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Thinking Clearly About Medical Marijuana

by Stephen Propatier

February 6, 2015

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Donate Medical cannabis (aka medical marijuana)is currently being usedas a medical treatment. Ithas many concerning similarities to many types of alternative medicine. Unlike most alternative medicine good research does show promise as a reliablemedical treatment. This is afascinating dichotomy to me as a medical professional and the use of medical cannabis is aninteresting thought exercise for the critical thinker. There is good evidence for some uses and myriad of poorly supported treatment modalities. Advocates both for and against demonstrate a disdain of scientific exploration. As a skeptic I think thisis fertile ground for flexing our critical-thinking muscles.

Recently, David Noonan atScientific Americanwrote a relatively uncritical essay about medical marijuana, called "How Medical Marijuana's Chemicals May Protect Cells."The title is accurate but the operative word for this researchismay,yet thatis not how he presents the findings. Like most of the positive puff pieces on this drug it lacks a sound scientific critique of the research. Additionally, heexpoundsmedical marijuana'sinnumerable purported treatments and benefits. He fails to be critical of theresearch and instead he substitutesa lot of generalized marijuana promotion"a common failing forboth sides of the medical cannabis issue.Both the opponents and the advocates rush to judgment and both sides tend to cling to individual research rather than an overall assessment. The liberal application of isolated researchand ideologic rhetoric produces a muddy picture. As a skeptic it is always good to take a critical look at controversial medical topics even if you lack the training and the expertise to analyse all the details. Good critical thinking can help you parse the facts from the rhetoric.

Medical marijuana is not likehomeopathyorReiki;it has reasonable plausibility and reasonable evidence to back up some claims. Like those two useless treatments thereare reams of in-vitro, unreplicated, or poorly structured research. There is, in my opinion, a "quick-to-judge factor" that surrounds interpretation of all marijuanaresearch by both the pro and concamps. Overall, the research surrounding cannabis is interesting: some promising and some so obviously biased it should be thrown out.Buta tiny fraction of the research conducted on the drug has been well structured and replicated. Marijuana as a medical treatment is interesting, complicated, and promising. Let's take a close look and apply our critical thinking skills.

Medicalmarijuana andthe course it has taken on its way to being a medical treatment is to say the least, unusual. Its complicated history, as both an illegal recreational drug and multi-billion dollar criminal enterprise, has tarnished its name. Historically this has thrown upbarriers forexperimentation and research. Compounding the problems with making this a medical treatment is its advocates' disdain for the current medical system. Many in the pro-medical-marijuana grouphave a strong leaning towardsanti-medical/anti-scientific thinking. And in my opinion this is partly due to medical establishment eschewing them and partly due to purposeful blindness about the drug's shortcomings.

Medical marijuana originatedfrom folk remedies and anecdotes sharedamong recreational users. After a lot of outcrythe medical community finally added its voiceto push experimentation and research forward. Proposed applications for this drug seem to have far surpassed available research.That's always problematic for a medical treatment. Although it's true that the illegal recreational usesaved a possibly effective drug from thewastebasket,it is also true that the same recreational use has been animpediment for adopting and researching it as a drug.

Historically there was little advocacyinthe medical community due to marijuana's negativesocial connotations. There has long been almost unwavering political and moral opposition to the drug. Those opponents have likewise refused to consider evidence scientifically. They usually oppose the drug due to a social concerns: wide acceptance of an intoxicant, concerns aboutgateway drug use, or vaguely supported concerns about the consequences of regular use.There are many examples of socially accepted drugs both in medical use (opiates) and recreational use (alcohol) that have identical histories and similar shortcomings. The social and safety issues surrounding this drug aren't significantly different from those drugs.

Both advocates and opponents seem to want to championresearch that supports their position and dismiss research that doesn't. That should be a bigred flag: the safety and efficacy of a drug needs to be based onscience rather thancultural bias, research rather thansupposition.

Medical evaluationto quantify and extract usable elements from cannabis have been blunted by both sides. Proponents often advocatethat only the whole plant is beneficial, typically describing it as the so-calledentourage effect. They claim that isolated compounds are insufficient because there are supposedly undetectable elements to marijuana that cannot be quantified or measured, that the active ingredients are too synergistic, numerous, or complex to separate and use. However, there are no well-controlled studies for inhaled cannabis. This organism varies species to species and plant to plant. There is no way that you are getting a consistent product fromthe straight plant"no way that something that is so content-arbitrary then requires a very specific combination to achieve efficacy. You can't have it both ways and expect predictable, safe results. Consequently, the weak whole-plant argument has become the fall backspecial pleadingwhenever the plant or its products individually fails in research.

Opponents reject plant use because of the perception that it is a foot in the door for an intoxicant.Opponents also point out that its products don't provide any new treatment options, and we already have effective drugs that do what this drug does. Although this is a reasonablecriticism, if you look at thisobjectively you will see a paucity of direct evidence in comparative studies. The answer is that we don't really know if it is superior, equivalent, or worse than existing drugs. Individual elements have been dosed and researched, such asnabiximols in Canada andthe United Kingdom.Like most good evidence supporting medical cannabis, the nabiximols study shows modest results on relatively subjective complaints like pain. Combination drugs are being explored, but there are no solid findings yet.To manycritical thinkers this is not a strong showing. For any other drug this would be evidence far too weakto promoteone treatment overanother already proven to be effective.

Medical marijuana offersother pseudoscientificred flags. One typical of manyother uselessalternative/complementary medicine paradigms is the medicalpanacea fallacy. Like many other sham treatments, you can name amedical problem and someone will claim that cannabissupposedly treats it. The list of proposed benefits for medical marijuana is ridiculously long,and includes reported maladies such uses as:

all cancers
Asperger’s syndrome
Crohn’s disease
multiple sclerosis
post traumatic stress disorder
trigeminal neuralgia
reflex sympathetic dystrophy
bipolar disorder
attention deficit disorder
Hashimoto’s encephalopathy
Post-polio paralysis
heroin addiction
Tourette's syndrome
spastic paraplegia
irritable bowel syndrome

Yes: that list includes both cancer and hiccups. When it comes to medical treatments there are no cure-alls. Frankly, it is impossible for any drug to be a panacea. It is totally implausible that medical marijuana could treat even a tiny fraction of these diseases. Good critical thinking has repeatedly shown us that if somethingis a treatment foreverything, then it probably treats nothing. I think medical marijuana is an exception to that rule insofar as it definitely has potential medical applications. But there is no way that it treatsthat many different medical problems. Anecdotally it may work,possibly as adissociative, which is just hiding problems not treating them.

Critically the most concerning thing about medical cannabis is the push to treatment. Forcing research is difficult but you can gin public supportfor it. Yet advocates seem to have jumped over research using an obtuse backwards kind of tautology: proponents argue that the drug’s illegality is preventing research, so it must be made legal for the sake of research and the best way to achieve that is to call it a medicine, so that we can legalize it and find out if it’s an effective medicine. This basically makes the public a phaseII human trialfor medical marijuana under the banner of compassionate medical care. That is not a scientific progression for a solid medical treatment. I recognize that it ispossible that thereis an undercurrent oflegalizing recreational marijuana. Or this philosophymay be a result of previous dismissal of marijuana by the medical community. No matter the origin, promoting medical marijuana as a treatment has become almost a belief system.

If we approach this medication critically what do we know?
  1. There is evidence that medical cannabis may help with psychiatric complaints and with subjective complaints like insomnia, pain.

  2. There is a mountain of poor-quality evidence claiming support for other uses for cannabis, but without good data to back up those assertions.

  3. Both proponents and opponents lack a good scientific methodology; they propose ideological, unsupported, and implausible claims.

  4. The actual efficacy and safety of medical cannabis is very murky.

  5. Its benefit as a medical treatment is unclear.

In my opinion, widespread adoption of medical marijuana is premature. Marijuana needs to be removed from USSchedule I so that research is possible. More research is needed. It may be an effective, safe pain medication. Currently the jury is out on that. Finding out the answer to that question is only possible if both the proponents and the opponents of medical marijuana can find some common ground around scientific inquiry.

I cannot in all good conscience recommend medical cannabis except in palliative terminal cases. It just has too many unknowns. Given the evidence I am just as likely to be prescribing a big fat placebo with a dissociative element as an effective medical treatment. It needs more research... period, the end. Currently it is not a treatment"it is a guess. It needs well-controlled duplicated studies; it needs the active ingredientsand theirinteractions to be identified. We need to know what is an effective dose and what’s a toxic one. It needs all of this before you can call this a treatment. I demand that level of knowledge before I give anything to patients. You can't cut corners because you believe something is effective. You can't base success of a treatment on patient satisfaction when you are dealing with medications that have recreational uses. Getting drunk may help you deal with pain, but it won't fix anything. I won't offer my patients a bottle of Jack Daniels anymore than I will offer them a bag of cannabis. It is just not a medical treatment. I demand more of my medical treatments and so should you.

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by Stephen Propatier

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