Should Joints Be In The Medicine Cabinet?

IRA FLATOW, host:

You're listening to SCIENCE FRIDAY from NPR. I'm Ira Flatow.

Up next, as I say, medical marijuana. Fourteen states have sanctioned the use of medical marijuana for conditions ranging from multiple sclerosis, anorexia and arthritis, to migraines, hepatitis C and Alzheimer's.

In states where medical marijuana is legal, all that stands between you and smoking pot is a doctor's prescription and a visit to a medical marijuana dispensary. As scientists search for more medicinal uses for the plant, some doctors are asking if smoking marijuana is really the best way to treat some of these illnesses. Is a marijuana pill, a pill form, a better alternative? And what does the research have to say about the medicinal uses for cannabis?

That's the subject of this week's cover story in Science News. The author in that, Nathan Seppa, is here to talk about it. He is the biomedical reporter for Science News, and joins us from our NPR studios in Washington. Welcome back to SCIENCE FRIDAY, Nathan.

Mr. NATHAN SEPPA (Biomedical Reporter, Science News): Hello, Ira, nice to be back.

FLATOW: You're welcome. Also with us is Dr. Herbert Kleber. He is professor of psychiatry at Columbia University and director on substance abuse there. He joins us here in our New York studio. Welcome to SCIENCE FRIDAY.

Dr. HERBERT KLEBER (Professor of Psychiatry; Director, Division of Substance Abuse, Columbia University): A pleasure.

FLATOW: Igor Grant is a distinguished professor and executive vice president of the Department of Psychiatry at the University of California, San Diego, School of Medicine. He's also the director of the Center for Medicinal Cannabis Research at UCSD. Thank you, Dr. Grant, for joining us.

Dr. IGOR GRANT (Director, Center for Medicinal Cannabis Research, University of California, San Diego): Yes, pleasure to be with you.

FLATOW: Thank you. Mitch Earleywine is professor of psychology at the State University of New York University at Albany. He is also on the advisory board of NORML, that's the National Organization for the Reform of Marijuana Laws. He is the author of the book "Substance Abuse Treatment: The Parents' Guides to Marijuana and Understanding Marijuana." Thank you for being with us today.

Mr. MITCH EARLEYWINE (Professor, Psychology University at Albany - State University of New York): Thank you, Ira.

FLATOW: Dr. Grant, there's a marijuana pill available. There's a synthetic form of THC, but you study the effects of inhaled marijuana, the whole plant, is that correct?

Dr. GRANT: Yes, that's true.

FLATOW: And why is that?

Dr. GRANT: Well, there's been a considerable amount of, at least, anecdotal evidence that delivering cannabis through an inhalational route gets it into the body more efficiently, distributed better. This has to do really with the absorption properties of THC and other cannabinoids, which are absorbed with more difficulty from the gastrointestinal tract than some other medications.

That doesn't mean it cannot be administered by the gut, but it may be the case that giving it by mouth, we have to actually go to quite a bit higher doses than have traditionally been recommended, for Marinol, for instance.

FLATOW: Tell us what diseases marijuana has been shown to be useful for treating.

Dr. GRANT: Well, in terms of the research here at the University of California, it seems that painful peripheral neuropathy, which is a type of burning, painful, unpleasant condition that can develop as a consequence of AIDS or diabetes or some other factors, as well, that that type of pain, for which we don't have really terrific treatments, does respond to the cannabinoids.

And so it may form, you know, an additional arm in the therapeutic armamentarium here.

FLATOW: Nathan Seppa, in your cover story, you look at some other research being done with cannabis. Give us an idea of what the potential for this is in medicine.

Mr. SEPPA: Yes, I was surprised by the scientific literature out there that really doesn't see the light of day in the common press and just in conversations like this.

And it goes well beyond what we think of as ailments treated by medical marijuana, has even gone on to include beyond MS, which is now being sort of understood to be a good target, is also cancer, per se.

In other words, the fact that THC, at least in lab studies now, pretty clearly can kill cancer cells, and this is an interesting development since cannabis is already used with cancer patients, mainly for pain and appetite stimulation, that sort of thing.

FLATOW: And you say we don't hear about most of this research. Why is that?

Mr. SEPPA: Well, it gets published in legitimate journals, but they're not necessarily out there in the front lines.

FLATOW: Is it being suppressed?

Mr. SEPPA: There's no way of knowing. I do know that practically every researcher I talked to said it just was more difficult to get marijuana-related studies published because of the recreational use of the drug.

FLATOW: Now, there's also another ingredient called CBD. Can you tell us what that is?

Mr. SEPPA: CBD is a well-kept secret, and it's in some ways the alter-ego of THC, which is the best-known cannabis component. It's the thing that makes people high, and it also has all sorts of salutary medical effects.

CBD has its own pluses. It's an anti-inflammatory and anti-oxidant, and it has the curious attribute of sort of negating the psychoactive effect of THC, or at least toning it down a bit, and this to researchers is a good thing because if they're going to use this as a medicinal drug, they'd just as soon not have the side effects.

FLATOW: Dr. Kleber, if smoking marijuana is shown to help people like this, what's wrong with that? You've written that you don't think it's right.

Dr. KLEBER: There's a number of problems with it, starting with the fact that we do have a Food and Drug Administration. There is no current medication being given by the smoking route, where you have all sorts of problems about potential lung cancer, and we do have a pill, which Dr. Grant has referred to, as did Nathan, and even though Nathan is right that there is better absorption by the smoked route, the beauty of the pill is that it lasts a lot longer.

And in many of the conditions for which THC might be useful, you want a longer duration of action than you want a quick up and down of the smoked route.

Also, nothing in any of these bills says anything about potency. When John Lennon in the '70s was talking about marijuana as a harmless giggle, marijuana was about two percent.

If you go into one of the numerous California dispensaries, it can go as high as 15 percent or more. And you're talking about a very potent drug there, and there's many, many side effects. We don't need the smoked route.

FLATOW: So there's no way for a doctor to say to you, if you really want to use it, try half a joint, half a cigarette, two, three because they really don't know what your level of tolerance is.

Dr. KLEBER: They don't know what your tolerance is, and the joint you buy today may be half the potency or twice the potency of the one that you buy tomorrow.

It's interesting that the current bill that's being proposed in New York state says you can purchase two and a half ounces, but it doesn't say two and a half ounces of what, whether it's the two percent or the 15 percent or whatever. So there's no way of a doctor being able to say here's what you should do.

And many of the claims for marijuana are really anecdotal. There's not a lot of controlled studies showing that it does work, and the whole point about cannabidiol is a fascinating one. I think there are potential therapeutic agents in a cannabis plant, and for example, a drug called Sativex has now been approved in Canada and in England for treatment of the spasms of multiple sclerosis and for neuropathic pain, and it is a combination of the THC and the cannabidiol taking by the aerosol route.

FLATOW: Dr. Earleywine, what's your reaction to this?

Dr. EARLEYWINE: The bottom line is this is really unethical to deny patients the relief that they can get from this plant because of these really miniscule, minor concerns that some physicians have because they're not accustomed to this.

The smoked route is not a preferable route, and we all understand that, but the cannabis vaporizer is available now, which is a gizmo that can heat cannabis to release the cannabinoids in a fine mist without lighting the plant on fire. Nobody gets any odd irritants for the respiratory system.

A student of mine and I have just published a paper showing that this will alleviate any respiratory symptoms people get if they are smoking cannabis. People who are concerned about potency are often connected to ideas about medications that are toxic. This is not a plant that creates a toxic dose.

More people die from taking aspiring than from smoking medical cannabis. Again, it's an issue where the potency problem is partly a product of prohibition. If we had the opportunity to test these strains and market them and list their THC concentration and their cannabidiol concentration, that would be great; but right now, in an underground market, who could afford to do that?

The bottom line is we've got compelling evidence that this can help headache and pain and nausea and vomiting and loss of appetite. If we're supposed to tell people with AIDS-related wasting that they can't use cannabis because they might get a cough, or we're afraid about the dosage, that's just offensive.

FLATOW: As someone who's an adviser to normal, are you suggesting that by legalizing marijuana, we might be able to study it more out in the open?

Dr. GRANT: Absolutely. Right now, the only way to get cannabis to administer in the laboratory is to go through an incredible process in order to get approval, and then you can only get one kind from one particular place, and only then if you got DEA approval. There are literally dozens of strains out there with all kinds of novel combinations of CBD and THC that need to be studied. And we're completely in the dark about this, and we're also falling behind other countries that aren't so prohibitionistic about all this. And I really feel like all our sick and dying are really suffering as a result.

FLATOW: 1-800-989-8255. Dr. Gordon in Berkeley, hi. Welcome to SCIENCE FRIDAY.

Dr. GORDON (Caller): ...Ira, and hello to your panel. I'm a physician here near Berkeley who has issued, by now, a couple of thousand recommendations for medical marijuana. And it's been a very gratifying practice in helping people with serious medical conditions get some relief. But unlike many of my colleagues in the field, I don't think it's a panacea. I think patient selection is very important. And I'm very careful to talk about potential side effects, especially in young people.

But I wanted to remind you guys of the rimonabant experience. Rimonabant was a medicine developed in Europe and Israel for weight loss and diabetes control. And the way it worked was to block endogenous cannabinoid receptors in the human brain. And this was working very, very well for weight loss and diabetes, but there was a small problem in that people became very, very depressed, even suicidally depressed, and rimonabants had to be withdrawn from the market.

So I think the lesson there - and there was an interesting article relevant to this in JAMA not too long ago - is that maybe we need our - there is indigenous cannabinoid system. Michael Pollan has written about the co-evolution of cannabis with the human brain. And in human beings, it seems there are endogenous cannabinoids, and maybe some people are deficient in those endogenous cannabanoids, and recommending medical marijuana can be actually replacement therapy and useful for many conditions.

FLATOW: Well, let me get a reaction. Anybody want to - go ahead. We'll go through. Let me get Dr. Kleber here, first.

Dr. KLEBER: The point that more people die from aspirin than from marijuana is simply one of these misstatements. It's true that there hasn't been overdose deaths from marijuana. However, there have been many deaths related to marijuana and driving. And there have been, for example - there is very good evidence now about relationship with marijuana, especially when it's used during adolescence and early adulthood...

Dr. GORDON: Absolutely, absolutely.

Dr. KLEBER: ...and schizophrenia.

Dr. GORDON: Absolutely. And worsening anxiety and worsening executive function. It's not a totally benign substance. But, you know, I hear from patients on a daily basis about how, you know, their physicians have let them down and how marijuana has been effective for them. And in terms of young people, there is a concept of harm reduction, doctor, you know? If an 18-year-old has kind of a marginal indication from medical marijuana, I would still rather allow them access to a safe, well-lit place to buy a medicine rather than have them take their life into their hands. And maybe with each recommendation that I issue, I'm saving a life in Mexico.

FLATOW: All right, Dr. Gordon, thanks for calling.

Dr. GORDON: Okay, be well.

FLATOW: 1-800-989-8255 is our number. We're talking about medical marijuana this hour on SCIENCE FRIDAY from NPR. I'm Ira Flatow, here with Nathan Seppa, Herbert Kleber, Igor Grant and Mitch Earleywine. Dr. Grant, what's your reaction to this? Yeah, don't we have - do we have a natural reception...

Dr. GRANT: This is an area where there's a lot of heat and not enough light, I would say. I think it is important to separate out the medical aspects of marijuana and how it would be used as a medicine, if it were to be shown that it's useful in certain conditions, to separate that out from recreational use and other kinds of factors.

FLATOW: Mm-hmm.

Dr. GRANT: With respect to the smoking route, I think everyone would agree that's not a preferred route. But that doesn't mean that it cannot be done safely under certain circumstances, in my opinion.

FLATOW: Mm-hmm.

Dr. GRANT: If marijuana were regulated like other drugs, controlled substances, one could, you know, think about pharmacies actually stocking the material at specific potency levels and so forth, so as to get people away from going on the street or to (unintelligible)...

FLATOW: Do you mean...

Dr. GRANT: ...which I agree are unregulated and actually can be dangerous.

FLATOW: Even you smoked it, you could have a certain...

Dr. GRANT: Yes, absolutely. And I was going to say, our studies were actually conducted as clinical trials with marijuana cigarettes supplied to us by the federal government at specified potencies, such as potencies of 4 percent or 7 percent, whatever it was that the clinical trial required. And also, by the way, they could supply placebo marijuana cigarettes, which smelled and tasted similar, but didn't have THC in them.

So it's completely possible to do these things and regulate them. Again, I don't want to come across as suggesting that smoking marijuana should be the preferred route of treating someone, but I can also envision a circumstance where people with severe illness or even terminal illnesses may find that route of administration to be a desirable, preferable - they might not even be able to tolerate an oral form for various reasons. And so in that circumstance, I'd say, if it's properly regulated, controlled, treated like a legitimate medicine, I think we'd probably be okay.

FLATOW: Nathan, some states allow marijuana for hepatitis C or Alzheimer's. Has it been studied for those diseases?

Mr. SEPPA: To my knowledge, only preliminarily. But, you know, you have to remember something about North American marijuana, which is, for years now, it's been recreationally grown. In other words, by definition, the growers wanted to have a lot of THC and not a lot of CBD. They have no medical interest in that.

And so, you know, my question for the other doctors here is at what point does one offset, you know, the other? In other words, how much of a psychoactive effect can you put up with if you've got someone who has cancer, who has AIDS who needs this drug?

FLATOW: All right. We're going to - we'll come back and answer that question after this break. Our number: 1-800-989-8255. You can also tweet us @scifri, or join the discussion on our website at sciencefriday.com and you can check in with your own opinions. Stay with us. We'll be right back after this break.

I'm Ira Flatow. This is SCIENCE FRIDAY, from NPR.

(Soundbite of music)

FLATOW: You're listening to SCIENCE FRIDAY, from NPR. I'm Ira Flatow.

We're talking this hour about medical marijuana with my guests, Nathan Seppa of Science News. You can check out his story - cover story at sciencenews.com. Herbert Kleber at Columbia University, Igor Grant who is at the Department of Psychiatry of UC San Diego, Mitch Earleywine who is at University of Albany in New York. Our number: 1-800-989-8255.

Nathan, you were posing a question. And for our listeners who just are tuning in now, tell us about - the question you posed was about two different ingredients that are in marijuana. And what were those ingredients, and what was the gist of your question again?

Mr. SEPPA: Well, that's right. They both have medicinal qualities. THC is the better known one, and also is what makes you high. CBD, lesser known but with not only medicinal effects, but sort of an offsetting effect on THC, has been bred out of American strains and in other places just because growers tilted toward whatever became stronger, a stronger kind of pot. So the question becomes: How do you - you know, in the medical marijuana sphere - how do you distinguish and how do you try to find higher quality, balanced marijuana?

FLATOW: In other words, if it were to become legalized or if it's going to be wider used in this country where people are going to get it themselves, how can they get a better quality, medicinally, of the marijuana is what you're saying?

Dr. GRANT: Ira, this just underlines the point that the dronabinol pill cannot be effective, in part because it's pure THC and it's orally administered. Without the CBD, you're going to get markedly more negative consequences associated with magical thinking. And because it's a pill, somebody who's vomiting from chemotherapy or something like that can't swallow it. It's going to be incredibly aversive and absurd.

And this is a big opportunity for us to say here's a chance to give people the relief they need using a plant with a 4,000-year medical history. Why are we standing in their way?

FLATOW: Herb Kleber.

Dr. KLEBER: Oh, yes. Can't wait to get a few points in here. As far that 18-year-old that one of his physicians who called in talked about, you know, rather he have a joint - well, there's a good data now that heavy marijuana use during college is markedly associated with college dropout. It affects memory. Remember that great line about the '70s - maybe that's when Ira was growing up - that was: If you remember the '70s, you weren't there, you know, which is a comment on marijuana's effect on memory.

Dr. GRANT: There are actually no data to support that, and I (unintelligible)...

FLATOW: There's a lot of acid going around at that time, also.

Dr. KLEBER: Well, there is data on the college dropout. I can give you the reference later if you want.

Dr. GRANT: Of course.

Dr. KLEBER: The other points are that everyone agrees - or hopefully, most people agree - that adolescent use, especially early and heavy, is bad. And yet, the data from the University of Michigan, from their Monitoring the Future studies, which have been going on for over 30 years, indicate the best predictor of adolescent use is perceived social risk and perceived social disapproval.

And my prediction is that as we have more of these medical marijuana referendum in various states, you're going to decrease social risk. You're going to decrease perceived social disapproval, and you're going to get increased adolescent use.

Dr. GRANT: Karen O'Keefe and I have shown that every state that has a medical marijuana law has no changes in teen use.

Dr. KLEBER: Well, there are different data on that, and there's an increase, in general, in marijuana use over the past few years. And my prediction is that we're going to see, in a few years, probably within the next three to five years, as these referendum take hold, we're going to see much more in the way of adolescent use.

Dr. GRANT: So how many people would suffer while we're waiting for these data to come in because you're concerned about some teenagers?

Dr. KLEBER: I'm not concerned about some teenagers. I'm concerned about many, many teenagers. Marijuana is addicting. About 10 percent of the people who take it get addicted to it. They have trouble stopping. I have treated a number of people who cannot stop marijuana. So I'm not just worried about, quote, "a few teenagers." Right now, marijuana is the largest drug in terms of treatment seeking in the United States.

FLATOW: But he raises an interesting point and, I think, a legitimate one. There - of course, given, there are going to be kids who are - I'll take your words - who are addicted to it, but what about the other people who could legitimately benefit from the medicinal use of it?

Dr. KLEBER: Well, my question is how many of them have tried existing drugs? I'm not talking about just Marinol. And soon, I would guess we're going to have Sativex in this country, which is a combination of the THC and the cannabidiol, and it's by the aerosol route. So there are other medications for cancer, for nausea and vomiting, for example. And if you're taking cancer chemotherapy, you may be better off with a pill because it lasts longer. So if you're going to go in for chemotherapy, you take the pill beforehand. And that's going to have a six-hour duration of action as opposed to smoking the joint, which is going to last for less than an hour or two.

Mr. SEPPA: And it costs three times as much, and we're just talking about a giant problem with our medical system. It seems absurd to spend all this money for a spray that you're going to spray in your mouth when there's a plant you could grow in your backyard to do the exact same thing.

Dr. KLEBER: It's taken us generations to develop an effective Food and Drug Administration that tells us reasonably that a drug that is marketed is safe, of known efficacy, et cetera. Now you're proposing that anyone who wants to take anything and put it on the market doesn't need FDA approval. I think that's a dreadful path to go down.

FLATOW: So you're saying that everybody who takes marijuana, who grows it themselves or actually buys it from the dispensary, is breaking the law.

Dr. KLEBER: Well, it depends on the state they're in.

FLATOW: Well, I mean, it's not an approved drug in any state.

Dr. KLEBER: It's not an approved drug in any state, but there are states that permit people, like the proposed bill in New York State would permit 12 plants or two and a half ounces.

FLATOW: 1-800-989-8255. Let's go for a couple of opinions here. Let's go to Christopher in Louisville. Hi, Christopher.

CHRISTOPHER (Caller): Hi. How are you?

FLATOW: Hi there.

CHRISTOPHER: I just wanted to tell my story real quick. I actually spent six years in the military as an officer in the Navy. I'm out on disability now, 70 percent, with Crohn's disease. And just - kind of to refute real quick the college drop-out - I actually have a degree from Centre College, which Forbes just named number one liberal arts institution in the South. So I got that degree in four years despite some marijuana use there. But I have a prescription for the duodenal pill now for 15 milligrams, twice a day. To me, the pill is worthless. It doesn't counter any of the effects that I have from Crohn's disease. And it doesn't give me the desired effects that I need from the whole plant.

So in my opinion, I grow the whole the plant now at this point and, you know, I know exactly what I'm growing. I know exactly what the THC, CBD percent is. It's a nice balance for what I have for my Crohn's disease. It's all organic, grown in the sunshine. I'm able to either smoke it or vaporize it. And the beauty of that, aside from the pill, is you're actually able to titrate the dose of at that point. I'm able to use as much or as little as I need to get the effect, whether I need to kill my nausea, whether I'm having some problems with appetite and I need to be hungry. But that's what - the nice part about the whole plant and about, you know, being able to grow the plant yourself because you know exactly what you're getting. You know exactly what you're putting into your body and how it can help you.

FLATOW: All right, Christopher. Thanks for calling. Nathan, could the plant be giving - there are like 400 compounds or more in that plant, right?

Mr. SEPPA: Yes. Well, at least 60 active ones. And, you know, the caller is saying exactly what researchers have been telling me for the last two months, which is, well, the pot pills have been around for 20-plus years but they have not taken off. They're selling okay. But people are willing to smoke this stuff because they can - exactly as he said - titrate their dose. In other words, if someone, say, has pain from cancer or AIDS, they start smoking, the pain goes away, they put out the joint. And what I'm hearing from researchers is that this is entirely the reason why this movement has taken off.

FLATOW: Let's go to the phones to Bill in Wichita. Hi, Bill.

BILL: Hi, Ira. I'm a current marijuana user myself, not a medical marijuana user but a recreational user. And I just - I personally feel - although I'd realized that there are some medical benefits to marijuana and there are some people who get benefits from smoking marijuana, I just feel that the whole medical marijuana movement, excuse me, is counterproductive to legalization of creational marijuana.

FLATOW: It's counterproductive.

BILL: Yes. It kind of - it gives opponents almost exactly what they want. Many of them say already that the medical marijuana movement is just a smokescreen for recreational legalization, which I feel it is. Although I feel marijuana should be legalized for recreational use, I just feel this whole idea of medical marijuana isn't really helping us out...

FLATOW: All right.

BILL: ...as far as our recreational users go.

FLATOW: Thanks for the call. Mitch Earleywine, any reaction to that?

Prof. EARLEYWINE: I've heard this argument before. And the problem is, I can't stand by live by while the sickest of the sick are suffering. And if this is the most efficient way to get them their relief, this is the path I want to take. I'm actually optimistic that as more and more people know people who use medical cannabis and see that it is essentially an easy substance to use and not one that creates all the demonic negative consequences we've been hearing about, that suddenly we'll be laying the groundwork for real drug reform. And suddenly we'll have, you know, police no longer wasting their time trying to throw people in jail for owning something they can grow in their backyard.

Dr. KLEBER: Just like in California, where they now have a referenda on a ballot for November to legalize recreational marijuana. So the gentleman's -the caller seems to be right on, that those states that legalize the medical, sooner or later you may then have an attempt to legalize the recreational.

FLATOW: Well, knowing your age, Dr. Kleber, you mean right on in the present sense, but not in the '60s sense.

(Soundbite of laughter)

FLATOW: I just wanted to make sure that you made that reference going back to us - all not remembering the '70s. I did remember that one from that generation. 1-800-989-8255. Nathan, you know, we started this program with the idea of talking about the medical uses and the scientific frontier of marijuana. And, of course, it's impossible to escape the legal and cultural ramifications. But could it appear that as scientists get more involved in understanding what's going on in those other - 400 other compounds, it might turn into something that can't be denied?

Mr. SEPPA: Well, it could be. I mean, one of the things I've been struck by with the callers is that use on the street for medicinal purposes often spurs research happening later. In other words, if you're a scientist and you're thinking about investing, say, three or four years of your life in some compound, you better have some anecdotal stories of it having worked out there. And it's interesting that the fellow who called in about Crohn's disease was getting a positive reaction because this very disease is being studied a lot now in Britain and Germany with some derivatives of cannabis.

FLATOW: Mm-hmm. All right, gentlemen. I want to thank you all for taking time to be with us today. We've run out of time. Nathan Seppa, biomedical research reporter for Science News. You can check out his story at sciencenews.com. Herbert Kleber is professor of psychiatry at Columbia University Medical School, director of the Division of Substance Abuse there.

Igor Grant is professor and executive vice-chairman of the Department of Psychiatry at University of California, San Diego, School of Medicine. And he's also director of the Center for Medicinal Cannabis Research at UCSD. And Mitch Earleywine, a professor of psychology at the University of Albany. I'm a SUNY graduate, I should know where University of Albany is in New York. Also an adviser on the Board of NORMAL that's the National Organization for the Reform of Marijuana Laws.

And I made a mistake with Nathan. He's at sciencenews.org. Thank you, gentlemen, for taking time to be with us today.

Dr. KLEBER: Thank you.

Mr. SEPPA: Thank you.

FLATOW: It's been a pleasure.

Dr. GRANT: You're welcome.

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