Medical marijuana should never be smoked

Arizona’s “medical marijuana” law passed in November 2010 by just over 4000 votes, 0.2% of all votes cast. I opposed it because it’s not really about medical marijuana, it’s designed so almost all the marijuana goes to recreational users. Had it been an honest medical marijuana law that gave most of the marijuana to genuinely ill people who would be helped by it, I never would have opposed it. There are real instances in which cannabinoids can provide relief of symptoms. Now that it has passed, we should make sure the law provides medical marijuana, not recreational marijuana.

First of all, marijuana for medical use should never be dispensed in a form that can be smoked. Marijuana can be made into capsules or suppositories or cooked into food, but marijuana smoke contains dozens of carcinogens. Preliminary research shows that smoking marijuana can increase the risk for respiratory problems and several types of cancer–lung, head and neck, testicular and bladder. This post reviews much of the research. The medical profession and others in public health have made a huge effort for several decades to eliminate the smoking of tobacco because it’s such a serious health hazard, and doctors should not recommend any substance to be smoked.

Following the adage, “First, do no harm,” doctors should always prescribe medications by the least harmful route of administration. And, in fact, we always try to give medications orally. For people whose illness makes it hard to take a pill or to keep one down, we have skin patches and suppositories. The last resort is injecting medicine. But there is no precedent for a medication that is smoked. To my knowledge, there is no medicine prescribed today that is smoked,  and for good reason. Smoking causes cancer and lung damage. And there is no need for a medication that is smoked; there is nothing that smoking accomplishes from a medical point of view that can’t be accomplished by safer routes of administration.  Arizona, and other states with medical marijuana laws, should forbid the dispensing of medical marijuana in any form that can be easily smoked.

Here’s some of the research on problems caused by smoking:

Research has shown that marijuana smokers have several respiratory tract changes, including lesions that are considered pre-cancerous. So far there is no evidence ofemphysema, but smoking marijuana does cause problems with airflow obstruction.

There are a small number of studies of cancer in marijuana smokers, some positive, some negative.   Negative studies are quite common in research, and all they mean is this particular study did not find this particular result. Negative studies are not proof unless it happens repeatedly and there are no positive studies. However, many pro-marijuana websites and media outlets have taken a single negative study and claimed marijuana does not cause cancer. There are also articles designed to look scientific that make this claim.  This is an incorrect reading of the research.

Two studies did show no increase in cancer in marijuana users, but both studies have been criticized for bias. One large study (Tashkin 2006) of 1200 people with head, neck and lung cancer showed no increase in cancer in marijuana smokers. Tashkin was the same researcher who had previously found that marijuana caused pre-cancerous changes in the respiratory tract, so he was surprised to find no increased cancer risk.  That large study has been criticized for selection bias—marijuana users in the control group were more likely to also smoke cigarette than the marijuana users in the group with cancer. The authors admitted selection bias possibly explained their negative findings.

One other study published in the American Journal of Public Health in 1997 (Sidney et al) that found marijuana smokers had no increase in cancer has been criticized for using subjects who were too young, so cancers would not have had time to develop.

There are several research studies showing increased cancer rates in marijuana smokers.

New Zealand study published in the European Respiratory Journal in 2008 looked at 79 patients with lung cancer and found the risk of lung cancer increased by 8 percent for every joint-year (averaging one joint daily for one year) and 7 percent for every pack-year (averaging one pack of cigarettes daily for one year), leading them to conclude that smoking marijuana posed the same lung cancer risk as smoking cigarettes.

Three North African case studies showed a very strong link between marijuana smoking and lung cancer, but none of these studies controlled for tobacco use, so these results are questionable.

A 2009 study done at the Fred Hutchinson Cancer Research Center in Seattle and published in the journal Cancer found that men who smoked marijuana once a week had twice the risk of testicular cancer when compared to men who never used marijuana, and marijuana was most strongly linked to nonseminoma, the most aggressive form of testicular cancer.

Research published in the journal Urology in 2006 showed increased rates of bladder cancer in marijuana smokers. They also found that marijuana-smoking patients were younger at the time of diagnosis than most patients with bladder cancer. Cigarette smoking is a major risk factor for bladder cancer, but the researchers concluded that smoking marijuana may be as bad or worse than cigarette smoking as
a risk factor for bladder cancer.

In 1999, a study published in the journal Cancer Epidemiology found that squamous cell carcinoma of the head and neck increased with marijuana use and there was a strong dose-response curve, the heavier marijuana users had higher rates of cancer. However, in 2004, a study published in Cancer Research found no association between marijuana user and squamous cell carcinoma.

This is not a complete list of studies, and there aren’t many. So it is not enough to draw definitive conclusions on marijuana and cancer. However, the evidence that marijuana smoking is linked to cancer is far more substantial than the research supporting marijuana as treatment for many of the disorders listed in Arizona’s new medical marijuana law.  Also, remember, it took decades of heavy tobacco use by large swaths of the population before we had a definitive link between tobacco smoking and cancer. Meanwhile, cigarette smoking killed Franklin Roosevelt, Humphrey Bogart, Edward R. Murrow, and tens of thousands more. The rule in the field of medicine is when in doubt, err on the side of caution. Caution says if preliminary evidence shows that marijuana smoking probably causes cancer, treat it as if it definitely does.

On several pro-marijuana websites I found the claim that there is no direct evidencelinking marijuana smoking to lung cancer in humans. That is exactly what the tobacco industry said for decades after the first studies came out linking cigarette smoking with lung cancer. What they said was technically true; until recently we did not know for certain the exact mechanism by which smoking caused cancer. However, the statistical evidence was overwhelming, so the tobacco industry was being completely disingenuous and so are the pro-marijuana groups who say marijuana doesn’t cause cancer. Anyone who claims that marijuana does not cause cancer is ignoring the research.

Also, in November 2010 an article printed in the European Journal of Immunologydescribed a possible mechanism by which smoking marijuana causes cancer and the research supporting this possible mechanism. If further studies support these findings, then we will have direct evidence linking marijuana smoking to cancer in humans.

Anyone who goes on the internet will find the pro-marijuana groups misrepresenting research. What they almost always do is take one study or one bit of information and run with it as if that were the whole story. That’s how Arizona ended up with a law that says marijuana is good for glaucoma even though the Glaucoma Foundation warns patientsnot to use marijuana because it could make their symptoms worse.

The American Cancer Society points out on its website that it’s hard to study marijuana and cancer because so many marijuana users also smoke cigarettes and because it’s hard to study illegal drugs. British cancer researchers noticed the same problem.

However, one part of the research is very clear. We know for certain that marijuana smoke contains many of the same carcinogens as tobacco smoke, produces more tar than tobacco, and that the way people smoke marijuana (down to the roach, unfiltered, inhaling deeply, holding it in) delivers more tar to the lungs than the way people smoke tobacco.

California’s Office of Environmental Health Hazard Assessment ruled in 2009 thatmarijuana smoke is carcinogenic. They are not calling the marijuana plant a carcinogen, just the smoke. That seems right; the research shows a link between smoking marijuana and several types of cancer also commonly caused by smoking tobacco. There is no evidence that ingesting marijuana by other methods causes cancer.

Smoking marijuana is also linked to respiratory problems. Research shows that marijuana smokers have decreased respiratory function, increased airflow obstruction, and fewer of the anti-oxidants that protect against cancer and heart disease.

In summary, smoking marijuana has been implicated in several health problems including cancer. Not definitively, but enough evidence to make it likely. So no doctor should be recommending marijuana in a form that can be smoked. And states with medical marijuana laws, including Arizona, should not allow such a potentially dangerous route of administration.

Marijuana can be mixed into food, formed into a suppository, or cooked in vegetable oil or butter and put into a capsule. Dispensaries should only be allowed to dispense marijuana in these forms, and they should not be allowed to sell marijuana in a form that can be smoked.

Marijuana users have responded to the harm of smoking by developing vaporizers so they can continue to inhale cannabinoids without the dangers of smoking.  However, thereason for vaporizing marijuana is still to get a quick high, just like smoking it. It still offers no medical advantage over taking cannabis orally or rectally, and it allows marijuana to be dispensed in the same form that can be smoked, allowing diversion. Besides, the vaporized product has not, to my knowledge, been tested for carcinogens.

So I strongly suggest the following addition to Arizona Department of Health regulation R9-17-311, and I recommend similar laws for every state with a medical marijuana law:

7. Marijuana may not be dispensed in its raw form or in any form that can easily be used by smoking it. Marijuana should only be dispensed in forms that can be taken orally, such as in foods or mixed with oil or butter and made into capsules, or rectally, as in suppositories. The dispensary will keep records listing the form in which the marijuana is dispensed.  Marijuana for medical use cannot be transported in its raw form. It must be turned into a dispensable form within 100 feet of the place where it is grown.

 

All marijuana dispensaries must post a warning that can be easily seen by anyone purchasing medical marijuana. The warning states: “Marijuana smoke contains known carcinogens and has been determined to be carcinogenic by ADHS.  Medical marijuana can only be dispensed in forms that are taken orally or rectally. Smoking marijuana obtained for medical use is considered illegal diversion and can be prosecuted. Possessing raw marijuana and smoking marijuana are still illegal under Arizona law.”

The rule against transporting marijuana in its raw form will also help law enforcement because, in other states with medical marijuana laws, it is a common practice for drug dealers to get marijuana cards so they can claim the marijuana they are carrying around is for medical use.

The known carcinogen statement is taken from California’s Office of Environmental Health Hazard Assessment.

 

The marijuana bandwagon is a bit exaggerated

Plus, two stories we’re not hearing

Imperial Beach, Calif: Liberal, Democratic, and opposed to marijuana

Imperial Beach, Calif: Liberal, Democratic, and opposed to marijuana

This post contains an op-ed written by Carolyn Short, and it highlights two things that rarely make it into the national news. One is the backlash against “medical” marijuana laws in some very liberal states. In California, individual cities regularly vote to ban marijuana dispensaries. Oregon voters also rejected dispensaries, but their state legislature, influenced by the marijuana lobby, created them anyway.

The other point is how vastly the pro-marijuana forces outspend their opponents. The dissatisfaction with “medical” marijuana in the state where it was born should be a national story. But money is always a good story, especially when a cause that presents itself as inevitable can only win when it has a huge spending advantage.

The image of a country embracing legalization is misleading. What looks like a steady march toward legalization is a combination of a well-organized marijuana lobby, an unfunded opposition and a media that tends to favor one side.

Other than the few percent who care about this issue and nothing else, public support for marijuana is a mile wide and an inch thick. There’s a reason for this: the public isn’t hearing both sides of the debate. So they’re not really convinced. They’re just feeling, “Well, I guess it’s okay.” The pro-marijuana arguments are not that strong; they are simply going unanswered. Not totally, of course, but the average news consumer is hearing mostly one side. Public opinion on marijuana could easily change if the opposition viewpoints were covered equally.

So here’s the op-ed:

Carolyn Short, attorney & anti-drug activist

Carolyn Short, attorney & anti-drug activist

Legalization is far from inevitable

By Carolyn Short

Since the 2012 election, national news coverage about marijuana has focused almost solely on Colorado and Washington, creating the impression the country is moving toward legalization. But anti-marijuana forces actually won most of the contests in 2012 and in 2010, and lost only when outspent by large margins.

In the last two elections, voters in four states considered initiatives to legalize pot. This year, Washington and Colorado voted “yes,” while Oregon voted “no.” Two years ago, California voted “no.”

In those same two elections, another four states voted on medical marijuana. The initiative in Massachusetts passed with 63 percent of the vote, while Arizona’s squeaked by with 50.1 percent. In Arkansas and South Dakota, the ballot measures were defeated.

So when voters considered legalization and medical marijuana, each side won half the contests. But there were also ballot measures to allow marijuana dispensaries in states where medical use was already legal, and the marijuana lobby lost those every time.

In 2012, five California cities voted on initiatives that would have allowed dispensaries; all five voted it down. In 2010, Oregon voters rejected a similar initiative. These two liberal West Coast states where voters saw the real-world effect of medical marijuana up close are apparently having second thoughts.

Screen Shot 2013-06-26 at 10.45.25 PMThat’s how the voting went, but money really explains how tenuous the pro-marijuana victories are.   The information about spending was obtained from two websites: Follow the money.org and Open Secrets.org. 

In Colorado, the marijuana lobby spent $3.5 million while opponents of legalization brought in only $700,000. In Washington, it was even more lopsided. The marijuana lobby spent $6 million, while opponents had just $16,000. That’s 375 to 1. It’s not easy to get out your message against those odds.

Money also mattered in the two states that passed medical marijuana laws. In Arizona, opponents were outspent $800,000 to $25,000. In Massachusetts, it was $1 million against a mere $600.

This financial advantage makes a big difference. First, it can cost several hundred thousand dollars to get an initiative on the ballot. So if it passes, and the public later decides they were misled and so-called “medical” pot goes mostly to drug abuse, it can be prohibitively expensive to get the issue back to the voters.

Second, marijuana advocates depend on misleading the public to win elections. Opponents can defeat these initiatives only if they can expose the deception.

In Colorado, 3 percent get their pot for cancer; 94 percent claim pain.

In Colorado, 3 percent get their pot for cancer; 94 percent for pain.

For example, to pass medical marijuana laws, the marijuana lobby runs ads designed to give the impression that the law is only for serious illnesses like cancer. That’s what happened in Arizona. And without money, opponents couldn’t tell voters that in most medical marijuana states, over 90 percent of the pot goes to people who claim pain, not serious illness

The marijuana lobby told voters in Washington that regulating marijuana would keep it out of the hands of teenagers. However, states with medical marijuana laws have much higher rates of teenage marijuana use, even when it’s strictly regulated. Voters never heard that message.

Stop Arresting Pts.orgIn Arizona, the Marijuana Policy Project called its campaign “Stop Arresting Patients.”  They wanted us to picture grannies in prison, doing their knitting surrounded by tattooed gang-bangers. But the marijuana lobby was never able to name a single genuine patient in jail or prison on a simple possession charge. That’s because there aren’t any; no one is arresting genuine medical patients. The whole premise of their campaign was false, but opponents couldn’t get that message out.

Pro-marijuana initiatives have succeeded so far only because proponents can vastly outspend the opposition. And despite that advantage, they still lost most of the recent votes. In the California and Oregon legalization battles, pro-marijuana forces outspent opponents by more than ten to one, and were still defeated. When opponents have the resources to fight back, they win.

So don’t assume that Americans are ready to legalize pot. If that were true, the marijuana lobby wouldn’t be spending millions trying to convince us.

This is an edited version of an op-ed that appeared in the Arizona Capitol Times on February 25, 2013.

Treatment works best combined with the threat of punishment

What neither the far right nor the far left understand

Originally posted on November 24, 2012

 

Good article in today’s Washington Post about a drug-addicted prostitute who couldn’t stay clean, and died on the streets. We can help these people, but first we have to tell liberals and conservatives they’re both wrong.

Liberals say addiction is a disease, which is true. But then they say stop punishing them and just give them treatment. What happens? Most addicts and alcoholics say no; that is, when they are being polite. The Amy Winehouse lineThey tried to make me go to rehab but I said ‘ no, no, no’  is every addict’s first response to help. So just offering treatment does no good.

Hard-line conservatives want to lock ‘em all up. For some addicts, prison is the best thing; it’s the only time they stay clean. But it’s expensive, and untreated, they get released and wind up in trouble again. Prisons are full of repeat offenders who never get treatment.

The answer is coerced treatment. Use the threat of punishment to keep them in treatment. And the moment they stray, throw them back in jail. We’re already doing this across the country with drug courts, HOPE in Hawaii, and dependency court for addicts who run afoul of Child Protective Services. One of my patients told me the best thing that ever happened to her was CPS taking her daughter away, because it forced her to get clean and stay clean to get her kid back.

Also, most people in jail and prison are substance abusers, and despite what the marijuana lobby wants us to believe, they are almost all there for a real crime they committed while under the influence. So why don’t we turn our jails and prisons in huge treatment programs. We’re already covering room and board. Just add some treatment staff.

Why don’t we do this? Politics. Politics and enabling. Enablers are well-meaning people who help an addict keep using. In the WAshington Post story, the chaplain who convinced the judge to send Amy to treatment instead of prison was enabling. Enablers on the left tend to believe that giving people the help and support they need will work. It doesn’t. Their cry is treatment, not punishment, but treatment alone does not work.

The left is now egged on by the marijuana lobby, a collection of politically savvy groups that represent drug users. Like millions of addicts and alcoholics everywhere, they hate treatment. They just want to get high. It seems crazy to let drug addicts and abusers rewrite the nation’s drug laws, but they now have the left on their side.

And the marijuana lobby hates coercion. Two of the four points of the Marijuana Policy Project’s mission statement say they want only “non-punitive, non-coercive” policies. They want us to believe they will get treatment when they are ready. Anyone who works in the addiction treatment field can tell you they are never ready until something really painful happens, like getting busted or fired. So the left won’t help us get to a sane drug policy.

On the far right, we hear lock ‘em up. But no money for treatment; that’s just coddling them. But that’s not just inhumane, it’s expensive. Society saves at least $12 in criminal justice costs, health care costs and lost economic activity for every $1 spent on treatment.   However, that’s a bit too nuanced for the far right.

We’re caught between the two tea parties. The tea party on the right refuses to pay for prevention and the tea party on the left (the ones who smoke their tea) just wants to abolish drug laws so they can get high in peace.

Centrist politicians are the ones who usually understand coerced treatment, using tough laws and the threat of punishment to get people clean and sober and keep them that way. Unfortunately, in today’s hyper-partisan climate, centrist politicians are practically extinct.

Why Democrats should steer clear of the marijuana lobby

Many Democrats have become closely allied with the pro-marijuana movement. In Colorado, where voters approved a constitutional amendment legalizing pot, the Democratic Party had already put support for legalization in their platform. In Montana, where Republicans tried to overturn the state’s medical marijuana law, Democrats have now put support for that law in their party platform.

And last May, 71 percent of congressional Democrats voted to eliminate funding used by the Obama Justice Department to raid large-scale medical marijuana operations they believed were providing the drug to recreational users. Only twelve percent of Republicans joined them so the measure failed.

Democrats should think twice before becoming the party of pot. I’m a lifelong, partisan Democrat, but I’ve also spent 25 years as a doctor treating drug abusers, and I know their games. They’re excellent con artists, and there’s good evidence that the marijuana movement has been conning us.

Medical marijuana laws were sold to over a dozen states with promises that they’re only for serious illnesses like cancer. However, once these laws passed, almost all the marijuana patients claimed pain, which is easy to fake and impossible to disprove. InOregon and Colorado, 94 percent of marijuana cardholders get their pot for pain. InArizona, it’s 90 percent. Serious illnesses barely register.

Also, research shows that pain patients are mostly female, whereas a recent National Survey on Drug Use and Health found that adult cannabis abusers were 74 percent male. So which one do marijuana patients resemble?

Only two states release data on gender. In Arizona, 73 percent of marijuana cardholders are male. In Colorado, it’s 68 percent. The best explanation for these skewed numbers is that most medical marijuana recipients are drug abusers who are either faking or exaggerating their problems just to get high.

No one should support this subterfuge, but especially not Democrats. It turns us into hypocrites. We fumed when President George W. Bush proposed gutting the Clean Air Act and called it the Clear Skies Initiative. That’s no more dishonest than calling pot “medical” when it almost all goes to recreational use.

Marijuana activists use phony science just like global warming deniers. For years they claimed pot was good for glaucoma, and never apologized when research found pot can actually make glaucoma worse. They still insist weed isn’t addictive despite everyaddiction medicine society saying it is. They’ve even produced their own flawed scientific studies supposedly proving that medical marijuana laws don’t increase teen use, when almost all the evidence says just the opposite. How can we criticize Republicans for disregarding science and making up facts if people on our side do the same?

Democrats know we need government regulation to protect the public from unhealthy products. However, the marijuana lobby wants us to distrust the FDA and DEA. The whole purpose of medical marijuana laws is to evade the regulatory power of these agencies. We’re the political party that got the FDA to regulate tobacco; from which side of our mouth would we now say the FDA can’t regulate pot?

Marijuana legalization also runs counter to the Democratic commitment to education as the best way to keep our economy strong. States with medical marijuana laws have always had much higher rates of teenage marijuana use, but now the effect is nationwide. Since 2008, teen use in America has increased 40 percent, and heavy teen use (at least 20 times per month) is up 80 percent. The drive to legalize pot is mostly to blame. It sends the message that weed is harmless, even though research clearly shows that marijuana interferes with learning. Teens who smoke pot regularly do worse in school, are twice as likely to drop out, and earn less as adults. Research even shows that teenage marijuana use lowers IQ and the effect appears to be permanent. No other drug, not even alcohol, affects academic performance like marijuana. How can we call education crucial for a competitive America, and then support laws that will blunt the next generation’s ability to compete?

Legalization would even undermine a successful Democratic program. Drug courts werestarted in 1989 under Dade County State Attorney Janet Reno and written into the 1994 Crime Bill by Senate Judiciary Chairman Joe Biden. President Clinton fought for that bill and it became law despite three-fourths of Republicans voting against it.

Drug courts use coercion, the threat of jail, to keep addicts in treatment. And it works. By combining tough drug laws with coerced treatment, drug courts have turned thousands of criminal addicts into clean and sober law-abiding citizens.

However, the pro-legalization Marijuana Policy Project opposes coerced treatment. That’s not surprising. They represent drug users, who just want to be left alone to get high. But if we side with them, we’re undercutting the Democratic answer to substance abuse.

Groups that want to legalize pot have coalesced into a powerful marijuana lobby, intent on pulling the nation in their direction. In effect, we now have two tea parties in this country. On the left they smoke their tea; on the right they throw it in the Boston harbor. Both tea parties distrust government, disregard science, and make selfish demands that would undermine the public good. What’s different, and what Democrats can be proud of, is that while Republicans have completely caved to their tea party, several Democrats, including the President, are standing up to ours. And protecting the long-held principles of the Democratic Party. (Note: at the time I wrote this, they were.)

A shorter version of this post appeared as an op-ed in the New York Times on November 7, 2012.