scientific evidence of the efficacy of CBD, as well as the expanding number of states that have legalized it, the Department of Justice issued an official memo in 2011 to all U.S. attorneys suggesting prosecutorial discretion,” Mr. Horowitz said. This memo provided some clarification and support for the 2009 “Ogden Memo,” named after former deputy U.S. Attorney General David W. Ogden, which provided guidance to federal prosecutors in states that authorized the legal use of medical marijuana. That memo started out ominously by clarifying the DOJ’s determination that “marijuana is a dangerous drug and that the illegal distribution and sale of marijuana is a serious crime that provides a significant source of revenue to large scale criminal enterprises, gangs, and cartels.” Specific to medical marijuana, the 2011 memo stated, “The Department’s view of the efficient use of limited federal resources as articulated in the Ogden Memorandum has not changed. There has, however, been an increase in the scope of … commercial cultivation, sale, distribution and use of marijuana for purported medical purposes … Persons who are in the business of cultivating, selling or distributing marijuana, and those who knowingly facilitate such activities, are in violation of the Controlled Substances Act, regardless of state law. Consistent with resource constraints and the discretion you may exercise in your district, such persons are subject to federal enforcement action, including potential prosecution.” However, the memo also acknowledged that, while “prosecution of significant traffickers of illegal drugs, including marijuana, remains a core priority, it is likely not an efficient use of federal resources to focus on enforcement efforts on individuals with cancer or other serious illnesses who use marijuana as part of a recommended treatment regimen consistent with applicable state law, or their caregivers.” In August 2016, the Ninth Circuit Court of Appeals ruled that the DOJ “cannot spend money to prosecute federal marijuana cases if the defendants comply with state guidelines that permit the drug’s sale for medical purposes,” because Congress barred the use of federal funds for this purpose. However, Senior U.S. Circuit Judge Diarmuid O’Scannlain cautioned against overconfidence, saying, “Congress could restore funding tomorrow, a year from now, or 4 years from now . . . and the government could then prosecute individuals who committed offenses while the government lacked funding.” In Congress, there has been broad bipartisan support for medical marijuana. The Compassionate Access, Research Expansion, and Respect States Act of 2015 (S. 683) was designed to amend the Controlled Substances Act to provide that control and enforcement provisions related to marijuana “shall not apply to any person acting in compliance with state law relating to the production, possession, distribution, dispensation, administration, laboratory testing, or delivery of medical marijuana.” It also would move marijuana from Schedule I (drugs with no currently accepted medical use) to Schedule II (substances with medical indications, but with a high potential for abuse). Unfortunately, when the bill was introduced in March 2015, it stalled. This bill was reworked and reborn as the Compassionate Access, Research Expansion, and Respect States Act of 2017 (S. 1374/H.R. 2920). This bill would protect medical marijuana patients who comply with state laws from federal prosecution, enable access to medical marijuana for veterans, remove cannabidiol from the list of controlled substances, and expand opportunity for medical and scientific research on the uses and effects of medical marijuana. Another promising bipartisan bill introduced by Dianne Feinstein (D-CA) in 2017 but not yet passed is the Cannabidiol Research Expansion Act (S. 1276), which would reduce the regulatory barriers associated with conducting research on the potential benefits of substances that are derived from marijuana, such as cannabidiol. The bill was referred to the House Judiciary Committee in May. Additionally, Sen. Orrin Hatch (R-UT) very recently introduced bipartisan legislation aimed at expanding cannabis research, called the Marijuana Effective Drug Study (MEDS) Act of 2017. Recent actions by U.S. Attorney General Jeff Sessions suggest that the government might be taking a step backward. In a May 2017 letter, Sessions asked Congress to undo the protections outlined in the Rohrabacher–Farr amendment, which precludes the DOJ from prosecuting any grower, distributor, retailer, or user of medical marijuana so long as they comply with state laws. In the letter, Mr. Sessions said, “I believe it would be unwise for Congress to restrict the discretion of the Department to fund particular prosecutions, particularly in the midst of an historic drug epidemic and potentially long-term uptick in violent crime. The Department must be in a position to use all laws available to contact the transnational drug organizations and dangerous drug traffickers who threaten American lives.” After this rather unexpected move by Mr. Sessions, in late July, lawmakers upheld the Rohrabacher–Farr amendment, legislation first introduced in 2003 by Rep. Dana Rohrabacher (R-CA), and former Reps. Sam Farr (D-CA) and Maurice Hinchey (D-NY), which prohibits the DOJ from spending funds to interfere with the implementation of state medical marijuana laws or to prosecute legal medical marijuana operations. The amendment had passed the House in May 2014 and became law in December 2014, although it requires annual renewal. The Senate Appropriations Com-mittee approved the inclusion of the Rohrabacher–Farr amendment (also known as the Rohrabacher–Blumenauer amendment, renamed after Rep. Earl Blumenauer [D-OR], who in 2017 became a lead cosponsor) in the Commerce, Justice, Science, and Related Agencies appropriations bill for fiscal year 2018. As a presidential candidate, Donald Trump had said in a televised interview that he supports medical cannabis “100%,” and that the issue should be left up to the states. However, the Trump administration has sent signals that it may reserve the right to ignore the Rohrabacher–Farr amendment and enforce federal law. In addition to strong bipartisan agreement on this issue, medical marijuana also is very popular with voters. A recent Quinnipiac poll found that 94% of respondents said they support the legal use of medical marijuana. And the people who use it vouch for its effectiveness: a representative health survey of 7,525 California adults produced by the Public Health Institute in partnership with the Centers for Disease Control and Prevention found that 92% of medical marijuana users said it “alleviates symptoms of their serious medical conditions” (Drug Alcohol Rev 2015;34:141–146). In supporting the medicinal use of marijuana by an estimated 2.5 million individuals in the United States, the marijuana industry is positioned to put almost $70 billion yearly into the U.S. economy by 2021. So it’s not difficult to imagine growing support across the country, even in the face of a potential federal crackdown. Beyond the federal confusion, the state laws vary. In most states, nurses can’t administer medical marijuana, and facilities can’t store it. In some states, physicians can recommend it, but they can’t prescribe it. There also is the question of resident rights. For example, if a patient is in severe pain and medical marijuana is the only thing that helps, can the family demand that the person be allowed to use it? If not, can they hold the facility legally responsible for withholding care that provides comfort and relief? These kinds of questions are yet to be definitively answered. The good news is that the scientific evidence supporting the benefits of medical marijuana is increasing. “This, along with Congressional and public support, is likely to open up the use for this treatment option moving forward,” Mr. Horowitz said. Senior contributing writer Joanne Kaldy is a freelance writer and communications consultant in Harrisburg, PA. With more patients using or wanting to use medical marijuana, skilled nursing facilities would be wise to have policies and procedures in place regarding its use. It is important to recall that since most nursing homes receive funding from federal programs and marijuana is a Schedule I controlled substance, the safest bet would be to prohibit the use of any and all marijuana on the premises. However, for facilities that choose to make medical marijuana available, policies and procedures to consider include: •Notification on admission of the facility’s medical marijuana policies and procedures.•Requirement that patients provide proof of registration.•Requirement that patients provide proof of identity and relationship with their primary caregiver.•Agreement by provider and patient to abide by the facility’s policies and procedures related to marijuana use.•Notification procedure for when marijuana is brought to the facility by the primary caregiver.•Explanation of storage, access, and use of marijuana by residents.•Copy or summary of state laws.•Details about where marijuana can be used (e.g., limited to resident’s room). Colorado legalized medical cannabis in 2000, but the modern dispensary system didn’t start until 2009. Patients must get a medical license to qualify for medical cannabis, although recreational use became legal there in 2014. The qualifying conditions for medical use vary by state, but in Colorado they include cancer, glaucoma, fibromyalgia, HIV/AIDS wasting disorders, chronic disabling pain/muscle spasms/neuropathy, seizures, chronic nausea, inflammatory bowel disease, multiple sclerosis, migraine/chronic headache, and post-traumatic stress disorder/war combat injury or illness. To get a license for use in Colorado, a patient must obtain a statement from a licensed physician that documents the qualifying condition(s), then must go to a certified medical cannabis physician to purchase a temporary license. The person then can buy medical marijuana.