There is no question that marijuana contains potent medicinal substances called “cannabinoids” that can relieve pain, reduce nausea and improve appetite. Two marijuana-derived medications, each containing a different cannabinoid, are approved for use in the United States. A third medication that contains biologically active cannabinoids more closely mirroring marijuana is available in Europe and Canada. It is undergoing clinical trials in the United States and is expected to be approved for use soon. The National Institutes of Health and the global pharmaceutical industry are actively engaged in research to better understand natural human cannabinoid systems and to develop safe and effective medications for pain and other indications. This work is promising.
The marijuana plant has served a valuable, even beneficent, role in healing over millennia, relieving suffering in circumstances as diverse as complicated childbirths, traumatic injury and terminal diseases. In the context of contemporary health care and pharmaceutical safety standards, however, plant-based marijuana cannot appropriately be viewed as a medication. Making marijuana legally available for medical use will not improve patient care.
Drugs approved for medical use in the United States undergo extensive safety and efficacy studies. Production and delivery systems are carefully monitored to assure uniform dosing and freedom from toxic contaminants. After drugs are introduced into clinical practice, post-marketing studies monitor them for unanticipated outcomes and withdraw approval when risks outweigh benefits. Prescription medications are prescribed and monitored by qualified clinicians who consider intended therapeutic actions against potential side effects for individual patients.
Herbal marijuana meets none of these criteria. Dosing of the active cannabinoids in marijuana is unpredictable due to variable levels in raw biologic material, as well as variable delivery systems (smoking, eating, vaporizing, distilling, etc.) and patient factors such as size, gender and metabolic pathways.
Combustible marijuana contains cancer-causing and otherwise harmful hydrocarbons and may contain potentially toxic contaminants such as molds or pesticides. The actual distribution chain for dispensed marijuana in other states rarely is limited to the intended population of those with medical need but is rather more widely available to the general population.
In addition, the approval of plant marijuana for medical use sends a message that marijuana use is safe. In reality chronic marijuana use is associated with diverse physical and psychological problems and poor work and school performance. It is second only to alcohol as a drug for which individuals seek addiction treatment.
There are very few patients whose pain or other symptoms cannot be well controlled with thoughtful medical care using medications or procedures currently approved for use in the United States. Numerous barriers exist to adequate pain and symptom management, however, including: lack of access to primary care, inadequate care coordination, limited availability of mental health services, poor reimbursement for care of complex chronic conditions, lack of awareness of available pain treatment options, and misunderstandings regarding the use of controlled substances, among many others.
The introduction of “medical marijuana” into New Hampshire will not overcome these barriers and improve patient care; rather it will introduce public health and administrative challenges that confound care.
Perhaps the most troubling aspect of “medical marijuana” is that it abrogates the responsibility of clinicians to meet patients’ clinical needs by delegating management of the complex condition of chronic pain to patients themselves.