Pubdate: Mon, 01 Jan 2007 Source: Canadian Family Physician (Canada) Copyright: 2007 The College of Family Physicians of Canada Contact: http://www.cfpc.ca Details: http://www.mapinc.org/media/4389 IS THERE A ROLE FOR MARIJUANA IN MEDICAL PRACTICE? These rebuttals are responses from the authors who were asked to discuss "Is there a role for marijuana in medical practice?" in the Debates section of the December issue (Can Fam Physician 2006;52:1531-3 [Eng], 1535-7 [Fr]). In these rebuttals, the authors refute their opponents' arguments. YES Mark A. Ware, MB BS, MRCP (UK), MSC Drs Kahan and Srivastava assert that marijuana is prescribed "under the guise of medical treatment" and object to "disguising it as medical therapy." This refusal to accept that some patients use cannabis as part of medical care runs contrary to current medical opinion, including the Canadian Medical Association's position.1 Under the Marihuana Medical Access Regulations, cannabis is not prescribed. Drs Kahan and Srivastava claim that cannabis use causes "pleasant psychoactive effects that are easily confused with direct analgesia." Cannabinoids have complex central actions, including analgesia. Are pleasant side effects a valid reason to withhold the drug from chronically ill patients? They list a number of risks, many of which are controversial. The carcinogenic potential of cannabis is not supported by clinical evidence. Exposure to smoked cannabis (50 joint-years; equivalent to 1 joint daily for 50 years) is not independently associated with increased risk of aerodigestive cancer; light cannabis use ((1 joint-year) might actually reduce risk of lung cancer.2 The anticancer properties of cannabinoids are fascinating.3 Cognitive effects of cannabis disappear after cessation of heavy use (50 joint-years).4 The risk for fatal accidents might actually be reduced compared with controls following cannabis use.5 No evidence of abuse of prescription cannabinoids has been found.6 Most cannabis research has been conducted under a paradigm of prohibition, and the study of risks is not yet balanced by much-needed research on benefits. All drugs have risks. To reject the therapeutic potential of cannabis and cannabinoids on the grounds of toxicity and potential abuse is to throw the baby out with the bath water. Dr Ware is Assistant Professor in Anaesthesia and Family Medicine at McGill University in Montreal, Que, Associate Medical Director of the MUHC Pain Centre, and a practising pain physician. He receives salary support from the Fonds de la recherche en sante Quebec and holds grants from the Canadian Institutes of Health Research. References 1. Canadian Medical Association Office for Public Health. Medicinal use of marijuana. Ottawa, Ont: Canadian Medical Association. Available from: www.cma.ca/index.cfm/ci_id/3396/la_id/1.htm. Accessed 2006 Nov 24. 2. Hashibe M, Morgenstern H, Cui Y, Tashkin DP, Zhang ZF, Cozen W, et al. Marijuana use and the risk of lung and upper aerodigestive tract cancers: results of a population-based case-control study. Cancer Epidemiol Biomarkers Prev 2006;15(10):1829-34. 3. Guzman M. Cannabinoids: potential anticancer agents. Nat Rev Cancer 2003;3(10):745-55. 4. Pope HG Jr, Gruber AJ, Hudson JI, Huestis MA, Yurgelun-Todd D. Neuropsychological performance in long-term cannabis users. Arch Gen Psychiatry 2001;58(10):909-15. 5. Bates MN, Blakely TA. Role of cannabis in motor vehicle crashes. Epidemiol Rev 1999;21(2):222-32. 6. Calhoun SR, Galloway GP, Smith DE. Abuse potential of dronabinol. J Psychoactive Drugs 1998;30(2):187-96. NO Meldon Kahan, MD, CCFP, FCFP Anita Srivastava, MD, CCFP, MSC Dr Ware states that cannabis has been used for thousands of years. Yet many time-honoured medical therapies are abandoned as it becomes evident that they are harmful or as they are replaced by more effective treatments. Dr Ware encourages family physicians to learn about the Marihuana Medical Access Regulations because physicians do not have to prescribe medical marijuana but simply to support its legal use. The access form might not be an official prescription, but patients will interpret the physician's signature as an endorsement of the therapeutic benefits of smoked marijuana. Patients trust their physicians and expect physicians to act in their best interests; therefore physicians should sign the form only if they truly believe that medical marijuana is safer or more effective than available alternatives. This position is untenable now that oral and inhaled pharmaceutical cannabinoids are available. Dr Ware admits that, although "cannabis has not yet been formally evaluated in clinical trials," family physicians should become more familiar with it because studies are under way. Yet most clinical trials are testing pharmaceutical cannabinoids, not smoked marijuana. We are reassured that marijuana has "safety data generated from 2 generations of recreational users." This statement is unreferenced, and we take issue with Dr Ware's commonly held view that cannabis is a harmless herbal remedy. Its harms are well studied and documented; marijuana smokers are likely at increased risk of prostate, head, and neck cancers1; bronchitis2; motor vehicle accidents3; psychosis4,5; and psychosocial difficulties. Marijuana smoke contains numerous toxins, and the rapid delivery of high doses of inhaled delta-9-tetrahydrocannabinol puts smokers at risk of psychomotor impairment and addiction. It is inadvisable for family physicians to prescribe an unproven and possibly harmful substance to their patients when far safer alternatives are available. Dr Kahan is Medical Director of the Addiction Medical Service at St Joseph's Health Centre in Toronto, Ont, and Head of the Alcohol Clinic at the Centre for Addiction and Mental Health. Dr Srivastava is a staff family physician at St Joseph's Health Centre and Head of the Opioid Clinic at the Centre for Addiction and Mental Health. References 1. Hashibe M, Straif K, Tashkin DP, Morgenstern H, Greenland S, Zhang ZF. Epidemiologic review of marijuana use and cancer risk. Alcohol 2005;35(3):265-75. 2. Tashkin DP, Baldwin GC, Sarafian T, Dubinett S, Roth MD. Respiratory and immunologic consequences of marijuana smoking. J Clin Pharmacol 2002;42(11):71-81. 3. Ramaekers JG, Berghaus G, van Laar M, Drummer OH. Dose related risk of motor vehicle crashes after cannabis use. Drug Alcohol Depend 2004;73(2):109-19. 4. Green AI, Tohen MF, Hamer RM, Strakowski SM, Lieberman JA, Glick I, et al. First episode schizophrenia-related psychosis and substance use disorders: acute response to olanzapine and haloperidol. Schizophr Res 2004;66(2-3):125-35. 5. Caspari D. Cannabis and schizophrenia: results of a follow-up study. Eur Arch Psychiatry Clin Neurosci 1999;249(1):45-9. - --- MAP posted-by: Elaine