News on the medical-marijuana front

Canada approves whole-cannabis extract for medical use. How will the drug warriors and anti-prohibitionists in this country react?

Advocates of the use of marijuana as medicine point out that, before becoming a drug of widespread abuse, cannabis was a part of the traditional pharmacopoeia, and that its primary psychoactive component, delta-9-THC, is an approved drug under the tradename Marinol.

Opponents point out that cannabis doesn’t really look very much like a medicine. We expect our medicines to be consistent in composition, but cannabis from different plants, or from different parts of the same plant, or from a given part of a given plant at different times of harvesting or time since harvesting, can vary enormously in both the overall levels of psychoactive agents they contain and in the ratios of those agents. Moreover, smoking is an imprecise way to take a medication (“one puff” isn’t nearly as well-defined a dosage as “one tablet”), aside from the problem of taking one’s medicine in a cloud of noxious gasses and particulate matter.

An obvious approach to the problem is to isolate specific active agents and make those available as medicines. That’s what was done with Marinol.

Alas, Marinol turned out to be mostly a bad idea. Delta-9-THC has anxiogenic (anxiety-inducing) effects; unmediated by the anxiolytic effects of cannabidiol (and perhaps other agents), pure Delta-9-THC provokes an unacceptably high rate of dysphoric and even panicky experiences. In addition, since Delta-9-THC is the primary intoxicating agent, apparently responsible for the what-was-I-trying-to-say-when-I-started-this-sentence short-term memory impact of pot-smoking, it’s hard to reach the goal of treatment without intoxication just using THC. (I have nothing against recreational intoxication, but as someone who was once a chronic pain patient I can tell you that a steady diet of it is no fun whatever.)

Moreover, Marinol is in pill form, which means that its actions are both slow and variable with the contents of the patient’s stomach, and problematic in use against nausea. (If the patient can’t keep anything down, giving him a pill for his nausea is likely to be futile.)

GW Pharmaceuticals of the UK approached the problem from the other end: rather than trying to isolate one chemical from cannabis, it figured out how to produce an extract containing all of the active chemicals in the original plant material, and to standardize the potency and control some of the important ratios, especially the THC-to-cannabidiol ratio. The resulting preparation can be taken either as a nasal spray or sublingually.

The news this week is that Health Canada (equivalent for these purposes to the FDA here) has approved GW’s product, called Sativex, for the treatment of neuropathic pain in MS patients.

Now the two sides in the war about drugs have some tricky choices to make, especially around the question of approving Sativex and other whole-cannabis extracts for use in this country.

The drug warriors have been proclaiming for 30 years that marijuana has no medical utility and comparing it to Laetrile. That might make it embarrassing for them to get behind Sativex, which after all is marijuana. Moreover, they need to worry about the phenomenon of “off-label” prescription: once the drug is approved, any physician can prescribe it for any condition, and the list of symptoms for which cannabis might reasonably be a palliative is long enough to cover virtually anyone. So approving Sativex would be tantamount to legalizing marijuana for any adult who can find a cooperative doctor.

On the other hand, the medical-marijuana fight is a complete loser for the drug warriors in political terms: strong majorities all over the country think that if a doctor wants to prescribe marijuana to a patient and the patient wants to take it the government shouldn’t interfere. Every referendum battle on the question has resulted in victory for the anti-prohibition side.

One possible line for the drug warriors to take is: “Of course marijuana isn’t a medicine, but see what a wonderful medicine has been developed from it! Ain’t science grand?” Since Sativex and other GW products won’t look like pot and won’t be smoked like pot, there would still be a clear symbolic line between taking your medicine and lighting up a doobie. Andrea Barthwell, who was John Walters’s deputy drug czarina for treatment and research, has been persuaded to push that line of thinking on behalf of GW.

But of course the drug warriors don’t hate marijuana because it’s bad for your lungs; they hate the fact that some people enjoy using it (and are legitimately worried that some of those people will enjoy it too much and get caught in abusing or dependent consumption patterns). Pot, unlike other illicit drugs, is already ubiquitously available, so making the increase in use due to legal availability might be slight at first. But the whole push to drug-test everyone in sight would be seriously set back if any one who likes to smoke pot can just explain away a positive cannabis test by waving a Sativex prescription.

My guess is that most of the drug warriors will take a somewhat incoherent middle position, arguing that Sativex shows by contrast how un-medical whole smoked cannabis really is, but then doing everything possible to block FDA approval or create special conditions to make it hard to actually get a Sativex prescription.

From the pro-pot side of the aisle, the calculations are even trickier. Yes, “medical marijuana” has been a great organizing issue, and a great way to make the prohibitionists look both heartless and scientifically illiterate. (That helps explain why the pro-drug side — apart from Rick Doblin’s MAPS — has denying the need for research; resolving this issue on a scientific basis would wreck it as a political issue.)

So will the pro-pot forces say “So there! Marijuana is too a medicine, and has been all along. The drug Health Canada just approved is marijuana. Thank you for making our point for us”? That’s a good point to score. But it raises a problem: if Sativex is marijuana, in an obvioulsy more pharmaceutically appropriate form, then why not push for Sativex approval in this country and give up on making natural cannabis legal for medical use? Does anyone really think that it’s preferable to take your medicine mixed with coal tars and volatile organic hydrocarbons?

Right now, it looks as if the pro-pot forces are going to take the opposite set of inconsistent positions, arguing that approval of Sativex shows that marijuana really is medicine, but that physicians ought to have the option of prescribing it, and patients the option of taking it, in the form of the crude smokable product, and of growing their own if they’re so minded.

If you guessed from the above that neither side of the drug-policy debate actually gives a rat’s ass about sick people, you’re a remarkably good guesser.

Footnote: It used to be the case that patients could bring back from abroad drugs approved in other countries but not here. During the Rohypnol scare, that rule was changed to exclude controlled substances. So bringing back Sativex from Canada will be illegal.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com