NOTE:
We
sincerely apologize to Dr. Willem
Scholten from the Office of Medical
Cannabis in the Netherlands, and to
Ms. Fran Klass from the Drug Information
Journal who holds the copyright. In
edition #4 on Page 14, in the article,
"Licensing in The Netherlands"
by Allen Town, quotes were taken fromÊthe
article "Dutch Measures To Control
Medical Grade Marijuana: Facilitating
Clinical Trials", by Willem Scholten
(Drug Information Journal, Vol. 35,
pp. 481-484, 2001)Êand we did not
interview Dr. Scholten, nor give proper
credit to Drug Information Journal.
Editorial:
Brian
Taylor Editor
In
this issue CHJ covers one of the most
important medical and ethical issues
of the century, an emotional battle
ground of conflicting beliefs, the
topic of pain. We have chosen to take
a substantial journalistic risk and
publish an edited, and slightly modified
version of a "White Paper" by
Dr. Ethan Russo. Although substantially
shorter, the content has been retained.
We have not tried to change the scientific
language and we are convinced that
our cannabis consuming readers will
make sense of the report regardless
of whether they understand every medical
term or not. We hope and expect our
readers will keep this edition as
a reference document and possibly
share it with their physicians.
Our
gratitude to Dr. Russo for sharing
this risk and for making available
to our readers and to the general
public, this timely and concise information.
Working with our advertisers and writing
the article on home growing options
in "Growing your own medicine
at home", I was struck by several
commonalities. They are owner-operators,
hands-on with products and involved
with their customers and suppliers;
your basic grass roots entrepreneurs.
They are optimistic, creative and
talented and have a long-range vision
of the future of the industry, some
have gotten there a bit early, some
are new, some are survivors from the
hemp movement. Watch out when they
get organized and look out for Canada's
newest trade association, the Cannabis
Bio-products Trade Association coming
to your province soon.
Interesting reaction from the US over
the Canadian Government same sex marriage
decision, and the pot law changes,
after we refused to go to war. Is
the philosophical gap widening, are
we truly the new "hippie nation"?
The Bush Administration and the new
drug Czar, Karen Tracy continue to
search for new ways to undermine the
authority of California and other
states that have approved the use
of medical marijuana, and now in a
new offensive are seeking the power
to investigate physicians who advised
seriously ill patients that medicinal
marijuana may be a legitimate treatment
for debilitating illness. As discouraging
as it may be to watch the second US
civil war unfold, I am heartened by
two events. The first was a recent
vote in congress that would have ended
the attack on the State medical marijuana
movement. The vote was lost 152 to
273, but the movement was substantial.
The debate that followed was as interesting,
as some of the "nays" admitted
that they were voting against the
bill not because they did not support
the medical user, but because their
constituents would not be comfortable.
At least this was acknowledging that
the vote was cultural political, not
scientific.
The
other event, not to be overlooked,
was a report from the International
Cannabinoid Symposium held in Canada
in June. Participants reported a new,
more positive attitude. No longer
was the DEA asking science to find
the damage that marijuana is wreacking
and researchers were more open-minded
and even enthusiastic over identifying
the positive impacts of the plant.
Finally on a hemp note. Recently Jason
Finnis,
Hemptown's chief operating officer
announced that he is looking to raise
$25 million to build mills in Canada
and a market for fabric-grade hemp,
which he is now forced to buy in China.
The reception that Jason received
from the same experts was at best
reserved. Well, let me change that
reception. You have my personal support
and that of many other Canadians.
Indeed a Canadian fabric operation
is possible and economically viable.
Are they unaware that this is the
guy who bounced back and has made
his hemp company Hemptown a "dizzying
success"? Yes you can, Jason!
LETTERS
Professional
compliment
"Congratulations
to Matt Elrod for his concise article
in the May/June issue of Cannabis
Health. As someone with extensive
first-hand knowledge of both HortaPharm
and GW Pharmaceuticals, I can attest
to the accuracy of the story, and
applaud his balanced and distinctly
unsensational presentation of the
issues. Consistent journalism of this
caliber will serve to promote your
magazine as a publication of serious
intent." Sincerely, David W. Pate,
Ph.D., M.Sc.
I'm
productive now!
This
is just a quick letter to say two
things. Firstly, I love your magazine.
Second, referring to issue #4, the
article on GW Pharmaceuticals.
I was addicted to heroin, then I put
myself on Methadone. I must just say
that marijuana is the ONLY way I was
able to succesfully get off Methadone.
The sweating disappears, the stomach
settles, and your appetite comes back.
I only smoke pot now, and will do
so forever. It honestly saved my life,
and I believe it still is! Also, I
found that smoking oil was the complete
"cure" for withdrawals. I found your
article so interesting, I faxed a
copy to my old "methadone" doctor.
I
am today a productive gardener and
a student andÊI am very interested
in the work that GW Pharmaceuticals
does. Any follow-up articles would
be great. KEEP UP THE GOOD WORK! Thanx
- Carol
Hippie Nation Invites:
Representatives
of the "Hippie Nation" From
left to right- Gordon Taylor - Librarian
Brian Taylor - Editor, Brian McAndrew
- Production Glenda Hordos - Store
Manager Barb Cornelius - Accounting
Lisa Smith - Sales Mandy Nordahn -
Distribution
Hello
from business-friendly B.C. Canada.
The staff of Cannabis Health Journal
and Cannabis Research Institute are
ready to help your company find a
home here in the beautiful Kettle
River Valley or any other part of
our fair nation. The Hippie Nation,
Land of the Free, Canada.
Grow Seminars Available:
Cannabis
Health Foundation in partnership with
Cannabis Research Institute, employees,
volunteers and friends offer the seminar
series "Growing a personal supply
of cannabis at home".
Level #1 (1.5 hours) Introductory
Cannabis Gardening covers the basics
and is suited to the person with some
gardening experience but no cannabis
experience.
Level #2 (1.5 hours) Intermediate
Cannabis Gardening expects participants
to understand the basics, and will
concentrate on the issues of volume
and quality of the finished product.
The
presenters are experienced, well seasoned,
entertaining, fun and informative.
Presentations include lecture, power
point, hands-on learning, and demonstrations.
Where possible, real cannabis plants
will be included in the sessions.
Cannabis is a fascinating phenomenon
in today's culture. The Cannabis Health
sessions are ideal for groups interested
in learning how cannabis is grown.
For
bookings and information call Cannabis
Research Institute Inc. Toll free
at 1-866-808-5566 and ask for Brian
Taylor
Production
Notes:
Brian McAndrew
Production Manager
Production
Notes Here we are at the end of our
first year and the Journal has gone
through quite an evolution in content
and design. It has been the job of
the editor to make sure that what
you are reading is going to capture
and keep your interest, with the sales
people finding the financial support
through the advertisers.
My job as production guy is to take
the stories that our editor gathers,
take the ads that the sales team gathers,
(some come in "camera ready"
and others I design) and lay it out
in a way that everyone likes. It has
to reflect the content of the stories
as well as everyone else's wishes.
We all discuss the kind of things
we want the cover and content to reflect,
and then it is up to me to do the
rest.
Since
the first edition and in every one
of them since, we have been incorporating
small changes to help make the magazine
more appealing visually as well as
easy to read. It also has to keep
up with the dynamic nature of the
cannabis issue. Some things go in
at the last minute. One thing we do
is to try and keep all the stories
in a continuous format to keep you
from jumping all over the place to
finish a story. It is impossible to
do it all the time, though. We play
with picture and colour to make it
more visually appealing. These small
changes help us improve the quality
of the Journal in either content,
design, or both. These changes have
been made with an evolutionary reaction
to our readership and advertisers.
It is with this in mind that I get
to be the one to announce a new cover
design for our First Anniversary Issue,
#7, November/December - the next one.
Not only a new cover, but a whole
new look and feel for our website
at cannabishealth.com.
We
have been maturing and feel this new
look and feeling with the cover and
web will reflect the way we have evolved
in this first year.
I
must say that I get a lot of freedom
to be able to create and do my thing.
I even get to write sometimes, but
I don't get my way all the time. Among
other things, I wanted to have a different
pic for the Hippie Nation, and I was
out voted...unanimously... oh well,
win some - lose some.
Cannabis and
Pain Management
The
following article is an edited composite
of a Policy Paper on Cannabis in Pain
Treatment presented to the American
Academy of Pain Management by Dr Ethan
Russo, MD
Effective
treatment of
acute, chronic and intractable pain
is a critically important public health
concern in the world today. Despite
a vast array of analgesic medicines
including anti-inflammatory and opioid
analgesics, countless patients continue
to suffer the burden of unrelieved
pain. Opiate addiction, and the recent
OxyContin¨ controversy underline the
importance of newer effective and
safe alternatives.
For
over a century, international commissions
have studied the issue of cannabis,
and virtually uniformly recommended
its decriminalization and provision
for medical applications, specifically
including the treatment of pain.
Cannabis has been employed as an analgesic
for thousands of years, and was utilized
in this country as well, particularly
for neuropathic pain, prior to its
effective removal from the American
market 65 years ago. Historical cannabis
supporters have included such physicians
and scientists as Galen, Dioscorides,
Parkinson, Linnaeus, Gowers, Weir
Mitchell, Osler, Solomon Snyder, and
many others. Cannabis remains a frequently
employed ethno-botanical agent in
pain management among indigenous peoples
of the world.
Modern
research on endogenous cannabinoids
and the cannabinoid receptor system
has demonstrated a scientific basis
for the efficacy of synthetic and
phytocannabinoids in pain management
based on serotonergic, dopaminergic,
Substance P, and glutamatergic mechanisms,
interactions with the endogenous opioid
system, as well as antioxidant and
anti-inflammatory effects. These mechanisms
have been demonstrated in both central
and peripheral systems. Adjunctive
effects of cannabis and cannabinoids
on depression, anxiety, spasticity,
tremor, nausea and anorexia also contribute
to treatment benefits in chronic pain
patients. Whole cannabis and its extracts
provide an entourage of cannabinoids,
terpenoids, and flavonoids that combine
to create a synergy of benefits in
holistic treatment of chronic and
intractable pain.
Systematic
examination of the toxicology and
side effect profile of cannabis and
cannabinoids on long-term cognitive,
other nervous system, endocrine, hematological,
and immunological function demonstrate
little documentation of significant
detrimental effects, and suggest a
safety margin well within that of
most prescription medicines. The sole
area of demonstrable concern surrounds
chronic pulmonary issues attendant
with smoked cannabis. These problems
are possibly avoidable with harm reduction
techniques such as vaporization, and
are totally so with alternative delivery
methods such as sublingual or nebulized
cannabis-based medicine extracts.
Fears of cannabis-induced psychosis,
addiction, and cognitive impairment
and deterioration have been largely
exaggerated.
Oral
synthetic THC (Marinol¨), a synthetically
derived THC dissolved in sesame oil,
was developed by Unimed Pharmaceuticals.
It is available in capsules of 2.5,
5 and 10 mg and is marketed in the
USA, Canada, Australia, and some areas
in Europe, and has proven quite disappointing
as a pain management tool. Cannabis
proper, and a variety of synthetic
agents are in various stages of clinical
investigation. Development and FDA
approval of synthetic cannabinoids
will require many years. In contrast,
cannabis-based medicine extracts have
proven safe and effective in a large
variety of pain conditions, and are
expected to attain governmental regulatory
approval in the UK, Western Europe
and Canada within a very short time.
The
History of Cannabis in Pain Management
Traditional
knowledge of cannabis in China may
span 5000 years, dating to the legendary
emperor, Shen-Nung. Julien (1849)
wrote of the physician Hoa-tho in
the early 2nd century and his use
of a cannabis extract in anesthesia
for major surgical procedures.
The
Atharva Veda of India (dating to between
1400 and 2000 BCE) mentions a sacred
grass for anxiety, bhang, which remains
a modern term for cannabis. Medical
references to cannabis date to Susruta
in the sixth to seventh centuries
BCE. Dwarakanath (1965), described
a series of Ayurvedic and Arabic traditional
preparations containing the herb indicated
for migraine, neuralgic and visceral
pains.
Similar
proof of the medicinal use of cannabis
exists in records and artifacts from
ancient Egypt, Assyria, Israel/Palestine/Judea,
and the Greek and Roman Empires.
In
common use throughout the Medieval
world and Renaissance Europe, the
medical use of cannabis, or "Indian
hemp" was reintroduced to the West
by O'Shaughnessy (1838-1840). His
treatise on the subject dealt with
the apparent utility of a plant extract
administered to patients suffering
from rabies, cholera, tetanus, infantile
convulsions, but also a series of
painful rheumatological conditions.
Of particular note, even patients
that succumbed to their illnesses
were greatly relieved by cannabis
with convincing palliative benefits.
Shortly thereafter in England, Clendinning
(1843) described his results of treatment
of 18 patients: 3 with headaches,
one with abdominal pain secondary
to tumor, one with pain secondary
to a laceration, two with rheumatic
joint pain, and one with gout. In
each case, the tincture of Indian
hemp provided relief, even in cases
of morphine withdrawal symptoms.
In Ireland, Donovan (1845) extensively
described his own extensive trials
with small doses of cannabis resin,
mainly in patients with various types
of neuropathic and musculoskeletal
pain. Effects were almost uniformly
impressive, with few side effects.
He also described the benefits of
local application of hemp leaf oil
on hemorrhoids and neuralgic pains.
Over
the next decades, numerous authorities
recognized cannabis as helpful for
painful conditions. Sir John Russell
Reynolds was eventually to become
Queen Victoria's personal physician.
He successfully treated her dysmenorrhea
with a cannabis extract throughout
her adult life (Reynolds 1868) and
used it extensively to treat migraine
and neuropathic pain.
Hobart
Hare (1887): I have found the efficient
dose of a pure extract of hemp to
be as powerful in relieving pain as
the corresponding dose of the same
preparation of opium... During the
time that this remarkable drug is
relieving pain a very curious psychical
condition sometimes manifests itself;
namely, that the diminution of the
pain seems to be due to its fading
away in the distance, so that the
pain becomes less and less, just as
the pain in a delicate ear would grow
less and less as a beaten drum was
carried farther and farther out of
the range of hearing.
In the French literature, See (1890)
submitted a detailed report on use
of cannabis in the treatment of various
disorders producing gastric and intestinal
pain, and found it preferable in efficacy
and side effects to opiates and bismuth.
Suckling (1891) noted the ability
of cannabis to allow migraine sufferers
to return to work.
An
American drug handbook stated the
following: (Lilly, 1898) "Antispasmodic,
analgesic, anesthetic, narcotic, aphrodisiac.
Specially recommended in spasmodic
and painful affections."
Hare (1922) still advocated use of
cannabis noting "For the relief
of pain, particularly that depending
on nerve disturbance, hemp is very
valuable."
An editor of the Journal of the American
Medical Association, as late as 1930
noted the ability of cannabis to achieve
a labor with pain burden substantially
reduced or eliminated, followed by
a tranquil sleep (Anonymous 1930)
without sequelae.
Despite
its political disenfranchisement,
Fishbein (1942) still advocated oral
preparations of cannabis in treatment
of menstrual (catamenial) migraine.
Cannabis
remained in the British armamentarium
somewhat longer, and was extolled
above opiates and barbiturates in
the treatment of the pain of hospitalized
patients with duodenal ulcers (Douthwaite,
1947).
In
Tashkent in the 1930's, cannabis or
nasha was employed medicinally, despite
Soviet prohibition (Benet 1975) for
headache and pain of defloration.
In Southeast Asia, cannabis remains
useful (Martin 1975). Everywhere it
is considered to be of analgesic value,
comparable to the opium derivatives.
Moreover, it can be added to any relaxant
to reinforce its action. Cooked leaves,
which have been dried in the sun,
are used in quantities of several
grams per bowl of water. This decoction
helps especially to combat migraines
and stiffness.
In
a book about medicinal plants of India
(Dastur, 1962) Charas [hashish] ---
is a valuable narcotic, especially
in cases where opium cannot be administered;
it is of great value in malarial and
periodical headaches, migraine, acute
mania, whooping cough, cough of phthisis,
asthma, anaemia of brain, nervous
vomiting, tetanus, convulsion, insanity,
delirium, dysuria, and nervous exhaustion;
it is also used as an anaesthetic
in dysmenorrhea, as an appetizer and
aphrodisiac, as an anodyne in itching
of eczema, neuralgia, severe pains
of various kinds of corns, etc.
In Colombia the analgesic effects
of a cannabis tincture were lauded
(Partridge 1975) "the knowledge
that cannabis can be used for treatment
of pain is widespread." Rubin
documented extensive usage of cannabis
in Jamaica for a variety of conditions
(Rubin, 1976; Rubin and Comitas, 1972),
including headache.
In
Brazil, Hutchinson (1975) "Such
an infusion [of leaves] is taken to
relieve rheumatism, "female troubles",
colic and other common complaints.
For toothache, marijuana is frequently
packed into and around the aching
tooth and left for a period of time,
during which it supposedly performs
an analgesic function".
Cannabis
and Cannabinoids as Medicine.
Cannabis Proper Cannabis is traditionally
employed therapeutically by smoking
or ingestion. Grotenhermen has produced
an excellent summary of "Practical
Hints" (Grotenhermen, 2002),
as have Brazis and Matthre (1997)
and Russo (2002).
Dosing
of therapeutic cannabis must be titrated
to the patient's need. In general,
5 mg of THC content represents a threshold
dose for noticeable effects in the
average adult (Grotenhermen 2002).
Whereas tolerance to cardiovascular
effects (tachycardia) and psychoactive
effects ("high") are achieved
after some days to weeks of chronic
usage, observed clinical and "anecdotal"
reports support retention of analgesic
efficacy over the long term. Occasionally,
upwards dose titration is necessary,
as is true for any agent.
Allergies to cannabis are rare, although
some may experience rhinitis symptoms,
particularly when exposed to the smoke
of the unrefined product. People employing
cannabis therapeutically must be warned
of the usual caveats assigned to any
potentially sedative drug: due care
with operation of machinery, motor
vehicles, etc., which are analogous
to the industry warnings for Marinol¨
(synthetic THC).
Acute over-dosages of cannabis are
self-limited, and most frequently
consist of panic reactions. These
are uniquely sensitive to reassurance
("talking down") and are
quite unusual once a patient becomes
familiar with the drug. Cannabis has
a unique distinction of safety over
four millennia of analgesic usage:
No deaths due to direct toxicity of
cannabis have ever been documented
in the medical literature.
Some
cannabis-drug interactions are apparent,
but are few in number. Additive sedative
effects with other agents, including
alcohol, may be observed. Similarly
however, additive or synergistic anti-emetic
and analgesic benefits may accrue
when combining dopamine agonist neuroleptics
and cannabis (Carta, Gessa, and Nava
1999). Cannabis may accelerate metabolism
of theophylline, while slowing that
of barbiturates. Anticholinergic-induced
tachycardia may be accentuated by
cannabis, while this effect is countered
by beta-blockers (Grotenhermen 2002).
Indomethacin seems to reduce slightly
the psychoactive and tachycardic effects
of cannabis (Perez-Reyes et al. 1991).
As discussed above, synergistic analgesic
benefits may accrue with concomitant
usage of cannabis and opioids (Cichewicz
et al. 1999; Hare 1887). CBD is a
powerful inhibitor of cytochrome P450
isozymes 3A4, 2C19, and 2D6 (Bornheim
et al. 1994; Bornheim and Grillo 1998)
indicating the need for caution in
cannabis patients taking that component
in conjunction with fentanyl, sildenafil
(Viagra¨), tricyclic antidepressants
and anti-arrhythmic drugs.
Crude
cannabis contains most of its THC
in the form of delta-9-THC acids that
must be decarboxylated by heating
to be activated. This occurs automatically
when cannabis is smoked, whereas cannabis
that is employed orally should be
heated to 200-210ûC. for 5 minutes
prior to ingestion (Brenneisen 1984).
Contrary
to disseminated propaganda in the
USA, average cannabis potency has
varied little over the last 3 decades
(ElSohly et al. 2000; Mikuriya and
Aldrich 1988). It is true that the
maximum potency has increased through
applied genetics, cultivation and
harvesting techniques. This goal is
achieved through production of clonal
cultivation of the preferred female
plants and maximization of the yield
of unsterilized flowering tops known
as sinsemilla (Spanish for "without
seed"). In this manner a concentration
of glandular trichomes where THC and
therapeutic terpenoids are produced
is effected. Resultant yields of THC
may exceed 20% by weight. This is
potentially advantageous, particularly
when smoked, because a therapeutic
dosage of THC is obtained with fewer
inhalations, thereby decreasing lung
exposure to tars and carcinogens.
As noted by Professor Wayne Hall (Lords
1998).
Indeed, it is conceivable that increased
potency may have little or no adverse
effect if users are able to titrate
their dose to achieve the desired
state of intoxication. If users do
titrate their dose, the use of more
potent cannabis products would reduce
the amount of cannabis material that
was smoked, thereby marginally reducing
the respiratory risks of cannabis
smoking.
A
considerable concentration of THC,
other cannabinoids and terpenoids
may also be achieved through some
simple processing of crude dried cannabis.
Techniques for sieving or washing
of cannabis to isolate the trichomes
to produce hashish are well described
(Clarke 1998; Rosenthal, Gieringer,
and Mikuriya 1997), and may produce
potential yields of 40-60% THC. Clarke
demonstrates a simple method of rolling
the resultant powdery material into
a joint of pure hashish, termed "smoking
the snake" (Clarke 1998), providing
a relatively pure product for inhalation.
Cultivation
techniques are beyond the scope of
this review, but emphasis should focus
on potent medicinal strains, scrupulous
organic cultivation of female plants,
clonal selection and augmentation,
and appropriate processing with a
high degree of quality control throughout
the process. It deserves emphasis
that clinical cannabis patients benefit
from consistent quality and dosing.
This is extremely difficult to achieve
on a practical basis, unless cloned
cannabis strains or standardized extracts
are employed. Additionally, although
cannabis is often touted as relatively
"pest-free," it is subject
to predation by a number of insects,
bacteria, viruses, fungi, etc. (McPartland,
Clarke and Watson 2000).
Cannabis
strains in the USA are THC predominant,
almost uniformly devoid of CBD content
(Gieringer 1999). While this may be
appropriate for certain medical conditions,
patients with concomitant muscle spasm,
anxiety, seizure disorders, or susceptibility
to psychoactive effects may not achieve
optimal results.
The
labor required to manage cannabis
genetics, culture, maintenance of
"organic" technique without
contamination, processing and quality
control are likely beyond the ken
and capabilities of most patients,
particularly those with chronic pain.
It remains the case that smoked cannabis
is a crude delivery system with some
inherent respiratory risk. This fact,
taken with the inability to develop
smoked cannabis into an FDA-approved
medicine in the USA, makes the development
of alternative rapid-delivery cannabis-based
systems mandatory.
Oral
use of cannabis
A variety of issues attend oral cannabis
administration. The most important
concerns bioavailability. Oral absorption
of cannabinoids is slow and erratic
at best, often requiring 30-120 minutes.
In HIV positive or chemotherapy patients
and in acute migraine, nausea and
emesis may preclude oral usage altogether.
Additionally, oral THC is subject
to the "first pass effect"
of hepatic metabolism yielding 11-hydroxy-THC,
considerably more psychoactive than
THC itself. Thus, some patients become
Òtoo highÓ even on low doses of medicine,
such as 2.5 mg of THC as dronabinol.
Advantages
of oral usage are its avoidance of
lung exposure in those who are immunosuppressed
or have impaired pulmonary function,
and its prolonged half-life. This
may be of advantage for nocturnal
complaints where sedation is less
of an issue.
Grotenhermen suggests dose titration
beginning with the equivalent of 2.5
mg of oral THC bid with increases
as needed and tolerated (Grotenhermen
2002). Most painful clinical conditions
require tid dosing of cannabis.
THC,
CBD and terpenoids are all highly
lipophilic. Gastrointestinal absorption
is markedly enhanced by inclusion
of lipids in the cooked preparations.
Therapeutic tincture extraction in
alcohol is also possible.
Smoked
cannabis
Techniques of smoking cannabis are
legion. Pharmacodynamically, smoking
would be an ideal method of application
of clinical cannabis, but for the
attendant pulmonary issues. Clinical
effects are noted within seconds to
minutes after smoking. Inhalation
avoids the first pass effect that
hampers oral use, and allows effective
dosage titration. When symptoms return,
repeat dosage is achieved quickly
and easily. Overdosage is frequently
avoidable.
Traditional smoking techniques in
the USA make prolonged holding of
a marijuana "toke" de rigueur.
From a dose-response standpoint, this
is unnecessary. Inhaled THC is well
absorbed after a very brief interval,
and subjective high and serum THC
levels do not increase beyond a maximum
10-second inhalation. Furthermore,
prolonged breath holding under pressure
increases the potential for hypoxia
or pneumothorax.
Contamination
of herbal cannabis by pesticides,
herbicides, and bacterial or fungal
agents is possible, and may represent
a threat to the smoker, especially
immunosuppressed patients. Scrupulous
cultivation techniques avoid some
of these issues. McPartland recommends
pasteurization of herbal cannabis
by heating in an oven of 150C. for
5 minutes (McPartland 2001).
Waterpipes
and bongs are popular techniques for
cooling smoke. While they may reduce
particulate matter as well, THC content
and pharmaceutical efficiency also
seem to be compromised. Surprisingly,
the unfiltered ÒjointÓ seems to represent
the most efficient means for conventional
smoking, although use of hashish in
a pipe (without tobacco) was not examined.
Vaporizers
for cannabis administration
Vaporization of herbal cannabis may
allow delivery of THC and terpenoid
components below the flash point of
the leaf, thereby reducing exposure
to smoke, tar and carcinogens. The
technology has been hampered in its
development by paraphernalia laws.
Initial investigations of available
devices had disappointing results,
but further studies have demonstrated
promising benefits on avoidance of
carcinogenic components from smoking
(Gieringer 2001). Research continues.
Sublingual
tincture of cannabis
This method of administration is under
investigation by GW Pharmaceuticals
in the United Kingdom employing combinations
of specific strains of cannabis that
are rich in THC or CBD. Terpenoids
and other minor components that are
important to therapeutic effects of
cannabis are retained. Dose-metered
sublingual sprays are currently in
Phase 2 and 3 clinical trials for
a variety of indications. Initial
results indicate good bioavailability
and excellent patient tolerance and
clinical effects. Painful conditions
have been of particular note in this
research.
Aerosol
THC preparations
Cannabis has a long history of use
in asthma, even as a smoked preparation.
A pure THC aerosol has been attempted
numerous times in the past. Physical
and delivery issues have been challenging,
but more interestingly, pure THC seems
to have an irritating and even bronchoconstrictive
effect when employed in isolation
(Tashkin et al. 1977). Some authors
believe that anti-inflammatory effects
of concomitant terpenoid and flavonoid
administration are necessary for full
effects and tolerance in pursuit of
the pulmonary route. Further research
is underway by GW Pharmaceuticals,
Inhale Therapeutic Systems, and possibly
others.
Marinol¨
(dronabinol, synthetic THC)
Marinol¨
is a synthetically derived THC dissolved
in sesame oil, developed by Unimed
Pharmaceuticals. It is available in
capsules of 2.5, 5 and 10 mg and is
marketed in the USA, Canada, Australia,
and some areas in Europe. Until 1999,
Marinol¨ was a Schedule II drug in
the USA with close scrutiny to its
usage, which was restricted to indications
of AIDS-associated anorexia and cancer
chemotherapy. After safety studies
revealed a low potential for abuse
or diversion, dronabinol was "down-scheduled"
to Schedule III in 1999, allowing
refill prescriptions for up to 6 months,
and its "off-label" administration
for any indication. Clinicians have
utilized Marinol¨ to only a limited
degree. Its bioavailability is only
25-30% of an equivalent smoked dose
of THC (Association 1997). Additional
problems include the first pass effect
of hepatic metabolism, which results
in the production of a more psychoactive
metabolite 11-hydroxy-THC, and its
considerable cost, which may exceed
US $600 per month for the lowest dosage
of 2.5 mg tid. Considerable anecdotal
data supports preference by patients
of smoked cannabis over dronabinol.
Nabilone
Nabilone
is a synthetic cannabinoid said to
be pharmacologically similar to THC,
but more potent, less apt to produce
euphoria, and possessing lower "abuse
potential" (Association 1997).
It is produced by Eli Lilly Company
as Cesamet¨ and is available in the
UK, Canada, Australia and certain
countries in Europe as an agent for
nausea in chemotherapy. Some scattered
reports have noted benefit on spasticity
in MS, and effects on dyskinesias.
A
group in the UK assessed analgesic
effects of nabilone in patients including
some with neuropathic pain (Notcutt,
Price, and Chapman 1997). Side effects
of drowsiness and dysphoria were troubling.
Several patients claimed improved
pain relief and fewer side effects
with smoked cannabis and preferred
it to this legal alternative. Nabilone's
cost was also estimated to be 10 times
higher than cannabis even at black
market rates.
Future
Directions and Needs
Future
directions for research on cannabis
and cannabinoids will be primarily
determined by political factors. Studies
with smoked cannabis in the USA will
continue under constraints imposed
by NIDA: limited access to low potency
smoked marijuana with rigorous oversight.
Such studies may have limited applicability
to the actual potential of true medical-grade
cannabis or cannabis-based medicine
extracts.
Herbal
cannabis as a smoked medicine will
never fulfill FDA guidelines to become
a prescription medicine. Such a process
requires absolute standardization
of constituents, rigorous quality
control, bacteriological purity, safety,
reliability, reproducibility, and
uniform dose titration. In contrast
cannabis-based medicine extracts,
whether employed sublingually or via
aerosol, can easily meet this burden
and will likely achieve market approval
in Europe and Canada within months.
Too Good to
be True
By
Paul Henderson
A
few months ago the potential for marijuana
decriminalization and the subsequent
government distribution of marijuana
to patients was sky high. Back in
April Prime Minister Jean Chretien
announced his government was "not
afraid to take on controversial issues"
and would decriminalize marijuana
to reduce the harm of criminal records
that young people face.
Into the summer, July 9 was a date
greatly anticipated by anti-prohibition
advocates, as it was the day the government
had to either start distributing medicine
to exemption-holding patients or the
marijuana possession law would be
rendered invalid.
A
couple of positive stories for medicinal
marijuana users and a win-win situation,
right?
Too
good to be true.
The
incremental improvements many felt
were inevitable and forthcoming have
turned out to be disastrous and, according
to advocates and those on the front
lines of making medicinal marijuana
easier to get for patients, things
are worse, not better.
Refusing
to take a real position of any kind,
it seems the federal government decided
to follow a path whereby they pleased
everyone. As a result they are instead
pissing everyone off. The ruse Health
Canada and the Ministry of Justice
attempted to pull, talking out of
both sides of their mouth, has blown
up and the government is looking dumber
than ever. A disastrous "decriminalization"
bill has been tabled, and Health Minister
Ann McLellan is using the recent court
decisions as a platform to tell us
what she really thinks: that marijuana
has no medicinal value.
And
as a result of the tabling of Bill
C-38 and the government being forced
into distribution the American anti-drug
zealots are mad, doctors are mad,
patients are mad, everyday pot smokers
are mad: So who was this pseudo-decriminalization
and reluctant effort at distribution
supposed to please? Tough to get an
answer to that.
Criminal
lawyer and anti-prohibition advocate
Alan Young said that the whole premise
of decriminalization is based on the
premise that marijuana is a relatively
harmless substance and he was led
to believe the government understood
this. Now he knows he was wrong.
"The
proposed bill was not just a disappointment,
it was a major disillusionment with
a process that should have borne fruit,"
Young told Cannabis Health. "I've
worked on this way too long to have
them give me such a compromised piece
of legislation."
The
only possible benefit that most can
see in the legislation, Bill C-38,
is the fact that those caught with
minor amounts will avoid a criminal
record. Instead they will pay a fine
up to $150. The reality though is
that under the current Controlled
Drugs and Substances Act (CDSA) most
police simply confiscate small amounts
and let people off with a warning.
Now the police have a discretionary
ability to give fines to people who
maybe can't afford them.
It
looks like that in most cases, Bill
C-38 actually provides for harsher
enforcement and Young says the proposed
bill cannot even be called "decriminalization".
Rather it is in fact a worst-case
scenario.
"I
don't care if you go to jail or not
(even though that is a big issue)"
Young said. "For me criminal
law means the power to arrest, detain,
and search, and that's what they haven't
taken away. You cannot demystify a
substance like marijuana when you
still let Officer Friendly take you
down to the station and deprive you
of liberty. (Justice Minister Martin)
Cauchon left it to the discretion
of the police to decide whether to
treat you like a highway traffic offender
or whether to treat you like a criminal.
That's not decriminalization, that's
the worst-case scenario where a low-level
unaccountable official is making the
decision."
Senator
Pierre Claude Nolin, chairman of the
Canadian Senate Select Committee on
Illegal Drugs told DRCNet in an interview
before the bill was tabled, "What
the prime minister is proposing is
not decriminalization, it is what
I call depenalization. We are removing
the criminal penalties, but the behaviour
itself remains criminal, it just triggers
a lesser penalty. This is the shadow
of the first step."
Others have much harsher words for
Bill C-38: "Pathetic, shameful,
corrupt and incompetent." That's
what Dominic Cramer, president of
Toronto Hemp Company (THC) said about
the bill.
Tell us what you really think Dominic.
"I
would like to be able to applaud them
for at least doing something, but
screw thatÉwhat choice did they have?
I am embarrassed and ashamed to be
a Canadian today and encourage the
resignation of our disgraceful Health
and Justice Ministers."
While those who support prohibition
call Bill C-38 "decriminalization"
and are infuriated by this "liberal"
move by the government, some who support
truly liberalized drug laws say this
is not a step in the right direction
but looks more like a long walk off
a short pier.
Senator Nolin suggested that this
is at least a first step but Cannabis
Health asked Alan Young if he thought
this was at least a step in the right
direction: "No. I'd like to say
'yes',, in fact I was to be paid a
fair amount of money by American lobbyists
to support Cauchon and I turned it
down, and I'd like to have the money.
The thing with law reform, you can't | 
