Pubdate: Mon, 30 Mar 2015
Source: Daily Review (Towanda, PA)
Copyright: 2015 The Daily Review
Contact:  http://www.thedailyreview.com/
Details: http://www.mapinc.org/media/1015
Authors: James Loewenstein, Eric Hrin and Max Bennett
Series: Looking at marijuana legalization in PA.

A MEDICAL VIEW ON MEDICAL MARIJUANA LEGALIZATION

Many Doctors Want More Research to Be Done on Medical Marijuana 
Before a Decision Is Made on Whether to Legalize It

Editor's Note: This is part two of a three-part series by The Daily 
Review looking at the possibility of legalization of marijuana in Pennsylvania.

Most states now allow the use of medical marijuana, and Pennsylvania 
could be one of the next ones to legalize it.

Last year, the Pennsylvania Senate passed legislation which would 
legalize the use of an extract of the marijuana plant for certain 
categories of medical problems, and the bill has been reintroduced in 
the Legislature this year as Senate Bill 3. The election last year of 
Gov. Tom Wolf, who supports Senate Bill 3, increases the chances that 
it, or similar legislation, will be enacted in the Keystone State.

Testing limited with Schedule 1 drugs

But most doctors believe that more research needs to be done on 
medical marijuana before a decision is made on whether to legalize 
it, according to Dr. Martin Mikaya, a physician who works in the 
Emergency Room at Memorial Hospital in Towanda.

The "main difficulty" with medical marijuana is that proper 
scientific studies have still not been yet done to show that it would 
be safe and effective for doctors to prescribe it to patients, he said.

The "gold standard" in medical research is "peer-reviewed, 
randomized, double-blind" studies, which all medicines are subjected 
to before the Food and Drug Administration will allow them to be 
prescribed by doctors to their patients, said Mikaya, who added that 
none of those studies have been conducted on medical marijuana. In 
the case of medical marijuana, those studies would show, among other 
things, whether medical marijuana "is effective as a medicine" and 
"whether its benefits outweigh its risks," Mikaya said.

And Mikaya and the Pennsylvania State Nurses Association blame the 
lack of research on the fact that the federal government has 
classified marijuana as a "Schedule 1" drug, which says no medical 
value exists with the drug.

Being Schedule 1 means testing is extremely limited, and most tests 
other than a few federal tests, are done internationally, said Betsy 
Snook, CEO of the Pennsylvania State Nurses Association.

"We cannot do extensive studies in the United States with it being 
Schedule 1," she said.

Other examples of Schedule 1 drugs are LSD, peyote, heroin, and ecstasy.

It would be easier to do research on medical marijuana if the federal 
government reclassified marijuana to, for example, a Schedule 2 
controlled substance, Mikaya said.

Oxycontin and other narcotics are Schedule 2, which is a lesser 
labeling, Snook said.

A scientific issue, not political

"What we are seeing now is more like a movement" of people who are 
pushing for the legalization of medical marijuana, Mikaya continued. 
There is a "group of people" who are "demanding" that medical 
marijuana be legalized, he said.

And the position of most medical societies in the United States, 
including the Pennsylvania Medical Society, is that before a decision 
is made on legalizing medical marijuana, the proper research needs to 
be done on it, he said.

"In other words, we shouldn't (legalize medical marijuana) just based 
on a political movement. The decision should be based on sound 
scientific research," he said.

The Pennsylvania Medical Society outlined its concerns about 
legalizing medical marijuana in a 16-page white paper, which it 
presented to the Pennsylvania House Health and Judiciary committees 
on March 24.

"While many states have pushed for new laws to legalize the use of 
marijuana for medical reasons, there are few well-controlled studies 
that demonstrate its effectiveness," the Pennsylvania Medical Society 
noted in a news release that it issued about the white paper. "As 
such, most major state and national medical professional societies 
have not yet supported its use in patient care until further research 
is conducted to show it is a safe and effective medicine for use in a 
wide variety of settings."

Despite the shortage of adequate studies, public support appears to 
be growing for medical marijuana, particularly since the 2013 release 
of CNN's documentary "Weed" featuring Sanjay Gupta, MD, the medical 
society noted in its news release.

"Currently, 11 states have legalized CBD (cannabidiol) for medical 
use, while 23 others to some degree have approved CBD and THC," the 
news release states. "CBD and THC are two of marijuana's cannabinoid 
components. THC is marijuana's psychoactive component, while CBD is 
thought to have little, if any, psychoactive effect."

"There are positive, anecdotal stories of medical marijuana having 
helped patients - for example to treat children with seizure 
disorders and veterans with post traumatic stress disorder," Dr. 
Steve Shapiro, a pediatrician and trustee of the Pennsylvania Medial 
Society, said in the medical society's news release. "We have to 
acknowledge that we have patients and families looking for help and 
hope with the reality that we do not know a great deal about how 
medical marijuana works, what it is best used for, and what the 
actual dosing and other requirements are to best prescribe it. As a 
pediatrician, concerning to me is using marijuana to treat children 
and not knowing the long-term effects of THC on brain development. As 
scientists we need to know more."

"We have joined other national groups in calling for more research 
and making it easier for researchers to have access to marijuana for 
scientific purposes," Karen Rizzo, MD, president of the Pennsylvania 
Medical Society, said in the news release.

Those who push for legalization point to "hundreds" or "thousands" of 
studies that have been conducted around the world demonstrating 
marijuana's benefit in treating health issues, the medical society's 
news release states.

However, few of them have what is considered to be the "gold 
standard" in medical research - large randomized, double-blinded 
placebo-control studies, the medical society noted in the news release.

"According to the white paper, with the exception of Marinol and 
Cesamet (two man-made cannabis medications) which have gone through 
the rigorous FDA approval process, providers looking to recommend 
other forms of medical marijuana will find themselves unable to 
answer important questions concerning non-approved versions," the 
medical society stated in the news release.

Studies needed for use with seizures

While doctors hear, anecdotally, that medical marijuana has helped 
children who have been having seizures, those are "just stories," 
Mikaya said. There needs to be a large study done on whether medical 
marijuana would be appropriate to give to such children, and it 
should involve a large number of patients, and be peer-reviewed and 
double-blind, he said.

Problems have resulted from giving medical marijuana to children with 
seizures in Colorado, where marijuana and its derivatives are now 
legal, according to a March 22 letter that American Epilepsy Society 
president Amy Brooks-Kayal, MD wrote to state Rep. Matt Baker, who is 
chairman of the Health Committee in the Pennsylvania House of Representatives.

Brooks-Kayal, who works at Children's Hospital Colorado, stated those 
problems were documented in a study by a team from Children's 
Hospital Colorado that was presented during the AES Annual Meeting in 
December 2014 and has recently been accepted for publication in the 
journal Epilepsy & Behavior.

The study found that artisanal (traditionally prepared) 'high CBD' 
oils resulted in "no significant reduction in seizures in the 
majority of patients and in those for whom the parents reported 
improvements, these improvements were not associated with improvement 
in electroencephalograms (EEGs), the gold standard monitoring test 
for people with epilepsy."

She continued: "Additionally, in 20 percent of cases reviewed 
seizures worsened with use of cannabis, and in some patients there 
were significant adverse events. These are not the stories that you 
have likely heard in your public hearings, but they are the reality 
of practitioners at Children's Hospital Colorado who have cared for 
the largest number of cases of children with epilepsy treated with 
cannabis in the U.S."

"The families and children coming to Colorado are receiving 
unregulated, highly variable artisanal preparations of cannabis oil 
prescribed, in most cases, by physicians with no training in 
pediatrics, neurology or epilepsy," the letter reads. "As a result, 
the epilepsy specialists in Colorado have been at the bedside of 
children having severe dystonic reactions and other movement 
disorders, developmental regression, intractable vomiting and 
worsening seizures that can be so severe they have to put the child 
into a coma to get the seizures to stop."

Brooks-Kayal noted that not a lot is known in these situations.

"Because these products are unregulated, it is impossible to know if 
these dangerous adverse reactions are due to the CBD or because of 
contaminants found in these artisanal preparations," she wrote.

Criteria needed to avoid abuse

Dr. Stephen Renzi in Troy said prescribing medical marijuana would 
need to follow strict criteria in order to avoid abuse by people who 
go "doctor shopping," which is when people seeking drugs find doctors 
who easily prescribe the drugs being sought.

"If it becomes legalized medically, you're going to have the same 
problems as oxycontin and oxycodone," said Renzi, who is an internist.

For that reason, Renzi said criteria must be established for 
prescribing the drug.

One factor Renzi was concerned about was the type of work a patient 
may be involved in.

"If you have a Commercial Driver's License, you can't use (medical 
marijuana)," he said. "If you're doing manual labor, you could have a 
chance of getting hurt."

Renzi said only one situation exists where he would feel comfortable 
prescribing marijuana.

"End of life type pain would be the only reason I would prescribe 
it," he said. "Those people could live normal lives."

As for more typical uses for medical marijuana such as chronic pain, 
Renzi said other drugs are available to relieve such conditions and diseases.

Regarding the debate, Renzi said it will be one to watch, especially 
for what patients are included in the final version of the bill, and 
that he is neither for nor against Pennsylvania's foray into medical marijuana.

Education essential

The Pennsylvania State Nurses Association (PSNA) has been actively 
touring the state to educate health care professionals on medical 
marijuana and have been one of the state's strongest advocates of 
making marijuana available to certain patients.

"In our position, the first thing we recommend is to educate everyone 
about this," PSNA CEO Betsy Snook said.

Snook talked about a nurse who came to one of PSNA's "Medical 
Marijuana: Myths & Medicine" education presentations.

Snook said the nurse, who works at a skilled nursing facility, said 
her patients asked her about medical marijuana and the nurse said she 
did not know enough about it to discuss it with said patients.

"That's not a good enough answer for a nurse," Snook said.

She said health care providers not only need to be educated, but need 
to comment on the topic to make the best possible bill in Pennsylvania.

While the current version of the bill places limits on what diagnoses 
are needed to prescribe marijuana, Snook said in talks with Gov. 
Wolf's office, it's been established that room exists in the bill to 
include or exclude more diagnoses.

"We're going to continue to make it the best bill we can," she said.

Some drugs that treat spasmodic disorders leave patients in 
"catatonic states," she said.

Snook said doctors prescribed marijuana tinctures in the 1800s for 
spasmodic disorders before marijuana prohibition took effect.

The PSNA supports the legalization of medical marijuana under three 
conditions: it must be medically prescribed, tightly controlled, and 
strictly monitored.

Snook also said because marijuana is still illegal on the federal 
level, the PSNA is pushing for doctors to be protected from federal 
punishment for prescribing the drug.

On Monday, April 6, look for part three in The Daily Review's series, 
when we will discuss the possibility of recreational marijuana 
legalization in Pennsylvania with local representatives and area 
members of the law enforcement community.
- ---
MAP posted-by: Jay Bergstrom