Marijuana Pain Management
Before I begin with my perspective on marijuana pain management, let me say that this was one of the most difficult postings I have ever authored. The recent legalization of marijuana in some states (also called cannabis after the official taxonomic name Cannabis sativa), the gradually accumulating objective scientific literature on the substance, and the lack of universal agreement on its use and abuse, has made this a particularly difficult topic to write on.
Marijuana use in the United States is not a recent phenomena. From the very founding of the colonies, marijuana has been grown and used in the U.S.. In fact, early historical documents show that the colonists were encouraged to grow hemp (the agricultural term for marijuana) as an excellent plant source for rope and clothing. Even George Washington grew hemp on his farm in Mount Vernon, New York as one of 3 primary crops.
So what happened? It is complicated with many conflicting historical references but many historians site the increasing use of marijuana as a “recreational drug” as being the beginning of the real legal reprisal against marijuana. As early as 1853, recreational cannabis was listed as a “fashionable narcotic”. By the 1880’s, oriental-style hashish parlors were flourishing alongside opium dens, to the point that one could be found in every major city on the east coast. It was estimated there were around 500 such establishments in New York City alone.
The legal backlash really started when the Pure Food and Drug Act was passed by the United States Congress in 1906 and required that certain special drugs, including cannabis, be accurately labeled with contents. Previously, many drugs had been sold as patent medicines with secret ingredients or misleading labels.
What followed was a series of federal congressional laws that culminated in the Marijuana Tax Act of 1937 effectively making possession or transfer of cannabis illegal throughout the United States under federal law, excluding medical and industrial uses, through imposition of an excise tax on all sales of hemp. Since the federal government had no authority under the 10th Amendment to regulate medicines, that power being reserved by individual states in 1937, a tax was the only viable way to legislate marijuana.
The decision of the United States Congress to pass the Marijuana Tax Act of 1937 was based on poorly attended hearings and reports based on questionable studies. In 1936 the Federal Bureau of Narcotics (FBN) noticed an increase in reports of people smoking marijuana, which further increased in 1937. The Bureau drafted a legislative plan for Congress seeking a new law, and the head of the FBN, Harry J. Anslinger, ran a campaign against marijuana.
But there was mischief afoot. Newspaper mogul William Randolph Hearst’s empire of newspapers used “yellow journalism” (the use of eye-catching headlines with little facts) pioneered by Hearst to demonize the cannabis plant and spread a public perception that there were connections between cannabis and violent crime. His motivation was less than altruistic.
With the invention of the decorticator (a machine that strips the skin off of marijuana plant stalks), hemp became a very cheap substitute for the wood pulp that was used for making paper in the newspaper industry. This would have effected Hearst’s existing pricing as he had long-term contracts with Canadian wood suppliers. There has also been allegations that the wealthiest man in America at the time, Andrew Mellon (who was Secretary of the Treasury), was deeply invested in a new fiber that was being developed called Nylon.
Hemp could be a competitor to the emerging Nylon industry (developed by the DuPont family). With the negative media attention and the back channel motivations of Mellon and DuPont, the federal government intensified its efforts to regulate cannabis… and succeeded.
To be fair, there are some industrial historians who refute this connection. Evidently, the fiber that is produced from the stems of marijuana plants is too inferior for paper making. They contend that DuPont’s motivation was really to impact the silk industry (as Nylon could be produced and used for women’s stockings at a much cheaper cost than silk production).
We may never know the truth about the back channel communications. Nevertheless, the assault on marijuana had already been deeply ingrained into the culture of the Federal Bureau of Narcotics which eventually became the Office of National Drug Control Policy (ONDCP). The head of the ONDCP is charged, by law, to oppose any attempt to legalize the use (in any form) of illicit drugs.
The present head of the ONDCP is Michael Boticelli. He was appointed by President Obama August 28, 2014. He has publicly stated that he was an alcoholic and has been in recovery for years. Perhaps his insight into addiction will help enlarge the perspective of the ONDCP…only time will tell.
What Is Marijuana?
Marijuana is a plant that has the official name Cannabis sativa. There are more than a dozen other species of the plant. It belongs to the plant family Cannabaceae. Various names given to the plant and plant parts are: anascha and kif (resinous material and flowering tops mixed with the leaves); banji , hemp , cannabis , shesha , dimba , dagga , suma , vingory , and machona (entire plant); bhang and sawi (dried mature leaves); charas (resinous material); ganga (flowering tops); hashish and esrar (resinous material with flowering tops); and marijuana or marihuana (leaves and flowering tops).
Commercial preparations in the U.S. include dronabinol ( Marinol – an FDA schedule III drug) and nabilone ( Cesamet – an FDA schedule II drug). Other preparations of the drug have been extracted and are available in other countries. There are over 420 different compounds isolated from marijuana, of which THC (Tetrahydrocannabinol) is the most biologically active compound.
The concentration of THC varies in different parts of the plant, being higher in the bracts, flowers, and leaves and lower in the stems, seeds, and roots. THC concentration varies from insignificant amounts in hemp varieties to 3% to 6% in smoked marijuana and more than 6% in the resinous, compressed paste obtained from the dried flowers. Different cultivation methods and varieties contribute to variations in potency.
How Does Marijuana Work?
Any biologically active molecule exerts its influence when it is bound to a receptor in the body (a place where the substance attaches and initiates a chemical reaction). Marijuana works through the endocannabinoid receptor system (ECRS or ECS) of the body.
The ECS is involved in a variety of physiological processes including appetite, pain-sensation, mood, memory, immune modulation, and in mediating the psychoactive effects of cannabis. There are at least 2 different types of ECS receptors in play when it comes to marijuana.
The cannabinoid receptor type 1, often abbreviated as CB1, is a G protein-coupled cannabinoid receptor located primarily in the central and peripheral nervous system (also found in lesser density in the lung, reproductive, and vascular endothelial tissues).
The cannabinoid receptor type 2, abbreviated as CB2, is a G protein-coupled receptor and is located primarily on cells of immunity (in particular T lymphocytes). These receptors are also found in retinal and microglia cells (in lesser density).
The human body actually manufactures its own substances that attach to these receptors too. The locations of these receptors begins to explain the effects that marijuana can have on the human body. A receptor is located on the cells of the organs that are affected by marijuana.
What Types Of Effects Can Marijuana Have On The Human Body?
The following effects of marijuana have been demonstrated by human and animal studies:
- Glaucoma: reductions in eye pressure have been documented in both animal and human studies.
- Chronic Neuropathic Pain: supported by both animal and human studies. The disorders that seem to be associated with the greatest pain reductions with medical marijuana are HIV neuropathic pain, Diabetic neuropathy, and Multiple Sclerosis.
- Cancer Chemotherapy Induced Nausea and Vomiting: both animal study and human study evidence.
- Appetite Stimulant: this has been shown in HIV patients.
- Cancer Pain
- Rheumatoid Arthritis Pain
- Post-operative Pain
- Sleep Disorders
- Anxiety Neurosis
- Tourettes Syndrome
- Delaying demyelination and nerve cell death
The difficulty with the literature and the benefits of medical marijuana are numerous. I will opine on this at the conclusion of this article.
What Is The Effective Dose Of Marijuana?
Clinical studies have used a wide range of preparations and usually allow dosage titration for effect, making standard dosage recommendations difficult. Furthermore, the quantification of dose requires a way to measure the amount of THC actually absorbed with a given method of administration (inhaled, ingested, or ophthalmic drops)
The following are the general recommendations that I was able to find in my research:
Doses of 25 to 50 mcg topical THC, and 5 mg oromucosal THC reduced the intraocular pressure in studies in patients with resistant glaucoma.
A large, multicenter trial used initial doses of 5 mg oral THC daily, self-titrated up to 25 mg THC daily for up to 52 weeks.
Estimates of relative efficacy for THC compared with codeine for pain are 10 mg THC to 60 mg codeine (the pain equivalency between the two). THC is distributed rapidly throughout the body, especially to tissues with high lipid content.
What Are The Side Effects Of Marijuana?
Based on the receptor sites for THC, you can infer that the majority of side effects will be behavioral and neurological. Here is an incomplete listing of them:
- Impaired cognitive ability
- Rapid heart rate
- Low blood pressure
- Mouth lesions
- Dry mouth
- Increased systolic blood pressure
- Worsening of psychosis
Information regarding safety and efficacy of medicinal marijuana in pregnancy and lactation is lacking.
A systematic review of long-term toxicity due to non-medical (recreational) cannabis use found increased risks for psychotic events, respiratory events, cardiovascular events, as well as for cancers of the lung, head and neck, brain, cervix, prostate, and testis. Heavy cannabis use is also associated with bone loss.
Does Marijuana Use Lead To Addiction?
There is abundant medical and non-medical opinion that points to marijuana as a “gateway drug” (meaning it leads to the abuse of more toxic illicit substances). Here again, the difficulty in studying a substance that has been made illegal makes objective prospective studies difficult to perform. Most studies on addiction from marijuana have to be retrospective under such circumstances (the least reliable format for doing a research study as there is no meaningful way to control for confounding variables).
It matters just who is performing the study. There is no way to completely eliminate bias when performing a study. The organization that is sponsoring the study may have a less than objective perspective. Take special note of this when reading about the effects of marijuana when the study has been sponsored by a pro-legalization group (the study may be remarkably positive) or when the government sponsors a study (the study may be remarkably negative).
When looking at the Addictology literature, the association between marijuana use and other more addictive drug abuse can be demonstrated. However, this is also true of tobacco use and alcohol. They are more powerfully associated with further drug abuse than marijuana is. Just how successful have we been at making those substances illegal (consider Prohibition)?
Association is not necessarily causation (though it is commonly believed as such). Here again, what information has been used to make this claim? The information on incidence of likely addiction from any drug is hard to come by. Who would volunteer for such a study?
When I have spoken to addicts in recovery, many often said that marijuana is a “gateway drug.” Of course, this does not take into account the unique genetic and psychological features of the person saying that (hardly an objective analysis). Perhaps it was for them, given their unique features, but would not be for another?
I do find it interesting that in the days when opium and marijuana were legal for any use in the U.S. you often found an “opium den” alongside a “marijuana parlor.” There seems to be some connection.
Any substance that enhances the Limbic system (the area of the brain that coordinates emotion) may have a habituating affect. Furthermore, nearly any substance has the potential to be “addictive” given the complexities of human emotions and the human brain.
The objective evaluation of whether marijuana automatically leads to more addictive substances may have to wait. With the legalization of marijuana in several states, the objective study of it and its addictive potential should be easier to perform. It will not take long to see the sociological effects of these reforms in the states that have made them.
Portugal has decriminalized all personal use of drugs since 2001. Perhaps a closer look at the societal implications of their decision would give some insight? Even then, could we generalize the affect on their culture with our own?
Until then, the many questions I have raised will likely be answered unobjectively. Whether you want marijuana legalized or not will likely dictate how you answer my questions. But are you correct? Has the “War on Drugs” benefited our nation? Will we be able to incarcerate our way out of this “epidemic?”
Where Has Marijuana Been Decriminalized Or Legalized?
Our nation is fast becoming a “patchwork quilt” of states that have legalized cannabis, others who have decriminalized cannabis, and those who still maintain a posture of illegality (marijuana is still officially illegal by federal law). I have included the diagram above to introduce you to the diversity of our nation on this issue.
It is important to note that there is also a vast array of opinions internationally. Be sure you understand those international differences when you travel abroad. You may be surprised at how liberal (or conservative) the country you are visiting is as regards the use of marijuana. Don’t assume that all Caribbean nations take the same liberal posture (or European for that matter).
I am against the unrestricted use of marijuana in the U.S. without more prospective, placebo controlled, double blinded studies. It makes sense to proceed cautiously (even if the public wants to legalize the use of marijuana in an unrestricted manner). I hold to this belief because of some common sense reasons:
- The chemical properties of marijuana infer that it could become a substance of abuse.
- The historical association of “opium dens” and “marijuana parlors” (which occurred before the government made marijuana illegal) infers a connection.
- Addictologists nearly all agree on the addictive potential of cannabis.
- The testimonies of addicts often show association between marijuana use and devolution to more serious drugs of abuse.
However, I am in favor of a gradual loosening of the restrictions for medical marijuana. I hold to this belief for the following reasons:
- There is enough evidence scientifically that cannabis has benefits for certain conditions. This has been shown even while there have been severe restrictions placed on research of the substance.
- The use of medical marijuana needs to be further studied.
- There are many medications used in chronic pain management, that have an addiction potential, which could be lowered or even replaced with medical marijuana.
- Marijuana has a very low over dose potential (some studies even claim there has never been an over dose death from cannabis).
- The focus of law enforcement on marijuana does not seem consistent with its abuse or overdose potential.
I hope you have enjoyed this article. If you have further questions please comment.
Wishing you joy and healing.