2. Medical Use of Marijuana. NEJM. 2013;368:866–868. Available online aswww.nejm.org/doi/full/10.1056/NEJMcide1300970. [PubMed]  –>

Medicinal Use of Marijuana (Reference 2)

N Engl J Med 2013; 368:866-868February 28, 2013DOI: 10.1056/NEJMclde1300970

CASE VIGNETTE

Marilyn is a 68-year-old woman with breast cancer metastatic to the lungs and the thoracic and lumbar spine. She is currently undergoing chemotherapy with doxorubicin. She reports having very low energy, minimal appetite, and substantial pain in her thoracic and lumbar spine. For relief of nausea, she has taken ondansetron and prochlorperazine, with minimal success. She has been taking 1000 mg of acetaminophen every 8 hours for the pain. Sometimes at night she takes 5 mg or 10 mg of oxycodone to help provide pain relief. During a visit with her primary care physician she asks about the possibility of using marijuana to help alleviate the nausea, pain, and fatigue. She lives in a state that allows marijuana for personal medicinal use, and she says her family could grow the plants. As her physician, what advice would you offer with regard to the use of marijuana to alleviate her current symptoms? Do you believe that the overall medicinal benefits of marijuana outweigh the risks and potential harms?

• Option 1: Recommend the Medicinal Use of Marijuana
• Option 2: Recommend against the Medicinal Use of Marijuana

Option 1 (118)

Option 2 (118)

OPTION 1

Recommend the Medicinal Use of Marijuana

J. Michael Bostwick, M.D.

Within established doctor–patient relationships, I endorse thoughtful prescription of medicinal marijuana for patients in situations similar to Marilyn’s. A largely anecdotal but growing literature supports its efficacy, particularly for pain or nausea that is unresponsive to mainstream treatments.1 In 1970, marijuana was designated a Schedule I drug under the Controlled Substances Act, a classification indicating a high potential for abuse and a lack of medical value.2 But physicians face a catch-22: although 18 states have legalized medicinal marijuana, physicians in those states who write prescriptions violate the law of the land.
Federal policy has failed to keep pace with recent scientific advances. Laboratory research has elucidated the far-flung endocannabinoid system that modulates neurotransmitter networks throughout the body through cannabinoid-1 (CB1) receptors that are preferentially distributed in the brain and cannabinoid-2 (CB2) receptors that are prominent in gut and immune tissues. Among dozens of cannabinoids in raw marijuana, two show medicinal promise. The first, Δ9-tetrahydrocannabinol (Δ9-THC), is the CB1 ligand that recreational users prize. The second, cannabidiol (CBD), acting on CB2, lacks psychoactivity but works synergistically with Δ9-THC to minimize “highs” and maximize analgesia.2,3
Arguments for and against medicinal marijuana are manifold. Under federal law, the drug is illegal. However, given widespread state defiance, the cannabis horse long ago burst from the federal jurisdictional barn. In Colorado, a handful of physicians write half the state’s prescriptions for medicinal marijuana, for questionable indications.4 Just because a few rogue doctors flout lax legislation to abet pot-mill commerce, that doesn’t justify depriving all physicians of the right to prescribe medicinal marijuana. No trials under the auspices of the Food and Drug Administration (FDA) have compared medicinal marijuana with traditional analgesics.5 Because of marijuana’s Schedule I status, industry is thwarted in its attempts to develop compounds with endocannabinoid agonist or antagonist qualities that might have analgesic, appetite-modulatory, immunosuppressant, antiemetic, neuroleptic, or antineoplastic effects, among other possibilities.2 Some people may contend that dose determination by patients deviates from modern medical practice,3,6 but adjustment of medications by patients is ubiquitous in hospitals through patient-controlled analgesia pumps. Some people argue that as a drug of abuse, marijuana has no business being used for clinical purposes. Yet, several Schedule I drugs have close cousins with legitimate medical applications. Heroin and morphine derivatives have an illicit–licit kinship, as do “ecstasy” (3,4-methylenedioxymethamphetamine) and stimulant drugs central to the treatment of attention deficit–hyperactivity disorder, as well as phencyclidine and ketamine, an anesthetic agent.2
Meanwhile, Marilyn seeks relief from the consequences of metastatic breast cancer. Neither acetaminophen nor oxycodone has proven to be effective against the serious pain of spinal and visceral metastases. Neither ondansetron nor prochlorperazine has relieved the nausea, which may have been induced by doxorubicin. More aggressive narcotics could be prescribed (risking the worsening of gastrointestinal symptoms), but Marilyn asks her doctor whether medicinal marijuana might offer the singular advantage of reducing pain and nausea simultaneously.
Inhaled pharmaceuticals are commonplace, but in the United States no vaporized inhalant is currently available as an alternative to medicinal marijuana, pending FDA approval of nabiximols, currently in phase 3 trials (ClinicalTrials.gov number, 01337089).6 With slow onset and unreliable bioavailability, oral cannabinoids are ill suited to relieving Marilyn’s acute distress.2 If she had no recreational experience with marijuana, Marilyn could find medicinal marijuana’s psychoactive effects unacceptable, although noxious psychoactivity also limits opiate use. Should Marilyn experience benefit, however, she would channel 5000 years of medical history, including the century when cannabis derivatives routinely resided in American doctors’ black bags.1
In sum, I believe that physicians who prescribe medicinal marijuana should do so only when conservative options have failed for fully informed patients treated in ongoing therapeutic relationships. As federal gridlock prevents much-needed research, patients such as Marilyn deserve the potential relief that medicinal marijuana affords.

Disclosure forms provided by the author are available at NEJM.org.

CITING ARTICLES

1. 1Amir I. A. Ahmed, Geke A. H. van den Elsen, Marjolein A. van der Marck, Marcel G. M. Olde Rikkert. (2014) Medicinal Use of Cannabis and Cannabinoids in Older Adults: Where Is the Evidence?. Journal of the American Geriatrics Society 62:2, 410-411
   CrossRef

1. 3Adler , Jonathan N. , Colbert , James A. , . (2013) Medicinal Use of Marijuana — Polling Results. New England Journal of Medicine 368:22,
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SOURCE INFORMATION

From the Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN.