Here is a question that might stump even the most avid trivia junkie: Members of what profession reliably fought cannabis prohibition at the landmark legislative battles of the past century? The answer, to the surprise of many, is doctors. The medical community was there to fight the Marihuana Tax Act in 1937, the Boggs Act in 1951 and the scheduling of cannabis in the Controlled Substances of Act of 1970, and this tradition continues today with the newly formed Doctors for Cannabis Regulation (DFCR). The group, founded by Philadelphia-based psychiatrist David L. Nathan, boasts prominent honorary board members such as a former U.S. Surgeon General, a former Center for Substance Abuse Treatment director, the founder of Annual Review of Psychiatry and the Harvard Mental Health Letter and the Chairman of the National Council on Alcoholism. Likewise, DFCR Treasurer and spokesperson Dr. Sunil Aggarwal famously led the effort to get the American Medical Association (AMA) to call for a review of the Schedule I status of cannabis, the first such AMA statement since the 1930s. Dr. Aggarwal spoke with PRØHBTD about the organization, prohibition and medical perspectives on cannabis.
How has the process been for bringing doctors on board?
It's exciting. We let the doctors know our principles and ask, “Do you support this?” You just get overwhelming support in corners that hadn’t had a venue before to talk about this… a Stanford faculty member, a Brown faculty member, somebody affiliated with Harvard… people who recognize that the overall health impact of prohibition is detrimental. It impacts medical cannabis work, not to mention general health and well-being. Some of our honorary board members are extremely well-regarded in their areas, including our former Surgeon General and former Director of the Substance Abuse and Mental Health Services Administration (SAMHSA), which is the primary government organization looking at problematic substance use, prevention and treatment. Cannabis has been such a big part of that for so long that it's nice to see somebody who did that job recognize the folly of prohibition.
What is the general feeling within the medical community when it comes to cannabis? Is there negative stigma associated with doctors who embrace it?
Being a younger doc, I can tell you that I've seen a shift in the overall medical community discussions just through my training period. In my residency applications, I was very out front about my work in cannabis' health purposes, but I found a great deal of interest along the residency interview trail from rank-and-file attending physicians and faculty members. Everyone was curious and wanted to learn more. We didn’t even talk about cannabis as something that discredits you. It wasn't like that at all. I could say the same thing from speaking at national medical meetings—American Medical Association, American Psychiatric Association, some rehabilitation medicine organizations, palliative care—everybody wants to talk about it.
Then spilling over into questions about legal ramifications and prohibition, surveys were done by the likes of Medscape, which is a solid, highly regarded medical publication. According to their survey, most physicians believe it should be legal for medical purposes, and 60 percent of doctors who tried marijuana said it should be totally legal. That distinction right there, use or no use, is interesting, and it suggests that resistance [to legal cannabis] might be generational. It also demonstrates how dependent people are on what they hear rather than what they know firsthand. That's probably true for the general population as well.
The Medscape survey noted that 82 percent of oncologists supported legal medical cannabis, more so than any other medical field. You work in palliative care. Why might doctors dealing with serious conditions like cancer be more bullish on medical cannabis?
You got it exactly right. Oncology has been one of the first medical groups, specialties, to strongly support cannabis for medical purposes. That goes back to the '70s. The first state programs—before the medical marijuana laws in California and beyond—were cancer-based treatment programs in places like Michigan, New York and even Tennessee. It was a widespread phenomenon. Many major cancer centers, Sloan Kettering and the like, participated in those programs, and it was a time when extremely emetogenic cancer treatments causing nausea and vomiting were being developed. The only chance a patient had to take this was if they could tolerate the symptoms. At that time, there were very few quality anti-nausea medicines. Doctors got it right away that people needed cannabis.
There was another survey of Harvard oncologists in the '90s that Rick Doblin and Mark Kleiman did that showed similarly strong support. It was handed down through training from the '70s going on into the '90s, so they were early adopters. Today, even though we have other treatments for those symptoms, oncologists basically don't have a lot of time. Patients are facing serious, and in some cases, terminal illnesses, and the doctors recognize that if something helps, that's what they’re going to do. It's just a strong ethic of supporting cancer patients. Palliative care... that ethic has similarly spilled over. In fact, the medical cannabis movement, you could say, was a palliative movement.
A state-led Colorado study looked at the impact of cannabis legalization. The findings were mostly positive with teen use and drugged and drunk driving down. The only negative finding was an increase in cannabis-related medical emergencies. My guess is that the increase stemmed from people who ate too many edibles without a proper understanding of how they work. As a doctor, if somebody does eat too many edibles or does too big a dab, how can they address the anxieties and paranoia that might result?
First, let me address the Colorado data on medical-related cannabis admissions and visits. That data includes all possible places where cannabis might have been referenced in an emergency visit of any kind. It might just be, "I don't know what happened to me today, but here are the things that I did in the last couple of days." It shows up in the medical record that way. Not all of those emergencies are directly related to cannabis intake. You can look at the actual metric they used there, which is a common metric used nationally for emergency room mentions called the Drug Abuse Warning Network, or DAWN data. This study looks just like that.
Some of the increase probably stems from people talking about cannabis more openly because nobody is facing the loss of their freedom and rights because they admit to it. There are still ongoing issues with some employment discrimination and people in federal programs that don't recognize state laws, but by and large, it's been an opening of the conversation. Patients are now more free to discuss cannabis with their doctors, and doctors are more free to write it in the medical record.
Yes, there are people who overused cannabis and became worried, anxious and panicked. Speaking from my own experience and not as part of Doctors For Cannabis Regulation, I can tell you there's a whole lot of literature that suggests certain compounds can blunt the psychological effects of THC overuse. Those are things like black pepper, lime juice, pine oil, things that have a high terpene content and can be quickly ingested or inhaled. Doctor Ethan Russo, one of the world's experts on cannabis and cannabinoid medicine, covered some of this in articles like “Taming THC.” Those things can blunt the effect and free up some of those receptors. You can avoid a trip to the emergency room if you try to eat some black peppers, or black peppercorns.
Also, Val Curran at University College London has done some amazing work on how CBD-rich cannabis makes people less prone to problems with cannabis intoxication, including panic, anxiety and temporary psychosis. All of those things can be blunted if you inhale CBD-rich cannabis. These are different pharmacological tricks and tools that can be used to help people, just like, if you drink too much alcohol, you start drinking water or eating food or doing things that reduce the blood-alcohol level. These are some things that can potentially reduce the cannabinoid effect. There's also reassurance and home environment and making sure people know that whatever effects might be occurring, they are transient and self-limited. I think education is needed.
In the cannabis community there's this belief, whether true or not, that Big Pharma wants to squash cannabis because it might take away from their high-priced medications. Is that a reality you see in the medical world?
I see much more of a pharmaceuticalization happening around cannabis as medicine. It’s more like a monopolization or oligopolization of cannabis production for use in therapeutic purposes in which people say, "I want to be the only legitimate sole supplier of cannabis-based products for patients and the public." Because of the way drug development and profit-driven medicine is done, pharmaceutical companies are certainly concerned about sufficient return on investment when millions of dollars are poured into R&D. They want to make sure, when they put out a product, that it has a sufficiently high price point and availability to make a return on investment. Competition from local production and local cannabis systems can jeopardize that price point and that market penetration.
Those are some of the very real issues these companies have raised with the government, saying that their data shouldn't be used to change the view of crude cannabis, even though their products are made directly from it and people can make the exact same thing or a similar version. Those problems are inherent in the structure of profit-driven medicine, and we do need to be wary of that.
I'm not opposed to the pharmaceuticalization of cannabis and cannabis products, but that should not be used to impede access to the organic botanical, which is a traditional plant medicine with special protections based on that under international law. This is a plant that can exist both in integrative, traditional spaces and highly concentrated or pharmaceutical preparations. We'll do well to have both rather than either/or.
What does common sense regulation look like from a medical perspective?
We haven't hammered it down to the fine details. We all agree on preventative education for minors, industry regulation—very general but common sense—some form of government oversight in production, testing, regulating, distribution and sale. That's the general framework. Then recognizing taxation as part of that framework. Yes, we should generate taxes and then use those taxes to fund research, education, substance abuse treatment and give back to the communities that lost a lot of resources due to the cost of the Drug War and enforcing prohibition. All of that, for us, is common sense.
David Jenison (firstname.lastname@example.org) is Editor-in-Chief at PRØHBTD.