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News on the medical-marijuana front
Advocates of the use of marijuana as medicine point out that, before
becoming a drug of widespread abuse, cannabis was a part of the
traditional pharmacopoeia, and that its primary psychoactive component,
delta-9-THC, is an approved drug under the trade name Marinol.
Opponents point out that cannabis doesn't really look very much like a
medicine. We expect our medicines to be consistent in composition, but
cannabis from different plants, or from different parts of the same
plant, or from a given part of a given plant at different times of
harvesting or time since harvesting, can vary enormously in both the
overall levels of psychoactive agents they contain and in the ratios of
those agents. Moreover, smoking is an imprecise way to take a medication
("one puff" isn't nearly as well-defined a dosage as "one tablet"),
aside from the problem of taking one's medicine in a cloud of noxious
gasses and particulate matter.
An obvious approach to the problem is to isolate specific active agents
and make those available as medicines. That's what was done with Marinol.
Alas, Marinol turned out to be mostly a bad idea. Delta-9-THC has
anxiogenic (anxiety-inducing) effects; unmediated by the anxiolytic
effects of cannabidiol (and perhaps other agents), pure Delta-9-THC
provokes an unacceptably high rate of dysphoric and even panicky
experiences. In addition, since Delta-9-THC is the primary intoxicating
agent, apparently responsible for the
what-was-I-trying-to-say-when-I-started-this-sentence short-term memory
impact of pot-smoking, it's hard to reach the goal of treatment without
intoxication just using THC. (I have nothing against recreational
intoxication, but as someone who was once a chronic pain patient I can
tell you that a steady diet of it is no fun whatever.)
Moreover, Marinol is in pill form, which means that its actions are both
slow and variable with the contents of the patient's stomach, and
problematic in use against nausea. (If the patient can't keep anything
down, giving him a pill for his nausea is likely to be futile.)
GW Pharmaceuticals of the UK approached the problem from the other end:
rather than trying to isolate one chemical from cannabis, it figured out
how to produce an extract containing all of the active chemicals in the
original plant material, and to standardize the potency and control some
of the important ratios, especially the THC-to-cannabidiol ratio. The
resulting preparation can be taken either as a nasal spray or
sublingually.
The news this week is that Health Canada (equivalent for these purposes
to the FDA here) has approved GW's product, called Sativex, for the
treatment of neuropathic pain in MS patients.
Now the two sides in the war about drugs have some tricky choices to
make, especially around the question of approving Sativex and other
whole-cannabis extracts for use in this country.
The drug warriors have been proclaiming for 30 years that marijuana has
no medical utility and comparing it to Laetrile. That might make it
embarrassing for them to get behind Sativex, which after all is
marijuana. Moreover, they need to worry about the phenomenon of
"off-label" prescription: once the drug is approved, any physician can
prescribe it for any condition, and the list of symptoms for which
cannabis might reasonably be a palliative is long enough to cover
virtually anyone. So approving Sativex would be tantamount to legalizing
marijuana for any adult who can find a cooperative doctor.
On the other hand, the medical-marijuana fight is a complete loser for
the drug warriors in political terms: strong majorities all over the
country think that if a doctor wants to prescribe marijuana to a patient
and the patient wants to take it the government shouldn't interfere.
Every referendum battle on the question has resulted in victory for the
anti-prohibition side.
One possible line for the drug warriors to take is: "Of course marijuana
isn't a medicine, but see what a wonderful medicine has been developed
from it! Ain't science grand?" Since Sativex and other GW products won't
look like pot and won't be smoked like pot, there would still be a clear
symbolic line between taking your medicine and lighting up a doobie.
Andrea Barthwell, who was John Walters's deputy drug czarina for
treatment and research, has been persuaded to push that line of thinking
on behalf of GW.
But of course the drug warriors don't hate marijuana because it's bad
for your lungs; they hate the fact that some people enjoy using it (and
are legitimately worried that some of those people will enjoy it too
much and get caught in abusing or dependent consumption patterns). Pot,
unlike other illicit drugs, is already ubiquitously available, so making
the increase in use due to legal availability might be slight at first.
But the whole push to drug-test everyone in sight would be seriously set
back if any one who likes to smoke pot can just explain away a positive
cannabis test by waving a Sativex prescription.
My guess is that most of the drug warriors will take a somewhat
incoherent middle position, arguing that Sativex shows by contrast how
un-medical whole smoked cannabis really is, but then doing everything
possible to block FDA approval or create special conditions to make it
hard to actually get a Sativex prescription.
From the pro-pot side of the aisle, the calculations are even trickier.
Yes, "medical marijuana" has been a great organizing issue, and a great
way to make the prohibitionists look both heartless and scientifically
illiterate. (That helps explain why the pro-drug side -- apart from Rick
Doblin's MAPS -- has denying the need for research; resolving this issue
on a scientific basis would wreck it as a political issue.)
So will the pro-pot forces say "So there! Marijuana is too a medicine,
and has been all along. The drug Health Canada just approved is
marijuana. Thank you for making our point for us"? That's a good point
to score. But it raises a problem: if Sativex is marijuana, in an
obviously more pharmaceutically appropriate form, then why not push for
Sativex approval in this country and give up on making natural cannabis
legal for medical use? Does anyone really think that it's preferable to
take your medicine mixed with coal tars and volatile organic hydrocarbons?
Right now, it looks as if the pro-pot forces are going to take the
opposite set of inconsistent positions, arguing that approval of Sativex
shows that marijuana really is medicine, but that physicians ought to
have the option of prescribing it, and patients the option of taking it,
in the form of the crude smokable product, and of growing their own if
they're so minded.
If you guessed from the above that neither side of the drug-policy
debate actually gives a rat's ass about sick people, you're a remarkably
good guesser.
Footnote: It used to be the case that patients could bring back from
abroad drugs approved in other countries but not here. During the
Rohypnol scare, that rule was changed to exclude controlled substances.
So bringing back Sativex from Canada will be illegal.
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