Physicians' Perspective

MEDICAL CANNABIS UPDATE: SMOKELESS MARIJUANA

Oregonians passed the Oregon Medical Marijuana Act (OMMA) in 1998 and
will vote this fall to upgrade the OMMA. [Vote Yes on Measure 33,
discussed elsewhere this issue.]

Most Americans support medical cannabis (marijuana) and agree patients
should not be arrested for using marijuana under medical supervision.
Nevertheless, the most criticized aspect of medical marijuana is the
smoke. The question is, can patients benefit from cannabis without
inhaling smoke and the cancer-causing agents (carcinogens) created
when plants combust?

There are no studies showing cannabis smoking causes cancer or
emphysema, but cannabis smoke contains measurable carcinogens. We know
smoking marijuana can cause irritated airways (bronchitis) with cough
and chest pain. The prestigious Institute of Medicine issued a report
in 1999 agreeing cannabis is medicine but expressing concern about
smoke. The highest risks for long-term cannabis smoking are seen in
regular users, including patients.

In the past, if one needed immediate benefit from cannabis to control
vomiting, one had to smoke it. Eating cannabis or swallowing
FDA-approved Marinol (synthetic THC) requires an hour to work. Smoking
works almost immediately and so is attractive to those seeking
immediate relief from pain, spasm, nausea, etc.

Fortunately, there is an alternative to smoking cannabis called
vaporizing that avoids nearly all carcinogens but offers the rapid
relief previously found only by smoking. Cannabis releases medicinal
vapors above 140 C (284 F) but doesn't release benzene and other
carcinogens until it reaches 200 C (392 F) and will not combust
(release smoke) until it reaches 230 C (446 F).

This means if a device gently cooks cannabis at 140 to 190 C (284 to
374 F), one can inhale the herbal medicine in the smokeless vapor
without inhaling the carcinogens found in smoke.

Fortunately, smokeless cannabis inhalers are available now. If you
know patients who smoke cannabis, make sure they know about
vaporizers. At my website www.omma1998.org, link to the medical
cannabis bibliography and look under scientific articles online for a
detailed discussion of vaporization and vaporizers.

Why don't all patients use them? The primary obstacle is cost, with
the best vaporizer being over $500. Hopefully, as medical cannabis
becomes more accepted, relaxation of paraphernalia laws will combine
with product demand to make vaporizers affordable.

Another obstacle is some persons do not tolerate inhaling any
medicine. Even asthma inhalers irritate our airways, taste bad, and
take practice to use correctly. The vapors from standard medical
cannabis are almost entirely botanical/natural THC, which does not
cause cancer or emphysema but can irritate airways.

One way to minimize risk of irritation to airways is to ingest
cannabis by mouth to control predictable symptoms and inhale vaporized
cannabis to control unpredictable symptoms. This would include
"breakthrough pain" or pain that occurs in spite of the regular dosing
of oral pain medicine. This type of protocol would be consistent with
modern pain treatment standards.

Like other dried powdered herbal medicines, one can easily make
capsules from cannabis after heating 10 or more minutes at about 100
C or 212 F. The mild heating activates raw cannabis by removing a
carbon dioxide molecule. But if one uses too much heat, the medicinal
components vaporize. Heat activation occurs during the process of
vaporizing, smoking, or cooking cannabis, but for capsules, it's
useful to activate the cannabis before ingestion to make it more
potent and digestible.

Even on an empty stomach, oral cannabis takes an hour to work but
lasts 4 to 6 hours. The cost of cannabis capsules for most OMMA
patients is pennies compared to synthetic pharmaceutical THC (Marinol)
that can cost more than $20/pill and is without biologically active
compounds naturally found in botanical cannabis. One can only hope the
ability to grow one's own medicine will increase access to medicine
for Oregonians as the Oregon Health Plan shrinks and drug costs
continue to skyrocket.

Treatment of pain or other symptoms in any patient routinely requires
adjustments or titration of dose. Cannabis offers an advantage because
no lethal overdose exists, which makes it safer than standard pain
treatment medicine offered by the pharmaceutical industry. Cannabis
represents a legitimate alternative in many treatment situations. If
risks of smoking are removed, the risk of cannabis is the same as THC
described at www.marinol.com

With harm reduction technology like vaporization, economy of growing
one's own medicine, and no lethal overdose from cannabis; patients and
doctors have another tool to ease human suffering.