So just how medicinal is medicinal marijuana?
It seems a reasonable question, given Oklahomans will be voting June 26 on whether to join 30 other states in legalizing medical marijuana — or, as some prefer, medical cannabis.
Experts seem to generally agree that chronic pain sufferers, chemotherapy patients and people with HIV/AIDS may well benefit from an oil or a pill or a deep breath of a cannabis component.
But even then, the answers are not as cut and dried (no pun intended) as one might think. The science of medical marijuana is more anecdotal than empirical, and for almost 50 years the federal government has hindered research in the field much more than it’s helped.
As a result, determining which treatments help people, and to what extent, remains hazy.
Again, no pun intended.
Certainly, it’s no laughing matter for a woman we’ll call Jane. Her son, in his early 20s, has developed a condition that results in constant pain such that “he says it’s like his leg is full of hot lava.”
Doctors at the Mayo Clinic, Jane said, prescribed a heavy dose of painkillers, but one told her the drugs would kill her son within five years if his condition did not.
In desperation, Jane began smuggling cannabis-based products from states where they are legal — which is why she didn’t want to be identified for this story.
“I’m a conservative Republican,” Jane said. “We’ve never done anything illegal in our lives.”
She said the cannabis extract, which her son takes as a “tincture” under his tongue, has allowed a reduction in his opioid intake and improved his mobility.
For Jane, the possibility of being able to legally provide her son some relief from his pain outweighs all other considerations about State Question 788 and illustrates the dilemma many patients and medical providers find themselves in.
Generally, researchers agree cannabis in some form can provide relief from certain conditions. But the evidence is mostly anecdotal or derived from small studies with more variables than scientists like.
“Desperation breeds a desire for anything to give some relief,” said Dr. Kevin Taubman, a Tulsa vascular surgeon and University of Oklahoma medical school professor. “The population most likely to benefit from cannabis are people in palliative care, who have cancer, for instance, for treating pain and suffering.”
Taubman is co-chair of the No on 788 coalition, which includes the state’s major health care, business and law enforcement organizations.
Taubman said his argument is with the regulatory framework, or lack thereof, in SQ 788, and not with the idea that cannabis has some medicinal benefits.
“Medical marijuana programs exist that have been very beneficial,” he said. “This (SQ 788) is not it.”
Cannabis chemistry is incredibly complex. The typical plant contains more than 100 cannabinoids — chemicals that act on the nervous and immune systems — in an almost endless number of combinations, depending on plant variety and other factors.
By far the two most important cannabinoids are delta-9 tetrahydrocannabinol, known as THC, and cannabidiol, or CBD.
THC produces marijuana’s euphoric effect. For more than 30 years, synthetic forms of THC have been used to treat nausea and loss of appetite in AIDS and chemotherapy patients.
CBD has no intoxicating effect and some forms of it are already legal in Oklahoma. CBD products such as oils and ointments are sold in a few retail stores, while large doses are restricted to treatment of a few types of childhood seizures.
Most states strictly limit the conditions that can be treated by medical cannabis. Taubman and his colleagues would like to see that in Oklahoma, too.
SQ 788 does not specify qualifying conditions, but its backers say that will be up to lawmakers and regulators.
Determining qualifying conditions is often the result of less-than-sound reasoning, said University of California-Irvine neuroscientist and pharmacologist Daniele Piomelli, the editor-in-chief of the journal Cannabis and Cannabinoid Research.
At least some qualifying conditions, Piomelli said, “are not based on any research. You have a long list of (conditions), for many of which cannabis is useless. And the danger is, you don’t want folks to reject other treatments and think they can do it just with cannabis.”
Piomelli was a member of a National Academies of the Sciences, Engineering and Medicine committee that surveyed existing research on medical marijuana and published a report in 2017.
He said the group concluded there is “high-quality data” to support the use of some forms of cannabis to treat nausea, especially during chemotherapy and in AIDS patients.
“Good evidence” was also found for the use of cannabis in the treatment of chronic pain, Piomelli said, especially as an alternative to more-addictive opioids.
“Cannabis is never the perfect drug, but if it provides relief and reduces the use of opioids, it should be considered,” he said.
SQ 788 supporters point to statistics indicating opioid deaths and prescriptions have declined in states with medical marijuana, but Piomelli said it is not clear what other factors might be involved.
Finally, the committee recommended cannabis for the treatment of multiple sclerosis spasticity and other forms of seizure.
Piomelli said there are many other promising areas, including some studies that indicate cannabis may kill certain types of cancer cells and shrink highly aggressive forms of brain tumors. Boosters say it has at least the potential to cure migraines, lessen Parkinson’s symptoms, clear up bowel trouble and even improve the user’s sex life.
But, Piomelli said, “by and large the evidence is very scant.”
And that seems to be the biggest obstacle to medical marijuana — a lack of research.
The federal government is largely responsible for that. Marijuana was outlawed in 1937, but the Controlled Substance Act of 1970 classified all cannabis — including the harmless varieties of hemp used for industrial purposes — as a Schedule I substance, along with heroin and other exceedingly dangerous drugs. That meant they could not be legally grown or used anywhere, with a few tightly controlled exceptions.
Even at the time, experts considered such a designation unwarranted. Author John Hudak, in his 2016 history of the criminalization of marijuana, said then-President Richard Nixon insisted it be listed as a Schedule I substance because of his hatred of “African Americans and hippies.”
“A lot of people thought cannabis was like a poison, and it’s not even a very dangerous drug,” said Piomelli. “But it has an effect (some people) don’t like.”
Marijuana’s status as a Schedule I substance makes research much more difficult. For instance, Mississippi State University is the only place in the country where marijuana for experimental purposes can be legally grown. Piomelli said it is “not representative of what someone would get in a store (in California) or, even worse, on the black market.”
This is important because of the wide range in the chemical composition of different strains and even individual plants. Sunil Aggarwal, a researcher at the University of Washington, says “there is more genetic diversity in cannabis than in breeds of dog.”
And that brings up another problem Taubman and others have with medical marijuana. It is not like pharmaceuticals, which are manufactured to certain specifications and dispensed in standard doses.
As even advocates such as Aggarwal agree, figuring out how much of which cannabinoid to administer in which form is still largely a hit-and-miss proposition.
“It’s like the days of the apothecary, the old mortar and pestle,” said Taubman.
Fortunately, cannabis by itself is not lethal in any dosage. But it can impair reactions, contributing to serious and even deadly accidents, and indications are it can have negative long-term effects on brain function, especially in young people.
Piomelli warns that federal restrictions on cannabis research is creating a void being filled by industry-funded studies.
“The key thing is that we must study (cannabis) rigorously,” said Piomelli. “Unless we act, (industry-sponsored) science is going to replace good science. The research of cannabis companies is going to replace high-quality research.”