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

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



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



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.


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  1. Lee Weber Jun 24, 2014 - 05:40 AM
    I do believe that the debate on the medical uses of any euphoria-inducing, psychoactive substances will continue until we, as a society, come to understand and possibly tolerate euphoric effect instead of moralize or criminalize it.  Isn't this the real debate?  Whether we can "condone" pr "permit" use of a drug which creates an intense sense of well-being (which is habit forming).  I personally think that the risk/benefit analysis is the best way that we try to justify any drug's use.  But my main question is: Why are we even debating cannabis, when opioids are and have been legalized for decades in the use of pain management?
  2. charles coryn Feb 08, 2014 - 05:34 PM


     You be the judge.  This video, presented by Dr. Alan Shackelford, proves cannabis is medicine.  In this case, epileptic symptoms from Dravet's Syndrome are reduced by 90%, following the initial doses of cannabis (high CBD).  Seeing is believing.........



    IACM-Bulletin of 25 August 2013

    USA: Sanjay Gupta of CNN says that Americans have been systematically misled about cannabisDr. Sanjay Gupta, CNN's chief medical correspondent, apologized for opposing the medical use of cannabis and stated "I did part of that misleading." He apologized for publicly opposing cannabis legalization, saying there was "no scientific basis" to claim cannabis had no medical benefits. "We have been terribly and systematically misled for nearly 70 years in the United States, and I apologize for my own role in that," he wrote in a post on 8 August on He noted the high rates of prescription drug deaths, and said, "I couldn’t find one documented case of someone dying of a marijuana overdose." In January 2011, Gupta was named "one of the 10 most influential celebrities" by Forbes magazine.He said he did not look hard enough at research on the topic, and found some new research that had been done since then. He was encouraged to look into the issue further upon meeting a 5-year-old girl in Colorado for whom medical cannabis has sharply cut down on the amount of seizures she had been suffering. Time spent with her and others made him realize that medical professionals should be responsible for providing the best care possible, and that could include cannabis.

  3. J F Lydon MD Nov 01, 2013 - 11:19 AM

    I concur with a number of my colleagues who say that science & evidence based medicine should be the over-arching guide here.  PERHAPS certain isolated compounds- purified-rigorously studied per the FDA just maybe might show some value.   But this widespread "stoner" notion that it is only "Mother Nature" and should be widely legalized is absurd. To suggest that a plant in a dried leaf form, with hundreds of different compounds can be rolled up into a cigarette and smoked- to suggest THAT use is somehow "beneficial" is ridiculous.

    A substance which can trigger psychosis? Which conclusively shows adverse changes in learning, cognition, and structural changes in the brain? To make that substance widely available?



    As the saying goes "What kind stuff you smokin'?

  4. Ken S Oct 18, 2013 - 07:19 PM
    Lets face the facts people, the herb cannabis has been on this planet as of day one. Humans are NATURALY addictive, if it feels good do it, BIG surprise. Now combine that with being a criminal for possessing or using a natural growing plant is totally absurd. Then because weed is illegal, they make synthetic cannabis, which contains who the hell knows what and the dumb lawmakers wonder why people are CRAZY!!! Treat weed like alcohol, cigarettes, gambling, legal prostitution, riding your motorcycle with out a helmet, getting tattoos, gun ownership, and anything else that has legal, and age restrictions, and let it be, that is what America is all about. There is help out there if you got a problem ,but others just use and do not abuse. Tobacco Kills, Alcohol Kills, Weed just makes YOU kill a bag of chips.    
  5. Lynn Brown Nov 10, 2012 - 11:02 AM

    Iam in the situation of Chris with a child who is addicted to drugs.  My son started with marijuana which made him function at a sub optimal level during high school. He progressed to other drugs but continued to use marijuana.  He had a psychotic break asa result of drug overdose and a severe manic episode lasting four months.  Using a large amount of "medical"marijuana during that episode directly resulted in a psychotic incident where he needed to be hospitalized. After a period of abstinence he resumed use of drugs and rapidly escalated to heroin dependence, using marijuana regularly during the period. Attempts to stop using opiates failed even after near death overdose and attempts to stop marijuana use failed as well.  The times when my son actually accepted treatment for his addiction involved pressure from law enforcement as addicts resist treatment.  He is now getting treatment but the prospects for containing the addiction before he dies from overdose are uncertain. His future is bleak.


    The legalization campaign was very misleading because it suggested that marijuana was less dangerous than alcohol and would be a "safer"alternative. However, from what I have seen marijuana complements alcohol and tobacco and other substance use, so drug users add more and more substances to their repertoire with marijuana more or less a constant.  Continuing to use marijuana just primes use of other substances. Heavy marijuana users do have effects on the lungs and do use tobacco as well, often mixing them together.  The mentally ill also use marijuana at a higher rate than the general population in an effort to self-medicate.  Lots of young people are currently experimenting with a wide array of drugs and we as parents are left with the dysfunctional children, the lost years of no education, health care costs, legal costs; we are the collateral damage. These addicts may then have children and their children will be more collateral damage of damaged parents.  We can't separate marijuana from this mix because its effect on the  brain is similar, it is getting more potent, and it is part of polysubstance abuse/dependence.  It is not a safe alternative to alcohol.


    Instead of legalizing marijuana the proponents of legalization should  be trying to limit use of substances in young people starting with alcohol and marijuana.   If we can't limit youth use of alcohol and tobacco and marijuana currently, legalization will only exacerbate what is already a horrible situation.  Neither thecurrent system nor legalization are the path to treat addiction which continues to be misunderstood and swept under the rug.

  6. bob Jul 24, 2012 - 06:10 AM

    It's not the Cannabis which is the problem, it's the pattern in the brain. Use EFT to change the pattern.

    Don't blame it on the beautiful plant. Obesity is not caused by the food.

  7. Tom O'Connell mD Jul 03, 2012 - 02:09 PM
    The Ignorance and bias reflected by both the ASAM white paper and some of the comments are appalling. What they reflect is the degree to which the medically uninformed principles Watergate architects John Mitchell and Richard Nixon were able to insert into the Controlled Substances Act of 1970.That law is the intellectual provenance of the "war on drugs" and has been responsible for a cascade of social and medical disasters in the four decades since its passage. How that law can be repealed and whether our species can recover from its many similar blunders is, as yet uncertain, but the ASAM screed is not hopeful.
  8. Raul Sora May 31, 2012 - 07:22 PM
    As one of the physicians stated our patients are not criminals. Substance abuse and dependency have been damned as being a problem of criminals, the spiritually weak and of morally depraved individuals. It is the stance of our regulatory licensing agencies and the stance of the government in general. Psychiatric disorders are thinly veiled as ,'Diseases.' Once the veneer is off society deems them the problems of 'Bad people.' This society is too entrenched in puritan principles and too entrenched on the use of substances for a variety reasons. Maybe its time for the people to accept their emotional, psychic needs and for the government to stop trying to teach us to be good people.
  9. Ian Forster May 31, 2012 - 02:34 AM

    I am a Canadian Addiction and pain physician. In Canada we have "Legalised" medical cannabis. The rules for certifying a pain patient as being appropriate for cannabis use seem to ebb and flow depending on the pressures of the current government on the bureaucracy that runs the program. I wholeheartedly support the notion that if Cannabis is to be used as a "Drug" then it should be subject to all the scrutiny that any new drug coming to market receives. There is now some research underway and a few good studies are showing that there may well be advantages for some patients using cannabinoids. As with all drugs there are positive and negative effects as a result of drug use. A balanced opinion as to the wisdom of cannabis use in given situations is only going to be possible if full studies are done and subjected to scrutiny by such organizations as the FDA in the US and Health Canada here in Canada. Current use was as a result of a political decision and had no clinical evidence to support it. Now, it appears, we are stuck with it, and physicians have been put in the position of being the "Gatekeeper" for access. Not an enviable position.

  10. David Withers MD May 21, 2012 - 09:33 AM

    The negative effects of smoked marajuana are pretty well known.  The positive effects of smoking marijuana are not well known and may be slim or none.  This is 2012.  It should be evidence based. 


    Seems political in nature.  We need to stick to science.  The roles of CB1 and CB2 receptors are getting better defined.  I am unaware of any drug used theraputically that is rolled up and smoked that is approved by the FDA.  If THC or congenors become useful in a big way, I would hope that the benefits outweigh the risks and the drug is not simply rolled up and smoked without oversight.

  11. Elizabeth Stuller, MD May 17, 2012 - 01:17 PM
    In my clinical experience as an addiction psychiatrist I continue to advocate that cannabis has negative impact on the brain. We repeatedly see on SPECT brain imaging, that cannabis usage typically causes decreased activity in the posterior temporal lobes bilaterally, and causes prefrontal cortex hypoperfusion. As the prefrontal cortex continues to grow until an individual is approximately 25 years of age, young adolescents and adults with immarture prefrontal cortexs with cannabis abuse and dependence are at increased risk including, cognitive impairment, lack of motivation and follow through, and poor executive function leading to increased risk taking and possible injury or death. Also please be mindful that this policy does not address the ongoing problems we are seeing now with the rampant production of synthetic cannabis such as K2 and Spice. See Dr Amen's article on High Resolution Brain SPECT imaging in Marijuana Smokers with AD/HD. Journal of Psychoactive Durgs, Volume 30, No.2 April-June 1998. Pgs 1-13.
  12. ed wilson May 17, 2012 - 10:28 AM

    I agree with the position statement completely. I see no reason MM could not be used for proven benefit, but would highly restrict it. Dosage forms need to be difficult to divert to different administration forms, e.g. unsmokable tablets. Physicians should be under threat of losing DEA license if prescribing MJ off label (or for what they are doing now in states that allow MJ prescribing).

  13. Dwight Burdick, MD May 17, 2012 - 04:11 AM

    We are making a grave mistake in joining any effort to support new legal controls over the use of marijuana as medication. Marijuana does not currently meet scientific criteria for safe use as a medicine. Ethical physicians have no business being involved in the peddling of snake oil. Until there is scientific evidence proving medical benefits which outweigh the medical risks, ASAM is incorrect in any attempt to address this issue with any legislation or regulation other than those presently governing the use of medication by physicians. At the same time we should support ethical scientific research into the potential pharmacological benefit of any old or new substance.

    In the same vein, we should oppose the insertion of legal measures into purely medical issues such as the recreational abuse of substances. Legal measures are ineffectual, even counterproductive, and can only fail in motivating change. We of ASAM are physicians obligated to address medical issues with medical responses.

    Those who fail to learn from history are doomed to repeat it.

    Our patients are patients, not criminals.

    We are physicians, not lobbyists.

  14. Joe Troncale, MD May 16, 2012 - 10:40 PM

    I find it very interesting that politics reigns over science in this matter. Show me one scientific paper where cannabis is a life-saving drug of choice for the treatment of any significant illness. 

    There is no such literature.

    The potential side effects of the substance are well documented and have shown to be unacceptable such as depression and suicide. Addiction to marijuana in a significant percent of users (6-8) is real and well-documented. There are black box warnings on many drugs that are much less dangerous than cannabis. The push for legalization has more to do with putting money in pockets than helping patients.

  15. David Mathis DO May 16, 2012 - 10:06 PM
    It is my understanding that research is underway using analogs of cannabis for several potential medical uses including cancer, diabetes and inflammatory diseases. Do you have any details on current research results for medical use?
  16. Peter Sanchez, MD May 16, 2012 - 09:10 PM

    Allow the FDA to investigate and study cannabis for medical purposes and let the federal government oversee its distribution and safety

  17. Karen Andresen Mar 14, 2012 - 03:45 AM

    My high school son had a big addiction problem to cannabis, as well as the other boys in treatment in Utah. We had to resort to sending him out of state and away from the negative influences. He was an A student and Boyscout, and now he lacks motivation and is using again, after a year away. .I hope California does something to protect its citizens from drug abuse. There is a lot of work to be done in this state.


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