Legalization of cannabis for medical use
This paper offers an analysis and literature review in support of and the challenges associated with the legalization of cannabis for medical use. Recent peer-reviewed scientific studies progressively support historical and anecdotal evidence of the efficacy of Medical Cannabis (MC) in the treatment of many chronic health issues. The online databases CINAHL, PubMed and Medline were used to search for literature relevant to this topic. Majority of the articles show the effectiveness of MC in the management of wide-ranging medical diagnoses, but for a nuanced review, articles that reflect the challenges with this approach are also highlighted. There is growing research evidence to support the integration of MC into current therapeutic models for the management of various medical conditions, but more research is recommended for more broad-based conclusive evidence.
The Research Paper: First Draft
Cannabis (marijuana) is derived from the plant Cannabis sativa and classified as a schedule 1 drug and therefore federally prohibited for recreational and therapeutic purposes but in recent times there has been a slew of state legislations that have either legalized it for medical use and/or for recreational use as well. MC has become one of the most important public health issues of our time, because of the controversy evoked by its recreational use and the perceived effect it has on users and the society in general, but the dilemma occurs when there is at least significant anecdotal evidence of its effectiveness with users in treating or ameliorating the symptoms associated with various chronic medical conditions. While robust clinical research into the documented subjective effectiveness of MC on a myriad of health issues is lacking, the available literature points to the potential that must be explored in full to enhance the knowledge base about cannabis.
The historical antecedents and the patient-reported evidence should create the momentum to encourage scientific investigations into these observations and there is a real positive trajectory on this topic, given traction by a recent article in Salem News (2019) on the World Health Organization (WHO)’s change of position on MC. After more than 60 years of a zero tolerance stance on cannabis, this change is consequent upon the increasing scientific evidence of its therapeutic value. The report reiterates that this effectively repeals a 65-year old WHO position that cannabis should be abolished from all legitimate medical practice. This was declared a major policy breakthrough and a resounding defeat of politics by the strength of evidence.
Following prohibition since the 1970s, there have been progressive initiatives at the state and citizenry level to reinstate the use of cannabis for medical purposes. The psychoactive nature of cannabis and its addictive properties have added political, social and legal dimensions to a debate that should be driven by the science, based on evidence (Rubens, 2014). Therefore, it is valid to concede that the current wave of legalizations of MC across states in the US is more from social acceptance than from a robust increase in scientific knowledge (Marcoux, Larrat, & Vogenberg, 2013).
The use of medical cannabis as a treatment modality for a wide range of chronic medical and/or painful conditions has shown promising effectiveness especially in cases that have been refractory to current therapeutic approaches. There is an increasing body of research evidence to support this assertion and this paper is an attempt to review the evidentiary basis.
Methods
Several online databases were searched using inclusion criteria relevant to the project topic. CINAHL yielded 58 articles, PubMed, 43 and Medline 26. Of the 127 total articles available for review, 19 were eventually used for their specific relevance to the trajectory of this paper.
Historical and Cultural Perspectives
The plant cannabis sativa has been cultivated and used over several millennia by different cultures for the treatment of various ailments and even for its psychoactive properties in religious rituals (Hindu and Buddhist traditions). In their review of this history, Hand et al. (2016) argue that the cultural and medicinal uses of cannabis through a historical point of view is important to understand the imperative of its integration into modern therapeutic regimens. The authors reveal the documented records of its use from over 6000 years; the earliest recorded use for medical purposes being found in the ancient Chinese pharmacopeia Pen-ts’ao ching dating back to 2700 BC and affirmed its effectiveness in treating conditions like joint pains, gout and even as a surgical anesthetic. The authors chronicle this history over the succeeding millennia as its use spread westward through India, Arabia, Africa and the Americas. Among the earliest documented medicinal use of cannabis in the United States (US) was in 1860, as recorded by the Ohio State Medical Society in the successful treatment of various diseases like asthma, gonorrhea and rheumatic pain (p.3). However, in 1970, a federal ban on its use (recreational or medicinal) was effected by the promulgation of the Controlled Substances Act, when it was classified as a schedule 1 drug. In the state of Florida where this author resides, MC was introduced by the legislature in 2014 (Smith & Lannon, 2017).
Current Evidence-Based Science
The two main active ingredients in cannabis are delta-9 tetrahydrocannabinol (THC), a psychoactive compound and the non-psychoactive Cannabidiol (CBD). The deeper understanding of human physiologic cannabinoid system and cannabinoid pharmacology has over the last two decades, led to the development of synthetic analogues of cannabis like nabiximols, nabilone and dronabinol (Marinol) some of which are used for both research purposes as well as in the treatment of disease and symptoms.
Evidence is growing, with a slew of disease-specific studies where MC provided clinically and statistically significant improvements in patients’ symptoms and quality of life, for example, from a cross-sectional survey in the management of the side effects of post radiation therapy for patients with head and neck cancers (Elliot et al., 2016) observed both subjective and objective improvements in these side effects, like sticky saliva, xerostomia, anorexia and pain; In a multi-center retrospective study, the authors Tzadok et al. (2016) recorded significant (89%) reductions in the frequency of seizures in pediatric patients treated with MC for pediatric intractable epilepsy. Other significant improvements were observed in their behavior patterns, motor skills, alertness and sleep. These results are encouraging because pediatric intractable epilepsy also happens to be one of the most mentioned anecdotal successes with cannabis therapy; In a survey involving over 2500 non-cancer patients, Zaki et al. (2017) showed a significant (more than 70%) reduction in symptoms from Post-Traumatic Stress Disorder (PTSD), anxiety, depression, sleep disturbances and arthritis in patients with these conditions; A similar result was obtained in a different study, with significant improvement in PTSD symptoms and overall quality of life in patients who were treated with MC (Chan et al, 2017). The import of these results on servicemen and women returning from active duty with this diagnosis cannot be overstated.
The symptom of chronic pain (especially neuropathic pain of diverse etiology) is arguably the most common indication cited for the use of MC. Whereas opiates remain the drug of choice for pain management, there is evidentiary support from a Canadian cross sectional survey, that the use of MC in opiate-dependent patients resulted in significant reduction in the use of the opiates, as well as reduction in alcohol and other illicit drug use (Lukas, Baron & Jikomes, 2019). The authors argue that with the current opioid crisis across the US, which has turned into a public health epidemic, results like this one provide the impetus for further MC legalizations as a potential vehicle for containing the crisis.
The effect of MC on muscle spasticity associated with multiple sclerosis refractory or drug resistance to usual treatment forms has been studied widely and the results are generally impressive. 10 years of clinical evaluations were reviewed by Giacoppo, Bramanti & Mazzon (2017) on patients who received the oromucosal spray Sativex (combined delivery of THC and CBD) for this indication and observed not only the significant relief of spasticity, but a general improvement in their quality of life.
The response of inflammatory bowel disease to treatment with MC as evidenced by retrospective, prospective and randomized controlled studies revealed significant improvements in the symptoms of abdominal pain, diarrhea and nausea (Kinnucan, 2018). Even more encouraging was the observation that in patients with Crohn’s disease specifically, there was significant improvement in the Crohn’s Disease Activity Index (CDAI), with clinical remission noted in 45% of patients. However, this was not associated by a parallel improvement in the objective disease biochemical markers like C-reactive protein (CRP).
In the highly sensitive area of cancer research and treatment, the experimental study by Romano et al., (2014) on the proliferation of colorectal cancer cells, revealed the inhibitory effect of MC on colon carcinogenesis. If this is duplicable in other independent studies, its clinical importance for the management of patients with colorectal cancer cannot be overstated.
Cannabis as Complementary Alternative Medicine
In this diverse and multicultural environment where holistic and culturally competent healthcare has seen the incorporation of Complementary and Alternative Medicines (CAM) into allopathic medical therapies, some experts and studies have called for a change of mindset as regards the exclusion of MC in this category (Bruce, 2018). He argues that if patients are truly getting significant relief/remission of their symptoms or chronic medical conditions by using MC, this should be the driving force behind its legalization, at least as CAM. A corollary to this position is that legalization would free investigators to conduct full scale clinical trials, (without the impediment of regulations engendered by its current classification), further advancing and improving the existing body of knowledge about the pharmacological profile of cannabis, document unanticipated drug side effects and interactions with other medications and consequently develop correct dosing parameters for the drug (Nutt et al., 2013).
Challenges
From socio-political, ethical and legal perspectives, there are valid concerns and challenges facing the mainstream integration of MC as an accepted tool in the regimen of refractory therapeutics. For instance, even as multiple states pass legislations legalizing MC, authors like Marcoux, Larrat & Vogenberg (2013) contend that the ambiguities created by the dichotomy between states and federal laws, leave health care providers legally exposed on the implementation side of the equation. They make another important observation that public acceptance seems to be the driving force behind medical cannabis legislations, rather than clinical data and this is a legitimate concern.
Another factor not commonly discussed in the debates regarding MC is the training and preparedness of the physicians who are charged with writing the prescriptions. In their article on this subject, Evanoff et al., (2017) reveal that while over half of the states in the US have now legalized the use of cannabis for medical purposes, there is a significant lagging in the training of physicians to administer the programs, from medical school through residency and fellowship training. There appears to be an incongruence between the enthusiasm for legislative change to legalize medical cannabis and the educational preparedness of the physicians who are supposed to fill the prescriptions, which raises an obvious challenge to its effective implementation.
The medical and science communities have also raised pertinent ethical concerns about the yet undetermined respiratory and second-hand environmental effects of the smoked forms of MC, since their pharmacokinetic and pharmacodynamic characteristics through this route have not been fully elucidated (Sagy et al., 2018).
One of the major social concerns about the legalization of MC is the potential to act as a gateway drug for other illicit substance abuse, or at the minimum, the transition to recreational use. The latter fear is not unfounded, as some studies (Stolzenberg, D’Alessio & Dariano, 2016) have shown that in states that have passed MC laws, there is an increased likelihood of recreational usage among the juvenile demographic. The authors postulate that this behavior could stem from the de-stigmatization of cannabis use associated with the law, as well as the attenuation of fears of negative health effects of the drug.
To adopt and implement MC into clinical practice, Wan et al., (2017) posit that these challenges must be met by high quality scientific research validating the common anecdotal efficacies of MC and using the evidence to develop indication-specific, dose and route-adjusted drug vehicles, moving away from the unreliable and erratic characteristics inherent in the smoking forms.
Conclusion
With numerous anecdotal evidences, now supported with many and growing empirical studies, MC is showing great promise as an acceptable and effective therapeutic approach to a myriad of clinical indications that hitherto have not been amenable to current treatment modalities. However, more research is needed to develop a widely acceptable, dose-dependent drug vehicles that address the legitimate pharmacokinetic and pharmacodynamic concerns associated with the smoked form. Furthermore, the streamlining of states legislative efforts and federal statutory positions on cannabis will be necessary to remove the ambiguities associated with the interpretation of these laws and the dilemmas inherent in their implementation for health care providers.