Pubdate: Tue, 24 Mar 2015
Source: New York Times (NY)
Column:  A Conversation With
Copyright: 2015 The New York Times Company
Contact: http://www.nytimes.com/ref/membercenter/help/lettertoeditor.html
Website: http://www.nytimes.com/
Details: http://www.mapinc.org/media/298
Author: Claudia Dreifus

SEEKING THE FACTS ON MEDICAL MARIJUANA

Twenty-three states and the District of Columbia have legalized 
medical marijuana, but scientific research into its appropriate uses 
has lagged. Dr. Mark Ware would like to change that.

Dr. Ware, 50, is the director of the Canadian Consortium for the 
Investigation of Cannabinoids and the director of clinical research 
of the Alan Edwards Pain Management Unit of McGill University Health 
Center. Medical marijuana has been legal in Canada for 16 years, and 
Dr. Ware, a practicing physician, studies how his patients take the 
drug and under what conditions it is effective.

We spoke for two hours at the recent meeting of the American 
Association for the Advancement of Science and later by telephone. 
Our interviews have been condensed and edited for space.

Q. How did you become interested in the medical possibilities of cannabis?

A. In the late 1990s, I was working in Kingston, Jamaica, at a clinic 
treating people with sickle cell anemia. My British father and 
Guyanese mother had raised me in Jamaica, and I'd attended medical 
school there.

One day, an elderly Rastafarian came for his annual checkup. I asked 
him, "What are your choices of medicines?" He leaned over the table 
and said, "You must study the herb."

That night, I went back to my office and looked up "cannabis and 
pain." What I found were countless anecdotes from patients who'd 
obtained marijuana either legally or not and who claimed good effect 
with a variety of pain-related conditions.

There were also the eye-opening studies showing that the nervous 
system had specific receptors for cannabinoids and that these 
receptors were located in areas related to pain. Everything ended 
with, "More studies are needed."

So I thought, "This is what I should be doing; let's go!"

Was getting started that easy?

Actually, not.

That summer, I went to England and considered working with a British 
pharmaceutical concern researching cannabinoids. But just then, a 
Canadian court took up the case of an epileptic who'd been arrested 
when he used cannabis for his seizures. The court essentially 
legalized medical marijuana throughout Canada.

When I heard that, it seemed like Canada was the place I should be 
going to. I packed up my young family and moved to Montreal. What I 
proposed to McGill was a clinic where we might evaluate the claims of 
patients about medical marijuana.

So much of what we knew about the drug was anecdotal. Some of it was 
folkloric. My idea was to listen to the patients' stories and put 
them to a clinical evaluation.

When you first moved to Canada in 1999, what was known about medical marijuana?

We certainly knew that cannabinoids were analgesic in animal models. 
There were case reports floating around of people with multiple 
sclerosis who'd been helped.

In California, people with H.I.V. were using it for appetite 
stimulation, nausea and pain. Cancer patients sometimes used it to 
curb nausea from chemotherapy.

Since then, there have been at least 15 good-quality trials around 
the world. Cannabinoids are reported to help with H.I.V.-associated 
neuropathy, traumatic neuropathy, multiple sclerosis, pain from 
diabetes. There have also been a few small studies on fibromyalgia and PTSD.

When you talk about translational medicine, a drug usually moves from 
"bench to clinic." But cannabis has had this unique trajectory: The 
patients were using it on their own, and then you had these papers, 
often based on a few case studies. And sometimes, you had later 
trials which led to drugs - like with H.I.V. patients' using 
cannabis, which led to Marinol.

Tell us about some of your own research.

One investigation we published in the Canadian Medical Association 
Journal in 2010 studied 23 patients who used three slightly different 
levels of cannabis preparations and one placebo for two months. They 
had one puff three times a day. We found that the 9.4 percent THC 
level was superior to the placebo in terms of its effect on pain.

We also found that it helped with anxiety and sleep. Interestingly, 
our patients appeared to actually use very small quantities of the 
drug to control their symptoms, a lot less than recreational users.

Later this spring, we hope to take this research further by launching 
what we think will be the first ever longitudinal study of medical 
marijuana patients. We'll follow the long-term effects of those of 
our regular patients who've been using it for chronic conditions. 
We'll look at safety over the years.

Why do you think cannabis use has been generally so under-researched?

The fundamental answer is that the illegality of the drug has 
stigmatized most research. In Canada, people are sometimes afraid 
because of the perception that they are working with illegal 
substances, even when that's no longer the case.

In the United States, it's a different matter, because on the federal 
level, cannabis is listed as a Schedule I drug, like heroin. That 
means that the medical community is quite restricted in gaining 
access to research materials.

At the same time, there are more than 20 states where medical 
marijuana, to differing degrees, is legal. However, the plants grown 
in Colorado may be quite different from those grown elsewhere. 
Moreover, the medically eligible conditions vary from state to state.

This lack of standardization has been another factor making research 
difficult, because when you're talking about cannabis in one state 
and cannabis in another, you may not be talking about the same thing.

You've said that physicians call you frequently for practical advice 
about the drug. What do they ask?

The most common question is, "How do I make the distinction between 
patients who want it for medical or recreational use?" The other call 
I get is from a clinician who wants me to take his patient and 
explain whatever I can.

Actually, I wish those doctors would inform themselves better; a lot 
of information does exist, though we need more. I believe that by not 
informing themselves, physicians aren't fully serving their patients.

In Canada, for instance, we've noticed that our oncologists generally 
don't tell their patients about medical marijuana. It's the nurses 
who'll go, "Dear, why don't you go outside and have a puff."

Your own Canadian Medical Association reminds its members that they 
are not obligated to write marijuana prescriptions because there is 
"insufficient evidence on clinical risks and benefits." What is your 
take on their stance?

Well, I agree with them, at least on this: We need more research.

I think the time has come for us as a global community to agree on 
what we want to know and then go get it. And our patients need to 
move away from self-experimenting with substances and derivatives we 
don't know about, and move to a situation where we know what they are 
using and where we can better help them. This isn't going away.
- ---
MAP posted-by: Jay Bergstrom