Medical Marijuana

81. Medical Marijuana - Law & Policy - 6-22-12

(Medical Cannabis and the Constitution's Commerce Clause) "Congress has exercised its Commerce Clause authority to categorically ban marijuana. The Supreme Court has upheld this plenary prohibition.19 In Gonzales v Raich, a divided Court held that the Commerce Clause enables Congress to prohibit the local cultivation and use of marijuana, despite more permissive regulations under California law.20 Writing for the majority, Justice Stevens found that precedent 'firmly established' Congress’ power under the Commerce Clause to regulate purely local activities that have a substantial effect on interstate commerce.21 The Raich majority held that Congress can prohibit local marijuana cultivation and use, because it was part of a 'class of activities' constituting the national black market for marijuana.22 The Court reasoned that local cultivation and use, even for limited medical purposes, affected supply and demand in the national black market, making regulation over local use 'essential' to undermining the broader underground industry nationwide.23 The majority distinguished Raich from earlier precedent that circumscribed Congress’ Commerce Clause power, finding that those earlier cases involved statutes that regulated purely non-economic activities, while this one aims to nullify a particular application of a valid statutory scheme.24"

Woods, Jordan Blair, "The Kingpin Act vs. Calfornia's Compassionate Use Act: The Dubious Battle Between State and Federal Drug Laws," University of the District of Columbia Law Review (Washington, DC: The University of the District of Columbia David A. Clarke School of Law, 2011) Volume 15, Number 1, p. 50.

82. Medical Marijuana in States Prior to Passage of California's Prop 215

Beginning in 1978, thirty-seven states enacted some form of medicinal cannabis legislation other than effective laws. These include:
Therapeutic Research Programs (state-run therapeutic research programs, not operable because of federal obstruction): Alabama, California, Georgia, Illinois, Massachusetts, Minnesota, New Jersey, New York, South Carolina, Texas.
Symbolic Prescriptions (patients allowed to possess cannabis only if obtained through prescription, not operable because the CSA bars physicians from writing prescriptions for Schedule I drugs): Arizona, California, Connecticut, District of Columbia, Iowa, New Hampshire, Tennessee, Virginia, Wisconsin.
State Rescheduling (not operable because federal scheduling supersedes state schedules): Alaska, Iowa, Montana, Tennessee, and the District of Columbia.
Non-binding Resolutions Urging Federal Rescheduling: California, Michigan, Missouri, New Hampshire, New Mexico, Rhode Island, Washington.

"Beginning in the late 1970s, a number of state governments sought to give large numbers of patients legal access to medical marijuana through federally approved research programs.

"While 26 states passed laws creating therapeutic research programs, only seven obtained all of the necessary federal permissions, received marijuana and/or THC (tetrahydrocannabinol, the primary active ingredient in marijuana) from the federal government, and distributed the substances to approved patients through approved pharmacies. Those seven states were California, Georgia, Michigan, New Mexico, New York, Tennessee, and Washington.

"Typically, patients were referred to the program by their personal physicians. These patients, who often had not responded well to conventional treatments, underwent medical and psychological screening processes. Then, the patients applied to their state patient qualification review board, which resided within the state health department. If granted permission, they would receive marijuana from approved pharmacies. Patients were required to monitor their usage and marijuana’s effects, which the state used to prepare reports for the FDA. (Interestingly, former Vice President Al Gore’s sister received medical marijuana through the Tennessee program while undergoing chemotherapy for cancer in the early 1980s.)

"These programs were designed to enable patients to use marijuana. The research was not intended to generate data that could lead to FDA approval of marijuana as a prescription medicine. For example, the protocols did not involve doubleblind assignment to research and control groups, nor did they involve the use of placebos.

"Such programs were discontinued by the mid-1980s, and the federal government has since made it more difficult for researchers to obtain marijuana for study, preferring to approve only those studies that are well-controlled clinical trials designed to yield essential scientific data."

Marijuana Policy Project, "State by State Medical Marijuana Laws 2015 with a December 2016 Supplement - How to Remove the Threat of Arrest," (Washington, DC: MPP, February 2017), p. 1, last accessed January 8, 2019.

83. US Department of Veterans Affairs, Medical Marijuana, and Pain Management

"If a Veteran obtains and uses medical marijuana in manner consistent with state law, testing positive for marijuana would not preclude the Veteran from receiving opioids for pain management in the Department of Veteran Affairs (VA) facility. The Veteran would need to inform his provider of the use of medical marijuana, and of any other non-VA prescribed medications he or she is taking to ensure that all medications, including opioids, are prescribed in a safe manner. Standard pain management agreements should draw a clear distinction between use of illegal drugs, and legal medical marijuana. However, the discretion to prescribe, or not prescribe, opioids in conjunction with medical marijuana, should be determined on clinical grounds, and thus will remain the decision of the individual health care provider. The provider will take the use of medical marijuana into account in all prescribing decisions, just as the provider would for any other medication. This is a case-by-case decision, based on the provider's judgment, and the needs of the patient."

Petzel, Robert A., Letter to Michael Krawitz from the Dept. of Veterans Affairs concerning its position on medical marijuana, (Washington, DC: Department of Veterans Affairs, Under Secretary for Health, July 6, 2010).

84. American Nurses Association Position Statement on Medical Cannabis

"'It is the shared responsibility of professional nursing organizations to speak for nurses collectively in shaping health care and to promulgate change for the improvement of health and health care' (ANA, 2015, p. 36). Therefore, the ANA strongly supports:

"#&149; Scientific review of marijuana’s status as a federal Schedule I controlled substance and relisting marijuana as a federal Schedule II controlled substance for purposes of facilitating research.

"• Development of prescribing standards that includes indications for use, specific dose, route, expected effect and possible side effects, as well as indications for stopping a medication.

"• Establishing evidence-based standards for the use of marijuana and related cannabinoids.

"• Protection from criminal or civil penalties for patients using therapeutic marijuana and related cannabinoids as permitted under state laws.

"• Exemption from criminal prosecution, civil liability, or professional sanctioning, such as loss of licensure or credentialing, for health care practitioners who discuss treatment alternatives concerning marijuana or who prescribe, dispense or administer marijuana in accordance with professional standards and state laws."

"Revised Position Statement: Therapeutic Use of Marijuana and Related Cannabinoids." American Nurses Association Board of Directors. 2016.

85. Medical Marijuana - 5-29-10

(Categories of Cannabinoid Medicines) "They [cannabinoid medicines] fall into three categories: single molecule pharmaceuticals, cannabisbased liquid extracts, and phytocannabinoid-dense botanicals–the main focus of this article (Figure 2). The first category includes US Food and Drug Administration (FDA)-approved synthetic or semisynthetic single molecule cannabinoid pharmaceuticals available by prescription. Currently, these are dronabinol, a Schedule III drug and nabilone, a Schedule II drug. Though both are also used offlabel, dronabinol, a (-)trans-[delta]9-tetrahydrocannabinol (THC) isomer found in natural cannabis, has been approved for two uses since 1985 and 1992, respectively: the treatment of nausea and vomiting associated with cancer chemotherapy in patients who have failed to respond adequately to conventional antiemetic treatments and the treatment of anorexia associated with weight loss in patients with AIDS.10,11 Nabilone, a synthetic molecule shaped similarly to THC, has also been approved since 1985 for use in the treatment of nausea and vomiting associated with cancer chemotherapy.12,13
"The second category of cannabinoid medicines being used in the United States includes a line of cannabis-based medicinal extracts developed by several companies. The industry leader is GW Pharmaceuticals, a UK-based biopharmaceutical company whose lead product is currently undergoing FDA-approved, multisite Phase IIb clinical trials for the treatment of opioid-refractory cancer pain in the United States14 and has received prior approval for Phase III clinical trials in the United States. This botanical drug extract which goes by the nonproprietary name nabiximols has already secured approval in Canada for use in the treatment of central neuropathic pain in multiple sclerosis (in 2005) and in the treatment of intractable cancer pain (in 2007).15 It is also available on a named patient basis in the United Kingdom and Catalonia,16,17 a scheme which allows a doctor to prescribe an unlicensed drug to a particular “named patient,” and has been exported to 22 countries to date.
"The third category of cannabinoid medicines currently being used in the United States includes the Schedule I medicinal plant Cannabis sativa L. itself, which, while currently unavailable for general prescription use in the United States, is in use in the context of two active controlled clinical trials,18,19 33 completed controlled clinical trials,20-52 and one on-going, yet essentially defunct, three-decade investigational clinical study.53,54"

Aggarwal, Sunil K.; Carter, Gregory T.; Sullivan, Mark D.; ZumBrunnen, Craig; Morrill, Richard; and Mayer, Jonathan D., "Medicinal use of cannabis in the United States: Historical perspectives, current trends, and future directions" Journal of Opioid Management, (Weston, Massachusettes: May/June 2009) Vol. 5:3, pp. 153-154.

86. No Association Between Medical Marijuana Dispensaries and Crime

(Dispensaries and Crime) "The cross-sectional results suggest that dispensaries are not associated with crime rates; however, current media and policy efforts have focused their attention on the place-based regulation of these dispensaries to protect the public against crime (California Police Chief’s Association, 2009; City of Los Angeles, 2010; Lopez, 2010). Based on the limited evidence presented by this study, it is unclear if place-based policies will be effective."

Kepple, Nancy J. and Freisthlere, Bridget, "Exploring the Ecological Association Between Crime and Medical Marijuana Dispensaries," Journal of Studies on Alcohol and Drugs (Piscataway, NJ: The State University of New Jersey Rutgers, July 2012) Volume 73, Issue 4, p. 529.

87. California Medical Association and Medical Cannabis

"CMA [California Medical Association] policy has acknowledged the criminalization of cannabis to be a failed public health policy (HOD 704a-09) and has recognized a public movement toward the legalization of cannabis (HOD 101a-10). Cannabis illegality has perpetuated the effective prohibition of clinical research on the properties of cannabis and has prevented the development of state and national standards governing the cultivation, manufacture, and labeling of cannabis products, similar to those governing food, tobacco and alcohol products, most of which are promulgated by federal agencies."

"Cannabis and the Regulatory Void: Background Paper and Recommendations," California Medical Association (Sacramento, CA: 2011), 11.

88. Medical Marijuana - Research - 11-9-12

“Vaporization as a ‘Smokeless’ Cannabis Delivery System”
Donald Abrams, M.D., University of California, San Francisco
(vaporization of cannabis) "The aim of this study was to evaluate the use of a vaporization system (the Volcano; VAPORMED® Inhalatoren; Tüttlingen, Germany) as a “smokeless” delivery system for inhaled cannabis. Because of concerns regarding the practicality and palatability of using cannabis cigarettes as a standard treatment, there has been an interest in developing alternative delivery systems. Participants were randomly assigned to receive low, medium, or high dose (1.7, 3.4, or 6.8% tetrahydrocannabinol) cannabis cigarettes delivered by smoking or by the vaporization
system on six study days.
"The full results of this study have been published in the journal Clinical Pharmacology & Therapeutics (Abrams, et al., 2007 – see reference list). Eighteen healthy volunteers were recruited to participate in the research. The analysis indicated that the blood levels of vaporized cannabis are similar to those of smoked cannabis over a six hour period. However, blood concentrations of THC at 30 and 60 minutes after inhalation were significantly higher in vaporized cannabis as compared to smoked cannabis. In addition, carbon monoxide levels were significantly reduced with vaporization compared with smoked cannabis. Fourteen participants preferred vaporization, 2 preferred smoking, and 2 reported no preference. In summary, vaporization of cannabis was found to be a safe mode of delivery, and participants had a preference for vaporization over smoking as a delivery system in this trial."

Center for Medicinal Cannabis Research, "Report to the Legislature and Governor of the State of California presenting findings pursuant to SB847 which created the CMCR and provided state funding," University of California, (San Diego, CA: February 2010), p. 12.

89. Medical Marijuana - Law & Policy - 1-4-12

(Ethics of Recommending Medical Cannabis to Patients) "Portions of the American Medical Association’s Code of Medical Ethics, Opinion 1.02 – The Relation of Law and Ethics reads, 'Ethical values and legal principles are usually closely related, but ethical obligations typically exceed legal duties. In some cases, the law mandates unethical conduct.' 'In exceptional circumstances of unjust laws, ethical responsibilities should supersede legal obligations.'[56] An 'exceptional circumstance of unjust laws' may be interpreted as the federal ban on cannabis for medical use. Sixteen states and the District of Columbia found the federal government’s prohibition on prescribing and using medicinal cannabis so unjust as to create laws in direct violation of federal statute. Therefore, one could surmise that prescribing cannabis for the purpose of harm reduction is ethical even though it violates federal law. In addition, Hayry suggests that the idea of 'freedom' also provides an ethical reason for prescribing cannabis and he writes, '… whatever the legal situation, respect for the freedom of the individual would imply that requests like this (for medicinal cannabis) should be granted, either by health professionals, or by society as a whole.'[57]"

Collen, Mark, "Prescribing Cannabis for Harm Reduction," Harm Reduction Journal (London, United Kingdom: January 2012) Vol. 9, Issue 1, p. 5.

90. Medical Marijuana - Law and Policy - 5-17-11

(Federally-Subsidized Public Housing and Medical Cannabis) "In sum, PHAs [Public Housing Agencies] and owners may not grant reasonable accommodations that would allow tenants to grow, use, or otherwise possess, or distribute medical marijuana, even if in doing so tenants are complying with state laws authorizing medical marijuana-related conduct. Further, PHAs and owners must deny admission to those applicant households with individuals who are, at the time of consideration for admission, using marijuana. See 42 U.S.C. § 13661(b)(1)(A); Lester Memorandum at 2.
"We note, however, that PHAs and owners have statutorily-authorized discretion with respect to evicting or refraining from evicting current residents on account of their use of medical marijuana. See 42 U.S.C. § 13662(b)(1); Lester Memorandum at 5-7. If a PHA or owner desires to allow a resident who is currently using medical marijuana to remain as an occupant, the PHA or owner may do so as an exercise of that discretion, but not as reasonable accommodation. HUD regulations provide factors that PHAs and owners may consider when determining how to exercise their discretion to terminate tenancies because of current illegal drug use. See 24 C.F.R. § 966.4(1)(5)(vii)(B)(factors for PHAs); 5.852 (factors for PHAs and owners operating other assisted housing programs)."

Kanovsky, Helen, R. "Medical Use of Marijuana and Reasonable Accommodation in Federal Public and Assisted Housing," U.S. Department of Housing and Urban Development (Washington, DC: January 20, 2011), pp. 10-11.

91. Medical Marijuana - Orgs - 12-19-09

US-Based Medical and Scientific Organizations Which Support Access to Medical Cannabis:
The American Academy of Family Physicians (1989, 1995); American Academy of HIV Medicine (2003); American College of Physicians (2008); American Medical Association's Council on Scientific Affairs (2001); American Medical Students Association (1993); American Nurses Association (2003); American Preventive Medical Association (1997); American Public Health Association (1995); Association of Nurses in AIDS Care (1999); Federation of American Scientists (1994); HIV Medicine Association (2006); Institute of Medicine (1982 & 1999); Kaiser Permanete (1997); Lymphoma Foundation of America (1997); National Association for Public Health Policy (1998); National Nurses Society on Addictions (1995); and Physicians Association for AIDS Care.

Patients out of Time, "Organizations Supporting Access to Therapeutic Cannabis," (Howardsville, VA: January 2009).

92. History of Medical Cannabis in the US

"Cannabis indica became available in American pharmacies in the 1850’s following its introduction to western medicine by William O'Shaughnessy (1839).6 In its original pharmaceutical usage, it was regularly consumed orally, not smoked. The first popular American account of cannabis intoxication was published in 1854 by Bayard Taylor, writer, world traveler and diplomat."

Geiringer, Dale, "Origins of Cannabis Prohibition in California" Contemporary Drug Problems," originally published as "The Forgotten Origins of Cannabis Prohibition in California," Contemporary Drug Problems, (Summer 1999 - substantially revised June 2006) Vol 26, #2, p. 4.

93. General Conclusions

IOM's Marijuana and Medicine: Assessing the Science Base (1999)

"At this point, our knowledge about the biology of marijuana and cannabinoids allows us to make some general conclusions:
"· Cannabinoids likely have a natural role in pain modulation, control of movement, and memory.
"· The natural role of cannabinoids in immune systems is likely multi-faceted and remains unclear.
"· The brain develops tolerance to cannabinoids.
"· Animal research demonstrates the potential for dependence, but this potential is observed under a narrower range of conditions than with benzodiazepines, opiates, cocaine, or nicotine.
"· Withdrawal symptoms can be observed in animals but appear to be mild compared to opiates or benzodiazepines, such as diazepam (Valium)."

Janet E. Joy, Stanley J. Watson, Jr., and John A Benson, Jr., "Marijuana and Medicine: Assessing the Science Base," Division of Neuroscience and Behavioral Research, Institute of Medicine (Washington, DC: National Academy Press, 1999), p. 3.

94. Tolerance

In the Institute of Medicine's report on medical marijuana, the researchers examined the physiological risks of using marijuana and cautioned, "Marijuana is not a completely benign substance. It is a powerful drug with a variety of effects. However, except for the harms associated with smoking, the adverse effects of marijuana use are within the range of effects tolerated for other medications."

Janet E. Joy, Stanley J. Watson, Jr., and John A Benson, Jr., "Marijuana and Medicine: Assessing the Science Base," Division of Neuroscience and Behavioral Research, Institute of Medicine (Washington, DC: National Academy Press, 1999), p. 126-127.

95. Movement Disorders and Medical Cannabis

"The abundance of CB1 receptors in basal ganglia and reports of animal studies showing the involvement of cannabinoids in the control of movement suggest that cannabinoids would be useful in treating movement disorders in humans. Marijuana or CB1 receptor agonists might provide symptomatic relief of chorea, dystonia, some aspects of parkinsonism, and tics."

Janet E. Joy, Stanley J. Watson, Jr., and John A Benson, Jr., "Marijuana and Medicine: Assessing the Science Base," Division of Neuroscience and Behavioral Research, Institute of Medicine (Washington, DC: National Academy Press, 1999), p. 169.

96. Therapeutic Value

The Institute of Medicine's 1999 report on medical marijuana stated, "The accumulated data indicate a potential therapeutic value for cannabinoid drugs, particularly for symptoms such as pain relief, control of nausea and vomiting, and appetite stimulation."

Janet E. Joy, Stanley J. Watson, Jr., and John A Benson, Jr., "Marijuana and Medicine: Assessing the Science Base," Division of Neuroscience and Behavioral Research, Institute of Medicine (Washington, DC: National Academy Press, 1999).

97. Uses for Medical Cannabis

"Advances in cannabinoid science of the past 16 years have given rise to a wealth of new opportunities for the development of medically useful cannabinoid-based drugs. The accumulated data suggest a variety of indications, particularly for pain relief, antiemesis, and appetite stimulation. For patients such as those with AIDS or who are undergoing chemotherapy, and who suffer simultaneously from severe pain, nausea, and appetite loss, cannabinoid drugs might offer broad-spectrum relief not found in any other single medication."

Janet E. Joy, Stanley J. Watson, Jr., and John A Benson, Jr., "Marijuana and Medicine: Assessing the Science Base," Division of Neuroscience and Behavioral Research, Institute of Medicine (Washington, DC: National Academy Press, 1999), p. 177.

98. Increased Use

The Institute of Medicine's 1999 report on medical marijuana examined the question whether the medical use of marijuana would lead to an increase of marijuana use in the general population and concluded that, "At this point there are no convincing data to support this concern. The existing data are consistent with the idea that this would not be a problem if the medical use of marijuana were as closely regulated as other medications with abuse potential." The report also noted that, "this question is beyond the issues normally considered for medical uses of drugs, and should not be a factor in evaluating the therapeutic potential of marijuana or cannabinoids."

Janet E. Joy, Stanley J. Watson, Jr., and John A Benson, Jr., "Marijuana and Medicine: Assessing the Science Base," Division of Neuroscience and Behavioral Research, Institute of Medicine (Washington, DC: National Academy Press, 1999). p. 99.

99. Potential Adverse Effects of Cannabis

"For most people, the primary adverse effect of acute marijuana use is diminished psychomotor performance. It is, therefore, inadvisable to operate any vehicle or potentially dangerous equipment while under the influence of marijuana, THC, or any cannabinoid drug with comparable effects."

Janet E. Joy, Stanley J. Watson, Jr., and John A Benson, Jr., "Marijuana and Medicine: Assessing the Science Base," Division of Neuroscience and Behavioral Research, Institute of Medicine (Washington, DC: National Academy Press, 1999), p. 125-126.