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PUBLIC POLICY STATEMENTS


The Role of the Physician in "Medical" Marijuana

Adoption Date:
April 12, 2010
Supported by: American Academy of Pain Medicine, American Osteopathic Academy of Addiction Medicine

American Society of Addiction Medicine

The Role of the Physician in "Medical" Marijuana

**Note: This historical policy statement is available as part of ASAM's Policy Archives, but it is no longer considered current ASAM policy. Please contact ASAM's advocacy staff at advocacy@asam.org for questions related to ASAM's position on this topic.

Below are the Abstract and Executive Summary for this position paper. To view the entire document, please read the PDF.

ABSTRACT

Objectives: Research into the therapeutic potential of cannabis and cannabinoids has lagged behind that of other modern medications. The recent discovery and elucidation of the endocannabinoid receptor system, coupled with improvements in technology and new research tools, has facilitated analytical, pharmacological, and other preclinical research. The conundrum in many states is that liberal cannabis distribution to patients with various medical conditions occurs in a setting where little scientific evidence exists to guide this process in a rational, ethical manner to protect patient health and safety. The purpose of this review is to examine the circumstances that led to this situation and explore the scientific issues involved in moving toward a resolution. It also sets out recommendations to assist physicians in coping with these issues and proposes policy recommendations for consideration that, if adopted, could reduce the potential for more problems in the future.

Results: Review findings indicate that in order to think clearly about “medical marijuana,” one must distinguish first between 1) the therapeutic potentials of specific chemicals found in marijuana that are delivered in controlled doses by nontoxic delivery systems, and 2) smoked marijuana. Second, one must consider the drug approval process in the context of public health, not just for medical marijuana but also for all medicines and especially for controlled substances. Controlled substances are drugs that have recognized abuse potential. Marijuana is high on that list because it is widely abused and a major cause of drug dependence in the United States and around the world. When physicians recommend use of scheduled substances, they must exercise great care. The current pattern of “medical marijuana” use in the United States is far from that standard.

Conclusions: All cannabis-based and cannabinoid medications should be subjected to the rigorous scrutiny of the Federal Food and Drug Administration (FDA) regulatory process. This process provides important protections for patients, making medications available only when they: 1) are standardized by identity, purity, potency and quality; 2) are accompanied by adequate directions for use in the approved medical indication; and 3) have risk/benefit profiles that have been defined in well-controlled clinical trials.

Key Words: cannabis, cannabinoid medication, medical marijuana

 

EXECUTIVE SUMMARY

Research into the therapeutic potential of cannabis and cannabinoids has lagged behind that of other modern medications. The recent discovery and elucidation of the endocannabinoid receptor system, coupled with improvements in technology and new research tools, has facilitated analytical, pharmacological, and other preclinical research. Clinical research is also increasing, although only a small number of controlled studies meeting modern scientific standards have been published.

All cannabis-based and cannabinoid medications should be subjected to the rigorous scrutiny of the Federal Food and Drug Administration (FDA)1 regulatory process. This process provides important protections for patients, making medications available only when they: 1) are standardized by identity, purity, potency and quality; 2) are accompanied by adequate directions for use in the approved medical indication; and 3) have risk/benefit profiles that have been defined in well-controlled clinical trials. The FDA has set forth the criteria that must be met if a botanically-based medication is to achieve marketing approval through this process.

All major medical organizations support the FDA approval process. Both the American Medical Association (AMA) and the American College of Physicians (ACP) have rejected the use of state legislative enactments to determine whether a medication should be made available to patients. The Institute of Medicine has also rejected this approach and has called for further research into the development of nonsmoked, reliable delivery systems for cannabis-derived and cannabinoid medications. Rigorous research is needed better to understand the significance of different cannabinoid formulations and ratios, methods of administration, and dose-response relationships. Cannabis has a range of effects, some of which may be disturbing to patients with serious medical conditions, adversely impact their cognitive skills, or impair their lung function. Such effects should be better understood, particularly in the context of chronic medical use.

“Medical marijuana,” currently distributed pursuant to state legislation, does not accord with critically important aspects of the modern scientific model. It lacks quality control and standardization; can be contaminated with pesticides and microbes; and does not assure patients a reliable and reproducible dose. Increased cannabis potency heightens the risk of adverse events, especially among cannabis-naïve patients, as well as the dangers of dependence and addiction. There are no effective risk management measures to prevent diversion and abuse, especially by adolescents.

The practice of medicine must be evidence-based; all medical interventions should be justified by high-quality data. Despite the paucity of rigorous scientific data, dispensaries are now distributing cannabis and cannabis products to large numbers of individuals. Yet physicians, who are the gatekeepers of this process under state law, have inadequate information on which to base their judgment if they choose to discuss cannabis as a treatment option with their patients. Physicians should carefully consider their ethical and professional responsibilities before issuing a cannabis recommendation to a patient. A physician should not advise a patient to seek a treatment option about which the physician has inadequate information regarding composition, dose, side effects, or appropriate therapeutic targets and patient populations.