In our last WeEdu installment, we talked about how cannabis helps combat the painful and uncomfortable symptoms of numerous medical conditions. We also discussed the endocannabinoid system to get a better understanding of how, exactly, cannabis acts on the body. Many medical cannabis patients agree that using cannabis tinctures, topicals, extracts, and/or smokable cannabis helps reduce unpleasant symptoms without causing significant side effects. However, if you ask most doctors across the country, they’d be reluctant to recognize cannabis as a valid medical treatment. This creates a huge rift between patients, who depend on cannabis for symptom relief, and their doctors, who dismiss its efficacy. However, it’s an issue where both sides are worth examining. While anecdotal evidence supports the use of cannabis, its role in clinical studies is a fairly recent development, and it’s been fairly limited. In many ways we still don’t completely understand this plant, and we often don’t entirely know the internal mechanisms by which it helps people.
You may be asking yourself, “Why aren’t all doctors on board with medical cannabis?” This week’s WeEdu lesson zeros in on the convergence of science, medicine, and the law. Read on to learn about the uphill battles involved in cannabis research and the “soft science” of cannabis.
The Good - How Cannabis Helps
The conversation around medical cannabis in the US really didn’t take off until the 1970s, when researchers found that the plant helped patients living with glaucoma. A man named Robert Randall had been using cannabis for his glaucoma and took the federal government to court, arguing that the FDA should permit him to use cannabis as part of their investigational new drug program. Remarkably, he won his court case, and researchers confirmed that cannabis did, in fact, help treat Randall’s glaucoma. Even more remarkably, the government began working with the University of Mississippi to grow, harvest, and distribute cannabis to a very limited number of patients with approved conditions. There are still a handful of individuals who remain enrolled in that program to this day. Despite this federally-run medical cannabis program, cannabis remains illegal at the federal level with no signs of changing soon.
From the late-1970s through the mid-1980s, cancer patients in New Mexico suffering from extreme nausea and vomiting who did not get relief from pharmaceutical drugs could apply to a statewide program that administered oral THC extracts and smokable flower to patients. Over 90% of patients reported significant improvements in their nausea and vomiting, with some patients experiencing the ability to manage all aspects of their symptoms thanks to cannabis. This later led to investigational studies on the efficacy of cannabis to treat the symptoms of HIV/AIDS.
Though much remains unknown, there are a number of symptoms that researchers can confirm are managed by cannabis. These symptoms are often recognizable to individuals who use cannabis regularly, even for recreational purposes. For example, everyone knows that cannabis gives users “the munchies,” so it makes sense that cannabis would help with indigestion and a lack of appetite. Similarly, if you smoke enough of an indica strain, you’ll wind up “in-da-couch” (as the saying goes), so of course cannabis can help with insomnia and other related sleep disorders - including PTSD for many patients.
Other uses of cannabis remain clouded in mystery. For example, many people use cannabis to help cope with issues like anxiety. And yet, anxiety itself is often brought on by excessive cannabis consumption, at least in people who are new to strong, high-quality cannabis products. How can the same symptom be cured in some people while simultaneously being flared up in others? We simply don’t know because there’s been insufficient research on the efficacy of medical cannabis. That’s where things get complicated.
The Bad - What Medical Experts Don’t Understand
Much remains unknown about the role of cannabis as medicine. Despite its clear role in treating a number of conditions, there are still many other symptoms and conditions for which cannabis hasn’t been definitively proven to be a viable treatment option, despite anecdotal evidence from patients who depend on cannabis.
There are numerous cases where cannabis has improved the health and wellbeing of patients without conclusive clinical confirmation of its efficacy. Many cases are largely based on patients reporting an improvement in their symptoms. For example, one study on patients with multiple sclerosis found no significant improvement in quantifiably measured symptoms, like frequency and intensity of muscle spasms, yet patients reported fewer spasms along with an increase in quality of life. Those patients felt less debilitated by their illness, which begs the question, Isn’t that sufficient proof?
For the medical and scientific communities, anecdotal evidence is not definitive. And with good reason! Rushing a pharmaceutical drug through clinical trials without sufficient understanding of the drug’s reactions in the body puts patients at risk. Researchers need to prove that the drug is safe and that it will be effective for a majority of patients who use that medication. Results need to be reproducible in order for the medical community to support a treatment option, which is why it takes so long for new pharmaceutical medications to enter the market after they’ve started the clinical trial period.
Medical cannabis use has been linked with a significant decrease in patient dependence on pharmaceutical drugs. And while that’s certainly good for many patients when you consider the often-dangerous side effects of many drugs, it also leads into another issue for many doctors: the fact that cannabis is often smoked. Chances are, your doctor isn’t going to be thrilled if you casually mention that you’ve started smoking anything (including tobacco), let alone that you’re smoking something as “medicine.” There’s a certain stigma around the idea of medicine that needs to be smoked, largely because when we talk about pharmaceutical medications we primarily deal with pills and liquids. You can measure out a teaspoon of cough syrup or count out two pills from a bottle, but cannabis use is so subjective that there’s no universal dosing instructions that will work for everyone. For example, taking two puffs off a vape pen may affect people in dramatically different ways. But at least vape pens have a fairly consistent cannabinoid content if you stick with the same brand; cannabis flower can have even more variance due to factors like THC content and growing conditions across different batches of cannabis. All of these issues complicate the medical community’s opinion of cannabis when it comes to its potential medicinal use. And then, of course, there are the legal hurdles.
The Ugly - How The Law Affects Research And Treatment
The main reason why we know so little about the potential role of cannabis in a clinical setting is because in the United States, it’s still federally listed as a Schedule 1 drug. That means that, at least in the eyes of the federal government, cannabis has no recognized medical use, a high potential for abuse, and a host of potential safety concerns - inconceivably, it’s listed in the same scheduling category that heroin and cocaine fall under.
Even if you were running a research facility in a US state that has legalized medical and/or recreational cannabis, you can’t simply run to the dispensary or call up a friend of a friend. If you want your work to be taken seriously and you don’t want to compromise the integrity or the legal standing of your facility, which is likely run by a university or a medical organization, you need to abide by federal laws. Failure to do so could cost you federal research grants, your job, and your reputation as a scientist or medical professional.
First, researchers must submit an application with the Food and Drug Administration (FDA) to conduct an investigational new drug study. Then they have to get authorization from the National Institute on Drug Abuse to acquire cannabis, and they’ll need to get licensing and registration through the Drug Enforcement Agency to ensure that all of the cannabis used in the study is measured and accounted for at every stage of the study. Even if the researchers have been compliant with all of these steps, the FDA maintains the right to shut down research, even after it’s already begun. There are also specific guidelines to how and where cannabis can be stored during the course of the study. This may require the installation of a special vault or safe. Some states also require an additional level of authorization - a controlled substances certificate issued by a state board of medical examiners, or a controlled substances registration status given by state-level government offices. Depending on where the clinical studies are set to take place, there may be additional burdens to bear. For example, a university or medical organization may require researchers to submit to an internal review process, even if they’ve been compliant with federal and state-level requirements.
You get the picture - it’s a lot of work and a lot of money just to request a medical cannabis study, all without any guarantee that your project will be approved. Why go through all that hassle? Many researchers ask themselves the same question.
Research, of course, isn’t the only area in which state-wide legalization and federal law have clashed. The very idea of cannabis being legal at the state level, even for medical purposes, has been rigorously contested by the federal government. The Obama Administration issued the Cole Memo in 2013 directing the Department of Justice to avoid interfering with medical cannabis patients, doctors, and dispensaries that operate in full compliance with state law. Prior to that order, federal agents frequently raided growing operations, dispensaries, and even people’s private property, even when those individuals and organizations were obeying statewide legislation governing cannabis use. The Department of Justice rolled back the protections offered by the Cole Memo in January 2018 under the direction of Attorney General Jeff Sessions, meaning technically, the DOJ could begin raids again. So even something as innocent as medical cannabis research has once again become a complicated issue as federal law continues to conflict with state laws, despite the fact that more than half of the states in the country have legalized medical cannabis to some degree.
If you’re wondering how we can solve this broken system, the answer is in the hands of lawmakers. If enough members of Congress supported rescheduling of cannabis at the federal level, there would be fewer DoJ raids in legal states and fewer obstacles for researchers. Voting is the only effective tool that citizens have in the fight to understand cannabis and unlock its possible medical applications. We already know that CBD is a proven anti-inflammatory agent that can actually slow the progression of ailments like rheumatoid arthritis. We also know that cannabis can help people struggling with cancer, HIV/AIDS, Parkinson’s disease, multiple sclerosis, and ALS/Lou Gehrig's Disease. Countless veterans depend on cannabis to cope with PTSD after returning home from combat. How many other symptoms and conditions can cannabis potentially treat? How many people’s quality of life could be improved by further research and easier access to safe, legal cannabis? Unless changes are made at the federal level, we may never know.
If you’re interested in trying medical or recreational cannabis but you’re not sure where to begin, tune into our next lesson. We’ll be discussing what to expect on your first visit to a dispensary so that you can feel empowered to make the right choices that will best meet your needs.