Before 1930, Fremont, Neb., farm fields were plush with hemp (cannabis), not corn. A large factory in Fremont processed hemp to make cords to bind wheat. When hemp production was banned by the U.S. government in the 1930s, the hemp plants remained and went “feral” in the ditches and riverbeds of Nebraska. Today, throughout Nebraska, marijuana and hemp grow well and wild from the Missouri River to the Wyoming state line. The tall cannabis plants provide coverage and food (seeds) for pheasants.
To date, millions of citizens in 14 states in the U.S. have legalized marijuana for use by patients as part of their medical management of chronic disease conditions, such as the “wasting syndrome” of HIV/AIDS and for cancer patients who are affected by severe nausea and vomiting due to radiation or chemotherapy. In February 2010, the Iowa Board of Pharmacy voted 6 to 0 to recommend to the Iowa legislature that medical marijuana be studied and adopted for use by residents of Iowa. The Iowa legislature will consider the recommendation in its 2011 session. The American Medical Association also has recently recommended that marijuana be lowered by the U.S. Drug Enforcement Administration (DEA) to a class of scheduled drugs to permit researchers to further scientifically validate the efficacy and appropriateness of medical marijuana in health care settings.
Historically, for thousands of years, cannabis has been used for many things: food, clothing, sails and rigging, and shelter (the clothes worn by our forefathers and the tops of covered wagons that crossed the Nebraska prairies were derived from cannabis). Cannabis extracts have been used medicinally for centuries. Prior to the U.S. government ban, these medicinals were widely manufactured and marketed by the Parke-Davis company.
There are two paradigms in modern medicine. The first paradigm is evidence-based medicine, which is derived from knowledge and experience validated by scientific analysis of evidence. Evidence-based medicine has superceded belief-based medicine, which is derived from judgment, intuition and beliefs untested by scientific principles.
The second paradigm of modern medicine is patient-centered medicine. Patient-centered medicine incorporates the patient’s personal values (moral, religious, ethical) into medical decision making. Integrating patient preferences into therapeutic plans increases the likelihood of better patient outcomes. Doing so emphasizes the totality of the patient’s life and experiences due to the impact of their diseases versus the traditional absolute focus only on the patient’s disease itself.
In 1925, Francis W. Peabody stated, “The secret of the care of the patient is in caring for the patient.” Caring for the patient means that the role of the health care provider is to accurately diagnose the patient, emphasizing total experience, not disease; find out what the patient and his family wants; help patients find the appropriate, right information for them; support patients throughout the decision-making process; measure outcomes and the efficacy of any treatment plan.
So, the two paradigms of modern medicine come together with the discussion of medical marijuana. Is there evidence of medical marijuana’s appropriateness and efficacy in modern health care and do some patients want the legal ability to choose to try medical marijuana after they have been carefully evaluated by a knowledgeable, caring health care professional? In 14 states, millions of law-abiding citizens have said, “Yes.”
The chemical constituents in marijuana vary greatly. The main psychoactive ingredient (TetraHydroCannabinol or THC) belongs to a group of chemicals known as cannabinoids. The good news is there are numerous cannabinoids and other chemical constituents in the marijuana plant that are not psychoactive but do have potential medical benefit. Researchers want the ability to clarify the chemical nature and clinical pharmacology of these nonpsychoactive cannabinoids.
Botanists who have studied the gene pool of the cannabis plant can selectively design and clone marijuana plants to contain only those cannabinoids of benefit to patients, while deleting or minimizing cannabinoids with adverse effects (psychoactive or cardiovascular effects such as tachycardia or hypotension). These designer plants are known as “chemovars.” The external appearance of the plants (phenotypes) look very similar, but the chemical constituents that are directed by the genetic information within the DNA (genotypes) of the plants can vary markedly.
Proponents of medical marijuana know that marijuana, as one substance only, has a broad effect on many aspects of chronic conditions: perception of and coping with pain, the control of nausea and vomiting, the relief of anxiety and depression, etc. Melissa Etheridge, a breast cancer survivor, famously said, “Instead of taking five or six of the prescriptions, I decided to go the natural route and smoke marijuana.” The broad beneficial action of marijuana is starkly contrasted with the selective “magic bullet” of most modern expensive proprietary medications.
Over the last 12 years, citizens, law enforcement and elected representatives in 14 states have agonized, debated and legislated medical marijuana use in their states. The state closest to Nebraska with Nebraskan values that allows medical marijuana use is Montana. The Montana template could serve as a basis to begin the study of appropriate evidence-based use of medical marijuana in Nebraska.
It should be understood by everyone that the characteristics of medical marijuana users differ greatly from recreational marijuana users. The distinguishing characteristics include:
- The majority of medical marijuana users are adults, not adolescents.
- The majority of medical marijuana users begin marijuana use when they are over 35 years of age and did not abuse marijuana as adolescents.
- The majority of medical marijuana users are articulate and have completed high school, and many are or have been gainfully employed with advanced university degrees.
- The majority of medical marijuana users would discontinue regular marijuana use if their underlying medical condition were completely cured.
- The majority of medical marijuana users are sincerely concerned about their quality of life and its impact upon others.
- The majority of medical marijuana users, prior to suffering from their current medical condition, were gainfully employed and responsible contributors to family, society and the workforce.
- The majority of medical marijuana users are willing to return to the workforce and positively contribute to society if their symptoms improve.
- The majority of medical marijuana users are behaviorally, emotionally and psychologically normal.
- The majority of medical marijuana users do not have a criminal record and do not pursue criminal activities to obtain marijuana.
- The majority of medical marijuana users do not use marijuana recreationally or in social situations.
- The majority of medical marijuana users do not simultaneously use or combine their marijuana with alcohol, tobacco or other illicit substances.
- The majority of medical marijuana users do not have any curiosity or interest in using more addicting or dangerous illicit substances such as cocaine, heroin, LSD, methamphetamine, Ecstasy (MDMA), etc.
- The majority of medical marijuana users titrate their use of medical marijuana to attain the maximum therapeutic effect with the minimal amount of adverse marijuana use side effects, intoxication or the marijuana “high.”
- The majority of medical marijuana users show no evidence of the purported “amotivational syndrome.”
- The majority of medical marijuana users are not “risk takers” and do not seek “stimulation” or escape from boredom by using marijuana.
- The majority of medical marijuana users are not under “peer pressure” to use marijuana.
- The majority of medical marijuana users are goal-oriented, motivated to live the best life possible under their current circumstances and generally are law-abiding citizens.
- The majority of medical marijuana users have strong political views concerning “patient choice,” based upon their personal values, that incorporate the use of medical marijuana and other scientifically validated therapies universally, under medical supervision, for adults who have bona fide, qualifying, approved medical conditions.
- The majority of medical marijuana users do not exhibit “abstinence” signs or symptoms if marijuana use is abruptly terminated.
- The majority of medical marijuana users do not continue to use medical marijuana if they feel the marijuana is of no benefit to the control of the signs or symptoms of their medical condition.
Since marijuana is not available by prescription (being a DEA Schedule I drug along with heroin and LSD), marijuana can only be recommended by health care providers in those states where medical marijuana is legal. Licensed health care providers should ethically be 100 percent detached from other aspects of the lucrative medical marijuana industry. They should not own or operate licensed marijuana dispensaries nor should they aid or abet patients in the procurement of medical marijuana. Additionally, the same standard of care needs to be applied to patients considering the use of medical marijuana for approved conditions as would be applied for the management of a patient with any other medical condition such as diabetes mellitus or Alzheimer’s disease.
There is a “gold standard” of care for medical marijuana patients that caring health care professionals should self-impose and strive to attain. Components of this gold standard include a true, established health care professional-patient relationship, including all aspects of a complete written or electronically documented medical record as well as an appropriate multidimensional treatment plan. Careful management, monitoring of outcomes and evaluation of the treatment plan are also needed. Each Doctor of Medicine states, in the Hippocratic Oath upon receiving his or her medical degree, “Primum non nocere”—“First, do no harm.” If and when Nebraskans weigh the benefits and risks of medical marijuana in approved medical conditions in the future, evidence-based medicine, patient-centered medicine and “First, do no harm” need to be the primary focuses of the discussion.