Mind and Body

A doctor weighs in on legalizing marijuana

From a public policy perspective, alcohol and marijuana should be treated the same way

Photo by Scott Kingsley

Dr. Michael Fine, the former director of the R.I. Department of Health,. offers his views on the legalization of marijuana and the future directions of medical marijuana.

By Dr. Michael Fine
Posted 4/18/16
A family doctor and the former director of the R.I. Department of Health weighs in on the pros and cons of legalizing marijuana, at a time when the R.I. General Assembly is debating the issue.
What is the best way to change the federal classification of marijuana as a drug that will speed the kinds of research necessary to evaluate the potential benefits of its use? Is there a way to create a better database about the potency and the content of marijuana being sold and used as a medicine? As part of the legalization process undertaken in Rhode Island, is there a way to promote transparency of corporate ownership of marijuana distributors and their financing? Are there ways to target the revenue from taxation of the sale of marijuana in such a way to protect it from being sunk into the state’s general revenue fund.
The state is still in the midst of an epidemic of drug overdose deaths, the numbers of which appear to be growing, according to the latest data available from the R.I. Department of Health. The reality is that we may not know the full extent of the number of overdose deaths in 2015 until much later this fall. Is there a way for the agency to speed up that process as a public information and transparency priority?
The new statewide overdose prevention plan, which focuses in part on increasing the clinical treatments option for addiction through the use of suboxone, also called for investments in peer recovery coaching and support.
The importance of the peer recovery community cannot be underestimated in the development of a comprehensive strategy, different from a clinical approach, so that addiction is treated as a brain disorder, and recovery is possible without necessarily resorting to dependency on substitute medications to control the cravings.
Health insurance reimbursements for alternative strategies to pain management – shifting dependence away from prescription painkillers – may need a further helpful push from the R.I. General Assembly.

PROVIDENCE – First off, there is nothing medical about marijuana. Marijuana sometimes helps people who are suffering.

But the relief from suffering is not what makes a substance or a treatment medical. There are no well done, unbiased reproducible double blind cross-over studies that let clinicians know how to effectively treat a condition or disease with smoked or edible marijuana – the studies that are necessary to consider any treatment medical treatment.

Put another way, in order for any treatment to be considered medical treatment, we need to be able to tell you with reasonable accuracy and precision about the benefits of a certain dose of a substance used for a length of time, as well as about the risks of that dose over time – information that could come from the scientific studies I described.

With the exception of a few good studies on using pharmaceutically extracted active ingredients from marijuana to treat the spastic of multiple sclerosis and chronic pain due to a specific kind of nerve damage, studies which let physicians and other clinicians know how to prescribe marijuana to treat a specific problem using inhaled or edible marijuana at a certain dose over a certain time simply don’t exist. This is inadequate science on which to base medical treatment.

Marijuana is also not generally supplied in a way that allows for dosing precision; so it is hard to write an intelligent prescription except for those medications made from marijuana’s one of active ingredients, that have gone through a pharmaceutical process and are dispensed by a pharmacy.

When I authorize you to have and use smoked or edible marijuana, I have no way of knowing how much of its active ingredient you will get. All I know is that you have a condition that some people think is improved by marijuana, or a condition that is severe enough to justify compassionate use – our way of saying that you are so sick that our collective compassion dictates an exception from the law.

When I write for 250 milligrams of Amoxicillin, I know what I’m writing, and you know what you are getting. Go to the marijuana dispensary and they may be able to tell you the percentage of THC and what they think that strain is good for, but neither you nor I know if they’re right.

There are more than 60 pharmacologically active substances in cannabis, which makes smoked or eaten cannabis difficult to study and even more difficult to prescribe. While there are ongoing studies of the effects of many of these substances, such as THC or CBD, even studies that show efficacy for specific diseases and conditions will not inform prescribing of smoked or edible marijuana unless each plant is tested by a laboratory that uses rigorous quality control and is certified as doing so by expert professional organizations.

Even then, prescribing is likely to be dicey until all the cannabinoids are rigorously tested, so that a patient doesn’t get a dose of something that may be harmful to them while they are getting a certain amount of that which may have been shown to be likely beneficial.

Making you feel better
That said, marijuana very likely makes people with certain illnesses and chronic conditions feel better.

It likely helps people who are nauseated feel less nauseated. It likely helps people with chronic pain feel less pain. It likely helps people with cancer and other chronic diseases improve their appetites. And, since we have otherwise failed to effectively treat many people in pain, that gives people in pain the emotional license to seek treatments illegally. The compassionate side of us wants people who are in pain to suffer less, and thus have access to marijuana when they need it.

At the same time, there is good evidence that marijuana is harmful, at least to some of us. Between eight and 11 percent of users will become dependent – a number that is larger when people start using before age 15 or use daily, and smaller when they begin using as adults and use rarely.

Some people argue that marijuana is not addictive, because the symptoms of marijuana withdrawal are less severe than withdrawal from alcohol, heroin, or cocaine.

But there is very good evidence that a withdrawal syndrome exists, although that withdrawal syndrome is much milder than withdrawal from alcohol, heroin, methadone, or cigarettes.

There is good evidence that people who start using marijuana in adolescence suffer long- term and perhaps permanent brain damage, impacting their ability to learn.

There is a public policy interest in keeping adolescents from using marijuana, at least until they are older. Not that it’s easy to get adolescents to do anything their parents, or society, asks.

And, there is also reason to want to prevent adults from becoming dependent or getting addicted to marijuana, because the democratic process depends on their active engagement, their agency, which is what addiction removes.

Good news, bad news, worse news
The good news, if that is what we want to call it, is that we don’t have a clearly recognized marijuana overdose syndrome. People don’t usually die from overdoses of marijuana. This is what makes marijuana completely different from heroin, cocaine and prescription drugs.

The bad news is that our public policy doesn’t recognize this difference, which makes it harder for us to address the unique challenges that marijuana use represents.

The worse news is that our public policy, which fails to recognize what we actually know, makes people even more cynical about their government at a time when government needs to be bringing people together.

Is marijuana use a gateway to addiction to other drugs? Here, the evidence isn’t so clear.

On the one hand, most heroin and cocaine users used marijuana before they used cocaine. But that doesn’t mean the use of marijuana leads to heroin and cocaine use. Most heroin and cocaine users also used – and became addicted to – prescription opiates first. And cigarettes. And drove cars.

We need to be thoughtful about what we say and how we characterize causality, because we need to be accurate if our public policy is going to have any meaning.

Since the dependence on prescription opiates is more powerful, both physically and psychologically, it’s likely that opiates are a gateway to heroin.

For the 10 percent of us who are susceptible to dependence and addiction, marijuana use is perhaps a first step that would have more likely come through alcohol or prescription drugs if it hadn’t come through marijuana.

But the easy availability of marijuana in high schools may introduce people susceptible to substance use disorder at a younger age. So, very likely, marijuana is a gateway for people who would have found a gateway later on.

At the same time, it is also important to recognize that marijuana use may constrain some addiction to heroin, cocaine, and prescription drugs, as there is evidence that marijuana use reduces the likelihood that some people will abuse prescription and illicit opiates.

Some people susceptible to addiction become dependent on marijuana and don’t progress to more difficult dependencies and addictions. There is evidence showing that states with medical marijuana laws had smaller increases in drug overdose deaths once we started reining in the widespread availability of prescription opiates, a process that was associated with an increase in heroin use and drug overdose death.

When we authorized medical marijuana, both the number of people using marijuana and the number of people using and dependent on opiates increased, making us, for a time, the most drug using state in the nation. When Colorado legalized recreational marijuana, both the percentage of Coloradoans using marijuana and the percentage using illicit drugs increased.

Survey data always has to be taken with a grain of salt, but it suggests an association between marijuana use and the use of other illicit drugs in the population even though marijuana use by individuals may sometimes constrain progression to more dangerous and addictive substances.

For some people, it seems, marijuana is a first step in a dangerous direction. For others, marijuana acts like a dam. It satisfies a thirst for substance use and appears to prevent advancing to more dangerous substances. And still others, many others, appear to be able to use marijuana occasionally, with no long-lasting impacts.

More than 100,000 Rhode Islanders use marijuana regularly. This use has many known public health risks, some possible public health benefits, some personal health benefits, and many personal health risks. Many people appear to enjoy marijuana.

This widespread use contributes to a culture of drug and alcohol use, which is associated with increasing numbers of drug overdose death and increasing use of other more dangerous drugs. How can we mitigate the risks, not restrict personal freedom, improve the public’s health and create a culture that is inventive, human and successful, all at the same time?

A policy disaster for 50 years
Our public policy around marijuana has been a disaster for more than 50 years. The federal government classifies marijuana as a controlled substance just as addictive and dangerous as heroin, although there is no evidence to support that classification.

Because marijuana is easy to grow and easy to use, it is easily available illegally. Marijuana is so readily available that it makes a mockery of our attempt to arrest our way out of the marijuana problem, and our approach to marijuana gives lie to the claims we tell our kids about other – more dangerous – drugs.

From a public policy perspective, marijuana is much like alcohol, which also has medicinal uses – as a cough suppressant and short-term anxiety treatment.

Alcohol is also easy to produce locally. And, like marijuana, alcohol has been impossible to control through the law enforcement process. [Alcohol was specifically exempted from the Controlled Substance Act of 1970, the statute used to classify marijuana as dangerous and illegal].

From a public policy perspective, alcohol and marijuana should be treated the same way.

We are moderately successful at restricting access to alcohol for adolescents by combining law and social pressure. Our best hope for marijuana is to limit access for adolescents for whom there is significant and measurable potential harm, and use every means at our disposal to discourage use by anyone under 18.

It should be noted that alcohol is actually more dangerous than marijuana. It is more addictive, and its withdrawal syndrome is the most dangerous withdrawal syndrome we know of – killing as many as 10 percent of the people who go through it. Alcohol is associated with acts of personal and sexual violence in a way that marijuana is not.

Every emergency room doctor I know would much rather care for a person intoxicated with marijuana than someone drunk on alcohol.

A mixed blessing
It is also time we admit that Rhode Island’s medical marijuana law has been at best a mixed blessing. That legislation brought symptom relief to many people who needed it, which is a good thing.

But it was also associated with increased marijuana use across the state. In 2013 – before Colorado legalized marijuana – Rhode Island was the most marijuana-using state in the nation, and during the same period, we became the most drug-using state in the nation. It’s time to claim our victories, admit our failures, and change our policy, using what we have learned.

The best public policy would be for us to legalize marijuana the way we have legalized alcohol. We can’t control the supply of either marijuana or alcohol through law enforcement, the prisons, the jails, and the courts.

The best public policy is for us to calculate the cost of marijuana dependence and use in adolescents and adults, apply that cost as a tax on marijuana sales, and use the tax proceeds to pay for drug treatment programs and for programs that effectively treat pain and prevent drug use.

If we legalize we should also consider creating draconian penalties for those who sell or give marijuana to adolescents. A dealer can make $10,000 dollars in a day, so a $10,000 fine is inadequate.

We need financial penalties for selling to minors so severe that no one in their right mind [or their business and personal associates] would ever think about even talking to minors about selling them pot, which means we need penalties that would involve the sacrifice of houses, cars, and future income in Rhode Island.

While we can’t be sure those penalties will prove effective, they can’t be any more ineffective than our current failed approach. Such penalties, combined with well-funded prevention programs that create after-school and evening recreation and job programs for all our kids, might have a ghost of a chance, while our current approach can only continue to fail.

But if we legalize, we must do so in a way that carefully measures and contains use. We must use every strategy at our disposal to discourage use, to inform the public about the actual risk, and to empower parents to protect their children from use.

And. if we legalize, and still can’t reduce use among young people, or start to see addiction to other drugs getting worse, we must be ready to make access to marijuana supply more restrictive.

We have to keep our eye on the ball, and not be distracted by the profit motive of those who are involved in marijuana sales and distribution. Our kids and our culture are too valuable to put them up for sale.

As soon as we pass intelligent and safe legalization and taxation legislation, we should repeal Rhode Island’s medical marijuana legislation. It was poorly drafted and allowed more access to more product by more people than was necessary for true compassionate use. It also undermines the integrity of medicine as a profession, because it falsely labels a process medical that is not medical at all.

One small personal observation
Like many people of my generation, I smoked a little pot in high school, back when the marijuana was 10 times less potent than it is now. And I liked it. I liked the way it made me feel, and I even liked the different perspective it gave me.

But I noticed something: as much as I liked it, I could still feel the effects from getting high a week or two or even three weeks after toking up.

It made my brain logy and slow. As soon as I started medical school, I gave it up, because I didn’t want to risk any impairment in my thought process as long as I was responsible for the care and lives of others. I had lots of other things to do that were interesting – writing, reading, practicing, and learning, so I didn’t miss pot at all.

There are two lessons I learned from this experience. The first is based in science. It turns out that THC, the active ingredient in pot, is lipophilic, which means that it binds to fat cells in the body. That means that the metabolites of THC hang around in the body for as long as 60 days. To me, that means that my lingering feeling of sluggishness was a real phenomenon.

People who smoke pot regularly probably have some alteration in their cognitive ability and performance days to weeks after getting high, even if they and others around them do not notice that impairment.

The second lesson comes from the fact that I didn’t miss smoking pot because I had lots of other things I wanted to do and got pleasure from. I’m an incredibly lucky guy. I have had lots of amazing opportunities in my life – part work, part family, part community.

Some days I imagine life without those opportunities. If I didn’t have those things that give me pleasure, how would pot stack up? Without other opportunities, I might have been tempted to get high more.

Human beings often pursue the path of least resistance. If we want people to get high less, we need to think about how to better support opportunities for everyone. The more doors we open, the less likely it will be that people choose the door to getting high – a door that some people chose because it is the easiest, and sometimes the only pleasurable activity the lives that have been offered them and that they have built for themselves.

Dr. Michael Fine was director of the R.I. Department of Health 2011-2015. He is a family physician.

Comments

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Anne Armstrong

This is nonsense because every single one of the reasons cited about the alleged failings of cannabis titration, dosing, and results are extant ONLY because of the federal ban on research.

Doctors lose market share when people have enough cannabis because the people don't get sick as often, they make meaningful changes to their lifestyles, and they rely on their own inner wisdom rather than slavishly following the voice of authority.

The gig is up for this type of puffery and self - promotion.

Monday, April 18, 2016
Ted Almon

Without further editorializing on the topic, I would only point out that Dr. Fine is a well-recognized authority and expert on Public Health who has peerless credentials for both his public service and professional achievement. I have no idea who Anne Armstrong may be, but I would point out that the topic of legalization involves the prospect of eventual commercialization which many will perceive as an economic opportunity. Therefore we can expect significant misinformation on the subject, which is how I personally am inclined to perceive her comments.

Tuesday, April 19, 2016

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