Wednesday, August 24, 2011

A Reasonable Plan for Medicinal Marijuana?

Medical Marijuana A recent editorial in the Baltimore Sun [August 18, 2011] recommends that a new proposal in Maryland allowing medical schools and teaching hospitals to administer medicinal marijuana appears to be a safe, practical way to help patients cope with chronic pain or illness. At the same time, this sort of approach could avoid the abuses of marijuana laws that have plagued some states and encourage other states to adopt medicinal marijuana programs for the first time.

Maryland's approach in the past to the medical use of marijuana has been somewhat ambivalent. The state legislature in 2003 reduced penalties for persons convicted of possessing small amounts of the drug if they could prove “medical necessity” in court. But possession was still a crime, leaving bona fide patients with a conviction on their records. It also made judges, rather than healthcare providers, the ultimate arbiters of what constitutes medically necessity. Most perplexing, the law made no provision for patients to purchase the drug legally; consequently, even persons with legitimate medical necessity had to break the law to buy marijuana.

Earlier this year, the Maryland Senate had passed a bill allowing physicians to prescribe medical marijuana to certain patients, and it established a strictly regulated network of state-sanctioned dispensaries and marijuana growers to supply the drug. However, that initiative stalled in the House of Delegates, largely because of objections by Maryland Health Secretary Dr. Joshua M. Sharfstein, who cited a lack of scientific consensus over the potential risks versus benefits of marijuana. The proposal also was also opposed by law enforcement organizations on the grounds it would be too difficult to limit marijuana use to legitimate medical patients.

Sharfstein worked with the state panel that came up with the new proposal to put academic centers such as the Johns Hopkins University and the University of Maryland in charge of administering the state's medical marijuana program and assessing the drug’s risks and benefits. According to the editorial, “This is an eminently reasonable approach that balances caution with the desire to help people who are suffering. While there is plenty of anecdotal evidence suggesting marijuana can help these patients, the state shouldn't embark on a major shift in drug policy unless it has a firm scientific foundation to stand on.”

COMMENTARY: Previously, we have written only a few UPDATES on medicinal marijuana (cannabis) for pain [here]. This topic is somewhat of a political and regulatory “hot potato,” further burdened by a deficit of large-scale, well-designed clinical trials of the drug for various chronic pain conditions.

Reader responses to one of our UPDATES [here] presented a mixed portrayal of medicinal marijuana. While some note that it helped their pain, others comment that after awhile marijuana smoking seemed to exacerbate pain. An interesting aspect discussed by some was that, even in the absence of significant or enduring pain relief, psychotropic effects of marijuana provided relief from caring or worrying about the pain — a beneficial anxiolytic effect or psychological reprieve of sorts — which, in itself, might be clinically meaningful.

Medicinal marijuana is already legal in 13 states and the District of Columbia. However, state legislators are wary of repeating the experience of California, whose law in 1996 legalizing medical marijuana resulted in a swarm of “pot shops” and practitioners of dubious integrity seeking financial gain by prescribing the drug for practically anyone.

Maryland’s current laws create a thorny dilemma: patients demonstrating legitimate medical necessity may possess and use marijuana, but they have to purchase it illegally on the black market where the drug is of unknown quality. The new model holds promise for controlled distribution of pharmaceutical-grade marijuana to patients who might benefit, while, at the same time, researchers at Maryland's highly regarded medical institutions can gather and analyze the data needed to more adequately assess marijuana's therapeutic effects.

Would this sort of model also be appropriate for other states? Surely it might present certain barriers to access, especially for patients in areas not served by major medical centers. And, even in large urban areas there could be difficulties for many disadvantaged patients if drug costs are not covered by public insurance (eg, Medicaid, Medicare) or other third-party payers. So, perhaps the model is not perfect but it could be a reasonable beginning for the many states that currently eschew medicinal marijuana altogether. What do you think? Comment below.