Saturday, September 16th 2017
New Mexico State Department of Health
Medical Cannabis Advisory Board
Medical Cannabis Program
PO Box 26110
Santa Fe, NM, 87502-6110
Medical Cannabis Program
PO Box 26110
Santa Fe, NM, 87502-6110
Petition: Requesting The Inclusion Of A New Medical Condition: that "qualified patient" means a resident of New Mexico who has been [diagnosed by a practitioner as having a debilitating medical condition and has received written certification and] issued a registry identification card [issued] pursuant to the Lynn and Erin Compassionate Use Act [and] on the basis of: (1) having been diagnosed by a practitioner as having a debilitating medical condition; or
(2) status as a veteran;
Table of Contents
Pg. 1 Cover Page
Pg. 2 Petition Introduction
Pg. 3 Petition Purpose and Background
Pg. 34 Relief Requested In Petition
Pg. 35 - 38 References
Petition Introduction: Requesting The Inclusion Of A New Medical Condition: that "qualified patient" means a resident of New Mexico who has been [diagnosed by a practitioner as having a debilitating medical condition and has received written certification and] issued a registry identification card [issued] pursuant to the Lynn and Erin Compassionate Use Act [and] on the basis of: (1) having been diagnosed by a practitioner as having a debilitating medical condition; or (2) status as a veteran;
Making a persons stauts as a Veteran to qualify into the Medical Cannabis Program is not saying that all Veterans are sick in any way, this qualifying option is being Petitioned for- due to the fact that Veterans of military service have a disproportionately higher rates of certain debilitating medical conditions as compared to the general population. And the inclusion of a persons Veterans status would enable safe and eqaul access to medical cannabis in the State’s program.
New Mexico’s medical cannabis history started in 1978, after public hearings the legislature enacted H.B. 329, the nation’s first law recognizing the medical value of cannabis. The New Mexico’s medical cannabis program (MCP) is the only program in the U.S. that places sole responsibility for regulation on the state’s Department of Health. Doctors must comply with state requirements for patients to be considered for applying to the medical cannabis program.
In the Lynn and Erin Compassionate Use Act, (2007) the law states; The Secretary of Health shall establish an advisory board consisting of eight practitioners representing the fields of neurology, pain management, medical oncology, psychiatry, infectious disease, family medicine and gynecology. The practitioners shall be nationally board-certified in their area of specialty and knowledgeable about the medical use of cannabis. The members shall be chosen for appointment by the Secretary from a list proposed by the New Mexico Medical Society. A quorum of the advisory board shall consist of three members. The advisory board shall:
A. review and recommend to the department for approval additional debilitating medical conditions that would benefit from the medical use of cannabis;
B. accept and review petitions to add medical conditions, medical treatments or diseases to the list of debilitating medical conditions that qualify for the medical use of cannabis;
C. convene at least twice per year to conduct public hearings and to evaluate petitions, which shall be maintained as confidential personal health information, to add medical conditions, medical treatments or diseases to the list of debilitating medical conditions that qualify for the medical use of cannabis;
D. issue recommendations concerning rules to be promulgated for the issuance of the registry identification cards; and
E. recommend quantities of cannabis that are necessary to constitute an adequate supply for qualified patients and primary caregivers.
First, do no harm. As an important step in becoming a doctor, medical students must take the Hippocratic Oath. And one of the promises within that oath is “first, do no harm”.
A. review and recommend to the department for approval additional debilitating medical conditions that would benefit from the medical use of cannabis;
B. accept and review petitions to add medical conditions, medical treatments or diseases to the list of debilitating medical conditions that qualify for the medical use of cannabis;
C. convene at least twice per year to conduct public hearings and to evaluate petitions, which shall be maintained as confidential personal health information, to add medical conditions, medical treatments or diseases to the list of debilitating medical conditions that qualify for the medical use of cannabis;
D. issue recommendations concerning rules to be promulgated for the issuance of the registry identification cards; and
E. recommend quantities of cannabis that are necessary to constitute an adequate supply for qualified patients and primary caregivers.
First, do no harm. As an important step in becoming a doctor, medical students must take the Hippocratic Oath. And one of the promises within that oath is “first, do no harm”.
We have a sound law in the Lynn and Erin Compassionate Use Act, as Section 2 reads; PURPOSE OF ACT.--The purpose of the Lynn and Erin Compassionate Use Act is to allow the beneficial use of medical cannabis in a regulated system for alleviating symptoms caused by debilitating medical conditions and their medical treatments.
“ARTICLE 2B. LYNN AND ERIN COMPASSIONATE USE ACT
N.M. Stat. Ann. § 26-2B-2 (2009)
§ 26-2B-2. Purpose of act
The purpose of the Lynn and Erin Compassionate Use Act [26-2B-1 NMSA 1978] is to allow the beneficial use of medical cannabis in a regulated system for alleviating symptoms caused by debilitating medical conditions and their medical treatments.
HISTORY: Laws 2007, ch. 210, § 2.
EFFECTIVE DATES. --Laws 2007, ch. 210, § 12 makes the act effective July 1, 2007.”
Mosby’s Medical Dictionary states that “medical treatment” means; the management and care of a patient to combat disease or disorder. Medical treatment includes: Using prescription medications, or use of a non-prescription drug at prescription strength; and or treatment of disease by hygienic and pharmacologic remedies, as distinguished from invasive surgical procedures. Treatment may be pharmacologic, using drugs; surgical, involving operative procedures; or supportive, building the patient's strength. It may be specific for the disorder, or symptomatic to relieve symptoms without effecting a cure.(Mosby's Medical Dictionary, 9th edition.)
What is a chronic medical condition?
A chronic disease is one lasting 3 months or more, by the definition of the U.S. National Center for Health Statistics. Chronic diseases generally cannot be prevented by vaccines or cured by medication, nor do they just disappear. Harvard Medical Dictionary defines chronic as: Any condition that lasts a long time or recurs over time; chronic pain as: Pain that persists after an injury has healed or a disease is over; and chronic pain syndrome as : Long-term, severe pain that doesn't spring from an injury or illness, that interferes with daily life, and is often accompanied by other problems, such as depression, irritability, and anxiety.
A chronic disease is one lasting 3 months or more, by the definition of the U.S. National Center for Health Statistics. Chronic diseases generally cannot be prevented by vaccines or cured by medication, nor do they just disappear. Harvard Medical Dictionary defines chronic as: Any condition that lasts a long time or recurs over time; chronic pain as: Pain that persists after an injury has healed or a disease is over; and chronic pain syndrome as : Long-term, severe pain that doesn't spring from an injury or illness, that interferes with daily life, and is often accompanied by other problems, such as depression, irritability, and anxiety.
What is the meaning of debilitating?
Something that's debilitating seriously affects someone or something's strength or ability to carry on with regular activities, like a debilitating illness. Debilitating comes from the Latin word debilis, meaning "weak." That's why you'll often see the adjective used to describe illness, despite the negative reference.
Something that's debilitating seriously affects someone or something's strength or ability to carry on with regular activities, like a debilitating illness. Debilitating comes from the Latin word debilis, meaning "weak." That's why you'll often see the adjective used to describe illness, despite the negative reference.
Petition Purpose and Background
The purpose of this petition is; Requesting The Inclusion Of A New Medical Condition: "qualified patient" means a resident of New Mexico who has been [diagnosed by a practitioner as having a debilitating medical condition and has received written certification and] issued a registry identification card [issued] pursuant to the Lynn and Erin Compassionate Use Act [and] on the basis of: (1) having been diagnosed by a practitioner as having a debilitating medical condition; or (2) status as a veteran.
This petition for the Medical Treatment that pertains to Requesting The Inclusion Of A New Medical Condition: "qualified patient" means a resident of New Mexico who has been [diagnosed by a practitioner as having a debilitating medical condition and has received written certification and] issued a registry identification card [issued] pursuant to the Lynn and Erin Compassionate Use Act [and] on the basis of: (1) having been diagnosed by a practitioner as having a debilitating medical condition; or (2) status as a veteran;is being provided to the state Department of Health Medical Cannabis Program so the advisory board can review and recommend to the department for approval additional debilitating medical conditions that would benefit from the medical use of cannabis with the Lynn and Erin Compassionate Use Act.
Who Should Qualify for Medical Cannabis Use?
According to Americans For Safe Access Policy Studies & Research:
Background: The most fundamental aspect of medical cannabis laws is the relationship between a patient and their physician. It is often only the physician and the patient that possess information about a patient’s health condition. However, many public officials and others who oppose medical cannabis laws often make assumptions about people’s health. The media have even fomented such inappropriate assumptions by naming a category of patients “Young Able Bodied Males,” condemning certain patients by visual assessment alone.
Findings: The health care information discussed between a patient and physician is considered private and protected under federal HIPAA laws. It is typically the purview of state medical boards to assess whether a physician has inappropriately recommended cannabis to someone who should not be qualified. Studies have shown in some medical cannabis states that the majority of patients suffer from chronic pain, an ailment that is not obviously detectable by another person. Nevertheless, police will often harass and arrest patients based on the assumption that someone is faking their illness.
Position: Medical professionals should have an unrestricted ability to recommend cannabis therapeutics and that should not be impacted by law enforcement’s perceptions.
According to Americans For Safe Access Policy Studies & Research:
Background: The most fundamental aspect of medical cannabis laws is the relationship between a patient and their physician. It is often only the physician and the patient that possess information about a patient’s health condition. However, many public officials and others who oppose medical cannabis laws often make assumptions about people’s health. The media have even fomented such inappropriate assumptions by naming a category of patients “Young Able Bodied Males,” condemning certain patients by visual assessment alone.
Findings: The health care information discussed between a patient and physician is considered private and protected under federal HIPAA laws. It is typically the purview of state medical boards to assess whether a physician has inappropriately recommended cannabis to someone who should not be qualified. Studies have shown in some medical cannabis states that the majority of patients suffer from chronic pain, an ailment that is not obviously detectable by another person. Nevertheless, police will often harass and arrest patients based on the assumption that someone is faking their illness.
Position: Medical professionals should have an unrestricted ability to recommend cannabis therapeutics and that should not be impacted by law enforcement’s perceptions.
“Qualifying medical condition” shall mean any condition for which treatment with medical cannabis would be beneficial, as determined by a patient's qualified medical professional, including but not limited to cancer, glaucoma, positive status for human immunodeficiency virus, acquired immune deficiency syndrome (AIDS), hepatitis C, amyotrophic lateral sclerosis (ALS), Crohn’s disease, Parkinson’s disease, post-traumatic stress disorder, arthritis, chronic pain, neuropathic and other intractable chronic pain, and multiple sclerosis.
“Qualifying patient” shall mean a person who has a written recommendation from a qualified medical professional for the medical use of cannabis.
Per the V.A. -Definition: Veteran: A “veteran” is a person who. served in the active military, naval or air service, and. was discharged or released under conditions other than dishonorable. A veteran is a former member of the Armed Forces of the United States (Army, Navy, Air Force, Marine Corps, and Coast Guard) who served on active duty, the National Guard and Reserve is included.
Veterans and Medical Cannabis
A Note from Americans for Safe Access [ http://www.safeaccessnow.org/veterans_booklet ]
“We are committed to ensuring safe, legal availability of marijuana for medical uses. Today over one million Americans are legally using medical marijuana—or "cannabis," as it is more properly called—under the care of their medical professional, and nearly half the country lives in a state where this treatment is an option. This publication series is intended to help medical professionals, patients and policymakers better understand how cannabis may be used safely and effectively as a treatment for many medical conditions. You will find information on:
A Note from Americans for Safe Access [ http://www.safeaccessnow.org/veterans_booklet ]
“We are committed to ensuring safe, legal availability of marijuana for medical uses. Today over one million Americans are legally using medical marijuana—or "cannabis," as it is more properly called—under the care of their medical professional, and nearly half the country lives in a state where this treatment is an option. This publication series is intended to help medical professionals, patients and policymakers better understand how cannabis may be used safely and effectively as a treatment for many medical conditions. You will find information on:
While the federal prohibition of cannabis has limited modern clinical research and resulted in considerable misinformation, a scientific consensus on its therapeutic value has emerged, based on a growing body of successful clinical trials and preclinical research. The experience of patients, medical professionals and research has revealed that cannabis can safely treat a remarkably broad range of medical conditions, often more effectively than conventional pharmaceutical drugs. For some of the most difficult to treat conditions, such as multiple sclerosis and neuropathic pain, cannabis often works when nothing else does.
Why Marijuana is Legal to Recommend
Medical professionals have a legal right to recommend marijuana as a treatment in any state, as protected by the First Amendment. That was established by a 2004 United States Supreme Court decision to uphold earlier federal court rulings that doctors and their patients have a fundamental Constitutional right to freely discuss treatment options. State rules for qualifying an individual patient for legal protections when using medical marijuana differ as to who may make the recommendation and for what conditions, as well as how that recommendation is communicated to the appropriate state authorities. Medical professionals and individual patients should familiarize themselves with the applicable laws and regulations in their state. ASA provides state-by-state resources to help at: AmericansForSafeAccess.org/state_by_state_recommending_cannabis
Under federal law, marijuana may not be prescribed, but its therapeutic use can be recommended without any legal jeopardy. The court rulings that protect medical professionals stem from a lawsuit brought by a group of doctors and patients led by AIDS specialist Dr. Marcus Conant. The suit was filed in response to federal officials who, within weeks of California voters legalizing medical marijuana in 1996, had threatened to revoke the prescribing privileges of any physicians who recommended marijuana to their patients for medical use.[1] Dr. Conant contended that such a policy would violate the First Amendment, and the federal courts agreed.[2, 3]
What doctors may and may not do. In Conant v. Walters, the Ninth Circuit Court of Appeals held that the federal government could neither punish nor threaten a doctor merely for recommending the use of marijuana to a patient.[4, 5] But it remains illegal for a doctor to "aid and abet" a patient in obtaining marijuana.[6] This means physicians and other medical professionals may discuss the pros and cons of medical marijuana with any patient, and recommend its use whenever appropriate. They may put that in writing or otherwise participate in state medical marijuana programs without fear of legal reprisal.[7] This is true even when the recommending medical professional knows the patient will use the recommendation to obtain cannabis through a state program.[8] What physicians may not do is provide cannabis directly to a patient[9] or tell patients how or where to obtain it.[10]
Patients protected under state law, not federal. As of July 2014, 23 states and the District of Columbia provide legal protections. However, all use of marijuana remains illegal under federal law, and in June 2005, the U.S. Supreme Court in Gonzales v. Raich ruled that state medical marijuana laws do not provide protection from federal prosecution.[11] Under the Obama Administration, the Department of Justice has issued three memos providing guidance to federal prosecutors, each indicating that individual patients and caregivers should not be federal enforcement priorities. The latest memo indicates enforcement should be left to states so long as they have effective regulations in place for use and distribution. An analysis by ASA of existing state laws and local regulations found that all reflect the same general enforcement priorities as the 2013 federal guidelines.[12]
For assistance with determining how best to write or obtain a legal recommendation for marijuana, please contact ASA at 1-888-929-4367.”
Medical Professionals Say Marijuana is Medicine
Thousands of studies published in peer-reviewed journals indicate marijuana has medical value in treating patients with such serious conditions as AIDS, glaucoma, cancer, epilepsy, and chronic pain, as well as a variety of such neurological disorders as multiple sclerosis, Parkinsonism, and ALS.
A 2013 poll conducted by the New England Journal of Medicine found that three out of four clinicians would recommend the use of medical marijuana for a hypothetical cancer patient.[13] The use of medical marijuana has been endorsed by numerous professional organizations, including the American Academy of Family Physicians, the American Public Health Association, and the American Nurses Association. Its use is supported by such leading medical publications as The New England Journal of Medicine and The Lancet. The International Cannabinoid Research Society was formally incorporated as a scientific research organization in 1991 with 50 members; as of 2014, there are nearly 500 around the world. The International Association for Cannabinoid Medicines (IACM), founded in 2000, publishes a bi-weekly bulletin and holds international symposia to highlight emerging research in marijuana therapeutics.
The safety and efficacy of marijuana has been attested to by numerous government studies and reports issued over the past 70 years. These include the 1944 LaGuardia Report, the Shafer Commission Report in 1972, a review commissioned by the British House of Lords in 1997, the Institutes of Medicine report of 1999, research sponsored by Health Canada, and numerous studies conducted in the Netherlands, where cannabis has been quasi-legal since 1976 and is currently available from pharmacies by prescription.
Scientific Research Advances
While modern research has until recently been sharply limited by federal prohibition, the last few decades have seen rapid change. More than 15,000 modern peer-reviewed scientific articles on the chemistry and pharmacology of marijuana and cannabinoids have been published, as well as more than 2,000 articles on the body's natural cannabinoids and the receptors they attach to.[14] The discovery of the endocannabinoid system (ECS) opened a door to new understandings of how the body regulates internal systems and how the phytocannabinoids found in the marijuana plant interact with it. Endocannabinoids are crucial to bioregulation, and evidence suggests they play a role in inflammation, insulin sensitivity, and fat and energy metabolism, as well as chronic neurologic and immune conditions. The cannabinoid receptors CB1 and CB2 are identified targets for treating a remarkable variety of serious medical conditions.[15-18]
A 2009 review of controlled clinical studies with medical marijuana conducted over a 38-year period found that “nearly all of the 33 published controlled clinical trials conducted in the United States have shown significant and measurable benefits in subjects receiving the treatment.”[19] The review's authors note that the more than 100 different cannabinoids in marijuana have the capacity for analgesia through neuromodulation in ascending and descending pain pathways, neuroprotection, and anti-inflammatory mechanisms. Research into the therapeutic potential of cannabis and cannabinoids has expanded considerably in the past decade. As of May 2014, the Center for Medicinal Cannabis Research, a state-funded $8.7-million research effort at University of California campuses, had completed 13 approved studies. Of those, seven published double-blind, placebo-controlled studies examined pain relief, and each showed cannabis to be effective.[20]
No adverse health effects related to medical marijuana use have been reported, even among the most seriously ill and immune-compromised patients. Research on CD4 immunity in AIDS patients found no negative effects to the immune systems of patients undergoing marijuana therapy in clinical trials.[21] A complete health assessment in 2002 of four of the patients enrolled in the U.S. Investigational New Drug program who had used marijuana daily for between 11 and 27 years found marijuana to be clinically effective for each with no negative health consequences.[22]
In the United Kingdom, GW Pharmaceuticals has been conducting clinical trials for more than a decade with its marijuana medicine, Sativex® Oromucosal Spray, a controlled-dose whole-plant extract. GW's Phase II and Phase III trials show positive results for the relief of neurological pain related to: multiple sclerosis (MS), spinal cord injury, peripheral nerve injury (including peripheral neuropathy secondary to diabetes mellitus or AIDS), central nervous system damage, neuroinvasive cancer, dystonias, cerebral vascular accident, and spina bifida. They have also shown cannabinoids to be effective in clinical trials for the relief of pain and inflammation in rheumatoid arthritis and also pain relief in brachial plexus injury.[23-26]
Sativex® was approved in Canada for symptomatic relief of neuropathic pain in 2005, in 2007 for patients with advanced cancer whose pain is not fully alleviated by opiates, and in 2010 for spasticity related to multiple sclerosis. As of 2014, Sativex has been made available or approved for named patient prescription use in 24 countries, including the UK, Spain, Italy and Germany.
In the US, GW was granted an import license for Sativex® by the DEA following meetings in 2005 with the FDA, DEA, the Office for National Drug Control Policy, and the National Institute for Drug Abuse. Sativex® is currently an investigational drug in FDA-approved clinical trials as an adjunctive analgesic treatment for patients with advanced cancer whose pain is not relieved by opioids. In 2013, GW Pharmaceuticals received FDA approval to test a highly purified cannabinoid extract (cannabidiol or CBD) named Epidiolex® on a limited number of US children with seizure disorders. As of January 2014, seven US pediatric epilepsy specialists have been approved to treat 125 children with Dravet syndrome, Lennox-Gastaut syndrome, and other pediatric epilepsy syndromes.
MEDICAL MARIJUANA AND VETERANS CONDITIONS
As of May 2013, there were more than 23 million total living veterans of military service in the US. Of those, almost 17 million served in wars. That includes more than 1.7 million veterans of WWII, 2.2 million veterans of the Korean War, 7.4 million veterans of the Vietnam War, 2.3 million veterans from the Gulf War (1990-1991), and more than 1.3 million who served in Afghanistan or Iraq or both.
Veterans of military service have a disproportionately high rate of certain debilitating medical conditions as compared to the general population. Some of those conditions may result from injury or exposures to toxins, but not all. The correlation between military service and higher rates of the conditions discussed in this booklet are clear and well-documented, but the cause is not known for many.
That has created some barriers to treatment, as the Veterans Health Administration (VHA) has at times resisted classifying conditions affecting veterans as being the result of their military service. Soldiers exposed to radiation during their participation in weapons trials in the 1950’s and 1960’s, for instance, were sworn to secrecy. Those exposed to Agent Orange in Vietnam had to wait decades for the VHA to acknowledge the cancers and other conditions they suffered were the result of their service. It was more than 20 years before scientists identified the changes in the brains of many of those who returned from the Gulf War with a collection of neurological symptoms.
The VHA has also resisted making all recommended treatments available to veterans. Cannabis has been found to help many patients suffering from conditions that can afflict veterans as a result of their service, including chronic pain, cancer, ALS, traumatic brain injury, post-traumatic stress disorders, and phantom limb pain. State medical cannabis programs making therapeutic use legal with a doctor’s recommendation were in place for almost 15 years before the VA changed its policy to allow veterans who use medical cannabis to receive all VA health services. In January, 2011, Robert A. Petzel M.D., the Under Secretary for Health, issued VHA Directive 2011-004, which states that “patients participating in State marijuana programs must not be denied VHA services.”
CANNABIS AND CHRONIC PAIN
Veterans can experience persistent and disabling pain as the result of numerous and sometimes multiple causes. Among them are injuries to the back, neck and spinal cord; cancer; arthritis and other rheumatic and degenerative hip, joint and connective tissue disorders; and severe burns.
The Congressional Research Service reports that as of February 2013, the number of US military service members wounded in combat in Afghanistan and Iraq totaled 50,450. Combat wounds that can result in chronic pain include spinal and traumatic brain injuries. Between 2000 and 2012, there were more than 48,000 reported cases of moderate to severe brain injuries among active military service members.[27]
Pain is not a primary condition or injury, but rather a severe, frequently intolerable symptom that varies in frequency, duration, and severity according to the individual. The underlying condition determines the appropriate curative approach, but does not determine the proper symptom management. It is the character, severity, location and duration of the pain that determines the range of appropriate therapies.
Chronic pain is a widespread public health issue. Epidemiological statistics are alarming: In Europe, it is estimated that one in four adults has a chronic pain condition. In the US, it is estimated that at least 38 million adults suffer from chronic pain, and at least 12 million have used cannabis as a treatment.[28]
For veterans in pain, the goal is to function as fully as possible by reducing their pain as much as possible, while minimizing the often debilitating side effects of the pain therapies. Failure to adequately treat severe and/or chronic pain can have tragic consequences. Not infrequently, people in unrelieved pain want to die. Despair can also cause patients to discontinue potentially life-saving procedures (e.g., chemotherapy or surgery), which themselves cause severe suffering. In such dire cases, anything that helps to alleviate the pain will prolong and improve these veterans' lives.
Cannabis can serve at least two important roles in safe, effective pain management. It can provide relief from the pain itself (either alone or in combination with other analgesics), and it can control the nausea associated with taking opioid drugs, as well as the nausea, vomiting and dizziness that often accompany severe, prolonged pain. In addition, cannabis significantly enhances the effectiveness of opioid therapies.
Opioid therapy is often an effective treatment for severe pain, but all opiates have the potential to induce nausea. The intensity and duration of this nausea can cause discomfort and additional suffering that can lead to malnourishment, anorexia, wasting, and a severe decline in a patient's health. Some people find the nausea so intolerable that they are inclined to discontinue the primary pain treatment, rather than endure the nausea.
Inhaled cannabis provides almost immediate relief for nausea with significantly fewer adverse side effects than orally ingested Marinol. Inhalation allows the active compounds in cannabis to be absorbed into the bloodstream with greater speed and efficiency. It is for this reason that inhalation is an increasingly common, and often preferable, route of administration for many medications. Cannabis may also be more effective than Marinol because it contains many more cannabinoids than just the THC that is Marinol's active ingredient. The additional cannabinoids may well have additional and complementary antiemetic qualities. They have been conclusively shown to have better pain-control properties when taken in combination than THC alone, and mitigate anxiety and other side-effects of THC.
Research on cannabis and pain management
Cannabis has been used as an analgesic for at least 5,000 years,[29-31] and patients often report significant pain relief from cannabis, even in cases where conventional pain therapies have failed.[32-37] Research has even shown that the natural endocannabinoid system has a role in regulating migraines.[38-40]
After reviewing a series of trials in 1997, the U.S. Society for Neuroscience concluded that “substances similar to or derived from marijuana could benefit the more than 97 million Americans who experience some form of pain each year.”[41] A 1999 study commissioned by the White House and conducted by the Institute of Medicine also recognized the role that cannabis can play in treating chronic pain: “After nausea and vomiting, chronic pain was the condition cited most often to the IOM study team as a medicinal use for marijuana.”[42] Between 1975 and 2009, there were more than 300 studies showing that cannabinoids and cannabis can help patients experiencing chronic pain.[43]
Orthopedic injuries including loss of limbs can result in chronic pain that is very difficult to treat. Military operations just in Iraq and Afghanistan have resulted in 1,715 amputations as of December 2012.[44] Amputations commonly result in phantom limb pain, a serious neuropathic pain condition affecting 50-80 percent of amputees, sometimes for many years. Phantom limb pain may occur during the first year after amputation and often remains chronic over months or years, either with no improvement or an increase in pain.[45-58]
Among U.S. veterans with current significant phantom limb pain, 27 percent had pain for more than 20 days per month, 10 percent for 11 to 20 days, 14 percent for 6 to 10 days, and 49 percent for 5 days or less per month.[59] Phantom limb pain is often poorly understood and difficult to manage. Current treatments include physical, behavioral, and medical approaches, including opioids and adjunct medications.[60]
A 1984 survey of 5,000 US veterans with amputations related to military service found that 78 percent had current phantom limb pain and only 1 percent had experienced relief from any treatment.[61] A small study of 48 British veterans with phantom limb pain found that 56 percent reported no relief from any pain medications.[62] That difficulty in relieving pain is common to other types of chronic neuropathic pain, such as may result from cancer, HIV/AIDS, or diabetes.
Cannabinoids may provide relief; some of the most encouraging clinical data on effects of cannabinoids on chronic pain are from studies of neuropathic pain.[63-68] The effectiveness of cannabis and cannabinoids in relieving neuropathic pain has been demonstrated in more than three dozen preclinical and clinical trials.[69] It is often effective when opioid painkillers have failed to provide relief.[70] A trial of smoked cannabis to treat HIV-associated daily neuropathic pain in 50 patients showed an average reduction of pain by 30 percent over a treatment course of only five days.[71] Cannabis can be effective for neuropathic pain even at low doses.72 Multiple trials indicate that a whole-plant cannabis extract (Sativex®) is effective in reducing pain in patients suffering intractable neuropathic pain.[72,73] A review of over 20 clinical trials on cannabis and cannabinoids found that whole plant cannabis and extracts are superior to oral THC for the treatment of pain. Health Canada approved Sativex® for prescription in the treatment of HIV-associated neuropathic pain in 2005 and cancer pain in 2007. The mechanism for that analgesic action involves both the body’s cannabinoid receptors and direct action on the neurons that transmit pain.[74-75]
The activity of the more than 100 cannabinoids and other components on the plant may explain its superiority in reducing pain when comparing whole plant cannabis and extracts to THC alone. For instance, the cannabinoids cannabidiol (CBD) and cannabichromene (CBC), the second and third most common active compounds on the plant, exhibit anti-inflammatory and analgesic actions, although weaker than THC. Similarly, beta-sitosterol, a non-cannabinoid ingredient found in cannabis, was able to decrease inflammation and edema in skin treatment.[76] And a unique flavanoid found only in cannabis, cannaflavin A, inhibits the inflammatory molecule PGE-2, thirty times more potently than aspirin.[77] Lastly beta-caryophyllene, a cannabinoid found in many plants besides cannabis, has strong anti-inflammatory properties but no noticeable side effects.[78] Beta-caryophyllen is the most commonly consumed FDA-approved cannabinoid in food.
The IOM report found that “basic biology indicates a role for cannabinoids in pain and control of movement, which is consistent with a possible therapeutic role in these areas. The evidence is relatively strong for the treatment of pain and intriguingly, although less well established, for movement disorder.” According to the IOM Report and numerous independent research articles, a number of areas in the brain that have an established role in sensing and processing pain respond to the analgesic effect of cannabis, adding that cannabinoids have been used successfully to treat cancer pain, which is often resistant to treatment with opiates. The effectiveness of cannabinoids in treating intractable cancer pain has been demonstrated in several subsequent clinical trials of a dosage-controlled sublingual spray.
Several studies have found that cannabinoids have analgesic effects in animal models, sometimes equivalent to codeine.[79-83] Cannabinoids also seem to synergize with opioids, which often lose their effectiveness as patients build up tolerance. One study found morphine was 15 times more active in rats with the addition of a small dose of THC. Codeine was enhanced on the order of 900 fold.[84] In 1990, researchers conducted a double-blind study comparing the antispasmodic and analgesic effects of THC, oral Codeine, and a placebo on a single patient suffering from a spinal cord injury.[85] Their findings confirmed the analgesic effects of THC being “equivalent to codeine.” A 1997 study made similar findings related to morphine.[86]
A 1999 article reviewing the body of scientific animal research concerning the analgesic effects of marijuana concludes that “[t]here is now unequivocal evidence that cannabinoids are antinociceptive [capable of blocking the appreciation or transmission of pain] in animal models of acute pain.”[87] The report further notes that multiple cannabinoids and noncannabinoid components can serve as anti-inflammatory agents, and so have potential in preventing and reducing pain caused by swelling (such as arthritis).
In short, the research community recognizes the potential benefits of cannabis for certain patients, including:
Chemotherapy patients, especially those being treated for mucositis, nausea, and anorexia.
Postoperative pain patients (using cannabinoids as an opioid adjunct to reduce the nausea and vomiting).
Patients with spinal cord injury, peripheral neuropathic pain, or central post-stroke pain.
Patients with chronic pain and insomnia.
AIDS patients with cachexia, AIDS neuropathy, or any significant pain.
Britain's House of Lords reached similar conclusions and called for making cannabis available by prescription.[88]
VETERANS AND CANCER
Veterans have higher rates of some cancers than the general population. The Armed Forces Health Surveillance Center reported in 2010 that, in the previous ten years, service members had higher rates of melanoma, brain, non-Hodgkin lymphoma, breast, prostate and testicular cancers than civilians. The Medical Surveillance Monthly Report in 2008 also found service members have higher rates of prostate and breast cancers. In some cases, those higher cancer rates are linked to exposures to chemicals, toxins, or radiation, in other cases the reasons have not yet been identified.[89]
Cancer rates vary by branch of service, gender and race, as well as dates and location of active duty. A 2009 study at Walter Reed Army Medical Center comparing reported cancer cases between 1990 and 2004 in the military and general population found higher incidence rates of prostate and breast cancers in the active duty military. Female soldiers have breast cancer rates 20-40 percent higher than other women.[90]
Researchers speculate chemical exposures may be a contributing factor in these breast cancer cases. Though the disease is extremely rare in men, dozens of male soldiers at Camp Lejeune have also developed breast cancers, possibly linked to a water supply that was contaminated with industrial solvents, benzene, and other chemicals from 1957 to at least 1987. Service members and their families stationed at Camp Lejeune in that time period also have unusually high rates of several other cancers, including esophageal, lung, bladder, multiple myeloma, scleroderma, non-Hodgkin’s lymphoma, leukemia, and other serious medical conditions.[91]
Exposures to chemicals or other toxins may also explain why thyroid cancer rates are significantly higher in the military than in the general population among white women, black women, and black men, according to a 2011 study of reported cases from 1990-2004 in individuals 20 to 49 years of age. As with other cancers, the study found the higher incidence rate of thyroid cancer varied by branch of service.[92]
Nuclear radiation has been a cancer factor for hundreds of thousands of veterans. Approximately 200,000 in Japan during the occupation in WWII were exposed to residual radiation from the use of atomic bombs at Hiroshima and Nagasaki. Another 200,000 were exposed during nuclear weapons testing between 1945 and 1962. Those who served the Gulf War and Operation Iraqi Freedom may have been exposed to depleted uranium. Among the types of cancer radiation can cause are thyroid, bone, breast, brain, colon, esophagus, lung, stomach, and pancreas as well as many others.[93]
Many veterans who served in Vietnam were also exposed to chemicals linked to cancer, in particular Agent Orange, an herbicide used extensively to destroy jungle foliage, that was frequently contaminated with dioxin, a dangerous toxin linked to increased risk of cancers, Type 2 diabetes, and Parkinson's disease. The cancers linked to Agent Orange exposure include soft-tissue sarcoma, Hodgkin’s disease, Non-Hodgkin’s lymphoma, multiple myeloma, chronic lymphocytic leukemia, and cancers of the prostate, lung, larynx, trachea and bronchus. For some cancers, the rates are dramatically higher for veterans exposed to Agent Orange. A 2008 study found they are more than twice as likely to have prostate cancer as the general population.[94]
A 2013 study of more than 2,700 veterans similarly found significantly higher rates of the deadliest, most-aggressive forms of prostate cancer. Researchers reported the overall risk of high-grade prostate cancer detection by biopsy is 52 percent higher in veterans exposed to Agent Orange, and the likelihood of finding the most aggressive form is 75 percent higher.[95]
VETERANS AND NEUROLOGICAL DISORDERS
Veterans disproportionately develop neurological conditions such as amyotrophic lateral sclerosis (ALS), Alzheimer's disease, and Parkinsonism for a variety of reasons, ranging from chemical exposures to Traumatic Brain Injury (TBI). From 2000 through the third quarter of 2013, the Department of Defense reports 287,861 diagnosed cases of TBI among active service members. Of those, more than 48,000 are classified as moderate to severe, and more than 10,000 were reported as not classifiable.[175] Even a mild or moderate TBI greatly increases the risk of several neurological disorders, including seizures and neurodegenerative disorders such as Alzheimer's and Parkinsonism.[176,177]
The risk for Alzheimer's in veterans who suffered a moderate TBI is more than 2.3 times higher, and more than 4.5 times higher for those with a severe TBI. The link between TBI and Parkinsonism has not been studied as extensively but is still well established as a linked condition that may not be seen for between six and 40 years.
Seizures are a common effect of most TBI, regardless of severity, with the risk increasing to as much as 95 times the general population. Post-traumatic epilepsy (PTE), in which seizures recur more than a week after the TBI, is less predictable than the initial seizures, but an increased risk remains for years after the initial injury.[178] PTE is likely to create more serious problems than other forms of epilepsy, with veterans who develop PTE more likely to have shortened lives and cognitive and motor problems.[179] PTE is commonly difficult to treat with conventional drug therapy, with cessation of seizures achieved in only 35 percent of those treated.[180,181]
Traumatic Brain Injury (TBI) can also result in neurological disorders. A high prevalence of epilepsy and other neurological disorders in US veterans who served in Afghanistan and Iraq were reported at the American Epilepsy Society's 67th Annual Meeting in December, 2013. The researchers found veterans are at a particularly high risk for psychological non-epileptic seizures (PNES) and epileptic seizure. Researchers at Duke found that 87,377 veterans with seizures diagnoses are currently in the VHA system, with higher incidences among veterans under the age of 46. Researchers at Baylor College of Medicine found a correlation between psychogenic non-epileptic seizures (PNES) among Afganistan and Iraq veterans who had PTSD or TBI diagnoses or both. Researchers who reviewed records for veterans diagnosed with PNES treated at the Portland, Oregon VAMC EMU from 2000-2011 found the majority continued to report seizures, even after three years of follow up, and only 21 percent were seizure free.
Cannabis may provide a superior alternative to other seizure medications, as clinical experience and more than 30 years of scientific research on how cannabinoids such as CBD and THC can reduce seizure activity have shown that it may work when other alternatives have failed. In addition to reports from patients and their families, the most recent studies in animal models found that CBD significantly reduced the percentage of those experiencing severe seizures and significantly reduced the mortality rate.[182-185]
Many people with seizure disorders treat their conditions with cannabis, and in late 2012 GW Pharmaceuticals received FDA approval to test a highly purified CBD extract named Epidiolex® on a limited number of US children with seizure disorders. So far, seven US pediatric epilepsy specialists have been approved to treat 125 children with Dravet syndrome, Lennox-Gastaut syndrome, and other pediatric epilepsy syndromes.[186]
Many veterans develop neurological disorders related to chemical exposures. Veterans who served in Vietnam may have been exposed to Agent Orange or other herbicides that can produce neurological disorders. Those who served in the Gulf War may have been exposed to nerve agents or other neurotoxic chemicals. A federal review in 1994 of research studies on the possible link between parkinsonism and chemicals used as herbicides and pesticides in Vietnam concluded that parkinsonian syndromes have been associated with both chronic and acute exposures to herbicides and pesticides.[187] Veterans with Parkinson’s disease who were exposed to Agent Orange or other herbicides during military service may be eligible for disability compensation and health care.
More than 200,000 veterans who served in the Persian Gulf during Operations Desert Shield and Desert Storm in 1990-1991 developed health problems that eventually became known as Gulf War illness. Research indicates that damage to the central nervous system is related to chronic symptoms of Gulf War Illness. While many symptoms of possible neurological disorders have been reported—including cognitive impairment, autonomic dysfunction, debilitating fatigue, and chronic widespread pain—no consensus on the diagnosis of the illness or its cause has been reached, though research published in 2013 describes changes to brain structure that explain many symptoms.
Brain imaging of Gulf War veterans found evidence that two types of changes in their brain structure correlate to a heightened sensitivity to pain, increased feelings of fatigue, and difficulties regulating heart rate and blood pressure, as well as memory problems – all symptoms of Gulf War Illness. Two other studies out of Georgetown also found evidence of neurological damage in Gulf War veterans, including abnormalities in the nerve cells in the brain that register fatigue and pain.[188,189]
A 2006 review of 22 studies of neurological function in Gulf War veterans also found that their incidence of amyotrophic lateral sclerosis (ALS) is significantly higher than among those who did not serve in that theater.[190]
CANNABIS AND NEUROLGICAL DISORDERS
Neurodegenerative diseases and movement disorders, which are sometimes interlinked, are among the many conditions that cannabis and cannabinoids may be particularly well suited to treat. Cannabinoids can protect the brain and central nervous system from the damage that leads to various neurological disorders. More than 100 research articles have been published on how cannabinoids act as neuroprotective agents to slow the progression of neurodegenerative diseases that disproportionately affect veterans. Researchers have also established that cannabinoids can alleviate the damage caused by strokes, as well as traumatic brain injury, spinal cord injury, and multiple sclerosis. No other medication offers the combination of anti-oxidative, anti-inflammatory and neuroprotective qualities of cannabis and cannabinoids.[191-193]
The therapeutic use of cannabis for treating neurological disorders has been known to western medicine for nearly two centuries. In 1839, Dr. William B. O'Shaughnessy wrote about cannabis that doctors had "gained an anti-convulsive remedy of the greatest value."[194] In 1890 Dr. J. Russell Reynolds, physician to Queen Victoria, noted in an article in The Lancet that for "organic disease of a gross character in the nervous centers . . . India hemp (cannabis) is the most useful agent with which I am acquainted."[195]
Extensive modern studies in both animals and humans have shown that cannabis can treat many movement disorders affecting people with neurolgical disorders because cannabinoids inhibit neurodegeneration and have antispasticity, analgesic, antitremor, and antiataxia properties.[196-214]
Research published in 2013 shows the active chemicals in cannabis are uniquely suited to fighting neurodegenerative diseases that can result from trauma, such as Alzheimer’s, Parkinson’s and amyotrophic lateral sclerosis (ALS).[215-217] The neuroprotective effects of cannabis, based on the combination of anti-inflammatory and anti-oxidant properties of the primary cannabinoids THC and CBD, is undergoing intense preclinical research for treating numerous neurodegenerative disorders.218 Recent research has revealed that chemicals similar to those in cannabis can also reduce the effects of serious brain injury and keep badly head-injured people alive.[219]
Neurodegenerative disorders such as Alzheimer's, Parkinson's and Huntington's diseases all share a number of common mechanisms: inflammation and over-stimulation of neurons and problems with supplying energy and oxygen to them. A 2012 review of experimental studies on the body’s cannabinoid system concluded that it operates on both cellular and molecular levels to protect neurons. Cannabinoids have antioxidant and anti-inflammatory effects that suppress the neuroinflammatory processes that contribute to neurodegenerative diseases as well as the progression of brain ageing. Cannabinoids play a protective role in regulating the mitochondrial activity that maintains the supply of energy and oxygen to brain cells, modulating molecular clearance processes to protect neurons, and regulating the production of new brain cells.[220]
In many neurodegenerative disorders, the body’s natural cannabinoid system has recently been found to be altered. That’s why much new research is devoted to determining how to manipulate the endogenous cannabinoid system with plant or synthetic cannabinoids to neurodegenerative disorders.[221,222]
Research has repeatedly demonstrated that plant cannabinoids exert the same neuroprotective effects as the body’s natural endocannabinoids. Recent studies of both animal models and human cell cultures of Parkinson’s disease have shown that the plant cannabinoids THC and CBD directly fight the disease and, in the case of the animal model, relieves its symptoms.[223-225]
Huntington’s disease is another neurodegenerative disorder for which there are currently limited treatment options but strong evidence for the benefits of cannabis-based medicine. Experimental studies of an animal model of Huntington’s disease found the progression of the disease was slowed by treatment with the plant cannabinoids THC and CBD. Both CB1 and CB2 receptors were shown to be involved in the protective, disease-fighting effects, something also indicated by a separate study that showed blocking the CB1 receptor in mice worsened the disease.[226-228] Researchers concluded that “cannabis-based medicine” is “capable of delaying disease progression.”
Brain injuries can also be mitigated by cannabinoids. The neuroprotective effects of cannabinoids such as CBD have also been shown in four separate studies published in 2013 to help fight the effects of several types of brain injury.[229-232] In one recent animal study of several types of brain injury, even a single very low dose of THC—three to four times less than create a noticeable behavioral effect—created a significant protective effect that lasted at least seven weeks.[233]
Multiple sclerosis, once thought to be primarily an autoimmune disorder, is now understood to be neurodegenerative.[234,235] In a federal court brief filed in support of physicians' right to recommend cannabis, the American Public Health Association notes that "a survey of British and American MS patients reports that after ingesting marijuana a significant majority experienced substantial improvements in controlling muscle spasticity and pain. An extensive neurological study found that herbal cannabis provided relief from both muscle spasms and ataxia (loss of coordination), a multiple benefit not achieved by any currently available medications."[236] Cannabinoids have also been shown to have powerful neuroprotective effects.[237, 238]
The endogenous cannabinoid system in the human body appears to be intricately involved in regulating normal physiology, including the control of movement. Central cannabinoid receptors are densely located in the basal ganglia, the area of the brain that regulates body movement, and appear to play a role in the manipulation of transmitter systems—increasing transmission of certain chemicals, inhibiting the release of others, and affecting how they are absorbed. [239-244]
Because they operate as modulators, endocannabinoids have paradoxical effects on the nervous system: sometimes they block neuronal excitability and other times they augment it. As scientists are developing a better understanding of the physiological role of the endocannabinoids, it is becoming clear that problems with the production or processing of these chemicals may be involved in the pathology of several neurological diseases.
Parkinson's disease has been linked to dysfunction in the body's dopamine system, specifically the production of too much of the neurotransmitter glutamate and oxidative damage to dopaminergic neurons. Studies have found a tight association between cannabinoids and dopamine, and recent research has produced anatomical, biochemical, and pharmacological evidence supporting a role for the endogenous cannabinoid system in the modulation of dopaminergic transmission.[245]
Oxidative stress in the brain is a major hallmark of motor and neurological diseases such as Parkinson's and Alzheimer's disease. Cannabinoids are able to protect neurons from oxidative damage.[246] The neuroprotective action of cannabinoids appears to result from their ability to inhibit reactive oxygen species, glutamate, and tumor necrosis factor. THC, CBD, and synthetic AM404 all contain phenolic groups in their chemical structure and are thus able to reduce radical oxygen species. Notably CBD has extraordinary antioxidant properties and can effect calcium homeostasis, both of which lead to positive effects against a wide range of neurodegenerative diseases.[247]
Few clinical trials have looked at cannabinoids and Parkinson's disease. However, research has shown that 25 percent of Parkinson's patients smoke cannabis, and 46 percent of these patients report improvement of side effects from long-term levodopa treatment.[248] A randomized placebo controlled study using extracts of cannabis produced significant improvements in patients' cognition. The authors note that they did not see improvements in pain or sleep disorders. They speculate that the oral route (versus inhaled) of cannabis ingestion leads to too much variability of cannabinoids in blood.[249]
Many diseases of the brain involve changes in inflammatory responses that lead to disease progression. Inflammation in the brain is mediated by microglial cells and treatments which target these cells can protect neurons from damage that leads to degeneration Multiple Sclerosis, Parkinson's and Alzheimer's disease are neuro-degenerative conditions for which cannabis and cannabinoid therapies show promise, both for treating the symptoms and the underlying disease by targeting microglial cells through cannabinoid receptors.[250]
Oxidative stress in the brain is a major hallmark of neurological disorders such as Parkinson's and Alzheimer's disease. Cannabinoids have well-established antioxidant properties that protect neurons from oxidative damage. Alzheimer's disease, characterized in part by a decrease in the production of new neurons, is associated with oxidative stress due to the membrane action of beta-amyloid peptide aggregates. A laboratory study published in 2004 indicates that one of the cannabis plant's primary components, cannabidiol (CBD), exerts a combination of neuroprotective, anti-oxidative and anti-apoptotic effects by inhibiting the release of the toxic beta-amyloid peptide.[251]
Recent studies suggest that endocannabinoids may control the growth and maturation of new neurons through the CB1 receptor.[252] Therefore, cannabinoids could reduce inflammation and protect brains in neurodegenerative conditions. The neuroprotective action of cannabinoids appears to result from their ability to inhibit reactive oxygen species, glutamate, and tumour necrosis factor. THC, CBD, and synthetic AM404 all contain phenolic groups in their chemical structure that can reduce oxidative stress on brain cells. Notably, CBD has extraordinary antioxidant properties and can affect calcium homeostasis, both of which lead to positive effects against a wide range of neurodegenerative diseases.
Cannabinoids represent an emerging therapeutic option for neurological disorders and neurodegenerative diseases. Targeted cannabinoid therapies are still in an early phase of development, but research suggests that they can be useful drugs for the treatment of many diseases.
This new research on cannabinoids and neurodegenerative diseases, coupled with the extensive work done on other neuroprotective and neurogenic qualities of cannabis and its components, indicates that cannabis may become the source of the most effective treatments for battling the neurological disorders that afflict millions of veterans.
How Cannabis Compares to Other Treatments
Chronic Pain Medications
According to the Institute of Medicine, "All of the currently available analgesic (pain-relieving) drugs have limited efficacy for some types of pain. Some are limited by dose-related side effects and some by the development of tolerance or dependence."
The opioid analgesics commonly used to combat pain include codeine (Dolacet, Hydrocet, Lorcet, Lortab); morphine (Avinza, Oramorph); oxycodone (Vicodin, Oxycontin, Roxicodone, Percocet, Roxicet); propoxyphene (Darvon, Darvocet) and tramadol (Ultram, Ultracet). These medicines can cause psychological and physical dependence, as well as constipation, dizziness, lightheadedness, mood changes, nausea, sedation, shortness of breath and vomiting. Taking high doses or mixing with alcohol can slow down breathing, a potentially fatal condition.
In addition, patients in pain are often prescribed muscle relaxants such as Robaxin and Flexeril; anti-anxiety agents such as Valium, Sinequan, Vistaril, Ativan and Xanax; hypnotics such as Halcion, Restoril, Chloralhydrate, Dalmane and Doral and anti-emetics such as Zofran, Compazine, Phenergan, Tigan and Marinol.
Robaxin's side effects include abnormal taste, amnesia, blurred vision, confusion, dizziness, drop in blood pressure and fainting, drowsiness, fever, flushing, headache, hives, indigestion, insomnia, itching, light-headedness, nasal congestion, nausea, pinkeye, poor coordination, rash, seizures, slowed heartbeat, uncontrolled eye movement, vertigo, vomiting and yellow eyes and skin.
Flexeril can cause abnormal heartbeats, aggressive behavior, agitation, anxiety, bloated feeling, blurred vision, confusion, constipation, convulsions, decreased appetite, depressed mood, diarrhea, difficulty falling or staying asleep, difficulty speaking, disorientation, double vision, excitement, fainting, fatigue, fluid retention, gas, hallucinations, headache, heartburn, hepatitis, hives, increased heart rate, indigestion, inflammation of the stomach, itching, lack of coordination, liver diseases, loss of sense of taste, low blood pressure, muscle twitching, nausea, nervousness, palpitations, paranoia, rash, ringing in the ears, severe allergic reaction, stomach and intestinal pain, sweating, swelling of the tongue or face, thirst, tingling in hands or feet, tremors, unpleasant taste in the mouth, urinating more or less than usual, vague feeling of bodily discomfort, vertigo, vomiting, weakness, and yellow eyes and skin.
The newer antiemetics, Anzamet, Kytril and Zofran, are serotonin antagonists, blocking the neurotransmitter that sends a vomiting signal to the brain. Rare side effects of these drugs include fever, fatigue, bone pain, muscle aches, constipation, loss of appetite, inflammation of the pancreas, changes in electrical activity of heart, vivid dreams, sleep problems, confusion, anxiety and facial swelling.
Reglan, a substituted benzamide, increases emptying of the stomach, thus decreasing the chance of developing nausea and vomiting due to food remaining in the stomach. When given at high doses, it blocks the messages to the part of the brain responsible for nausea and vomiting. Side effects include sleepiness, restlessness, diarrhea and dry mouth. Rarer side effects are rash, hives and decreased blood pressure.
Haldol and Inapsine are tranquilizers that block messages to the part of the brain responsible for nausea and vomiting. Possible side effects include decreased breathing rate, increased heart rate, decrease in blood pressure when changing position and, rarely, change in electrical activity of the heart.
Compazine and Torecan are phenothiazines, the first major anti-nausea drugs. Both have tranquilizing effects. Common side effects include dry mouth and constipation. Less common effects are blurred vision, restlessness, involuntary muscle movements, tremors, increased appetite, weight gain, increased heart rate and changes in electrical activity of heart. Rare side effects include jaundice, rash, hives and increased sensitivity to sunlight.
Benadryl, an antihistamine, is given along with Reglan, Haldol, Inapsine, Compazine and Torecan to counter side effects of restlessness, tongue protrusion and involuntary movements. Its side effects include sedation, drowsiness, dry mouth, dizziness, confusion, excitability and decreased blood pressure.
Benzodiazepine drugs Ativan and Xanax are prescribed to combat the anxiety associated with chronic pain. Ativan causes amnesia. Abruptly stopping the drug can cause anxiety, dizziness, nausea and vomiting, and tiredness. It can cause drowsiness, confusion, weakness and headache when first starting the drug. Nausea, vomiting, dry mouth, changes in heart rate and blood pressure and palpitations are possible side effects.
Cancer Medications
The American Cancer Society lists 269 medicines currently prescribed to treat cancer and its symptoms, and to treat the side effects of other cancer drugs. Some drugs are prescribed for pain caused by cancer, and cancer patients report pain relief with cannabis therapy. Many chemotherapy agents cause severe nausea and 13 drugs are currently prescribed to treat nausea, including Marinol, a synthetic form of delta-9-THC, the primary psychoactive component in cannabis.
Antiemetic medications used for treating nausea, and medications such as antihistamines that are sometimes prescribed in combination with antiemetics, are all discussed above, under pain medications.
Decadron (dexamethasone), a corticosteroid, is given with other chemotherapy drugs as an adjunct medication. Common side effects include increased appetite, irritation of stomach, euphoria, difficulty sleeping, mood changes, flushing, increased blood sugar, decreased blood potassium level. Possible side effects upon discontinuing the drug include adrenal insufficiency, weakness, aches, fever, dizziness, lowering of blood pressure when changing position, difficulty breathing, and low blood sugar.
Benzodiazepine drugs Ativan and Xanax are also prescribed to combat the effects of chemotherapy. Ativan causes amnesia. Abruptly stopping the drug can cause anxiety, dizziness, nausea and vomiting, and tiredness. It can cause drowsiness, confusion, weakness, and headache when first starting the drug. Nausea, vomiting, dry mouth, changes in heart rate and blood pressure, and palpitations are possible side effects.
In addition, in April 2003 the FDA approved the drug Emend (aprepitant) to help control delayed-onset nausea. It is given along with two other anti-nausea drugs. A regimen of three pills costs $250. The most common side effects with Emend are fatigue, nausea, loss of appetite, constipation and diarrhea.
Neurologic Medications
Benzodiazepines, levedopa, baclofen, dantrolene sodium, and tizanidine are the most widely used agents for reduction of spasticity. At high dosages, oral medications can cause unwanted side effects that include sedation, as well as changes in mood and cognition.
Benzodiazepines, which include Diazepam (Valium) and Clonazepam (Klonopin, Rivotril) are centrally acting agents that increase the affinity of GABA to its receptor. Diazepam is the oldest and most frequently used oral agent for managing spasticity. Benzodiazepine side effects include sedation, weakness, hypotension, GI symptoms, memory impairment, incoordination, confusion, depression and ataxia. Tolerance and dependency may occur and withdrawal on cessation. Tolerance may also lead to unacceptable dosage escalation.
Levedopa is common long-term treatment option for Parkinson's disease. Long-term use can result in diskynesia and is often a reason for not taking the drug. Diskynesia can lead to less control of voluntary movements and can result in tics or chorea. Dikynesia can result in excessive tongue rolling and after years of use it can manifest as "jerky" movements of the head and arms.
Baclofen (Lioresal) has been widely used for spasticity since 1967. It is a GABA agonist. Tolerance to the medication may develop. Baclofen must be slowly weaned to prevent withdrawal effects such as seizures, hallucinations and increased spasticity. It must be used with care in patients with renal insufficiency as its clearance is primarily renal. Side effects are predominantly from central depressant properties including sedation, ataxia, weakness and fatigue. May cause depression when combined with tizanidine or benzodiazepines.
Dantrolene Sodium (Dantrium) acts peripherally at the level of the muscle fiber and works best for cerebral palsy and traumatic brain injury. Because the action of dantrolene sodium is not selective for spastic muscles, it may cause generalized weakness, including weakness of the respiratory muscles. The side effects include drowsiness, dizziness, weakness, fatigue and diarrhea. In addition, hepatotoxicity (liver damage) occurs in < 1 percent of patients who take dantrolene sodium.
Tizanidine (Zanaflex) facilitates short-term vibratory inhibition of the H-reflex. Tizanidine in conjunction with baclofen or benzodiazepines has potential additive effects, including sedation and the possibility of liver toxicity. Dry mouth, somnolence, asthenia and dizziness are the most common side effects. Liver function problems and hallucinations may also occur.
Cannabis vs. Other Medications
Cannabis: By comparison, the side effects associated with cannabis are typically mild and are classified as “low risk.” Euphoric mood changes are among the most frequent side effects. Cannabinoids can exacerbate schizophrenic psychosis in predisposed persons, though it can also provide symptomatic relief in refractory schizophrenia. Cannabinoids impede cognitive and psychomotor performance, resulting in temporary impairment. Chronic use can lead to the development of tolerance. Tachycardia and hypotension are frequently documented as potentially adverse events in the cardiovascular system. A few cases of myocardial ischemia have been reported in young and previously healthy patients. Inhaling the smoke of cannabis cigarettes induces side effects on the respiratory system. Cannabinoids are contraindicated for patients with a history of cardiac ischemias. In summary, a low risk profile is evident from the literature available. Serious complications are extremely rare and are not usually reported during the use of cannabinoids for medical indications.
Why cannabis is safe to recommend
“The smoking of cannabis, even long term, is not harmful to health....” So began a 1995 editorial statement of Great Britain's leading medical journal, The Lancet. The long history of human use of cannabis also attests to its safety—nearly 5,000 years of documented use without a single death. In the same year as the Lancet editorial, Dr. Lester Grinspoon, a professor emeritus at Harvard Medical School who has published many influential books and articles on medical use of cannabis, had this to say in an article in the Journal of the American Medical Association:
One of medical cannabis greatest advantages as a medicine is its remarkable safety. It has little effect on major physiological functions. There is no known case of a lethal overdose; on the basis of animal models, the ratio of lethal to effective dose is estimated as 40,000 to 1. By comparison, the ratio is between 3 and 50 to 1 for secobarbital and between 4 and 10 to 1 for ethanol. Marihuana is also far less addictive and far less subject to abuse than many drugs now used as muscle relaxants, hypnotics, and analgesics. The chief legitimate concern is the effect of smoking on the lungs. Cannabis smoke carries even more tars and other particulate matter than tobacco smoke. But the amount smoked is much less, especially in medical use, and once marihuana is an openly recognized medicine, solutions may be found; ultimately a technology for the inhalation of cannabinoid vapors could be developed."[327]
The technology Dr. Grinspoon imagined in 1995 now exists in the form of “vaporizers,” (which are widely available through stores and by mail-order) and recent research attests to their efficacy and safety.[328] Additionally, pharmaceutical companies have developed sublingual sprays and capsule forms of the drug. Patients and doctors have found other ways to avoid the potential problems associated with smoking, though long-term studies of even the heaviest users in Jamaica, Turkey and the U.S. have not found increased incidence of lung disease or other respiratory problems. A decade-long study of 65,000 Kaiser-Permanente patients comparing cancer rates among non-smokers, tobacco smokers, and cannabis smokers found that those who used only cannabis had a slightly lower risk of lung and other cancers as compared to non-smokers.[329] Similarly, a study comparing 1,200 patients with lung, head and neck cancers to a matched group with no cancer found that even those cannabis smokers who had consumed in excess of 20,000 joints had no increased risk of cancer.[330]
Dr. Grinspoon notes, “the greatest danger in medical use of marihuana is its illegality, which imposes much anxiety and expense on suffering people, forces them to bargain with illicit drug dealers, and exposes them to the threat of criminal prosecution.” This was also the conclusion reached by the House of Lords, which recommended rescheduling and decriminalization.
In January 2013, the American Herbal Products Association (AHPA), which has a 30-year history of developing standards for the herbal products industry, issued recommendations for effectively regulating all aspects of cannabis distribution for patients. The regulatory recommendations, developed over two years by the AHPA Cannabis Committee address guidelines for cultivation, quality-assurance, analytics, cannabis product manufacture and labeling, storefront and delivery services, and personnel training.
In December 2013, the American Herbal Pharmacopoeia (AHP) released a monograph identifying cannabis as a botanical medicine. Written and reviewed by the world’s leading experts on cannabis, the monograph provides a full scientific understanding of the plant, its constituent components, and its biologic effects. It also establishes comprehensive standards for the plant's identity, purity, quality, and botanical properties.
Following the release of the monograph, ASA launched Patient Focused Certification, the first non-profit, third-party certification program based on the AHPA regulatory recommendations and the AHP standards. Patient Focused Certification (PFC) audits cultivators, distributors, manufacturers and laboratories to verify compliance with best-practice standards. PFC includes employee training, compliance inspections, ongoing monitoring, and an independent complaint process for customers, as well as comprehensive reviews of formulations and materials, independent testing, and facility inspections.
THE EXPERIENCE OF DOCTORS
Harvey L. Rose, M.D.
Both my research and my many years as a clinician have convinced me that marijuana can serve at least two important roles in safe and effective pain management. Ample anecdotal evidence and clinical observations, as well as significant research findings, strongly indicate that marijuana, for whatever reason, is often effective in relieving pain. This is true across a range of patient populations, including the elderly, the terminally ill seeking comfort in their final days, young adults stricken with life-threatening conditions, and cancer patients unable to tolerate the devastating effects of potentially life-saving therapies. Marijuana is also widely recognized as an antiemetic that reduces the nausea and vomiting often induced by powerful opioid analgesics prescribed for chronic, severe pain, as well as the nausea, vomiting and dizziness which often accompany severe and/or prolonged pain. I have had the benefit of consultations on this subject over many years with a range of treatment providers, including physicians, oncologists, pharmacologists, family practitioners, hospice workers, and pain specialists.
Specifically, I have found that cannabis can have an important opioid-sparing effect for pain patients. That is to say, that patients who are prescribed high doses of opioid analgesics can significantly reduce their reliance on these medications and improve their daily functioning by incorporating cannabis into their pain care regimen.
Marijuana not only has important analgesic properties but it also is an effective and important adjuvant therapy for patients suffering acute and/or chronic pain. No experienced and respected physician will deny that for such patients opioid therapy is central to palliative care. By the same token, the same experienced physicians will readily acknowledge that opioids often induce nausea and vomiting. For a number of pain patients, standard prescription antiemetics (e.g., Compazine, Zofran and Reglan) simply do not substantially reduce their nausea. For many, those medications are substantially less effective, or produce more debilitating side effects, than marijuana.
Quite simply, marijuana can serve much the same function for pain patients undergoing opiate therapy that it does for cancer patients undergoing chemotherapy: it suppresses the nausea and vomiting associated with treatment, and reduces the pain associated with prolonged nausea and retching, thereby increasing the chances that the patient will remain compliant with the primary treatment. With both chemotherapy and long-term pain management, failure to obtain and continue proper palliative and adjutant care can have dire, even fatal, consequences.
Finally, it is important to note that in my clinical experience observing patients who ingest cannabis for relief from pain and nausea and/or to stimulate appetite, I have witnessed no adverse complications. By contrast, many of the first-line pharmaceuticals used to combat cancer, HIV/AIDS, and pain associated with these and other illnesses can induce a variety of iatrogenic effects, including, in some instances, death. While patients may face serious legal implications related to their use of medical marijuana, as a physician I have yet to encounter a medical downside to their cannabinoid therapy. . . .
[A]gainst the backdrop of a growing body of scientific research, the reports of myriad pain patients, and the burgeoning clinical experience of physicians like myself, it is my considered opinion that cannabis can constitute an acceptable and sometimes necessary medicine to alleviate the immediate suffering of certain patients.
Dr. Rose has served as a medical officer in the Air Force, taught at UC Davis School of Medicine, and consulted with state legislative bodies.
Howard D. Maccabee, M.D.
Why Marijuana is Legal to Recommend
Medical professionals have a legal right to recommend marijuana as a treatment in any state, as protected by the First Amendment. That was established by a 2004 United States Supreme Court decision to uphold earlier federal court rulings that doctors and their patients have a fundamental Constitutional right to freely discuss treatment options. State rules for qualifying an individual patient for legal protections when using medical marijuana differ as to who may make the recommendation and for what conditions, as well as how that recommendation is communicated to the appropriate state authorities. Medical professionals and individual patients should familiarize themselves with the applicable laws and regulations in their state. ASA provides state-by-state resources to help at: AmericansForSafeAccess.org/state_by_state_recommending_cannabis
Under federal law, marijuana may not be prescribed, but its therapeutic use can be recommended without any legal jeopardy. The court rulings that protect medical professionals stem from a lawsuit brought by a group of doctors and patients led by AIDS specialist Dr. Marcus Conant. The suit was filed in response to federal officials who, within weeks of California voters legalizing medical marijuana in 1996, had threatened to revoke the prescribing privileges of any physicians who recommended marijuana to their patients for medical use.[1] Dr. Conant contended that such a policy would violate the First Amendment, and the federal courts agreed.[2, 3]
What doctors may and may not do. In Conant v. Walters, the Ninth Circuit Court of Appeals held that the federal government could neither punish nor threaten a doctor merely for recommending the use of marijuana to a patient.[4, 5] But it remains illegal for a doctor to "aid and abet" a patient in obtaining marijuana.[6] This means physicians and other medical professionals may discuss the pros and cons of medical marijuana with any patient, and recommend its use whenever appropriate. They may put that in writing or otherwise participate in state medical marijuana programs without fear of legal reprisal.[7] This is true even when the recommending medical professional knows the patient will use the recommendation to obtain cannabis through a state program.[8] What physicians may not do is provide cannabis directly to a patient[9] or tell patients how or where to obtain it.[10]
Patients protected under state law, not federal. As of July 2014, 23 states and the District of Columbia provide legal protections. However, all use of marijuana remains illegal under federal law, and in June 2005, the U.S. Supreme Court in Gonzales v. Raich ruled that state medical marijuana laws do not provide protection from federal prosecution.[11] Under the Obama Administration, the Department of Justice has issued three memos providing guidance to federal prosecutors, each indicating that individual patients and caregivers should not be federal enforcement priorities. The latest memo indicates enforcement should be left to states so long as they have effective regulations in place for use and distribution. An analysis by ASA of existing state laws and local regulations found that all reflect the same general enforcement priorities as the 2013 federal guidelines.[12]
For assistance with determining how best to write or obtain a legal recommendation for marijuana, please contact ASA at 1-888-929-4367.”
Medical Professionals Say Marijuana is Medicine
Thousands of studies published in peer-reviewed journals indicate marijuana has medical value in treating patients with such serious conditions as AIDS, glaucoma, cancer, epilepsy, and chronic pain, as well as a variety of such neurological disorders as multiple sclerosis, Parkinsonism, and ALS.
A 2013 poll conducted by the New England Journal of Medicine found that three out of four clinicians would recommend the use of medical marijuana for a hypothetical cancer patient.[13] The use of medical marijuana has been endorsed by numerous professional organizations, including the American Academy of Family Physicians, the American Public Health Association, and the American Nurses Association. Its use is supported by such leading medical publications as The New England Journal of Medicine and The Lancet. The International Cannabinoid Research Society was formally incorporated as a scientific research organization in 1991 with 50 members; as of 2014, there are nearly 500 around the world. The International Association for Cannabinoid Medicines (IACM), founded in 2000, publishes a bi-weekly bulletin and holds international symposia to highlight emerging research in marijuana therapeutics.
The safety and efficacy of marijuana has been attested to by numerous government studies and reports issued over the past 70 years. These include the 1944 LaGuardia Report, the Shafer Commission Report in 1972, a review commissioned by the British House of Lords in 1997, the Institutes of Medicine report of 1999, research sponsored by Health Canada, and numerous studies conducted in the Netherlands, where cannabis has been quasi-legal since 1976 and is currently available from pharmacies by prescription.
Scientific Research Advances
While modern research has until recently been sharply limited by federal prohibition, the last few decades have seen rapid change. More than 15,000 modern peer-reviewed scientific articles on the chemistry and pharmacology of marijuana and cannabinoids have been published, as well as more than 2,000 articles on the body's natural cannabinoids and the receptors they attach to.[14] The discovery of the endocannabinoid system (ECS) opened a door to new understandings of how the body regulates internal systems and how the phytocannabinoids found in the marijuana plant interact with it. Endocannabinoids are crucial to bioregulation, and evidence suggests they play a role in inflammation, insulin sensitivity, and fat and energy metabolism, as well as chronic neurologic and immune conditions. The cannabinoid receptors CB1 and CB2 are identified targets for treating a remarkable variety of serious medical conditions.[15-18]
A 2009 review of controlled clinical studies with medical marijuana conducted over a 38-year period found that “nearly all of the 33 published controlled clinical trials conducted in the United States have shown significant and measurable benefits in subjects receiving the treatment.”[19] The review's authors note that the more than 100 different cannabinoids in marijuana have the capacity for analgesia through neuromodulation in ascending and descending pain pathways, neuroprotection, and anti-inflammatory mechanisms. Research into the therapeutic potential of cannabis and cannabinoids has expanded considerably in the past decade. As of May 2014, the Center for Medicinal Cannabis Research, a state-funded $8.7-million research effort at University of California campuses, had completed 13 approved studies. Of those, seven published double-blind, placebo-controlled studies examined pain relief, and each showed cannabis to be effective.[20]
No adverse health effects related to medical marijuana use have been reported, even among the most seriously ill and immune-compromised patients. Research on CD4 immunity in AIDS patients found no negative effects to the immune systems of patients undergoing marijuana therapy in clinical trials.[21] A complete health assessment in 2002 of four of the patients enrolled in the U.S. Investigational New Drug program who had used marijuana daily for between 11 and 27 years found marijuana to be clinically effective for each with no negative health consequences.[22]
In the United Kingdom, GW Pharmaceuticals has been conducting clinical trials for more than a decade with its marijuana medicine, Sativex® Oromucosal Spray, a controlled-dose whole-plant extract. GW's Phase II and Phase III trials show positive results for the relief of neurological pain related to: multiple sclerosis (MS), spinal cord injury, peripheral nerve injury (including peripheral neuropathy secondary to diabetes mellitus or AIDS), central nervous system damage, neuroinvasive cancer, dystonias, cerebral vascular accident, and spina bifida. They have also shown cannabinoids to be effective in clinical trials for the relief of pain and inflammation in rheumatoid arthritis and also pain relief in brachial plexus injury.[23-26]
Sativex® was approved in Canada for symptomatic relief of neuropathic pain in 2005, in 2007 for patients with advanced cancer whose pain is not fully alleviated by opiates, and in 2010 for spasticity related to multiple sclerosis. As of 2014, Sativex has been made available or approved for named patient prescription use in 24 countries, including the UK, Spain, Italy and Germany.
In the US, GW was granted an import license for Sativex® by the DEA following meetings in 2005 with the FDA, DEA, the Office for National Drug Control Policy, and the National Institute for Drug Abuse. Sativex® is currently an investigational drug in FDA-approved clinical trials as an adjunctive analgesic treatment for patients with advanced cancer whose pain is not relieved by opioids. In 2013, GW Pharmaceuticals received FDA approval to test a highly purified cannabinoid extract (cannabidiol or CBD) named Epidiolex® on a limited number of US children with seizure disorders. As of January 2014, seven US pediatric epilepsy specialists have been approved to treat 125 children with Dravet syndrome, Lennox-Gastaut syndrome, and other pediatric epilepsy syndromes.
MEDICAL MARIJUANA AND VETERANS CONDITIONS
As of May 2013, there were more than 23 million total living veterans of military service in the US. Of those, almost 17 million served in wars. That includes more than 1.7 million veterans of WWII, 2.2 million veterans of the Korean War, 7.4 million veterans of the Vietnam War, 2.3 million veterans from the Gulf War (1990-1991), and more than 1.3 million who served in Afghanistan or Iraq or both.
Veterans of military service have a disproportionately high rate of certain debilitating medical conditions as compared to the general population. Some of those conditions may result from injury or exposures to toxins, but not all. The correlation between military service and higher rates of the conditions discussed in this booklet are clear and well-documented, but the cause is not known for many.
That has created some barriers to treatment, as the Veterans Health Administration (VHA) has at times resisted classifying conditions affecting veterans as being the result of their military service. Soldiers exposed to radiation during their participation in weapons trials in the 1950’s and 1960’s, for instance, were sworn to secrecy. Those exposed to Agent Orange in Vietnam had to wait decades for the VHA to acknowledge the cancers and other conditions they suffered were the result of their service. It was more than 20 years before scientists identified the changes in the brains of many of those who returned from the Gulf War with a collection of neurological symptoms.
The VHA has also resisted making all recommended treatments available to veterans. Cannabis has been found to help many patients suffering from conditions that can afflict veterans as a result of their service, including chronic pain, cancer, ALS, traumatic brain injury, post-traumatic stress disorders, and phantom limb pain. State medical cannabis programs making therapeutic use legal with a doctor’s recommendation were in place for almost 15 years before the VA changed its policy to allow veterans who use medical cannabis to receive all VA health services. In January, 2011, Robert A. Petzel M.D., the Under Secretary for Health, issued VHA Directive 2011-004, which states that “patients participating in State marijuana programs must not be denied VHA services.”
CANNABIS AND CHRONIC PAIN
Veterans can experience persistent and disabling pain as the result of numerous and sometimes multiple causes. Among them are injuries to the back, neck and spinal cord; cancer; arthritis and other rheumatic and degenerative hip, joint and connective tissue disorders; and severe burns.
The Congressional Research Service reports that as of February 2013, the number of US military service members wounded in combat in Afghanistan and Iraq totaled 50,450. Combat wounds that can result in chronic pain include spinal and traumatic brain injuries. Between 2000 and 2012, there were more than 48,000 reported cases of moderate to severe brain injuries among active military service members.[27]
Pain is not a primary condition or injury, but rather a severe, frequently intolerable symptom that varies in frequency, duration, and severity according to the individual. The underlying condition determines the appropriate curative approach, but does not determine the proper symptom management. It is the character, severity, location and duration of the pain that determines the range of appropriate therapies.
Chronic pain is a widespread public health issue. Epidemiological statistics are alarming: In Europe, it is estimated that one in four adults has a chronic pain condition. In the US, it is estimated that at least 38 million adults suffer from chronic pain, and at least 12 million have used cannabis as a treatment.[28]
For veterans in pain, the goal is to function as fully as possible by reducing their pain as much as possible, while minimizing the often debilitating side effects of the pain therapies. Failure to adequately treat severe and/or chronic pain can have tragic consequences. Not infrequently, people in unrelieved pain want to die. Despair can also cause patients to discontinue potentially life-saving procedures (e.g., chemotherapy or surgery), which themselves cause severe suffering. In such dire cases, anything that helps to alleviate the pain will prolong and improve these veterans' lives.
Cannabis can serve at least two important roles in safe, effective pain management. It can provide relief from the pain itself (either alone or in combination with other analgesics), and it can control the nausea associated with taking opioid drugs, as well as the nausea, vomiting and dizziness that often accompany severe, prolonged pain. In addition, cannabis significantly enhances the effectiveness of opioid therapies.
Opioid therapy is often an effective treatment for severe pain, but all opiates have the potential to induce nausea. The intensity and duration of this nausea can cause discomfort and additional suffering that can lead to malnourishment, anorexia, wasting, and a severe decline in a patient's health. Some people find the nausea so intolerable that they are inclined to discontinue the primary pain treatment, rather than endure the nausea.
Inhaled cannabis provides almost immediate relief for nausea with significantly fewer adverse side effects than orally ingested Marinol. Inhalation allows the active compounds in cannabis to be absorbed into the bloodstream with greater speed and efficiency. It is for this reason that inhalation is an increasingly common, and often preferable, route of administration for many medications. Cannabis may also be more effective than Marinol because it contains many more cannabinoids than just the THC that is Marinol's active ingredient. The additional cannabinoids may well have additional and complementary antiemetic qualities. They have been conclusively shown to have better pain-control properties when taken in combination than THC alone, and mitigate anxiety and other side-effects of THC.
Research on cannabis and pain management
Cannabis has been used as an analgesic for at least 5,000 years,[29-31] and patients often report significant pain relief from cannabis, even in cases where conventional pain therapies have failed.[32-37] Research has even shown that the natural endocannabinoid system has a role in regulating migraines.[38-40]
After reviewing a series of trials in 1997, the U.S. Society for Neuroscience concluded that “substances similar to or derived from marijuana could benefit the more than 97 million Americans who experience some form of pain each year.”[41] A 1999 study commissioned by the White House and conducted by the Institute of Medicine also recognized the role that cannabis can play in treating chronic pain: “After nausea and vomiting, chronic pain was the condition cited most often to the IOM study team as a medicinal use for marijuana.”[42] Between 1975 and 2009, there were more than 300 studies showing that cannabinoids and cannabis can help patients experiencing chronic pain.[43]
Orthopedic injuries including loss of limbs can result in chronic pain that is very difficult to treat. Military operations just in Iraq and Afghanistan have resulted in 1,715 amputations as of December 2012.[44] Amputations commonly result in phantom limb pain, a serious neuropathic pain condition affecting 50-80 percent of amputees, sometimes for many years. Phantom limb pain may occur during the first year after amputation and often remains chronic over months or years, either with no improvement or an increase in pain.[45-58]
Among U.S. veterans with current significant phantom limb pain, 27 percent had pain for more than 20 days per month, 10 percent for 11 to 20 days, 14 percent for 6 to 10 days, and 49 percent for 5 days or less per month.[59] Phantom limb pain is often poorly understood and difficult to manage. Current treatments include physical, behavioral, and medical approaches, including opioids and adjunct medications.[60]
A 1984 survey of 5,000 US veterans with amputations related to military service found that 78 percent had current phantom limb pain and only 1 percent had experienced relief from any treatment.[61] A small study of 48 British veterans with phantom limb pain found that 56 percent reported no relief from any pain medications.[62] That difficulty in relieving pain is common to other types of chronic neuropathic pain, such as may result from cancer, HIV/AIDS, or diabetes.
Cannabinoids may provide relief; some of the most encouraging clinical data on effects of cannabinoids on chronic pain are from studies of neuropathic pain.[63-68] The effectiveness of cannabis and cannabinoids in relieving neuropathic pain has been demonstrated in more than three dozen preclinical and clinical trials.[69] It is often effective when opioid painkillers have failed to provide relief.[70] A trial of smoked cannabis to treat HIV-associated daily neuropathic pain in 50 patients showed an average reduction of pain by 30 percent over a treatment course of only five days.[71] Cannabis can be effective for neuropathic pain even at low doses.72 Multiple trials indicate that a whole-plant cannabis extract (Sativex®) is effective in reducing pain in patients suffering intractable neuropathic pain.[72,73] A review of over 20 clinical trials on cannabis and cannabinoids found that whole plant cannabis and extracts are superior to oral THC for the treatment of pain. Health Canada approved Sativex® for prescription in the treatment of HIV-associated neuropathic pain in 2005 and cancer pain in 2007. The mechanism for that analgesic action involves both the body’s cannabinoid receptors and direct action on the neurons that transmit pain.[74-75]
The activity of the more than 100 cannabinoids and other components on the plant may explain its superiority in reducing pain when comparing whole plant cannabis and extracts to THC alone. For instance, the cannabinoids cannabidiol (CBD) and cannabichromene (CBC), the second and third most common active compounds on the plant, exhibit anti-inflammatory and analgesic actions, although weaker than THC. Similarly, beta-sitosterol, a non-cannabinoid ingredient found in cannabis, was able to decrease inflammation and edema in skin treatment.[76] And a unique flavanoid found only in cannabis, cannaflavin A, inhibits the inflammatory molecule PGE-2, thirty times more potently than aspirin.[77] Lastly beta-caryophyllene, a cannabinoid found in many plants besides cannabis, has strong anti-inflammatory properties but no noticeable side effects.[78] Beta-caryophyllen is the most commonly consumed FDA-approved cannabinoid in food.
The IOM report found that “basic biology indicates a role for cannabinoids in pain and control of movement, which is consistent with a possible therapeutic role in these areas. The evidence is relatively strong for the treatment of pain and intriguingly, although less well established, for movement disorder.” According to the IOM Report and numerous independent research articles, a number of areas in the brain that have an established role in sensing and processing pain respond to the analgesic effect of cannabis, adding that cannabinoids have been used successfully to treat cancer pain, which is often resistant to treatment with opiates. The effectiveness of cannabinoids in treating intractable cancer pain has been demonstrated in several subsequent clinical trials of a dosage-controlled sublingual spray.
Several studies have found that cannabinoids have analgesic effects in animal models, sometimes equivalent to codeine.[79-83] Cannabinoids also seem to synergize with opioids, which often lose their effectiveness as patients build up tolerance. One study found morphine was 15 times more active in rats with the addition of a small dose of THC. Codeine was enhanced on the order of 900 fold.[84] In 1990, researchers conducted a double-blind study comparing the antispasmodic and analgesic effects of THC, oral Codeine, and a placebo on a single patient suffering from a spinal cord injury.[85] Their findings confirmed the analgesic effects of THC being “equivalent to codeine.” A 1997 study made similar findings related to morphine.[86]
A 1999 article reviewing the body of scientific animal research concerning the analgesic effects of marijuana concludes that “[t]here is now unequivocal evidence that cannabinoids are antinociceptive [capable of blocking the appreciation or transmission of pain] in animal models of acute pain.”[87] The report further notes that multiple cannabinoids and noncannabinoid components can serve as anti-inflammatory agents, and so have potential in preventing and reducing pain caused by swelling (such as arthritis).
In short, the research community recognizes the potential benefits of cannabis for certain patients, including:
Chemotherapy patients, especially those being treated for mucositis, nausea, and anorexia.
Postoperative pain patients (using cannabinoids as an opioid adjunct to reduce the nausea and vomiting).
Patients with spinal cord injury, peripheral neuropathic pain, or central post-stroke pain.
Patients with chronic pain and insomnia.
AIDS patients with cachexia, AIDS neuropathy, or any significant pain.
Britain's House of Lords reached similar conclusions and called for making cannabis available by prescription.[88]
VETERANS AND CANCER
Veterans have higher rates of some cancers than the general population. The Armed Forces Health Surveillance Center reported in 2010 that, in the previous ten years, service members had higher rates of melanoma, brain, non-Hodgkin lymphoma, breast, prostate and testicular cancers than civilians. The Medical Surveillance Monthly Report in 2008 also found service members have higher rates of prostate and breast cancers. In some cases, those higher cancer rates are linked to exposures to chemicals, toxins, or radiation, in other cases the reasons have not yet been identified.[89]
Cancer rates vary by branch of service, gender and race, as well as dates and location of active duty. A 2009 study at Walter Reed Army Medical Center comparing reported cancer cases between 1990 and 2004 in the military and general population found higher incidence rates of prostate and breast cancers in the active duty military. Female soldiers have breast cancer rates 20-40 percent higher than other women.[90]
Researchers speculate chemical exposures may be a contributing factor in these breast cancer cases. Though the disease is extremely rare in men, dozens of male soldiers at Camp Lejeune have also developed breast cancers, possibly linked to a water supply that was contaminated with industrial solvents, benzene, and other chemicals from 1957 to at least 1987. Service members and their families stationed at Camp Lejeune in that time period also have unusually high rates of several other cancers, including esophageal, lung, bladder, multiple myeloma, scleroderma, non-Hodgkin’s lymphoma, leukemia, and other serious medical conditions.[91]
Exposures to chemicals or other toxins may also explain why thyroid cancer rates are significantly higher in the military than in the general population among white women, black women, and black men, according to a 2011 study of reported cases from 1990-2004 in individuals 20 to 49 years of age. As with other cancers, the study found the higher incidence rate of thyroid cancer varied by branch of service.[92]
Nuclear radiation has been a cancer factor for hundreds of thousands of veterans. Approximately 200,000 in Japan during the occupation in WWII were exposed to residual radiation from the use of atomic bombs at Hiroshima and Nagasaki. Another 200,000 were exposed during nuclear weapons testing between 1945 and 1962. Those who served the Gulf War and Operation Iraqi Freedom may have been exposed to depleted uranium. Among the types of cancer radiation can cause are thyroid, bone, breast, brain, colon, esophagus, lung, stomach, and pancreas as well as many others.[93]
Many veterans who served in Vietnam were also exposed to chemicals linked to cancer, in particular Agent Orange, an herbicide used extensively to destroy jungle foliage, that was frequently contaminated with dioxin, a dangerous toxin linked to increased risk of cancers, Type 2 diabetes, and Parkinson's disease. The cancers linked to Agent Orange exposure include soft-tissue sarcoma, Hodgkin’s disease, Non-Hodgkin’s lymphoma, multiple myeloma, chronic lymphocytic leukemia, and cancers of the prostate, lung, larynx, trachea and bronchus. For some cancers, the rates are dramatically higher for veterans exposed to Agent Orange. A 2008 study found they are more than twice as likely to have prostate cancer as the general population.[94]
A 2013 study of more than 2,700 veterans similarly found significantly higher rates of the deadliest, most-aggressive forms of prostate cancer. Researchers reported the overall risk of high-grade prostate cancer detection by biopsy is 52 percent higher in veterans exposed to Agent Orange, and the likelihood of finding the most aggressive form is 75 percent higher.[95]
VETERANS AND NEUROLOGICAL DISORDERS
Veterans disproportionately develop neurological conditions such as amyotrophic lateral sclerosis (ALS), Alzheimer's disease, and Parkinsonism for a variety of reasons, ranging from chemical exposures to Traumatic Brain Injury (TBI). From 2000 through the third quarter of 2013, the Department of Defense reports 287,861 diagnosed cases of TBI among active service members. Of those, more than 48,000 are classified as moderate to severe, and more than 10,000 were reported as not classifiable.[175] Even a mild or moderate TBI greatly increases the risk of several neurological disorders, including seizures and neurodegenerative disorders such as Alzheimer's and Parkinsonism.[176,177]
The risk for Alzheimer's in veterans who suffered a moderate TBI is more than 2.3 times higher, and more than 4.5 times higher for those with a severe TBI. The link between TBI and Parkinsonism has not been studied as extensively but is still well established as a linked condition that may not be seen for between six and 40 years.
Seizures are a common effect of most TBI, regardless of severity, with the risk increasing to as much as 95 times the general population. Post-traumatic epilepsy (PTE), in which seizures recur more than a week after the TBI, is less predictable than the initial seizures, but an increased risk remains for years after the initial injury.[178] PTE is likely to create more serious problems than other forms of epilepsy, with veterans who develop PTE more likely to have shortened lives and cognitive and motor problems.[179] PTE is commonly difficult to treat with conventional drug therapy, with cessation of seizures achieved in only 35 percent of those treated.[180,181]
Traumatic Brain Injury (TBI) can also result in neurological disorders. A high prevalence of epilepsy and other neurological disorders in US veterans who served in Afghanistan and Iraq were reported at the American Epilepsy Society's 67th Annual Meeting in December, 2013. The researchers found veterans are at a particularly high risk for psychological non-epileptic seizures (PNES) and epileptic seizure. Researchers at Duke found that 87,377 veterans with seizures diagnoses are currently in the VHA system, with higher incidences among veterans under the age of 46. Researchers at Baylor College of Medicine found a correlation between psychogenic non-epileptic seizures (PNES) among Afganistan and Iraq veterans who had PTSD or TBI diagnoses or both. Researchers who reviewed records for veterans diagnosed with PNES treated at the Portland, Oregon VAMC EMU from 2000-2011 found the majority continued to report seizures, even after three years of follow up, and only 21 percent were seizure free.
Cannabis may provide a superior alternative to other seizure medications, as clinical experience and more than 30 years of scientific research on how cannabinoids such as CBD and THC can reduce seizure activity have shown that it may work when other alternatives have failed. In addition to reports from patients and their families, the most recent studies in animal models found that CBD significantly reduced the percentage of those experiencing severe seizures and significantly reduced the mortality rate.[182-185]
Many people with seizure disorders treat their conditions with cannabis, and in late 2012 GW Pharmaceuticals received FDA approval to test a highly purified CBD extract named Epidiolex® on a limited number of US children with seizure disorders. So far, seven US pediatric epilepsy specialists have been approved to treat 125 children with Dravet syndrome, Lennox-Gastaut syndrome, and other pediatric epilepsy syndromes.[186]
Many veterans develop neurological disorders related to chemical exposures. Veterans who served in Vietnam may have been exposed to Agent Orange or other herbicides that can produce neurological disorders. Those who served in the Gulf War may have been exposed to nerve agents or other neurotoxic chemicals. A federal review in 1994 of research studies on the possible link between parkinsonism and chemicals used as herbicides and pesticides in Vietnam concluded that parkinsonian syndromes have been associated with both chronic and acute exposures to herbicides and pesticides.[187] Veterans with Parkinson’s disease who were exposed to Agent Orange or other herbicides during military service may be eligible for disability compensation and health care.
More than 200,000 veterans who served in the Persian Gulf during Operations Desert Shield and Desert Storm in 1990-1991 developed health problems that eventually became known as Gulf War illness. Research indicates that damage to the central nervous system is related to chronic symptoms of Gulf War Illness. While many symptoms of possible neurological disorders have been reported—including cognitive impairment, autonomic dysfunction, debilitating fatigue, and chronic widespread pain—no consensus on the diagnosis of the illness or its cause has been reached, though research published in 2013 describes changes to brain structure that explain many symptoms.
Brain imaging of Gulf War veterans found evidence that two types of changes in their brain structure correlate to a heightened sensitivity to pain, increased feelings of fatigue, and difficulties regulating heart rate and blood pressure, as well as memory problems – all symptoms of Gulf War Illness. Two other studies out of Georgetown also found evidence of neurological damage in Gulf War veterans, including abnormalities in the nerve cells in the brain that register fatigue and pain.[188,189]
A 2006 review of 22 studies of neurological function in Gulf War veterans also found that their incidence of amyotrophic lateral sclerosis (ALS) is significantly higher than among those who did not serve in that theater.[190]
CANNABIS AND NEUROLGICAL DISORDERS
Neurodegenerative diseases and movement disorders, which are sometimes interlinked, are among the many conditions that cannabis and cannabinoids may be particularly well suited to treat. Cannabinoids can protect the brain and central nervous system from the damage that leads to various neurological disorders. More than 100 research articles have been published on how cannabinoids act as neuroprotective agents to slow the progression of neurodegenerative diseases that disproportionately affect veterans. Researchers have also established that cannabinoids can alleviate the damage caused by strokes, as well as traumatic brain injury, spinal cord injury, and multiple sclerosis. No other medication offers the combination of anti-oxidative, anti-inflammatory and neuroprotective qualities of cannabis and cannabinoids.[191-193]
The therapeutic use of cannabis for treating neurological disorders has been known to western medicine for nearly two centuries. In 1839, Dr. William B. O'Shaughnessy wrote about cannabis that doctors had "gained an anti-convulsive remedy of the greatest value."[194] In 1890 Dr. J. Russell Reynolds, physician to Queen Victoria, noted in an article in The Lancet that for "organic disease of a gross character in the nervous centers . . . India hemp (cannabis) is the most useful agent with which I am acquainted."[195]
Extensive modern studies in both animals and humans have shown that cannabis can treat many movement disorders affecting people with neurolgical disorders because cannabinoids inhibit neurodegeneration and have antispasticity, analgesic, antitremor, and antiataxia properties.[196-214]
Research published in 2013 shows the active chemicals in cannabis are uniquely suited to fighting neurodegenerative diseases that can result from trauma, such as Alzheimer’s, Parkinson’s and amyotrophic lateral sclerosis (ALS).[215-217] The neuroprotective effects of cannabis, based on the combination of anti-inflammatory and anti-oxidant properties of the primary cannabinoids THC and CBD, is undergoing intense preclinical research for treating numerous neurodegenerative disorders.218 Recent research has revealed that chemicals similar to those in cannabis can also reduce the effects of serious brain injury and keep badly head-injured people alive.[219]
Neurodegenerative disorders such as Alzheimer's, Parkinson's and Huntington's diseases all share a number of common mechanisms: inflammation and over-stimulation of neurons and problems with supplying energy and oxygen to them. A 2012 review of experimental studies on the body’s cannabinoid system concluded that it operates on both cellular and molecular levels to protect neurons. Cannabinoids have antioxidant and anti-inflammatory effects that suppress the neuroinflammatory processes that contribute to neurodegenerative diseases as well as the progression of brain ageing. Cannabinoids play a protective role in regulating the mitochondrial activity that maintains the supply of energy and oxygen to brain cells, modulating molecular clearance processes to protect neurons, and regulating the production of new brain cells.[220]
In many neurodegenerative disorders, the body’s natural cannabinoid system has recently been found to be altered. That’s why much new research is devoted to determining how to manipulate the endogenous cannabinoid system with plant or synthetic cannabinoids to neurodegenerative disorders.[221,222]
Research has repeatedly demonstrated that plant cannabinoids exert the same neuroprotective effects as the body’s natural endocannabinoids. Recent studies of both animal models and human cell cultures of Parkinson’s disease have shown that the plant cannabinoids THC and CBD directly fight the disease and, in the case of the animal model, relieves its symptoms.[223-225]
Huntington’s disease is another neurodegenerative disorder for which there are currently limited treatment options but strong evidence for the benefits of cannabis-based medicine. Experimental studies of an animal model of Huntington’s disease found the progression of the disease was slowed by treatment with the plant cannabinoids THC and CBD. Both CB1 and CB2 receptors were shown to be involved in the protective, disease-fighting effects, something also indicated by a separate study that showed blocking the CB1 receptor in mice worsened the disease.[226-228] Researchers concluded that “cannabis-based medicine” is “capable of delaying disease progression.”
Brain injuries can also be mitigated by cannabinoids. The neuroprotective effects of cannabinoids such as CBD have also been shown in four separate studies published in 2013 to help fight the effects of several types of brain injury.[229-232] In one recent animal study of several types of brain injury, even a single very low dose of THC—three to four times less than create a noticeable behavioral effect—created a significant protective effect that lasted at least seven weeks.[233]
Multiple sclerosis, once thought to be primarily an autoimmune disorder, is now understood to be neurodegenerative.[234,235] In a federal court brief filed in support of physicians' right to recommend cannabis, the American Public Health Association notes that "a survey of British and American MS patients reports that after ingesting marijuana a significant majority experienced substantial improvements in controlling muscle spasticity and pain. An extensive neurological study found that herbal cannabis provided relief from both muscle spasms and ataxia (loss of coordination), a multiple benefit not achieved by any currently available medications."[236] Cannabinoids have also been shown to have powerful neuroprotective effects.[237, 238]
The endogenous cannabinoid system in the human body appears to be intricately involved in regulating normal physiology, including the control of movement. Central cannabinoid receptors are densely located in the basal ganglia, the area of the brain that regulates body movement, and appear to play a role in the manipulation of transmitter systems—increasing transmission of certain chemicals, inhibiting the release of others, and affecting how they are absorbed. [239-244]
Because they operate as modulators, endocannabinoids have paradoxical effects on the nervous system: sometimes they block neuronal excitability and other times they augment it. As scientists are developing a better understanding of the physiological role of the endocannabinoids, it is becoming clear that problems with the production or processing of these chemicals may be involved in the pathology of several neurological diseases.
Parkinson's disease has been linked to dysfunction in the body's dopamine system, specifically the production of too much of the neurotransmitter glutamate and oxidative damage to dopaminergic neurons. Studies have found a tight association between cannabinoids and dopamine, and recent research has produced anatomical, biochemical, and pharmacological evidence supporting a role for the endogenous cannabinoid system in the modulation of dopaminergic transmission.[245]
Oxidative stress in the brain is a major hallmark of motor and neurological diseases such as Parkinson's and Alzheimer's disease. Cannabinoids are able to protect neurons from oxidative damage.[246] The neuroprotective action of cannabinoids appears to result from their ability to inhibit reactive oxygen species, glutamate, and tumor necrosis factor. THC, CBD, and synthetic AM404 all contain phenolic groups in their chemical structure and are thus able to reduce radical oxygen species. Notably CBD has extraordinary antioxidant properties and can effect calcium homeostasis, both of which lead to positive effects against a wide range of neurodegenerative diseases.[247]
Few clinical trials have looked at cannabinoids and Parkinson's disease. However, research has shown that 25 percent of Parkinson's patients smoke cannabis, and 46 percent of these patients report improvement of side effects from long-term levodopa treatment.[248] A randomized placebo controlled study using extracts of cannabis produced significant improvements in patients' cognition. The authors note that they did not see improvements in pain or sleep disorders. They speculate that the oral route (versus inhaled) of cannabis ingestion leads to too much variability of cannabinoids in blood.[249]
Many diseases of the brain involve changes in inflammatory responses that lead to disease progression. Inflammation in the brain is mediated by microglial cells and treatments which target these cells can protect neurons from damage that leads to degeneration Multiple Sclerosis, Parkinson's and Alzheimer's disease are neuro-degenerative conditions for which cannabis and cannabinoid therapies show promise, both for treating the symptoms and the underlying disease by targeting microglial cells through cannabinoid receptors.[250]
Oxidative stress in the brain is a major hallmark of neurological disorders such as Parkinson's and Alzheimer's disease. Cannabinoids have well-established antioxidant properties that protect neurons from oxidative damage. Alzheimer's disease, characterized in part by a decrease in the production of new neurons, is associated with oxidative stress due to the membrane action of beta-amyloid peptide aggregates. A laboratory study published in 2004 indicates that one of the cannabis plant's primary components, cannabidiol (CBD), exerts a combination of neuroprotective, anti-oxidative and anti-apoptotic effects by inhibiting the release of the toxic beta-amyloid peptide.[251]
Recent studies suggest that endocannabinoids may control the growth and maturation of new neurons through the CB1 receptor.[252] Therefore, cannabinoids could reduce inflammation and protect brains in neurodegenerative conditions. The neuroprotective action of cannabinoids appears to result from their ability to inhibit reactive oxygen species, glutamate, and tumour necrosis factor. THC, CBD, and synthetic AM404 all contain phenolic groups in their chemical structure that can reduce oxidative stress on brain cells. Notably, CBD has extraordinary antioxidant properties and can affect calcium homeostasis, both of which lead to positive effects against a wide range of neurodegenerative diseases.
Cannabinoids represent an emerging therapeutic option for neurological disorders and neurodegenerative diseases. Targeted cannabinoid therapies are still in an early phase of development, but research suggests that they can be useful drugs for the treatment of many diseases.
This new research on cannabinoids and neurodegenerative diseases, coupled with the extensive work done on other neuroprotective and neurogenic qualities of cannabis and its components, indicates that cannabis may become the source of the most effective treatments for battling the neurological disorders that afflict millions of veterans.
How Cannabis Compares to Other Treatments
Chronic Pain Medications
According to the Institute of Medicine, "All of the currently available analgesic (pain-relieving) drugs have limited efficacy for some types of pain. Some are limited by dose-related side effects and some by the development of tolerance or dependence."
The opioid analgesics commonly used to combat pain include codeine (Dolacet, Hydrocet, Lorcet, Lortab); morphine (Avinza, Oramorph); oxycodone (Vicodin, Oxycontin, Roxicodone, Percocet, Roxicet); propoxyphene (Darvon, Darvocet) and tramadol (Ultram, Ultracet). These medicines can cause psychological and physical dependence, as well as constipation, dizziness, lightheadedness, mood changes, nausea, sedation, shortness of breath and vomiting. Taking high doses or mixing with alcohol can slow down breathing, a potentially fatal condition.
In addition, patients in pain are often prescribed muscle relaxants such as Robaxin and Flexeril; anti-anxiety agents such as Valium, Sinequan, Vistaril, Ativan and Xanax; hypnotics such as Halcion, Restoril, Chloralhydrate, Dalmane and Doral and anti-emetics such as Zofran, Compazine, Phenergan, Tigan and Marinol.
Robaxin's side effects include abnormal taste, amnesia, blurred vision, confusion, dizziness, drop in blood pressure and fainting, drowsiness, fever, flushing, headache, hives, indigestion, insomnia, itching, light-headedness, nasal congestion, nausea, pinkeye, poor coordination, rash, seizures, slowed heartbeat, uncontrolled eye movement, vertigo, vomiting and yellow eyes and skin.
Flexeril can cause abnormal heartbeats, aggressive behavior, agitation, anxiety, bloated feeling, blurred vision, confusion, constipation, convulsions, decreased appetite, depressed mood, diarrhea, difficulty falling or staying asleep, difficulty speaking, disorientation, double vision, excitement, fainting, fatigue, fluid retention, gas, hallucinations, headache, heartburn, hepatitis, hives, increased heart rate, indigestion, inflammation of the stomach, itching, lack of coordination, liver diseases, loss of sense of taste, low blood pressure, muscle twitching, nausea, nervousness, palpitations, paranoia, rash, ringing in the ears, severe allergic reaction, stomach and intestinal pain, sweating, swelling of the tongue or face, thirst, tingling in hands or feet, tremors, unpleasant taste in the mouth, urinating more or less than usual, vague feeling of bodily discomfort, vertigo, vomiting, weakness, and yellow eyes and skin.
The newer antiemetics, Anzamet, Kytril and Zofran, are serotonin antagonists, blocking the neurotransmitter that sends a vomiting signal to the brain. Rare side effects of these drugs include fever, fatigue, bone pain, muscle aches, constipation, loss of appetite, inflammation of the pancreas, changes in electrical activity of heart, vivid dreams, sleep problems, confusion, anxiety and facial swelling.
Reglan, a substituted benzamide, increases emptying of the stomach, thus decreasing the chance of developing nausea and vomiting due to food remaining in the stomach. When given at high doses, it blocks the messages to the part of the brain responsible for nausea and vomiting. Side effects include sleepiness, restlessness, diarrhea and dry mouth. Rarer side effects are rash, hives and decreased blood pressure.
Haldol and Inapsine are tranquilizers that block messages to the part of the brain responsible for nausea and vomiting. Possible side effects include decreased breathing rate, increased heart rate, decrease in blood pressure when changing position and, rarely, change in electrical activity of the heart.
Compazine and Torecan are phenothiazines, the first major anti-nausea drugs. Both have tranquilizing effects. Common side effects include dry mouth and constipation. Less common effects are blurred vision, restlessness, involuntary muscle movements, tremors, increased appetite, weight gain, increased heart rate and changes in electrical activity of heart. Rare side effects include jaundice, rash, hives and increased sensitivity to sunlight.
Benadryl, an antihistamine, is given along with Reglan, Haldol, Inapsine, Compazine and Torecan to counter side effects of restlessness, tongue protrusion and involuntary movements. Its side effects include sedation, drowsiness, dry mouth, dizziness, confusion, excitability and decreased blood pressure.
Benzodiazepine drugs Ativan and Xanax are prescribed to combat the anxiety associated with chronic pain. Ativan causes amnesia. Abruptly stopping the drug can cause anxiety, dizziness, nausea and vomiting, and tiredness. It can cause drowsiness, confusion, weakness and headache when first starting the drug. Nausea, vomiting, dry mouth, changes in heart rate and blood pressure and palpitations are possible side effects.
Cancer Medications
The American Cancer Society lists 269 medicines currently prescribed to treat cancer and its symptoms, and to treat the side effects of other cancer drugs. Some drugs are prescribed for pain caused by cancer, and cancer patients report pain relief with cannabis therapy. Many chemotherapy agents cause severe nausea and 13 drugs are currently prescribed to treat nausea, including Marinol, a synthetic form of delta-9-THC, the primary psychoactive component in cannabis.
Antiemetic medications used for treating nausea, and medications such as antihistamines that are sometimes prescribed in combination with antiemetics, are all discussed above, under pain medications.
Decadron (dexamethasone), a corticosteroid, is given with other chemotherapy drugs as an adjunct medication. Common side effects include increased appetite, irritation of stomach, euphoria, difficulty sleeping, mood changes, flushing, increased blood sugar, decreased blood potassium level. Possible side effects upon discontinuing the drug include adrenal insufficiency, weakness, aches, fever, dizziness, lowering of blood pressure when changing position, difficulty breathing, and low blood sugar.
Benzodiazepine drugs Ativan and Xanax are also prescribed to combat the effects of chemotherapy. Ativan causes amnesia. Abruptly stopping the drug can cause anxiety, dizziness, nausea and vomiting, and tiredness. It can cause drowsiness, confusion, weakness, and headache when first starting the drug. Nausea, vomiting, dry mouth, changes in heart rate and blood pressure, and palpitations are possible side effects.
In addition, in April 2003 the FDA approved the drug Emend (aprepitant) to help control delayed-onset nausea. It is given along with two other anti-nausea drugs. A regimen of three pills costs $250. The most common side effects with Emend are fatigue, nausea, loss of appetite, constipation and diarrhea.
Neurologic Medications
Benzodiazepines, levedopa, baclofen, dantrolene sodium, and tizanidine are the most widely used agents for reduction of spasticity. At high dosages, oral medications can cause unwanted side effects that include sedation, as well as changes in mood and cognition.
Benzodiazepines, which include Diazepam (Valium) and Clonazepam (Klonopin, Rivotril) are centrally acting agents that increase the affinity of GABA to its receptor. Diazepam is the oldest and most frequently used oral agent for managing spasticity. Benzodiazepine side effects include sedation, weakness, hypotension, GI symptoms, memory impairment, incoordination, confusion, depression and ataxia. Tolerance and dependency may occur and withdrawal on cessation. Tolerance may also lead to unacceptable dosage escalation.
Levedopa is common long-term treatment option for Parkinson's disease. Long-term use can result in diskynesia and is often a reason for not taking the drug. Diskynesia can lead to less control of voluntary movements and can result in tics or chorea. Dikynesia can result in excessive tongue rolling and after years of use it can manifest as "jerky" movements of the head and arms.
Baclofen (Lioresal) has been widely used for spasticity since 1967. It is a GABA agonist. Tolerance to the medication may develop. Baclofen must be slowly weaned to prevent withdrawal effects such as seizures, hallucinations and increased spasticity. It must be used with care in patients with renal insufficiency as its clearance is primarily renal. Side effects are predominantly from central depressant properties including sedation, ataxia, weakness and fatigue. May cause depression when combined with tizanidine or benzodiazepines.
Dantrolene Sodium (Dantrium) acts peripherally at the level of the muscle fiber and works best for cerebral palsy and traumatic brain injury. Because the action of dantrolene sodium is not selective for spastic muscles, it may cause generalized weakness, including weakness of the respiratory muscles. The side effects include drowsiness, dizziness, weakness, fatigue and diarrhea. In addition, hepatotoxicity (liver damage) occurs in < 1 percent of patients who take dantrolene sodium.
Tizanidine (Zanaflex) facilitates short-term vibratory inhibition of the H-reflex. Tizanidine in conjunction with baclofen or benzodiazepines has potential additive effects, including sedation and the possibility of liver toxicity. Dry mouth, somnolence, asthenia and dizziness are the most common side effects. Liver function problems and hallucinations may also occur.
Cannabis vs. Other Medications
Cannabis: By comparison, the side effects associated with cannabis are typically mild and are classified as “low risk.” Euphoric mood changes are among the most frequent side effects. Cannabinoids can exacerbate schizophrenic psychosis in predisposed persons, though it can also provide symptomatic relief in refractory schizophrenia. Cannabinoids impede cognitive and psychomotor performance, resulting in temporary impairment. Chronic use can lead to the development of tolerance. Tachycardia and hypotension are frequently documented as potentially adverse events in the cardiovascular system. A few cases of myocardial ischemia have been reported in young and previously healthy patients. Inhaling the smoke of cannabis cigarettes induces side effects on the respiratory system. Cannabinoids are contraindicated for patients with a history of cardiac ischemias. In summary, a low risk profile is evident from the literature available. Serious complications are extremely rare and are not usually reported during the use of cannabinoids for medical indications.
Why cannabis is safe to recommend
“The smoking of cannabis, even long term, is not harmful to health....” So began a 1995 editorial statement of Great Britain's leading medical journal, The Lancet. The long history of human use of cannabis also attests to its safety—nearly 5,000 years of documented use without a single death. In the same year as the Lancet editorial, Dr. Lester Grinspoon, a professor emeritus at Harvard Medical School who has published many influential books and articles on medical use of cannabis, had this to say in an article in the Journal of the American Medical Association:
One of medical cannabis greatest advantages as a medicine is its remarkable safety. It has little effect on major physiological functions. There is no known case of a lethal overdose; on the basis of animal models, the ratio of lethal to effective dose is estimated as 40,000 to 1. By comparison, the ratio is between 3 and 50 to 1 for secobarbital and between 4 and 10 to 1 for ethanol. Marihuana is also far less addictive and far less subject to abuse than many drugs now used as muscle relaxants, hypnotics, and analgesics. The chief legitimate concern is the effect of smoking on the lungs. Cannabis smoke carries even more tars and other particulate matter than tobacco smoke. But the amount smoked is much less, especially in medical use, and once marihuana is an openly recognized medicine, solutions may be found; ultimately a technology for the inhalation of cannabinoid vapors could be developed."[327]
The technology Dr. Grinspoon imagined in 1995 now exists in the form of “vaporizers,” (which are widely available through stores and by mail-order) and recent research attests to their efficacy and safety.[328] Additionally, pharmaceutical companies have developed sublingual sprays and capsule forms of the drug. Patients and doctors have found other ways to avoid the potential problems associated with smoking, though long-term studies of even the heaviest users in Jamaica, Turkey and the U.S. have not found increased incidence of lung disease or other respiratory problems. A decade-long study of 65,000 Kaiser-Permanente patients comparing cancer rates among non-smokers, tobacco smokers, and cannabis smokers found that those who used only cannabis had a slightly lower risk of lung and other cancers as compared to non-smokers.[329] Similarly, a study comparing 1,200 patients with lung, head and neck cancers to a matched group with no cancer found that even those cannabis smokers who had consumed in excess of 20,000 joints had no increased risk of cancer.[330]
Dr. Grinspoon notes, “the greatest danger in medical use of marihuana is its illegality, which imposes much anxiety and expense on suffering people, forces them to bargain with illicit drug dealers, and exposes them to the threat of criminal prosecution.” This was also the conclusion reached by the House of Lords, which recommended rescheduling and decriminalization.
In January 2013, the American Herbal Products Association (AHPA), which has a 30-year history of developing standards for the herbal products industry, issued recommendations for effectively regulating all aspects of cannabis distribution for patients. The regulatory recommendations, developed over two years by the AHPA Cannabis Committee address guidelines for cultivation, quality-assurance, analytics, cannabis product manufacture and labeling, storefront and delivery services, and personnel training.
In December 2013, the American Herbal Pharmacopoeia (AHP) released a monograph identifying cannabis as a botanical medicine. Written and reviewed by the world’s leading experts on cannabis, the monograph provides a full scientific understanding of the plant, its constituent components, and its biologic effects. It also establishes comprehensive standards for the plant's identity, purity, quality, and botanical properties.
Following the release of the monograph, ASA launched Patient Focused Certification, the first non-profit, third-party certification program based on the AHPA regulatory recommendations and the AHP standards. Patient Focused Certification (PFC) audits cultivators, distributors, manufacturers and laboratories to verify compliance with best-practice standards. PFC includes employee training, compliance inspections, ongoing monitoring, and an independent complaint process for customers, as well as comprehensive reviews of formulations and materials, independent testing, and facility inspections.
THE EXPERIENCE OF DOCTORS
Harvey L. Rose, M.D.
Both my research and my many years as a clinician have convinced me that marijuana can serve at least two important roles in safe and effective pain management. Ample anecdotal evidence and clinical observations, as well as significant research findings, strongly indicate that marijuana, for whatever reason, is often effective in relieving pain. This is true across a range of patient populations, including the elderly, the terminally ill seeking comfort in their final days, young adults stricken with life-threatening conditions, and cancer patients unable to tolerate the devastating effects of potentially life-saving therapies. Marijuana is also widely recognized as an antiemetic that reduces the nausea and vomiting often induced by powerful opioid analgesics prescribed for chronic, severe pain, as well as the nausea, vomiting and dizziness which often accompany severe and/or prolonged pain. I have had the benefit of consultations on this subject over many years with a range of treatment providers, including physicians, oncologists, pharmacologists, family practitioners, hospice workers, and pain specialists.
Specifically, I have found that cannabis can have an important opioid-sparing effect for pain patients. That is to say, that patients who are prescribed high doses of opioid analgesics can significantly reduce their reliance on these medications and improve their daily functioning by incorporating cannabis into their pain care regimen.
Marijuana not only has important analgesic properties but it also is an effective and important adjuvant therapy for patients suffering acute and/or chronic pain. No experienced and respected physician will deny that for such patients opioid therapy is central to palliative care. By the same token, the same experienced physicians will readily acknowledge that opioids often induce nausea and vomiting. For a number of pain patients, standard prescription antiemetics (e.g., Compazine, Zofran and Reglan) simply do not substantially reduce their nausea. For many, those medications are substantially less effective, or produce more debilitating side effects, than marijuana.
Quite simply, marijuana can serve much the same function for pain patients undergoing opiate therapy that it does for cancer patients undergoing chemotherapy: it suppresses the nausea and vomiting associated with treatment, and reduces the pain associated with prolonged nausea and retching, thereby increasing the chances that the patient will remain compliant with the primary treatment. With both chemotherapy and long-term pain management, failure to obtain and continue proper palliative and adjutant care can have dire, even fatal, consequences.
Finally, it is important to note that in my clinical experience observing patients who ingest cannabis for relief from pain and nausea and/or to stimulate appetite, I have witnessed no adverse complications. By contrast, many of the first-line pharmaceuticals used to combat cancer, HIV/AIDS, and pain associated with these and other illnesses can induce a variety of iatrogenic effects, including, in some instances, death. While patients may face serious legal implications related to their use of medical marijuana, as a physician I have yet to encounter a medical downside to their cannabinoid therapy. . . .
[A]gainst the backdrop of a growing body of scientific research, the reports of myriad pain patients, and the burgeoning clinical experience of physicians like myself, it is my considered opinion that cannabis can constitute an acceptable and sometimes necessary medicine to alleviate the immediate suffering of certain patients.
Dr. Rose has served as a medical officer in the Air Force, taught at UC Davis School of Medicine, and consulted with state legislative bodies.
Howard D. Maccabee, M.D.
In my practice, I commonly use radiation therapy to treat the whole spectrum of solid malignant tumors. Radiation therapy is often used after surgery or chemotherapy, as a second stage in treatment. Sometimes, however, radiation therapy is used concurrently with chemotherapy, or even as the first or only modality of treatment.
Because of the nature of some cancers, I must sometimes irradiate large portions of my patients' abdomens. Such patients often experience nausea, vomiting, and other side effects. Because of the severity of these side effects, some of my patients choose to discontinue treatment altogether, even when they know that ceasing treatment could lead to death.
During the 1980s, I participated in a state-sponsored study of the effects of marijuana and THC (an active ingredient in marijuana) on nausea. It was my observation during this time that some patients smoked marijuana while hospitalized, often with the tacit approval of physicians. I also observed that medical marijuana was clinically effective in treating the nausea of some patients.
During my career as a physician, I have witnessed cases where patients suffered from nausea or vomiting that could not be controlled by prescription anti-emetics. I frequently hear similar reports from colleagues treating cancer and AIDS patients. As a practical matter, some patients are unable to swallow pills because of the side effects of radiation therapy or chemotherapy, or because of the nature of the cancer (for instance, throat cancer). For these patients, medical marijuana can be an effective form of treatment.
Kate Scannell, M.D.
Because I was a cancer patient receiving chemotherapy at the same hospital where I worked, the elderly women with whom I shared the suite quickly surmised that I was also a doctor. The clues were obvious: the colleagues dropping by, the “doctor” salutations from co-workers and the odd coincidence that one of my suitemates was also one of my patients.
I braced myself for this woman's question, both wanting to make my-self available to her but also wishing that the world could forget that I was a doctor for the moment. After receiving my cancer diagnosis, dealing with surgery and chemo-therapy and grappling with insistent reminders of my mortality, I had no desire to think about medicine or to experience myself as a physician in that oncology suite. And besides, the chemotherapy, anti-nauseants, sleep medications and prednisone were hampering my ability to think clearly.
So, after a gentle disclaimer about my clinical capabilities, I said I'd do my best to answer her question. She shoved her IV line out of the way and, with great effort and discomfort, rolled on her side to face me. Her belly was a pendulous sack bloated with ovarian cancer cells, and her eyes were vacant of any light. She became short of breath from the task of turning toward me.
“Tell me,” she managed, “Do you think marijuana could help me? I feel so sick.”
I winced. I knew about her wretched pain, her constant nausea and all the prescription drugs that had failed her—some of which also made her more constipated, less alert and even more nauseous. I knew about the internal derangements of chemotherapy, the terrible feeling that a toxic swill is invading your bones, destroying your gut and softening your brain. I knew this woman was dying a prolonged and miserable death. And, from years of clinical experience, I, like many other doctors, also knew that marijuana could actually help her. From working with AIDS and cancer patients, I repeatedly saw how marijuana could ameliorate a patient's debilitating fatigue, restore appetite, diminish pain, remedy nausea, cure vomiting and curtail down-to-the-bone weight loss. I could firmly attest to its benefits and wager the likelihood that it would decrease her suffering.
Still, federal law has forbidden doctors to ... prescribe marijuana to patients [though doctors may legally recommend it.] In fact, in 1988 the Drug Enforcement Agency even rejected one of its own administrative law judge's conclusions supporting medicinal marijuana, after two full years of hearings on the issue. Judge Francis Young recommended the change on grounds that “marijuana, in its natural form, is one of the safest therapeutically active substances known to man,” and that it offered a “currently accepted medical use in treatment.”
Doctors see all sorts of social injustices that are written on the human body, one person at a time. But this one—the rote denial of a palliative care drug like marijuana to people with serious illness—smacks of pure cruelty precisely because it is so easily remediable, precisely because it prioritizes service to a cold political agenda over the distressed lives and deaths of real human beings.
Denis Petro, M.D.
As a practicing neurologist, I saw many patients for whom uncontrollable spasticity was a major problem. Unfortunately, there are very few drugs specifically designed to treat spasticity. Moreover, these drugs often cause very serious side effects. Dantrium or dantrolene sodium carries a boxed warning in the Physician's Desk Reference because of its very high toxicity…The adverse effects associated with Lioresal Baclofen are somewhat less severe, but include possibly lethal consequences, even when the drug is properly prescribed and taken as directed. Unfortunately, neither Dantrium or Lioresal are very effective spasm control drugs. Their marignal medical utility, high toxicity, and potential for serious adverse effects, make these drugs difficult to use in spasticity therapy.
[Dr. Petro then related his experience with a patient who was smoking cannabis for his symptoms. Dr. Petro and colleagues examined the patient and then asked him to refrain from smoking for six weeks. He continues:]
After six weeks he returned for another examination. At this time, he reported an increase in his symptoms to the point where he had leg pains, increased clonic activity, and uncontrolled leg spasms every night. More disturbing to him was urinary incontinence, which occurred on two occasions during leg spasms. On objective examination, in layman's terms, this patient's spasticity had increased dramatically in six weeks. This spasticity made his legs extremely rigid, he was finding it increasingly difficult to walk or sleep, and he was losing bladder control.
Following our examination, and at the patient's request, he left the clinic then returned one hour later to be examined for a second time. This second examination was remarkable. The earlier findings of moderate to severe spasticity could not be elicited. Deep tendon reflexes were brisk, but without spread, ankle clonus was absent, and the plantar response was flexor on the left and equivocal on the right.
In short, this patient had undergone a stunning transformation. Moreover, this unmistakable improvement had occurred in an incredibly brief period of time. Less than an hour separated the two examinations. On questioning, the patient informed us he had smoked part of one marijuana cigarette in the interval between examinations.
Denis Petro, M.D is a former FDA Review Officer and principal investigator on spasticity and cannabis.
Leo E. Hollister, M.D.
Patients with spinal cord injuries often self-treat their muscle spasticity by smoking cannabis. Cannabis seems to help relieve the involuntary muscle spasms that can be so painful and disabling in this condition. A muscle relaxant or antispastic action of THC was confirmed by an experiment in which p.o. doses of 5 or 10 of THC were compared with placebo in patients with multiple sclerosis. The 10 mg of THC reduced spasticity by clinical measurement. Such single small studies can only point to the need for more study of the potential use of THC or possibly some of its homologs. Diazepam, cyclobenzaprine, baclofen, and dantrolene, which are used as muscle relaxants, all have major limitations. A new skeletal muscle relaxant would be most welcome.
Leo E. Hollister, Veterans Administration Medical Center and Stanford University School of Medicine, Palo Alto, California.
Lester Grinspoon, M.D.
There are many case reports of marihuana smokers using the drug to reduce pain: post-surgery pain, headache, migraine, menstrual cramps, and so on. Ironically, the best alternative analgesics are the potentially addictive and lethal opioids. In particular, marihuana is becoming increasingly recognized as a drug of choice for the pain that accompanies muscle spasm, which is often chronic and debilitating, especially in paraplegics, quadriplegics, other victims of traumatic nerve injury, and people suffering from multiple sclerosis or cerebral palsy. Many of them have discovered that cannabis not only allows them to avoid the risks of other drugs, but also reduces muscle spasms and tremors; sometimes they can even leave their wheelchairs.
The years of effort devoted to showing that marihuana is exceedingly dangerous have proved the opposite. It is safer, with fewer serious side effects, than most prescription medicines, and far less addictive or subject to abuse than many drugs now used as muscle relaxants, hypnotics, and analgesics.
Thus cannabis should be made available even if only a few patients could get relief from it, because the risks would be so small. For example, as I mentioned, many patients with multiple sclerosis find that cannabis reduces their muscle spasms and pain. A physician may not be sure that such a patient will get more relief from marihuana than from the standard drugs baclofen, dantrolene, and diazepam—all of which are potentially dangerous or addictive—but it is almost certain that a serious toxic reaction to marihuana will not occur. Therefore the potential benefit is much greater than any potential risk.
Dr. Grinspoon is professor emeritus at Harvard University School of Medicine, and the author of numerous publications.
Because of the nature of some cancers, I must sometimes irradiate large portions of my patients' abdomens. Such patients often experience nausea, vomiting, and other side effects. Because of the severity of these side effects, some of my patients choose to discontinue treatment altogether, even when they know that ceasing treatment could lead to death.
During the 1980s, I participated in a state-sponsored study of the effects of marijuana and THC (an active ingredient in marijuana) on nausea. It was my observation during this time that some patients smoked marijuana while hospitalized, often with the tacit approval of physicians. I also observed that medical marijuana was clinically effective in treating the nausea of some patients.
During my career as a physician, I have witnessed cases where patients suffered from nausea or vomiting that could not be controlled by prescription anti-emetics. I frequently hear similar reports from colleagues treating cancer and AIDS patients. As a practical matter, some patients are unable to swallow pills because of the side effects of radiation therapy or chemotherapy, or because of the nature of the cancer (for instance, throat cancer). For these patients, medical marijuana can be an effective form of treatment.
Kate Scannell, M.D.
Because I was a cancer patient receiving chemotherapy at the same hospital where I worked, the elderly women with whom I shared the suite quickly surmised that I was also a doctor. The clues were obvious: the colleagues dropping by, the “doctor” salutations from co-workers and the odd coincidence that one of my suitemates was also one of my patients.
I braced myself for this woman's question, both wanting to make my-self available to her but also wishing that the world could forget that I was a doctor for the moment. After receiving my cancer diagnosis, dealing with surgery and chemo-therapy and grappling with insistent reminders of my mortality, I had no desire to think about medicine or to experience myself as a physician in that oncology suite. And besides, the chemotherapy, anti-nauseants, sleep medications and prednisone were hampering my ability to think clearly.
So, after a gentle disclaimer about my clinical capabilities, I said I'd do my best to answer her question. She shoved her IV line out of the way and, with great effort and discomfort, rolled on her side to face me. Her belly was a pendulous sack bloated with ovarian cancer cells, and her eyes were vacant of any light. She became short of breath from the task of turning toward me.
“Tell me,” she managed, “Do you think marijuana could help me? I feel so sick.”
I winced. I knew about her wretched pain, her constant nausea and all the prescription drugs that had failed her—some of which also made her more constipated, less alert and even more nauseous. I knew about the internal derangements of chemotherapy, the terrible feeling that a toxic swill is invading your bones, destroying your gut and softening your brain. I knew this woman was dying a prolonged and miserable death. And, from years of clinical experience, I, like many other doctors, also knew that marijuana could actually help her. From working with AIDS and cancer patients, I repeatedly saw how marijuana could ameliorate a patient's debilitating fatigue, restore appetite, diminish pain, remedy nausea, cure vomiting and curtail down-to-the-bone weight loss. I could firmly attest to its benefits and wager the likelihood that it would decrease her suffering.
Still, federal law has forbidden doctors to ... prescribe marijuana to patients [though doctors may legally recommend it.] In fact, in 1988 the Drug Enforcement Agency even rejected one of its own administrative law judge's conclusions supporting medicinal marijuana, after two full years of hearings on the issue. Judge Francis Young recommended the change on grounds that “marijuana, in its natural form, is one of the safest therapeutically active substances known to man,” and that it offered a “currently accepted medical use in treatment.”
Doctors see all sorts of social injustices that are written on the human body, one person at a time. But this one—the rote denial of a palliative care drug like marijuana to people with serious illness—smacks of pure cruelty precisely because it is so easily remediable, precisely because it prioritizes service to a cold political agenda over the distressed lives and deaths of real human beings.
Denis Petro, M.D.
As a practicing neurologist, I saw many patients for whom uncontrollable spasticity was a major problem. Unfortunately, there are very few drugs specifically designed to treat spasticity. Moreover, these drugs often cause very serious side effects. Dantrium or dantrolene sodium carries a boxed warning in the Physician's Desk Reference because of its very high toxicity…The adverse effects associated with Lioresal Baclofen are somewhat less severe, but include possibly lethal consequences, even when the drug is properly prescribed and taken as directed. Unfortunately, neither Dantrium or Lioresal are very effective spasm control drugs. Their marignal medical utility, high toxicity, and potential for serious adverse effects, make these drugs difficult to use in spasticity therapy.
[Dr. Petro then related his experience with a patient who was smoking cannabis for his symptoms. Dr. Petro and colleagues examined the patient and then asked him to refrain from smoking for six weeks. He continues:]
After six weeks he returned for another examination. At this time, he reported an increase in his symptoms to the point where he had leg pains, increased clonic activity, and uncontrolled leg spasms every night. More disturbing to him was urinary incontinence, which occurred on two occasions during leg spasms. On objective examination, in layman's terms, this patient's spasticity had increased dramatically in six weeks. This spasticity made his legs extremely rigid, he was finding it increasingly difficult to walk or sleep, and he was losing bladder control.
Following our examination, and at the patient's request, he left the clinic then returned one hour later to be examined for a second time. This second examination was remarkable. The earlier findings of moderate to severe spasticity could not be elicited. Deep tendon reflexes were brisk, but without spread, ankle clonus was absent, and the plantar response was flexor on the left and equivocal on the right.
In short, this patient had undergone a stunning transformation. Moreover, this unmistakable improvement had occurred in an incredibly brief period of time. Less than an hour separated the two examinations. On questioning, the patient informed us he had smoked part of one marijuana cigarette in the interval between examinations.
Denis Petro, M.D is a former FDA Review Officer and principal investigator on spasticity and cannabis.
Leo E. Hollister, M.D.
Patients with spinal cord injuries often self-treat their muscle spasticity by smoking cannabis. Cannabis seems to help relieve the involuntary muscle spasms that can be so painful and disabling in this condition. A muscle relaxant or antispastic action of THC was confirmed by an experiment in which p.o. doses of 5 or 10 of THC were compared with placebo in patients with multiple sclerosis. The 10 mg of THC reduced spasticity by clinical measurement. Such single small studies can only point to the need for more study of the potential use of THC or possibly some of its homologs. Diazepam, cyclobenzaprine, baclofen, and dantrolene, which are used as muscle relaxants, all have major limitations. A new skeletal muscle relaxant would be most welcome.
Leo E. Hollister, Veterans Administration Medical Center and Stanford University School of Medicine, Palo Alto, California.
Lester Grinspoon, M.D.
There are many case reports of marihuana smokers using the drug to reduce pain: post-surgery pain, headache, migraine, menstrual cramps, and so on. Ironically, the best alternative analgesics are the potentially addictive and lethal opioids. In particular, marihuana is becoming increasingly recognized as a drug of choice for the pain that accompanies muscle spasm, which is often chronic and debilitating, especially in paraplegics, quadriplegics, other victims of traumatic nerve injury, and people suffering from multiple sclerosis or cerebral palsy. Many of them have discovered that cannabis not only allows them to avoid the risks of other drugs, but also reduces muscle spasms and tremors; sometimes they can even leave their wheelchairs.
The years of effort devoted to showing that marihuana is exceedingly dangerous have proved the opposite. It is safer, with fewer serious side effects, than most prescription medicines, and far less addictive or subject to abuse than many drugs now used as muscle relaxants, hypnotics, and analgesics.
Thus cannabis should be made available even if only a few patients could get relief from it, because the risks would be so small. For example, as I mentioned, many patients with multiple sclerosis find that cannabis reduces their muscle spasms and pain. A physician may not be sure that such a patient will get more relief from marihuana than from the standard drugs baclofen, dantrolene, and diazepam—all of which are potentially dangerous or addictive—but it is almost certain that a serious toxic reaction to marihuana will not occur. Therefore the potential benefit is much greater than any potential risk.
Dr. Grinspoon is professor emeritus at Harvard University School of Medicine, and the author of numerous publications.
Occupational Hazards For Armed Services Members
Mineral fiber used in older buildings and ships; if inhaled deeply into the lungs can cause health problems
Usually liquid, used to dissolve, degrease, clean, strip paint, etc.
Metal that can be toxic for certain uses
Dental technicians, nuclear weapons technicians, and others with routine and usually safe exposure
Fuels such as diesel and JP-8 used to operate vehicles in the military
Polychlorinated biphenyl used as coolant and insulating fluid
Periodic back and forth movement that if severe, can cause health conditions
Harmful sounds from guns, equipment, and machinery that is often experienced during service
Chemical Agent Resistant Coating (CARC) used on military vehicles to resist corrosion and chemical agents
Due to the nature of war, combat soldiers are prone to the development of mental health conditions among which include post-traumatic stress disorder (PTSD). PTSD is characterized by “flashbacks, nightmares, severe anxiety, and uncontrollable thoughts following a disturbing event—which could either have been experienced or witnessed by the person” (“Post-traumatic Stress Disorder (PTSD)”). When symptoms intensify or persists for months to years, and when it begins to interfere with one’s functioning, PTSD is likely the diagnosis (“Post-traumatic Stress Disorder (PTSD)”). For a better understanding of the disorder the following link can certainly provide more information regarding the condition: http://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/basics/definition/con-20022540.
Although it is a serious mental health issue, it certainly can be improved upon through therapy, medications, and counseling which can all be managed by seeking out health care professionals (i.e. a psychiatrist) (“Post-traumatic Stress Disorder (PTSD)”).
While mental health concerns are common in soldiers, research indicates that only around fifty percent of said soldiers seek out help within one year (Kim et al.). According to a study, stigma as well as barriers to care are prominent reasons as to why these soldiers end up not pursuing treatment and help while facing a mental health condition (Kim et al.). Common stigmas that soldiers felt include being perceived as “dangerous/violent” or even “crazy” (Mittal et al.). Another stigma that demotivated these men and women from seek out help was the notion that combat veterans are at fault and are responsible for the development of PTSD (Mittal et al.). They preferred to remain silent in order to avoid being labeled as someone with a mental illness (Mittal et al.). Being labelled with any disease can bring associated stigmas with it, and this labeling can plant these incorrect stigmas into the minds of others. Remaining silent can, however, be dangerous, as PTSD can "affect quality of life, impairing psychosocial and occupational functioning and overall well-being,” and treatment is crucial for recovery (Schnurr et al.).
Stigma can also have a drastic impact on how soldiers view themselves and it can decrease their self-esteem (Kim et al.). Internalization of these incorrect stigmas only serve to further demoralize these individuals and prevent them from getting treatment. Aside from stigma, barriers to care (i.e. lack of time and a lack of method of transportation) was stated to also play in a role in preventing these individuals from receiving treatment (Kim et al.).
These incorrect stigmas and modes of thinking about PTSD, whether from the general public, military personnel, or even soldiers with PTSD, as is the case in self-stigma (in which they adopt common perceptions about their illness and allow it to define themselves), is certainly detrimental. None of the previously mentioned stigmas are true nor do they do troops any justice. They only serve to exacerbate the mental health condition of the individual and prevent recovery. Thus, it is crucial that stigma is recognized as being harmful never helpful, and discarding these notions from clouding our judgement is only a step forward.
References:
Kim, P. Y., J. L. Thomas, J. E. Wilk, C. A. Castro, and C. W. Hoge. “Stigma, Barriers to Care, and Use of Mental Health Services Among Active Duty and National Guard Soldiers After Combat.” Psychiatric Services 61.6 (2010): 582-88. Web. 12 Apr. 2015.
Mittal, Dinesh, Karen L. Drummond, Dean Blevins, Geoffrey Curran, Patrick Corrigan, and Greer Sullivan. “Stigma Associated with PTSD: Perceptions of Treatment Seeking Combat Veterans.” Psychiatric Rehabilitation Journal 36.2 (2013): 86-92. Web. 12 Apr. 2015.
“Post-traumatic Stress Disorder (PTSD).” Mayo Clinic. Mayo Clinic, 15 Apr. 2014. Web. 11 Apr. 2015.
Schnurr, Paula P., Carole A. Lunney, Michelle J. Bovin, and Brian P. Marx. “Posttraumatic Stress Disorder and Quality of Life: Extension of Findings to Veterans of the Wars in Iraq and Afghanistan.” Clinical Psychology Review 29.8 (2009): 727-35. Web. 10 Apr. 2015.
Veterans Need Equal Access
The U.S. Department of Veterans Affairs estimates that PTSD afflicts: Almost 31 percent of Vietnam veterans. As many as 10 percent of Gulf War (Desert Storm) veterans. 11 percent of veterans of the war in Afghanistan. An estimated 7.8 percent of Americans will experience PTSD at some point in their lives, with women (10.4%) twice as likely as men (5%) to develop PTSD. About 3.6 percent of U.S. adults aged 18 to 54 (5.2 million people) have PTSD during the course of a given year.
Roger Martin, Executive Director of Operation Grow For Vets, launched the organization after his own personal experiences with medical cannabis helped him realize that cannabis is not the harmful drug that he once believed it to be. After serving in the military, Martin was taking as much as 180 milligrams of oxycontin every day to treat chronic pain. At the same time, he took 20-30 milligrams of ambien in order to sleep through the night.
After trying to quit cold turkey on two separate occasions, Martin was advised to try suboxone treatment coupled with cannabis therapy. He was able to wean himself off the suboxone in as little as 5 1/2 weeks – such treatment typically takes 12-18 months. These days Martin relies on the use of infused edibles to help deal with bouts of chronic pain. According to him, he eats a cannabis-infused cookie each night in order to silence the pain long enough to sleep for 4-6 hours each night. More importantly, Martin is able to achieve this sort of relief without taking any sort of harmful pharmaceutical drugs.
Grow for Vets serves veterans who sustained a physical or mental injury, illness, or wound during their military service.
It is an unfortunate fact that many of the men and women who have sacrificed so much to protect the American way of life suffer so much physical and emotional pain — they number in the hundreds of thousands.
As the cannabis movement continues to cultivate itself in New Mexico, awareness of cannabis grows specifically for lawmakers at the Roundhouse in 2017. Legislation being debated ranges from; Medical Cannabis Program improvements & research for patients, Hemp legislation, and three proposals for the legalization of cannabis for adult use. Yes, there is a lot of amazing progress being made and people are becoming more educated on the positive qualities of cannabis. As New Mexico works to define a model for cannabis legalization that protects and improves the state’s medical cannabis program and puts patients first as well, lawmakers have a lot of history to contend with. New Mexico’s medical cannabis history started in 1978 (After public hearings the legislature enacted H.B. 329, the nation’s first law recognizing the medical value of cannabis). However, frustrations persist due to some basic misconceptions about cannabis and the medical cannabis program...below are some highlights that will make some rethink their theory that cannabis is bad for a person’s health.
“Marijuana, in its natural form, is one of the safest therapeutically active substances known to man.”
— DEA Administrative Law Judge Francis Young
Docket No. 86-22. 1988.
Medical Cannabis vs Prescriptions.
Prescription Pills: Each year, about 4.5 million Americans visit their doctor’s office or the emergency room because of adverse prescription drug side effects. A startling 2 million other patients who are already hospitalized suffer the ill effects of prescription medications annually, and this when they should be under the watchful eye of medical professionals. The most common non-severe or mild side effects from taking drugs include (there are many more, these are the most common): Constipation, Dermatitis, Diarrhea, Dizziness, Drowsiness, Dry mouth, Headache, and Insomnia.
What are the short and long term effects of prescription drugs? Short-term effects: Alertness, focus, sleeplessness, loss of appetite, increased blood pressure and heart rate, high body temperature.
Long-term effects: Addiction, paranoia and long-term insomnia, extreme weight change.
What are the effects of prescription drugs? Physical symptoms: Increased or decreased need for sleep, Appearing unusually energetic, or overly fatigued, Increased or decreased appetite.
These drugs come with side effects that range from birth defects and liver damage to suicidal behavior, blood clots, bladder cancer, Crohn’s disease, heart attacks, strokes, uncontrollable bleeding, heart failure and death: Chronic Pain Treatment drug Fentanyl (opioid). Type 2 diabetes drugs Avandia and Actos. Antidepressants Paxil, Prozac, Effexor, Zoloft and Lexapro. Mood stabilizer Depakote. Birth control pills Yaz and Yasmin. Acne medication Accutane. Blood thinners Pradaxa and Xarelto Osteoporosis treatment Fosamax. GranuFlo and NaturaLyte, which are used in dialysis.
Hair loss pill Propecia. Stop smoking cigarettes drug Chantix.
Grow for Vets serves veterans who sustained a physical or mental injury, illness, or wound during their military service.
It is an unfortunate fact that many of the men and women who have sacrificed so much to protect the American way of life suffer so much physical and emotional pain — they number in the hundreds of thousands.
In article in American-Statesman staff writer Jeremy Schwartz in 2012 noted that in 2011, “the Pentagon spent more on pills, injections and vaccines than it did on Black Hawk helicopters, Abrams tanks, Hercules C-130 cargo planes and Patriot missiles — combined.” The military spent at least $2.7 billion on antidepressants and more than $1.6 billion on opioid painkillers such as Oxycontin and hydrocodone over the past decade. More than $507 million was spent on the sleeping pill Ambien and its generic equivalents.” the pharmaceutical industry spent about $1.7 million for more than 1,400 trips for Defense Department doctors and pharmacists to places such as Paris, Las Vegas and New Orleans between 1998 and 2007. All those Pills killed a lot of Veterans, Cannabis has a 5000 year history with zero deaths associated with it.
“Its margin of safety is immense and underscores the lack of any meaningful danger in using not only daily doses in the 3.5 – 9 gram range, but also considerably higher doses.”
Physician, researcher, court-qualified cannabis expert
Cannabis Is Safe & The Federal Government Has A Patent For It.
The U.S. Patent Office issued patent #6630507 to the U.S.Health and Human Services filed on 2/2/2001. The patent lists the use of cannabinoids found within the plant cannabis sativa plant as useful in certain neurodegenerative diseases such as Alzheimer's, Parkinson's, and HIV dementia. Since cannabis sativa (marijuana) contains compounds recognized and endorsed by an agency of the U.S. government- Why is it that cannabis remains on the Federal Schedule One list of drugs? The issuance of patent #6630507 is a direct contradiction of the Government’s own definition for classification of a Schedule 1 drug. The U.S. government’s own National Institutes of Health researchers even concluded: “Based on evidence currently available the Schedule I classification is not tenable; it is not accurate that cannabis has no medical value, or that Information on safety is lacking.”
"The American Medical Association has no objection to any reasonable regulation of the medicinal use of cannabis and its preparations and derivatives. It does pretest, however, against being called upon to pay a special tax, to use special order forms in order to procure the drug, to keep special records concerning its professional use and to make special returns to the Treasury Department officials, as a condition precedent to the use of cannabis in the practice of medicine."
~Wm. C. Woodward, Legislative Counsel - 11:37 AM Monday, July 12, 1937
For over 5000 years, various strains of the green herb Cannabis sativa, or true hemp, have been among the most widely used of medicinal plants. This includes civilizations in China, India, Europe, Africa and the Middle East. Cannabis was used in the US from 1800’s to 1937 to treat more than 100 distinct diseases or conditions.
Cannabis is a NON-TOXIC substance. No one has ever died from taking cannabis. One hundred per cent of the scores of studies by American universities and research facilities show that toxicity does not exist in cannabis. (U.C.L.A, Harvard, Temple, etc.) All the in-depth medico-scientific clinical studies conducted (for example, US-Jamaican, US-Costa Rican, LaGuardia Report, etc) have revealed that cannabis contains no addictive properties in any part of the plant or its smoke, so, unlike and in contrast to tobacco, alcohol, and all the legal or illegal 'recreational' substances cannabis is both non-habit-forming and non-toxic.
Therefore cannabis is uniquely safe when compared to modern FDA approved prescriptions.
Cannabis stimulate CB1 and CB2 endocannabinoid receptors on the brain and other tissues that affect body systems, triggering a chain of temporary psychological and physiological effects. Initially it has a stimulant effect, followed by relaxation and overall reduction in stress. Analgesic effect. Blocks migraine or seizures. Helps mitigate or control symptoms of multiple sclerosis (MS), spinal injury, epilepsy. Lifts mood and enhances sense of well-being. Relieves chronic and neuropathic pain. Has synergistic effects with opiates and other drugs. Not all cannabis has the same potency or effect. May cause drowsiness, distraction, paranoia or anxiety (due to type of cannabis strain) and dry mouth - that”s it.
With many veterans relying on the Department of Veteran Affairs for health care, it’s become an increasingly difficult obstacle to get proper treatment. Veterans who are legally seeking medical cannabis cannot be prescribed or recommended for it by any physician employed by the U.S. federal government. The American Legion, the country’s largest wartime veterans organization, came out this year in support of allowing veterans to access medical cannabis, and urged Congress to remove cannabis from the Schedule 1 designation.
Rules, Regulations, & Policy Solution For Requesting The Inclusion Of A New Medical Condition: "qualified patient" means a resident of New Mexico who has been [diagnosed by a practitioner as having a debilitating medical condition and has received written certification and] issued a registry identification card [issued] pursuant to the Lynn and Erin Compassionate Use Act [and] on the basis of: (1) having been diagnosed by a practitioner as having a debilitating medical condition; or (2) status as a veteran;
The approval of this petition: Requesting The Inclusion Of A New Medical Condition: "qualified patient" means a resident of New Mexico who has been [diagnosed by a practitioner as having a debilitating medical condition and has received written certification and] issued a registry identification card [issued] pursuant to the Lynn and Erin Compassionate Use Act [and] on the basis of: (1) having been diagnosed by a practitioner as having a debilitating medical condition; or (2) status as a veteran; that is being provided to the state Department of Health Medical Cannabis Program so the advisory board can review and recommend to the department for approval additional debilitating medical conditions that would benefit from the medical use of cannabis with the Lynn and Erin Compassionate Use Act. The approval of this petition would bring the Department of Health in compliance with the intent of the law and uphold the spirit of the Lynn and Erin Compassionate Use Act, 2007. Fulfilling both;“ Section 2. PURPOSE OF ACT.--The purpose of the Lynn and Erin Compassionate Use Act is to allow the beneficial use of medical cannabis in a regulated system for alleviating symptoms caused by debilitating medical conditions and their medical treatments” And Section 6. ADVISORY BOARD CREATED--DUTIES: The advisory board shall: A. review and recommend to the department for approval additional debilitating medical conditions that would benefit from the medical use of cannabis.” New Mexico’s medical cannabis history started in 1978. After public hearings the legislature enacted H.B. 329, the nation’s first law recognizing the medical value of cannabis...the first law.
REFERENCES
Legal Citations
1. See "The Administration's Response to the Passage of California Proposition 215 and Arizona Proposition 200" (Dec. 30, 1996). https://www.ncjrs.gov/txtfiles/215rel.txt
2. See Conant v. McCaffrey, 172 F.R.D. 681 (N.D. Cal. 1997).
3. See id.; Conant v. McCaffrey, 2000 WL 1281174 (N.D. Cal. 2000); Conant v. Walters, 309 F.3d 629 (9th Cir. 2002).
4. 309 F.3d 629 (9th Cir. 2002).
5. Id. at 634-36.
6. Criminal liability for aiding and abetting requires proof that the defendant "in some sort associate[d] himself with the venture, that he participated in it as something that he wishe[d] to bring about, that he [sought] by his action to make it succeed."Conant v. McCaffrey, 172 F.R.D. 681, 700 (N.D. Cal. 1997) (quotation omitted). A conspiracy to obtain cannabis requires an agreement between two or more persons to do this, with both persons knowing this illegal objective and intending to help accomplish it. Id. at 700-01.
7. 309 F.3d at 634 & 636.
8. Conant v. McCaffrey, 2000 WL 1281174, at *16 (N.D. Cal. 2000).
9. 309 F.3d at 634.
10. See id.. at 635; Conant v. McCaffrey, 172 F.R.D. 681, 700-01 (N.D. Cal. 1997).
11. Gonzales v. Raich, 545 U.S. 1 (2005) 352 F.3d 1222.
12. Third Time the Charm? State Laws on Medical Cannabis Distribution and Department of Justice Guidance on Enforcement. Americans for Safe Access. November 25, 2013. http://americansforsafeacess.org/dojwhitepaper.
Research Citations
Veterans and Medical Cannabis
Veterans of military service have a disproportionately high rate of certain debilitating medical conditions as compared to the general population. Some of those conditions may result from injury or exposures to toxins, but not all. The correlation between military service and higher rates of the conditions discussed in this booklet are clear and well-documented, but the cause is not known for many.
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Image Source: NM Workforce 2015 Veterans Profile
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