Smoked marijuana is not good medicine

Larry LaBenneThe cannabis plant has a long history of medical use dating back many centuries, and extractives from the plant currently show strong potential for the treatment of a variety of medical conditions.

Smoked marijuana, however, does not meet today's criteria for use as a legitimate medicine. Decades of ongoing research have demonstrated that the risks associated with smoking marijuana far outweigh any potential medical benefits.

In spite of the established risks, the emerging legalization of smoked marijuana is resulting in its increased use for both medical and nonmedical purposes.

Along with more frequent use of this form of the drug, the incidence of adverse events is on the rise, yet the overall perception of risk is decreasing. Among the many factors that contribute to this decreased perception of risk is the campaign waged by healthcare practitioners who advocate for expanded medical use of smoked marijuana.

Healthcare practitioners, if informed of the risks, are in a key position to significantly contribute to public health by educating people on the risks of smoked marijuana, while advocating for the development of safe and effective alternative dosage forms.  

Next: The DEA position

The DEA position

The DEA publication titled "The DEA Position on Marijuana" makes a strong case for the continued classification of smoked marijuana as a schedule 1 controlled substance with no legitimate medical purpose.

The evidence-based publication cites more than 300 references to validate the arguments that the weight of scientific evidence overwhelmingly shows that marijuana is unsafe, regardless of the medical condition being treated; and that the DEA's position against smoked marijuana is not one of self-interest, but is formed by what independent scientific studies have been telling us for decades.

According to the publication, the DEA is not alone in opposing the use of smoked marijuana as a medicine. Many medical organizations, including the American Medical Association, the American Cancer Society, the National Multiple Sclerosis Society, and the American Glaucoma Society, agree that smoke is a very poor drug-delivery system, even as they and the DEA acknowledge the therapeutic potential of extractives and alternative dosage forms.

Next: The double standard

When is smoking anything okay?

It is difficult to imagine why any health professional would endorse the use of smoke as a drug-delivery system. Many of the same pharmacists who advocate for the elimination of tobacco products from pharmacies do not object to dispensing smokable marijuana.

It just does not make sense. When something is smoldering and producing smoke, most people would not dispute that inhaling the smoke would be harmful. Smoke is a product of combustion, and combustion produces carcinogenic hydrocarbons and hundreds of other known toxins, and marijuana smoke is no different.

In fact, according to a study published in 2008 by The American Chemical Society, there are significantly higher levels of ammonia, hydrogen cyanide, and aromatic amines in marijuana smoke than there are in tobacco smoke.

So why is there such a pervasive double standard when it comes to smoking medical marijuana?  

Next: Justified fun

Medicalized recreation

Perhaps the double standard has arisen because people who wish to take advantage of the law are using the concept of medical marijuana to justify their use marijuana for recreational purposes.

This assertion is not too difficult to believe. For example, in the opinion of Scott T. Imler, the co-author of California Proposition 215 (the 1996 ballot initiative that legalized medical marijuana in California), the medical marijuana program is "a joke.”

“We created Prop. 215 so patients would not have to deal with black-market profiteers," he has said. Now, however, "it has turned into a joke." He also stated, "Most of the dispensaries in California are little more than drug dealers with store fronts." And he added, "I think a lot of people have medicalized their recreational use." 

Next: In what universe?

Harmless? Really?

Many who argue that the recreational use of medical marijuana is not important base their position on the assumption that smoked marijuana is harmless. However, decades of research have clearly shown otherwise.  

Addiction. First off, contrary to popular belief, marijuana is addictive. According to the National Institute on Drug Abuse, as many as 50% of daily users become addicted and report withdrawal symptoms upon cessation of marijuana use.

AEs and the ED. Second, citing many studies published in JAMA,Archives of Internal Medicine,Respirology and elsewhere, the "DEA Position on Marijuana" points out that, in addition to its addictive potential, use of smoked marijuana is also implicated in numerous adverse health issues.

Acute health issues often result in emergency department (ED) visits. According to the Drug Abuse Warning Network (DAWN), smoked marijuana accounts for nearly half of all emergency department visits involving an illicit drug, second only to cocaine! Among the most common reasons that marijuana smokers end up in the ED are panic attacks, depersonalization, delusions, tachycardia, severe stomach pain, and intractable hyperemesis. 

Next: Just the body and the mind

Mental health. The "DEA Position on Medical Marijuana" also refers to many studies that describe chronic mental health issues resulting from use of smoked marijuana. Among the many well-documented issues are:

· The triggering or worsening of depression and anxiety disorders;

· Irreversible neuropsychological and neurocognitive deficits, especially memory loss, and impaired thinking and concentration;

· The triggering of schizophrenia and ongoing issues with paranoid delusions and hallucinations as a result of structural changes to the brain.

Physical health. Also described and referenced in the publication are many of the chronic physical health issues associated with smoked marijuana that are thought to result ultimately from the high level of tar and toxins produced by its combustion.

One of the studies cited concluded that just three marijuana cigarettes, on average, contain as much tar as an entire pack of nicotine cigarettes. In light of the level of tar and toxins a joint contains, it is no surprise that disorders involving destruction of lung tissue are among the most well-documented issues relating to physical health.

Another study concluded that bullous lung diseases occur up to 20 years earlier in marijuana smokers than they do in tobacco smokers. Pulmonary fibrosis, COPD, and precancerous lung conditions are also very well-documented consequences of smoking marijuana.

Beyond lung issues are increased risks of cancers of the bladder, reproductive organs, and head and neck, as well as heart/cardiovascular disorders.

Next: Nonsmoking casualties

Secondary targets

Unfortunately, the many adverse consequences associated with marijuana extend beyond the end user.

One example of a commonly occurring and very alarming scenario is unintentional ingestion by children. In just one study published in JAMA Pediatrics, titled "Pediatric marijuana exposures in a medical marijuana state," 1,378 patients younger than 12 years of age presented exposures to just one emergency department in the state of Colorado over a six-year period.

That is just one of many examples of how expanded access to marijuana is having a negative impact on innocent people.

Bottom line

Smoked marijuana is largely illegal because it is unsafe to use as a medication and its negative impact stretches far beyond the end user. For the protection of innocent people, it should remain illegal.

As pharmacists, who are known to be the most accessible and trusted of healthcare professionals, we have significant opportunity and responsibility to protect people by:

· Educating our patients on the facts about the established risks with using smoked marijuana as medicine;

· Applying our unique skill sets to advocate for the development of safe and effective alternative dosage forms and delivery-systems;

· Keeping smokable marijuana out of pharmacies.

The last point is most important. It is bad enough that most of us are already dispensing products on a daily basis that are only said to be safe and effective, when we know the opposite to be true.

Even worse, we often find ourselves in situations where we dispense pursuant to questionable prescriptions.

We need to get off of this slippery slope before it is too late. If smokable marijuana becomes uniformly legalized for dispensing in pharmacies, what will come next?

Let’s not find out.

Larry Labenneis staff pharmacist with Martin's Pharmacy in DuBois, Penn. Contact him at larrylabenne.rx@gmail.com.