Marijuana Medical Handbook: Practical Guide to Therapeutic Uses of Marijuana

Chapter 1

How Safe is Marijuana?

Marijuana is a remarkably safe drug. Although its primary active ingredients (THC and other cannabinoids) produce psychoactive effects at doses of a couple of milligrams, they do not have lethal effects. Unlike other psychoactive drugs, including alcohol, aspirin, opiates, nicotine, and caffeine, cannabis is not known to cause fatal overdoses. The DEA’s [Drug Enforcement Administration] own administrative judge Francis Young, in his 1988 decision recommending legalization of medical marijuana, wrote, Marijuana, in its natural form, is one of the safest therapeutically active substances known to mankind. From animal experiments, it has been estimated that a lethal dose of cannabis would be 20,000 to 40,000 times a normal dose: approximately 40 to 80 pounds of marijuana! No deaths from cannabis overdose have ever been recorded.

Marijuana’s safety may be explained by how it acts in the body. In recent years, scientists have discovered that marijuana’s active ingredients, the cannabinoids, work on a signaling system in our bodies known as the endogenous cannabinoid, or endocannabinoid system. Receptor cells for this system are concentrated in many parts of the brain and body, but are relatively lacking in the brainstem, which controls vital functions such as breathing and heartbeat. Therefore, even strong doses do not endanger life.

This is not to say that marijuana cannot have adverse effects. Like all drugs, marijuana can cause harm if taken in excess or abused. In addition, certain people simply respond poorly to marijuana,

RECREATIONAL DRUG-RELATED DEATHS, 1979-1998

Source: Centers for Disease Control, cited at http://briancbennett.com/charts/death/rec-intox-deaths.htm

finding it more unpleasant than beneficial. But what’s important is that people have access to accurate information about marijuana. Without information, how will they know whether it will benefit them, what dose they should take, and how they can gain access to a regular supply?

History of Marijuana as Medicine

Marijuana, botanically known as cannabis, has been around for thousands of years. It has several species or varieties, most notably cannabis sativa and cannabis indica. Until 1937, marijuana was legal and was commonly prescribed medicinally in the U.S. Despite its prohibition, marijuana continues to be one of the most widely used drugs in America.

The medical and recreational uses of cannabis have been known since ancient times. In China, it appears in the Pen Ts’ao as a remedy for gout, rheumatism, malaria, beriberi, constipation, and absentmindedness. Tradition ascribes the Pen Ts’ao to the legendary emperor Shen-Nung, said to be from the 3rd millennium BC, although modern scholarship dates it to the 1st century AD. The famous surgeon Hua T’o allegedly used cannabis to perform painless operations in the second century A.D. Eastern Indian documents in the Atharveda, dating from before the first millennium BC, also refer to the medicinal use of cannabis.

Cannabis was mentioned in medicinal texts by the ancient As-syrians, who referred to the hemp plant as qunnabu, an apparent etymological cognate of cannabis. Some Biblical scholars believe this is the same as the plant kaneh bosm (translated as aromatic cane) in Exodus 30:23, where God directs Moses to make a holy oil composed of cinnamon, kaneh bosm and kassia [Russo²].

In the Roman world, cannabis was described in the classic medical writings of Galen and Dioscorides, who imaginatively recommended the juice of the seed to prevent earaches and diminishing sexual desires, and flatulence. It was also regularly prescribed as an analgesic or painkiller³.

The oldest archeological evidence of medical use of cannabis dates from the discovery, in 1994, of an Egyptian tomb of the third century A.D. In the tomb were the remains of a young girl who had died in childbirth, accompanied by traces of hashish, or concentrated cannabis resin, which had apparently been used to ease the difficulties of labor.

An Irish physician, William B. O’Shaughnessy, brought knowledge of the medical properties of cannabis to Europe in 1839. He observed its use in India, then experimented with alcohol-based cannabis tinctures to treat rheumatism, rabies, cholera, tetanus, and convulsions. He described it as an analgesic and an anti-convulsive remedy of the greatest value. In Victorian times, cannabis came to be popular in the treatment of painful menstruation and childbirth, asthma, migraines, neuralgia, and senile insomnia. By the late nineteenth century, however, its use began to wane as stronger and more conventional medicines became available.

Marijuana’s use as a legal medicine was ended by a political misfortune. In 1937, the Marihuana Tax Act, a bill to ban marijuana, was brought before Congress. The director of the Federal Bureau of Narcotics, Harry Anslinger (who was, by the way, a former Prohibition official), led the attack on marijuana with bogus charges of madness and violence that focused on Hispanics, African Americans, and other minorities.

One of the most vocal groups to oppose the bill was the American Medical Association (AMA). Dr. William Woodward, the AMA’s spokesperson, argued that cannabis was not dangerous and that its medicinal use would be severely curtailed by the proposed measures. The Prohibitionists prevailed through the use of a well-organized campaign of misinformation, and marijuana has been functionally illegal in the U.S. ever since.

The Marihuana Tax Act of 1937 essentially ended the medicinal use of cannabis. In 1941, it was withdrawn from the U.S. pharmaceutical market because of the burdensome requirements of the law.

Nonetheless, government sponsored panels of medical experts continued to find marijuana harmless and even potentially useful. In 1944 an expert panel of the New York Academy of Medicine organized by New York City Mayor Fiorello LaGuardia concluded that marijuana was not addictive, did not lead to abuse of other drugs, and that public hysteria about it was unfounded. Commissioner Anslinger vigorously denounced the report, and sought to destroy as many copies as possible. In 1971, President Nixon appointed the Presidential Commission on Marihuana and Drug Abuse, led by Pennsylvania Governor William Shafer. When the commission unexpectedly recommended the repeal of laws against adult use of marijuana, Nixon promptly disavowed their report. Another study by the National Academy of Sciences came to similar conclusions in 1982, and was likewise ignored by President Reagan.

The medicinal value of marijuana was rediscovered during the recreational marijuana boom of the Sixties. In the early 1970s, it was reported that some young cancer patients found that smoking a joint could relieve the gut-wrenching nausea that resulted from chemotherapy. Clinical studies at Harvard and elsewhere soon confirmed marijuana’s anti-nausea properties. Meanwhile, other patients were discovering that marijuana could help relieve glaucoma, chronic pain and muscle spasticity from spinal injuries and multiple sclerosis, and other complaints.

Interest in the medical benefits of marijuana peaked in the late 1970s, when over 35 states passed legislation to establish medical marijuana research programs. Each program was eventually smothered by federal drug regulations, which made it virtually impossible to conduct scientific medical marijuana research.

Under the terms of the 1970 Controlled Substances Act, marijuana is classified as a Schedule 1 controlled substance, meaning that it has high abuse potential and no recognized medical use. Schedule 1 drugs cannot be used without explicit permission from the DEA and the Food and Drug Administration (FDA), which involves exhaustive paperwork, long delays, and almost certain refusal.

In 1972, the National Organization for the Reform of Marijuana Laws (NORML) petitioned the government to make marijuana a Schedule 2 drug, which would allow its medical use. This action developed into a lawsuit that dragged on for 20 years and ended in defeat for NORML. In the meantime, frustrated patients were forced to seek other legal remedies.

In 1976, Robert Randall, a glaucoma patient, succeeded in persuading the federal government to supply him with marijuana under a new FDA Compassionate Use protocol. With the support of his physician, Randall argued that marijuana was the only drug that would prevent him from going blind and won a lawsuit against the federal government. The government grudgingly agreed to supply Randall with free marijuana from its own research farm in Mississippi. In later years, more patients managed to enroll in the Compassionate Use program, which required elaborate, time-consuming paperwork from their physicians. Pressed by a flood of over 100 new applicants who had been struck by the AIDS virus, the government closed the program to new applicants in 1991. Today, just four surviving patients still receive marijuana legally in the U.S., for conditions including glaucoma, multiple sclerosis, and rare genetic diseases.

In 1988, following extensive testimony, DEA administrative judge Francis Young ruled that marijuana’s medical benefits were clear beyond question and that it should be reclassified as a Schedule 2 drug. Judge Young’s recommendation was promptly overruled by DEA chief John Lawn, who, despite the fact that morphine and cocaine had earned a Schedule 2 classification, expressed concern that it would send the wrong message about marijuana’s supposed harmfulness. After further legal twists and turns, a federal appeals court upheld the DEA ban in 1993. Hence, marijuana remains a Schedule 1 drug to this day.

Still, medical marijuana has attracted growing interest from health professionals. Although the AMA switched its position on marijuana after 1937, as it became more beholden to corporate interests, its California branch, the CMA, has called for research to establish guidelines for prescription use of cannabis. Other organizations have been bolder in advocating outright legalization of medical marijuana, including:

The American Public Health Association

The American College of Physicians

The American Nurses’ Association

The American Psychiatric Association

On Marijuana Legalization

Jocelyn Elders

"It is simply wrong for the sick and

suffering to be casualties in the war on

drugs. Let’s get rid of the myths and

institute sound public-health policy."

The American Academy of Family Physicians

The AIDS Life Lobby

The Physicians’ Association for AIDS Care

The New England Journal of Medicine

Consumer Reports Magazine

In 1996, California voters approved an initiative that recognized the value of medical marijuana to the sick. The California Compassionate Use Act (Proposition 215) exempted patients from prosecution for possessing or cultivating marijuana for medical use if they had a physician’s recommendation.

The federal government, led by Drug Czar Barry McCaffrey, attacked the initiative as contrary to federal law. The government threatened to have physicians arrested for recommending marijuana, but was blocked by a federal court decision, Conant v. Walters, which held that physicians were protected under the First Amendment in recommending marijuana. The government proceeded to attack medical marijuana by targeting growers, co-ops, and dispensaries providing medicine to patients, with raids that ensnared one coauthor of this book, Ed Rosenthal.

Meanwhile, in 1997, Drug Czar McCaffrey commissioned the national Institute of Medicine (IOM) to review the scientific evidence on the health benefits and risks of marijuana and drugs derived from it, known as cannabinoids. In 1999, the IOM reported that cannabinoids had potential therapeutic value, especially for nausea reduction, appetite stimulation, anxiety reduction and pain relief. The report cautioned against use of smoked marijuana on account of the respiratory hazards of smoking, but acknowledged that it remained the only good alternative for certain patients with chronic conditions. The report recommended further research and clinical trials including the development of non-smoked delivery systems. The federal government ignored the report and continued to oppose medical marijuana.

On Marijuana Legalization

Drew Carey

I think it’s clear by now that the federal government needs to reclassify marijuana. People who need it should be able to get it safely and easily.

Despite federal opposition, support for medical marijuana grew steadily following the passage of Prop. 215. Other states passed medical marijuana laws of their own: Oregon, Washington, Alaska, Nevada, Colorado, Maine, Montana, Hawaii, Vermont, Rhode Island and New Mexico. Canada’s highest court struck down the country’s marijuana laws and ordered the government to institute legal access for medical users.

To this day, the U.S. government continues to insist that all use of marijuana is illegal under the federal Controlled Substances Act (CSA). In 2005, the US Supreme Court upheld this position in its ruling Gonzalez v. Raich. The court rejected a challenge by two California patients, Angel Raich and Diane Monson, who argued that the government’s powers to regulate interstate commerce did not extend to their personal use and cultivation of medical marijuana under Prop. 215. While the court upheld the federal ban on medical marijuana, it did not question the validity of the state laws. Therefore patients are still protected from prosecution under state, though not federal, law in the 13 states with medical marijuana laws.

On Marijuana Legalization

Newt Gingrich

We believe licensed physicians are competent to employ marijuana, and patients have a right to obtain marijuana legally, under medical supervision, from a regulated source. Federal policies do not reflect a factual or balanced assessment of marijuana’s use as a medicant.

In practice, the DEA and Justice Department officials have insisted they have no interest in pursuing individual patients, but only large-scale traffickers. As a result, most patients who possess and grow for their own individual use have little to fear so long as they are discreet and comply with local medical marijuana laws.

Since the passage of Prop. 215, public use and acceptance of medical marijuana have grown dramatically. As of this writing, some 300,000 Americans are using marijuana legally. A 2002 Time magazine poll reported that 80% of Americans support legalizing medical marijuana. It is probably only a matter of time before federal law is reformed to restore the right of U.S. citizens to use medical marijuana.

Chapter 2

What Marijuana Does

Marijuana is primarily a psychoactive, or consciousness-altering, drug. Therapeutically, its effects are wide-ranging and substantial, while physical side effects are modest and often negligible.

Marijuana acts primarily through a family of chemicals known as cannabinoids, the most prominent and psychoactive of which is delta-9-tetrahydrocannabinol or THC. THC’s primary site of action is the brain, particularly the higher brain centers that affect consciousness. Cannabinoid receptors are concentrated especially in the hippocampus, which affects the higher functions of memory, feelings, and action. By acting on these higher brain systems, marijuana produces some of its most striking medicinal benefits, affecting perception of pain, mood, hunger, and muscle control. Marijuana may also produce more subtle medical effects through direct action on bodily tissues, such as immune system cells.

Marijuana users commonly report pleasurable sensations; after all, that’s why people use it recreationally. There are also people who find it makes them uncomfortable. In practice, its effects on different people and in different circumstances vary, depending on individual temperament, physiology, mood, and the famous set and setting defined by Dr. Timothy Leary: the initial mind set of the user and the surroundings in which the user gets high.

Here are some of the more commonly reported impressions of being high on cannabis:

• Heightened attentiveness to sensory stimuli, especially touch, taste, and sound; heightened interest in food and in music.

• Free flow of ideas in rapid, loose, dreamlike succession.

• Mild hallucinations with a double consciousness that some resemblances or connections are perceived, not real.

• Disruption of concentration and short-term memory.

• A sense of floating, light-headedness, or dizziness, and/or a sense of heaviness in the trunk and limbs.

• Hyperactivity, restlessness, hilarity, and talkativeness for the first hour or two, followed by sleepiness and/or torpor after two to six hours.

• Subjective time expansion, a tendency to overestimate the amount of time that has passed.

• Impaired executive decision-making and coordination, especially when performing complex tasks; confusion; difficulty expressing thoughts in words; slurred speech.

Chemical Composition of Marijuana

The peculiar medicinal and psychoactive effects of marijuana are primarily caused by the cannabinoids, which are a unique constituent of the marijuana plant. So far 86 cannabinoids have been identified in nature. Others have been chemically synthesized.

The main psychoactive ingredient in marijuana is delta-9-tetrahydrocannabinol, or THC (sometimes confusingly referred to as delta-1-THC under a different naming system). However, other cannabinoids also have medicinal and/or psychoactive properties.

Cannabidiol (CBD), cannabinol (CBN), cannabavarin (THCV), cannabigerol (CBG), cannabichromene (CBC), delta-8-THC, cannabicyclol (CBL), cannabitriol (CBT), and cannabielsoin are among the various natural cannabinoids. Most are known to have psychoactive and/or pharmacological effects, as do many other synthetic cannabinoid analogs.

Because delta-9-THC is the major psychoactive ingredient in marijuana, it is regularly used to measure the herb’s potency. Typical concentrations of THC are less than 0.5% for inactive hemp, 2% to 3% for marijuana leaf, and 4% to 7% for higher-grade marijuana. The highest concentrations in the plant occur in seedless marijuana buds, known as sinsemilla, which can contain 10% to 20% or more. Even higher concentrations can be produced in extracts, tonics, and hashish (concentrated cannabis resin).

Therapeutic oral doses range from 2.5 to 20 milligrams of THC. A typical joint (1 gram of 2.5% leaf or 0.5 gram of 5% better grade) contains 25 milligrams of THC. However, over half of this amount is commonly destroyed in combustion or lost in side stream smoke. Only 15%-50% of the THC in a marijuana joint actually reaches the bloodstream, leaving the actual inhaled dose closer to 3-12 milligrams [Brenneisen⁴].

THC does not actually occur in its active form in the cannabis plant. Rather, it occurs in the form of an acid known as tetrahydrocannabinolic acid or THC acid (THCA). When marijuana is burned in a cigarette or heated in cooking, the THCA is quickly converted to THC in a heat-driven reaction known as decarboxylation. Compared to THC, little is known about THCA. While it is not psychoactive, it has been recently discovered to have immuno-modulatory properties, like other cannabinoids [Verhoeckx⁵].

If you eat marijuana raw, you will not feel strong psychoactive effects because the THCA will not have been converted to THC. However, as marijuana ages, some of the THCA will become decarboxylated. The marijuana resin in hashish often contains high levels of active THC.

The next most common cannabinoid is CBD. CBD is the leading cannabinoid in hemp varieties of cannabis. Unlike THC, CBD lacks noticeable psychoactive effects and does not strongly interact with the body’s cannabinoid receptors. Nevertheless, there is growing evidence that CBD has valuable medical properties. CBD appears to work synergistically with THC, bolstering its medical effects while moderating its psychoactivity. CBD is thought to have anti-psychotic effects, dampening anxiety and panic reactions to THC. It is also thought to improve wakefulness and to enhance THC’s activity against pain and spasticity. In mice, pretreatment with CBD increased brain levels of THC nearly 3-fold, and there is strong evidence that cannabinoids can increase the action of other drugs. Thus it seems that the cannabinoids work in concert.

Taken by itself, CBD has anti-inflammatory, anti-anxiety, anti-epileptic, sedative and neuro-protective actions. It is also a potent anti-oxidant, protecting against chemical damage due to oxidation. Recent laboratory and animal studies have suggested that CBD could protect against the development of diabetes, certain kinds of cancer, rheumatoid arthritis; brain and nerve damage due to stroke, alcoholism and Huntington’s disease, and even prion infections such as mad cow disease. There is evidence that the dosage response to CBD is biphasic, meaning that its efficacy diminishes if the dose is too high or too low.

CBD is an essential ingredient in Sativex, the cannabis spray being developed by GW Pharmaceuticals in the UK. Sativex, which contains equal parts CBD and THC, has been approved for treatment of MS in Canada. GW is planning further research on the use of CBD in arthritis, inflammatory bowel diseases, psychotic disorders, and epilepsy.

CBD is produced alongside THC acid (THCA), the precursor of