Is There Medical and Moral Justification for the Use of Medical Marijuana?
In 2013, CNN Chief Medical Correspondent Sanjay Gupta reported that he had changed his mind on Marijuana since his 2009 Time Magazine article—”Why I would Vote No on Pot.” Gupta writes:
I apologize because I didn’t look hard enough, until now. I didn’t look far enough. I didn’t review papers from smaller labs in other countries doing some remarkable research, and I was too dismissive of the loud chorus of legitimate patients whose symptoms improved on cannabis.
Why did he change his mind? He argued that the Drug Enforcement Administration’s (DEA) classification of Schedule I, which carries with it a high potential for abuse, was not based on solid scientific evidence. Further, he believed that the benefits of Medical Marijuana (referred to as MMJ) had been understudied and that cases like Charlotte Figi, whose seizures went from 300 a week to 2-3 per month, was sufficient to swing his opinion to a favorable one (Gupta). Was Sanjay right? Is there sufficient evidence to support its medical and moral use? This article will seek to address that question.
Marijuana’s Presence in the United States
Marijuana comes from the dried flowering tops of the plant Cannabis sativa or Hemp plant. Several formulations are common. When the plant is dried and smoked or vaporized it is called Marijuana. When concentrated in a resin cake and ingested or smoked it is known as Hashish. A tincture can be consumed under the tongue. The oil (Hashish oil) can be smoked and inhaled, or infused and mixed with butter or cooking oil and consumed (Hill 2478). The substance was described in a Chinese medical compendium dating around 2737 BC (White 63).
Historically, it was likely introduced into Europe and America after being used in China and India then moving from Persia to Arabia (Roberts, Speedie, and Tyler 101). In addition to the social and medical utilization, the Cannabis plant is cultivated for its durable Hemp fibers, for its Hemp seeds that are used in smoothies or as a food topping, for use in paints, soap, and cattle food (102). Between 1850 and 1942, extract of Hemp or extractum Cannabis was listed in the National Formulary of the United States Pharmacopoeia (USP) which lists drug ingredients that meet certain scientific standards (White 63). In the US in the 19th and 20th centuries, extracts from Marijuana were common in patent medicines and used as stimulants1 or in the treatment of migraine headaches (Stearsman). In the 1960s and 1970s the drug exploded in popularity.
Socially, Marijuana continues to be the most used illicit drug in the United States for those 12 and older. In 2015, 22.2 million people aged 12 and older of 27.1 million illicit drug users were using Marijuana (Center 6). Unlike alcohol, nicotine, or opioid abuse, few people seek treatment for Marijuana addiction (O’Brien). Daily users of Marijuana can experience withdrawal symptoms of restlessness, irritability, mild agitation, insomnia, sleep disturbance, nausea, and cramping when the drug is stopped (O’Brien). Legally, in spite of multiple state laws that permit the recreational and/or medicinal use, the Federal Controlled Substance act of 1970 still prohibits the use and distribution of the substance. MMJ has legal status in 28 states, along with the District of Columbia (“28 Legal”).
While the plant contains more than 400 compounds, approximately 70 of the compounds are referred to as cannabinoids (D’Souza and Ranganathan 2431). The most noted cannabinoid is delta-9-tetrahydrocannabinol (delta-9-THC), which is often simply referred to as THC. THC is the psychoactive component that at certain concentrations gives users the “high” and “mellowed out” feeling (Mello and Mendelson). In the body, Marijuana acts on specific protein receptors (CB1) on nerve cells in the brain and in the peripheral tissues (CB2) (O’Brien). Medical Marijuana is thought to have several clinically useful medical properties which include, “antiemetic effects in chemotherapy recipients, appetite-promoting effects in AIDS patients, reduction of intraocular pressure in glaucoma, and reduction of spasticity in multiple sclerosis and other neurologic disorders” (Mello and Mendelson). However, “With the possible exception of AIDS-related cachexia, none of these attributes of Marijuana compounds is clearly superior to other readily available therapies” (Mello and Mendelson).
Marijuana is smoked in smaller hand rolled joints or larger cigar like blunts, in addition to pipes or bongs, which are water pipes used for smoking. Further, Marijuana is consumed in edibles such as brownies or brewed in teas (cf. “Marijuana (Cannabis)”). When the product is smoked, less than 150 compounds in addition to THC are released (Mello and Mendelson). Synthetic Marijuana compounds are also illicitly marketed as “incense” or “potpourri” and can be found under the names K2, Spice, RedX Dawn, Paradise, Ninja, Mr. Nice Guy, Fire, or Crazy Clown (“Drugs of Abuse”).
Commercially, in the US isolated compounds from Marijuana are approved by the FDA in two formulations. Dronabinol (Marinol®) (DEA Schedule III) is a capsule formulation that contains synthetic THC and is FDA approved for anorexia associated with AIDS and for nausea and vomiting associated with chemotherapy in those who have failed other conventional treatments (Clinical Pharmacology). Nabilone (Cesamet®) (Schedule II) is a capsule formulation containing a synthetic cannabinoid which is chemically similar to THC that is approved for nausea and vomiting associated with cancer chemotherapy. Neither of these drugs are firstline agents.
Two other agents are worthy of attention. The liquid extract nabiximols (Sativex®) is an oral spray that contains THC and cannabidiol (CBD) which is used for muscle stiffness and spasms in Multiple Schlerosis (“Sativex”). Nabiximols is approved in 27 countries and is in phase III trials in the US (Borgelt). Additionally, the liquid extract cannabidiol (CBD) (Epidiolex®) is in FDA clinical trials in the US for seizures associated with Dravet Syndrome and Lennox-Gastaut Syndrome (Borgelt). The drug is also available under a compassionate use program (orphan drug program) in the US (“Sativex”).
Examining the Safety and Efficacy of Medical Marijuana
Two questions are central to the usefulness of any medical substance: (1) Is it safe? and (2) Is it effective? Because public health is at risk and because patients are vulnerable when they are sick, the FDA stringently tests drugs that come to market through a multi-level process, assessing both safety and efficacy. Further, pharmacies are strictly regulated by federal and state laws to ensure that medications meet purity and quality standards. Traditionally in the US, agents have fallen into two categories, either the category of drugs (prescription or over the counter) or dietary supplements. Medical Marijuana does not fit neatly into either category.
Drugs must be approved by the FDA. While the approval process is far from perfect, these standards often safeguard the vulnerable. Recent estimates to bring a drug to market in the US top $2.6 billion (DiMasi et al. 20). Because of the sheer cost, research and development in rare medical conditions is often bypassed because manufacturers simply cannot recoup the costs. Many conditions for which Medical Marijuana is touted are not rare or unstudied. Yet, desperate patients often turn elsewhere for help, sometimes to dietary supplements, others engage in medical tourism traveling overseas seeking alternative care.
In the US, claims on the labels of herbal or dietary supplements are often confusing to the general public. For example, if an agent claims to treat an enlarged prostate, a condition known as Benign Prostatic Hyperplasia (BPH), it must be approved as a drug. However, if an agent claims to be used for “Prostate Health” it can be marketed as a supplement and bypass the FDA drug approval process. Generally, the public is less informed concerning supplements. Some think that supplements are safer because they are “natural,” over the counter, and have fewer side effects. But, there are legitimate safety and efficacy concerns with supplements.2
Medical Marijuana falls into a category all its own. Instead of being labeled for safe and effective use like over the counter drug products, Marijuana has little, if in any labeling. Marijuana is purchased from dispensaries. Dispensaries create safety concerns in packaging, potency, and degradation. If there are no packaging safeguards in place, child safety can be compromised. Incidents of fungal contaminants and pesticide residue have been reported (Schrot and Hubbard 131). In a pharmacy, staff are medically licensed and trained to inform vulnerable patients of risks and benefits, drug interactions, and contraindications.
Both state governments through taxation and dispensaries stand to make a hefty profit while the informed consent of vulnerable patients is compromised. For decades, laws and courts have upheld that patients have a right to objective information in making health care decisions in both research and medical practice.3 This principal of informed consent demands that patients have information disclosed to them about risks and benefits, that patients express understanding, that decisions be made voluntarily (not coerced), and that patients be competent to make these decisions (Osman 190-93).
Patients have a right to know objective information in making healthcare decisions. Physicians who write certificates for Medical Marijuana are advised to act in the patient’s best interest (Schrot and Hubbard 134). Patients have a right to know risks, benefits, and alternatives to treatments. From a scientific and medical perspective, patients who choose to smoke Marijuana acquired from dispensaries should be aware that the THC content can vary widely between different strains of Marijuana, that inhalation and subsequent absorption, distribution, metabolism and excretion will vary from patient to patient, and that currently there are no strict standards in place regarding potency, uniformity, or degradation to guarantee desired health outcomes. This is not to say that Medical Marijuana has no appropriate use. Rather, this is a strong caution for patients to take heart that they are venturing into an informational no man’s land.
Concerning effectiveness, it is important to understand that scientists and medical practitioners go to great lengths in distinguishing mere claims of efficacy that include anecdotes, testimonials, and public opinion from genuine supportive proof that is statistically supported in clinical trials (D’Souza and Ranganathan 2431). Merely using Marijuana and claiming it is effective is not sufficient to establish scientific proof for efficacy. Concerning smoking MMJ, smoke is a lung irritant and there is little medical support that endorses the combustion and inhalation of medical substances for therapeutic purposes. Claims of efficacy for Medical Marijuana are sometimes far reaching, even wild, and bring up images of medicine men who traveled from town to town claiming their tonic could heal nearly everything.
The study of Medical Marijuana is difficult for two reasons. For one, in the United States, there is difficulty in assessing both safety and efficacy because federal law prohibits Marijuana possession, use or distribution under the Controlled Substance Act of 1970.4 This means that researchers, public universities, federal and private funders are prohibited from exploring the safety and efficacy. When people apply results from the FDA approved synthetic formulations (dronabinol and nabilone) to Marijuana that is smoked, the data may not be reliable. The science of smoking is markedly different from oral ingestion. The FDA approved products contain a single synthetic cannabinoid compound (THC) that meets strict potency standards. However, smoked Marijuana contains approximately 480 substances, 66 which are active compounds that are combusted and inhaled (“Dronabinol”). Second, designing adequate studies for smokers is riddled with challenges because of differences in how people smoke. Marijuana smoking is not uniform. Few Marijuana smokers inhale, absorb, or metabolize Marijuana the same (Doering and Li). When smokers inhale, some may breathe deeper, while others may retain the smoke longer (Doering and Li).
Unsubstantiated claims abound as to efficacy. Some claim efficacy for conditions ranging from cancer to appetite loss (Doering and Li). Others claim that inhaled Marijuana (smoked) is useful for treating: nausea, glaucoma, appetite stimulation, membrane inflammation, leprosy, fever, dandruff, hemorrhoids, obesity, asthma, urinary tract infections, cough, anorexia associated with weight loss in AIDS patients, neuropathic pain, multiple sclerosis, for producing immunosuppression after renal transplantation, to reduce negative symptoms of schizophrenia, and to reduce symptoms of amyotrophic lateral sclerosis (ALS, Lou Gehrig’s disease) (Natural Medicine’s Database).
The Natural Medicines Database5 reviews dozens of studies and evaluates its findings for effectiveness from a range of effective to ineffective. For safety, it ranges from likely safe to unsafe. Additionally, it reports when there is insufficient evidence for either safety or efficacy.
The database reports that Marijuana may possibly be safe as an extract spray (Sativex®) when applied orally in the mouth. However, it is possibly unsafe when inhaled because of four case reports of large lung bullae and increased risk of lung cancer. In pregnancy, it reports that Marijuana is unsafe and can lead to reduced fetal growth. In lactation, Marijuana can pass into the milk, lead to delayed motor development and is likely unsafe. It reports insufficient evidence to evaluate Marijuana or Marijuana extract when taken orally (“Marijuana”).
From the effectiveness perspective, the database reports that Marijuana is possibly effective in HIV/AIDS-related anorexia when smoked, in Multiple Sclerosis (MS) when the oral spray Sativex® or oral extra formulation is administered, or in neuropathic pain when smoked. Because the data is less than definitive, the database passed on the effective or likely effective ranking for these conditions. For conditions such as amyotrophic lateral sclerosis (ALS, Lou Gehrig’s disease), cachexia, glaucoma and rheumatoid arthritis (RA) the database rated insufficient reliable evidence to rate (“Marijuana”).
In 2015, the Journal of the American Medical Association (JAMA) did a clinical review of studies between 1948 and March 2015 and focused on 28 randomized clinical trials for indications other than nausea and vomiting with chemo and appetite stimulation. What the review found was that several trials had “high-quality evidence” for treatment of chronic pain, neuropathic pain, and spasticity in MS indicating that Marijuana may be helpful in these conditions (Hill 2474).
Nationally, many major consensus bodies have reigned in on the use of Medical Marijuana. The American Medical Association has challenged the DEA to review its classification of Marijuana as a Schedule I controlled substance so that researchers may be free from the legal hindrance of investigation. They are clear that this is not an endorsement of the multiple state laws, but a plea for the DEA to step out of the way of further findings (American Medical Association). The American Cancer Society’s recommendations parallel the AMA’s (Alteri). The American Academy of Neurology (AAN) has stated “there is not sufficient evidence to make any definitive conclusions regarding the effectiveness of Marijuana-based products for many neurologic conditions” (Patel, et al. 1).
Can Medical Marijuana be Used in Good Conscience?
In making moral judgments, the conscience must be informed with knowledge. The conscience then either excuses man’s behavior and judges the behavior to be moral, or it accuses man making him feel guilty for a particular action or inaction (cf. Romans 2:15). Concerning the moral and medical use of Marijuana, it is important to distinguish between the social or recreational use of Marijuana and the medical use of Marijuana. The use is substantively different between the two motivations for use.
According to the Bible, the social use of Marijuana, whether smoked or ingested otherwise, should be avoided on several grounds. It should be avoided because currently it is a violation of federal law. While this federal law stands at odds with states that approve the recreational use, according to the Bible men are amenable to both laws. All people are to “be subject to the governing authorities” (Romans 13:1, ESV), otherwise they are resisting God (Romans 13:2; 1 Peter 1:13-14). Further, God urges man to be sober (1 Peter 1:13; 4:7; 5:8; 1 Thessalonians 5:6, 8). Sobriety is certainly compromised by the mind altering aspects of the substance. In time, and with repetitive use, one may become enslaved to the substance, even addicted. Peter said “that whatever overcomes a person, to that he is enslaved” (2 Peter 2:19). Paul said “I will not be enslaved by anything” (1 Corinthians 6:12). Additionally, man is to present his body as a holy living sacrifice and to glorify God in his body (Romans 12:1; 1 Corinthians 6:20). Someone who is recreationally getting high or stoned is hardly using their body to God’s standards of holiness or glory.
Are there morally acceptable grounds for using MMJ? Currently, the use of MMJ is forbidden by federal and some state laws. Under US law, to use MMJ is to violate God’s law and to ultimately resist God (cf. Romans 13:1-2; 1 Peter 1:13-14). What if the federal law changes? Would there be grounds to justify the moral use of MMJ? If the federal and state laws permit, one could use MMJ on moral grounds in a narrow set of circumstances. Currently, according to the current scientific understanding, the benefits would possibly outweigh the risks only in a certain few conditions such as chronic pain, neuropathic pain, and spasticity in MS. This number of conditions may grow in time.
If the laws change, a person could certainly maintain their holiness, glorify God in their body, and abstain from enslavement when using the substance for some debilitating condition. Faithful men and women do this on a regular basis when they take certain pain and mind altering medications (e.g., morphine or diazepam). Please note that the use here is not primarily to get high or experience some euphoria, but to treat a debilitating condition. The benefits in these scenarios outweigh the risks.
What about MMJ’s effect on sobriety? Can sobriety ever be compromised when sick, ailing or debilitated? Proverbs 31:6 states “Give strong drink to the one who is perishing, and wine to those in bitter distress.” While sobriety is admonished and encouraged, biblically there are times when one may forgo sobriety to aid medically (cf. 1 Peter 1:13; 4:7; 5:8; 1 Thessalonians 5:6, 8; 1 Timothy 5:23). For years, conscientious people have used hypnotics in surgery, narcotics for pain, antihistamines for allergies, antianxiety agents, and drugs that induce sleep.
Conclusion
Making decisions about MMJ can be difficult for law makers, health care providers, care givers, and patients. While several states legally permit MMJ for multiple medical conditions, these benefits need a solid scientific backing to justify a moral use. For now, claims of the benefits of MMJ often exceed what science has statistically confirmed. Clinically, it should be understood that there are several agents that are often more effective than Marijuana for debilitating conditions.
The Lord and His people deeply care and are compassionate about alleviating suffering and illness. One can certainly empathize with Charlotte Figi who suffered from hundreds of seizures per month and the difficult position her parents were in as they sought relief. Conditions like Dravet syndrome, Lennox-Gastaut syndrome, AIDS related cachexia, chronic pain, neuropathic pain and spasticity in MS certainly need viable agents to aid in suffering. If MMJ gained legal federal status, a medical moral use could be entertained in certain states when the medical benefits outweigh the risks. For now, in the United States, conscientious people should seek other options.
~
Daniel Stearsman received his formal education from the University of Florida College of Pharmacy (Pharm.D. 2000), and the University of South Florida College of Medicine (M.A. Bioethics and Medical Humanities 2009). He has taught Clinical Ethics in the college of Medicine at the University of South Florida, and Biblical and Biomedical Ethics, Christian Evidences, Topical Studies, and Acts at Florida School of Preaching.
Works Cited
“28 Legal Medical Marijuana States and DC - Medical Marijuana - ProCon.org.” Procon.org, 28 Dec. 2016. Web.
Abood, Richard. Pharmacy Practice and the Law. 7th ed. Burlington: Jones and Bartlett Learning, 2014.
Alteri, Rick, et al. “Marijuana and Cancer.” American Cancer Society. 4 Mar. 2015. Web.
American Medical Association. “AMA Policy: Medical Marijuana.” American Medical Association 2009. Web. 1/24/2017.
Borgelt, Laura, et al. “The Pharmacologic and Clinical Effects of Medical Cannabis.” Pharmacotherapy 33.2 (2013): 195-209.
Borgelt, Laura. Medical Marijuana Update: Getting Into the Weeds. CE Learning activity. FreeCE.com September 24, 2015.
Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). Retrieved from http://www.samhsa.gov/data/.
DiMasi, Joseph, et al. “Innovation in the Pharmaceutical Industry: New Estimates of R&D Costs.” Journal of Health Economics 47 (2016): 20-33.
Doering, Paul L., and Robin Moorman Li. “Chapter 48. Substance-Related Disorders I: Overview and Depressants, Stimulants, and Hallucinogens.” Pharmacotherapy: A Pathophysiologic Approach. Eds. Joseph T. DiPiro, et al. 9th ed. New York: McGraw-Hill, 2014.
“Dronabinol.” Clinical Pharmacology. 2017. Elsevier/Gold Standard. http://www.clinicalpharmacology-ip.com/default.aspx. Accessed 28 January 2017.
“Drugs of Abuse.” Dea.gov, DEA and DOJ, 2015, www.dea.gov/pr/multimedia-library/publications/drug_of_abuse.pdf#page=64.
D’Souza, Deepak, and Mohini Ranganathan. “Medical Marijuana: Is the Cart Before the Horse?” JAMA. 313. 24 (2015): 2431; doi:10.1001/jama.2015.6407.
Gupta, Sanjay. “Why I Changed My Mind on Weed.” Cnn.com. 8 August 2013. Web. 13 Feb. 2017.
Hill, Kevin. “Medical Marijuana for Treatment of Chronic Pain and Other Medical and Psychiatric Problems a Clinical Review.” Journal of American Medical Association. 313.24 (2015): 2474-83.
Jellin, Jeff Ed. Pharmacist’s Letter. 32.5 (2016): 25-30.
Therapeutic Research Center. “Marijuana.” Natural Medicines.therapeuticresearch.com. 2017. Web. 24 Jan. 2017.
“Marijuana (Cannabis).” Samhsa.gov. SAMHSA, 21 Nov. 2016, www.samhsa.gov/atod/Marijuana.
“Medical Marijuana.” Clinical Pharmacology. 2017. Elsevier/Gold Standard. http://www.clinicalpharmacology-ip.com/default.aspx. Accessed 28 January 2017.
Mello , Nancy K., and Jack H. Mendelson. “Cocaine and Other Commonly Abused Drugs.” Harrison’s Principles of Internal Medicine. Eds. Dennis Kasper, et al. 19th ed. New York McGraw-Hill, 2015.
O’Brien, Charles P. “Drug Addiction.” Goodman & Gilman’s: The Pharmacological Basis of Therapeutics. 12 ed. Eds. Laurence L. Brunton, et al. New York: McGraw-Hill, 2011.
Osman, Hana. “Informed Consent I.” Medical Ethics and Humanities. Eds. Frederick Paola, Robert Walker, and Lois LaCivita Nixon. Sudbury: Jones and Bartlett, 2010.
Patel, Anup, et al. “Position Statement: Use of Medical Marijuana for Neurologic Disorders.”Aan.com. 2014. Web. 2017.
Roberts, James, Marilyn Speedie, and Varro Tyler. Pharmacognosy and Pharmacobiotechnology. Baltimore: Williams & Wilkins, 1996.
“Sativex.” GWpharm, 24 January 2017, www.gwpharm.com/products-pipeline/sativex/.
Schrot, Richard J., and John R. Hubbard. “Cannabinoids: Medical Implications.” Annals of Medicine. 48.3 (2016): 128-41. doi:10.3109/07853890.2016.1145794.
Stearsman, Daniel. “Canibas Sativa L” Museum of Science and Industry. Tampa, Florida. Personal photograph. 2012.
United States, Congress, House, “Agricultural Act of 2014.” 2014.
White, Bruce David. Drugs, Ethics, and Quality of Life: Cases and Materials on Ethical, Legal, and Public Policy Dilemmas in Medicine and Pharmacy Practice. New York: Pharmaceutical Products, 2007.
Endnotes
1 The DEA Museum reported historically that Marijuana was classified as a stimulant. It is commonly understood that the substance possesses euphoric effects, but not strict stimulating properties.
2 When supplements make nutritional support claims they must make the following disclaimer “This statement has not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease” (Abood 53). Critics claim that the FDA is not doing enough to protect the general public from unsafe supplements under the Dietary Supplement Health and Education Act of 1994 (DSHEA). Often the public is unaware of potential interactions between supplements and over the counter medications or prescription medications. Further, there is a lack of quality standards for purity and strength, as well as manufacturing standards (Abood 56). For example, the supplement St. John’s wort can decrease the effectiveness of heart medications like Eliquis®, Digoxin, Xarelto® or the antirejection medication cyclosporine (Jellin 28). This is not to say that supplements do not work. Rather, supplements are not held to the same standards as drugs and patients are often less informed due to the labeling of the product.
3 The process of informed consent is demanded of practitioners who perform procedures (like surgeons) and for practitioners who dispense prescription drug products. Pharmacists have a duty to counsel patients on prescription drugs as codified in Omnibus Budget and Reconciliation Act of 1990.
4 Under the Agricultural Act of 2014 (Farm Bill) state departments of agriculture and institutions of higher learning may grow or cultivate industrial Hemp if the concentration of THC does not exceed 0.3 percent dry weight. See SEC. 7006 LEGITIMACY OF INDUSTRIAL Hemp RESEARCH (United States).
5 Natural Medicines Database prides itself on being “impartial; not supported by any interest group, professional organization or product manufacturer.” See https://naturalmedicines.therapeuticresearch.com/about-us.aspx.