Our Readers' Opinions
September 24, 2013

Marijuana and its medicinal calls

Tue Sep 24, 2013

by Tyrone Jack
Chief Pharmacist

Marijuana plants have been used since antiquity for both herbal medication, religious ceremonies and intoxication. The current debate over the medical use of marijuana is essentially a debate over the value of its medicinal properties relative to the risk posed by its use, and whether its position as a schedule 1 or (class A) drug is justified.{{more}}

It must be noted early thatzzzzzzzz modern medicine adheres to different standards from those used in the past. The question is not whether marijuana can be used as an herbal remedy, but rather how well this remedy meets today’s standards of efficacy and safety. We understand much more than previous generations about medical risks. Our society generally expects its licensed medications to be safe, reliable, and of proven efficacy; contaminants and inconsistent ingredients in our health treatments are not tolerated.

Although plants continue to be valuable resources for medical advances, drug development is likely to be less and less reliant on plants and more reliant on the tools of modern science. Molecular biology, bioinformatics software, analyses of genes and chemistry and development. Until recently, drugs could only be discovered; now they can be designed.

Can marijuana relieve health problems? Is it safe for medical use?

There is substantial consensus among experts on the scientific evidence and potential medical uses of marijuana. However, it is my view that if there is any future for marijuana as a medicine, it lies in its isolated components, the cannabinoids and their synthetic derivatives. Isolated cannabinoids will provide more reliable effects than crude plant mixtures. The crude plant mixtures present multiple quality assurance issues – standardization, variation in strengths, multiple chemical ingredients etc.

“Medicinal marijuana” refers to purified plant substances, including leaves or flower tops, whether consumed by ingestion or smoking.

The effects of marijuana “should be understood to include the composite effects of its various components; that is, the effects of tetrahydrocannabinol (THC), which is the primary psychoactive ingredient in marijuana, along with the effects of as many as 84 different cannabinoids and hundreds of other chemicals found in the plant.” Not all the effects of marijuana are necessarily due to THC, and the effects of THC are not always desirable. The concentration of THC varies dependant on climatic conditions, soil nutrients, plant strains and sex of the plant, as well as time of harvest. Product harvested in SVG has been analyzed as having as much as 22 – 24 per cent of THC, as against Jamaica in the region of 12 – 16 per cent. The two cannabinoids usually produced in greatest abundance are cannabidiol (CBD) and/or _9-tetrahydrocannabinol (THC), but only THC is psychoactive. The secretion of THC is most abundant in the flowering heads and surrounding leaves of the cannabis plant. The THC content varies in the different parts of the plant, example the flowers, are likely to be 10-12 times as potent as the leaves, 100 times as potent as the stalks, and over 300 times as potent as the root. The male form of the plant has very low concentration of THC and is discarded by local growers, and is farmed in some parts of the world for textiles. THC is converted to cannabinol (CBN) on exposure to air and light, this process reduces the THC concentration, especially in old samples which have not been stored under suitable conditions. These variations in yields and stability will present significant standardization challenges for marijuana to be registered as a medical product.

Primum non nocere — FIRST, DO NO HARM — This is the physician’s first rule whenever treatment is required to be prescribed to a patient — first, that treatment must not cause avoidable harm to the patient. The most contentious aspect of the medical marijuana debate is not whether marijuana can alleviate particular symptoms, but rather the degree of harm associated with its use.

At this point, our knowledge about the biology of marijuana and cannabinoids allows us to make some general conclusions:

Marijuana is not a completely benign substance. It is a powerful drug with a variety of effects. However, except for the harms associated with smoking, the adverse effects of marijuana use are within the range of effects tolerated for other medications.

— Cannabinoids likely have a natural role in pain modulation, control of movement, and memory.

— The natural role of cannabinoids in immune systems is likely multi-faceted and remains unclear; both negative and positive effects have been observed classically in HIV/AIDs patients.

— The brain develops tolerance to cannabinoids; a small population develops withdrawal syndrome.

–The harmful effects to individuals from the perspective of possible medical use of marijuana are not necessarily the same as the harmful physical effects of drug abuse.

— Any use of marijuana by people who have had previous mental health (psychotic symptoms) illness is detrimental. When people are ‘stoned’ they can forget to take their medications. Cannabis can also worsen delusions, mood swings, hallucinations and especially feelings of paranoia. Cannabis can both trigger further episodes of psychosis and other psychiatric illnesses, and complicate treatment.

— Cannabis use is associated with poor outcomes in existing schizophrenia and may precipitate psychosis in those with a predisposition. It appears that using larger amounts of cannabis at an earlier age and having a genetic predisposition increases the risk of developing schizophrenia.

— For most people, the primary adverse effect of acute marijuana use is diminished psychomotor performance. It is, therefore, inadvisable to operate any vehicle or potentially dangerous equipment while under the influence of marijuana.

— Marijuana smoke, like tobacco smoke, is associated with increased risk of cancer, lung damage, and poor pregnancy outcomes. Cellular, genetic, and human studies all suggest that marijuana smoke is an important risk factor for the development of respiratory cancer.

Marijuana as a substance is regulated as a Schedule A drug in SVG and as a Schedule 1 controlled substance drug under the 1961 Single convention on Narcotic Drugs. This convention aims to combat drug abuse by coordinated international action. Its lofty aims are concerned with “the health and welfare of mankind,” First, it seeks to limit the possession, use, trade in, distribution, import, export, manufacture and production of psychoactive and narcotic drugs exclusively to medical and scientific purposes. Second, it combats drug trafficking through international cooperation to deter and discourage drug traffickers. As the preamble continues, “addiction to narcotic drugs constitutes a serious evil for the individual and is fraught with social and economic danger to mankind.” At the same time, the Convention recognized “that the medical use of narcotic drugs continues to be indispensable for the relief of pain and suffering and that adequate provision must be made to ensure the availability of narcotic drugs for such purposes”. This convention has placed marijuana as a schedule one Substance, in effect saying it has no legitimate medical use. It has remained so for the last 50 years. This ranking infers that the drug has no useful medicinal purpose. And under local and international laws, persons, even physicians who prescribe it without first securing a research mandate from the state, can be prosecuted under the Drug (prevention of Misuse) Act or similar State parties’ legislations. Narcotic pain killers are placed in Schedule 11 or the Class B drug category in our Drug Act.

New advances in research of the marijuana drug product has unearthed and /or confirmed several important medical indications for which marijuana would be useful, they have also revealed significant correlation between studies of serious side effects, e.g escalating psychoses, memory loss, increased risk of damage to lungs and lung functioning, decreased sex drive, lowered sperm count in men, to name a few. Notwithstanding these the adverse effects of marijuana use, they are within the range of effects tolerated for other medications. Is it time for a critical reflection by the commission to the convention on the schedule to which Marijuana is placed?

The effects of cannabinoids on the symptoms studied are generally modest, and in most cases there are more effective medications. However, people vary in their responses to medications, and there will likely always be a subpopulation of patients who do not respond well to other medications. Research should therefore continue into the physiological effects of synthetic and plant-derived cannabinoids and the natural function of cannabinoids found in the body. More medications that can maximize the desired effects of cannabinoids and minimize the undesired effects can very likely be identified.

The accumulated data indicates a potential therapeutic value for cannabinoid drugs, particularly for symptoms such as, control of nausea and vomiting particularly useful in people with cancer, undergoing chemotherapy, which does not respond to conventional treatments, appetite stimulation, HIV-related wasting and cancer-related wasting, neurological disorders including (but not limited to) multiple sclerosis and motor neurone disease; and pain unrelieved by conventional treatments. It also confirms significant risk particular in chronic heavy smokers.

Science and Policy

Scientific analysis does not in itself solve a policy problem. It should not be the end of the debate, What it does is illuminate the common ground, bringing to light fundamental differences out of the shadows of understanding and misinformation that currently prevail.

Even when drugs are registered and used only for medical purposes, value judgments affect those policy decisions concerning its medical use and level of use or scheduling controls. The magnitude of a drug’s expected medical benefit affects regulatory judgments about the acceptability of risks associated with its use. Access and availability of alternate drugs are important determinants in policy decisions. Although drugs are normally approved for medical use only on proof of their ”safety and efficacy,” patients with life-threatening conditions are sometimes (under protocols for “compassionate use”) allowed access to unapproved drugs whose benefits and risks are uncertain. Value judgments play an even more substantial role in regulatory decisions concerning drugs, such as marijuana, that are sought and used for non-medical purposes. Policymakers then must take into account possible interactions between the regulatory arrangements governing medical use and the integrity of the legal controls set up to restrict nonmedical use.

Those calling for legalization for medical use in SVG and the wider Caribbean have to be mindful of the regions global obligation under the convention. And of the provision under article # 3 of the convention which provide an avenue for state parties to mount challenge to the present Scheduling of any control drug. We must be mindful also that the Caribbean is one of the newest regions introduced to marijuana use and one of the least advanced by way of research.