Pubdate: Fri, 22 Jan 2016
Source: Lexington Herald-Leader (KY)
Copyright: 2016 Lexington Herald-Leader
Author: Matthew Neltner
Note: Dr. Matthew Neltner is a Lexington physician.


Recently I read a national article about a medical team that looked 
the other way while a patient was smoking marijuana in the bathroom. 
On a closer reading of the article, the medical case was from over 20 
years ago. First mistake: not doing the math (we'll get to this in a 
minute). Second mistake: concluding that the answer is "medical" marijuana.

Did you know that the two major compounds that are medicinal in 
marijuana are already 100 percent legal here in Kentucky?

It's true. The Food and Drug Administration approved dronabinol 
(brand name Marinol) in 1985 for nausea and vomiting for chemotherapy 
patients and loss of appetite in AIDS. Dronabinol is delta-9- 
tetrahydrocannabinol (delta-9-THC), the main form of THC in marijuana.

The second compound in marijuana which appears to have medicinal 
value is also legal here: Gov. Steve Beshear signed a law in 2014 
permitting cannabidiol to be sold.

Two important principles of medicine people completely get wrong 
about "medical"marijuana. No. 1: Penicillin was derived from mold, 
but if you have a bacterial infection I'm not going to give you moldy 
bread. No. 2: The difference between a medication and a poison is the dose.

Let's talk about math. Cannabis in the 1970s was about 1 percent to 2 
percent THC; in the 1990s, it averaged 4 percent THC. Modern-day 
cannabis averages around 12 percent THC.

This 12 percent stuff goes by several names amongst the college 
students I meet: "Reggie" or "regular," but most people using 
"medical" marijuana are smoking products that are up to 30 percent 
THC. If someone is smoking one gram of "chronic" "skunk" or "loud" 
plant material that's 1000 mg times 30 percent THC equals 300 mg THC.

Consider that dronabinol comes in doses of 2.5 mg to 10 mg capsules, 
and that the FDA lists a maximum daily dose as 20 mg. My point is 
that most people who are smoking cannabis are overdosed on it, and 
there are alternatives.

In the case mentioned above from 20 years ago, let's say he was using 
one-half gram of cannabis (one joint), which likely contained 20 mg 
THC (500 mg times .04). With the strong "medical" cannabis that 
people use today that would range from 60 mg to 150 mg (500 mg times 
12 percent to 30 percent).

Assuming all other prescription medications had already failed it 
would be reasonable to try someone who was a chronic user on higher 
doses (lets say 20 mg to 30 mg) of dronabinol (and a taper of 
cannabidiol as well). There's a good chance a heavy cannabis user 
would experience cannabis withdrawal going from 150 mg a day to 30 mg 
a day. By the way, marijuana can also cause nausea in cases of high 
(pun not intended) dose usage.

The delivery method is worth noting as inhaled THC seems to have a 
very different absorption profile than orally administered 
dronabinol, which appears to have some inconsistent results from 
patient to patient.

This takes the debate back to public funding for research into drug 
delivery, rather than letting the commercial sector (or black market) 
develop habit-forming products that are marketed to children. As an 
aside: there is an interesting historical parallel in how humans bred 
tobacco to have more nicotine, and now cannabis with THC.

We need more research; I'd also like to see some guidelines for 
off-label use of dronabinol.

As far as "medical" marijuana goes, the debate will continue, I'm 
certain. Hypothetically speaking, if Tylenol doubled the rate of 
schizophrenia and bipolar disorder do you think there would be any 
debate about taking it off the shelves?

In my line of work I've definitely seen cases where cannabis caused 
side effects, including psychosis.
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MAP posted-by: Jay Bergstrom