Wednesday, November 2, 2016

The Flame Broiled Doctor: Reefer Madness

Second episode of the podcast series. Click here to download the audio. Transcript follows the jump.



Welcome back to the Flame Broiled Doctor podcast. I'm Dr. Frank Warsh, and you can get in touch with me on my website, drwarsh.blogspot.com, tweet me @drwarsh, or leave a comment on Soundcloud where you downloaded this episode. This is the second episode of the podcast, and it is titled "Reefer Madness." Hmm...I wonder what this will be about.

About a year ago, I attended a major family medicine conference in Toronto. You need so many hours of continuing education credits each year to stay in practice, and these national meetings are great places to network or bump into people I haven't seen in years. As you can imagine, a big conference means a big exhibitor's hall. Every time I'd attended this meeting in the past, the exhibitor's hall was usually laid out the same way. There's an aisle for the universities, an aisle for the recruiters, an aisle for various agencies, and a giant amount of space swallowed up by the drug companies. Well, last year things had changed. First, medicine has gone all-in on New Age, with all sorts of kiosks around mindfulness, yoga, and so on. There were the usual drug companies too, but the stars of the show? The Medical Marijuana companies.

Weed has apparently become The Next Big Thing in medicine, and people are hyping it as a treatment for anything, from pain to seizures to schizophrenia...whatever ails you, except maybe asthma or emphysema, weed is the answer. And honestly? In my last two years of practice, the demand from the patients exploded like nothing I'd seen since Viagra. Not all the requests had clinical merit, mind you. I recall one guy asking me for a marijuana script because, "I'm sometimes agitated or pissed off, but when I smoke weed it's like I relax and can't feel anything anymore." When I pointed out that he described the process of getting high, not treating a disease, he was none too pleased with me.

So I'm going to try and break down what we think we know about medical marijuana, and what we happen to know, and what we'll hopefully know in the not too distant future.

Marijuana, or Cannabis, has two active chemicals that we know of: THC and CBD. THC appears to be the chemical that makes you stoned, plus or minus anxious. THC is implicated in the psychosis some people suffer after taking cannabis, particularly in teens. CBD seems to be the beneficial chemical, and might mitigate the effects of the THC, but CBD doesn't seem to work by itself coming from plant sources like weed or hash. As a patient of mine once said, the strain of medical marijuana she took, with a high ratio of CBD to THC, gave her a "clear-headed high" as compared with the stuff she could buy from a guy who knows a guy. While I don't think medical textbooks are ready to differentiate a "clear-headed" high from a "regular" high, there's a good amount of low-level evidence to support the idea.

Time for an aside: what do I mean when I say low-level evidence? Well, over the last 40 years, medical researchers have noticed that quite often what works in a lab, or what people say on a survey, doesn't pan out when we run a controlled experiment with live patients, where one group of patients getting treated, and a second group getting a placebo or older treatment. Large controlled trials, with patients randomly assigned to the treatment or control group, or studies that pool the data from several controlled trials, are generally considered strong forms of evidence...high-level. The results of these studies will give us a good idea of how effective a treatment might be in practice. Animal studies, case reports on individual patients, or small studies with no control group can give us ideas of what might work and guide future research, but they're not terribly useful if we're looking to develop standards of practice...low-level evidence. Quality of research is a topic we'll come back to this again and again, but please feel free to send a question my way if you've got one. Okay, back to the weed.

Based on (pardon the pun) high-quality evidence, as of 2016 medical marijuana is really not a drug ready for prime time. First, let's look at the stuff it's not at all useful for. A whole pile of neurologic diseases: seizures, Huntington's disease, Parkinson's disease, Tourette's syndrome...even pharmaceuticals with THC or CBD do absolutely nothing for these conditions. Any research you're reading making such claims is between preliminary and bogus.

MS - multiple sclerosis - is the exception. There is decent evidence that oral forms of cannabis - prescribed medications and possibly plant oils - can help with spasticity (muscle stiffness and involuntary movement). THC in particular seems to help with the chronic pain that goes along with MS. However, the studies show very high placebo effects, which means that the drug doesn't add much beyond what users simply believe it does. Moreover, the effects were only found in the studies were only there for pills and oral formulations. Smoking marijuana caused nothing but worsening posture and side effects. No benefits, none. That comes from the American Academy of Neurology in a major 2014 review of the literature.

What about chronic pain from other causes, like nerve damage? That's where the benefits of medical marijuana are being extolled upon most often. There are some high-quality studies and reviews on this issue, but the results are not the miracle some people make it out to be. Very low doses - probably a few puffs of a low potency joint - does help with chronic pain. That's in the short term, because these studies were only run for a few weeks each. The best measure of effect we have was found in a randomized trial done by McGill University. They used different potencies of marijuana, topping out at a strain with a THC content of 9.4%. If you were ranking your pain on a scale from 1 to 10, using cannabis will lower your pain score by 0.7. That doesn't really "mean" anything, because pain is subjective, but that's a little more than half the average benefit seen with common medications we use called Gabapentin or Lyrica. Anecdotally, most patients don't do dramatically better on either of those medications, especially in terms of being able to do more of their daily activities. Overall marijuana isn't going to be a miracle cure here either.

I want to reiterate that the trials showed benefit at low amounts of low concentrations of THC. Even the Canadian-government-approved marijuana is significantly more potent than what was used in the studies, so it's possible even the "clinical" medical marijuana is too strong. Beyond the low doses, the studies showed that patients had nothing but more side effects, including getting high. Some people probably don't consider getting high to be a side effect, but it is as far as doctors are concerned.

What about mental illness? Marijuana is associated with all manner of mental illness, but it's also been proposed as a treatment. Anxiety, depression, even psychosis - marijuana, particularly marijuana high in CBD, has been put forward as a treatment for mental illness. The truth is, we don't know where we're at with this at all. The evidence out there is of quite a low quality, and I don't think anyone would recommend marijuana as a treatment for symptoms that it possibly causes. The good news is that a large randomized trial is underway looking at marijuana in mental illness, so we should have our answer in the not too far-off future.

Finally, just a few important findings related to public health, which I'm honestly surprised has even been an area of research. These are studies - good ones - that come out of the U.S., where they state-to-state differences in the law can allow researchers to draw comparisons. In states that allow access to medical marijuana, there is proportionately less suicide among young men. Moreover, legalized medical marijuana is associated with lower rates of opioid overdose...the drugs that kill, like fentanyl, oxycontin, and heroin. We can't conclude that medical marijuana is the cause of these better public health outcomes, but they should give pause to policymakers.

There's also no small irony here. Public health is the typical excuse used to put off legalizing marijuana, medical or otherwise..."it's a gateway drug, it destroys neighborhoods", etc., despite compelling evidence that it might reduce harms. Meanwhile, people have pushed for medical marijuana for decades, when the meaningful evidence shows it doesn't do much at all.

So to get on my soapbox, it's time to stop selling weed as a cure-all, or even a medical product. If it helps the patient's symptoms, especially if the patient is suffering from a terminal condition or an awful disease like MS or HIV, as far as I'm concerned that's fine. Smoke it if you've got it. But it's a recreational drug, just like alcohol, and it's long past time we treated it that way. Even the government-licensed distributors seem to get that selling it as medicine was never anything but a back-door to legalization. Don't believe me? One of Canada's biggest medical marijuana companies, Tweed, announced a licensing deal with Snoop Dogg. Yes, Snoop Dogg. They couldn't even pretend it was medical, say by partnering with Dr. Dre. Learn the lessons from Colorado - restrict the access, restrict the marketing, regulate the potency (particularly for edibles), tax the hell out of it, and use the proceeds to treat mental illness and addiction. It's "high time" we went ahead and did it.

Once again, I'd love to hear from you, whether it's about this topic or something else related to medicine or health care. Get in touch through my website, at drwarsh.blogspot.com, tweet me @drwarsh, or leave a note on SoundCloud. I'm Dr. Frank Warsh, the Flame Broiled Doctor, and thanks again for listening!

5 comments:

  1. Thanks for supporting patient access to opioids for chronic non-malignant pain. Things are changing so fast in both Canada and the US and the changes are hurting legitimate patients and their health care providers without doing a thing to decrease overdose deaths.

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    1. Thanks for commenting! What I find most infuriating is that there's no longer an effort to decide the cause of the problem before implementing a solution that in and of itself is half baked or beside the point.

      As an example, the Ontario government has directed an investigation into the biggest over prescribers of opioids. All well and good, except that there's no evidence these doctors' scripts have led to deaths, nor any attention given to unintended consequences. With 100% certainty, doctors are going to turn away patients that were not harming anybody, even themselves. Where will they get their drugs, I wonder?

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  2. Pretty good Article. Thank you.
    To find out how to get a medical marijuana card you should check MMjCCC.

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  3. Good content for The Flame Broiled Doctor: Reefer Madness, to know more Florida medical marijuana doctor

    ReplyDelete