Why I voted Against Amendment #2 (Medical Marijuana)

written by Matthew Rensberry, MD MBA on 2014-10-23

I early voted in Florida in the 2014 election. This is why I voted against Amendment #2 (Medical Marijuana).

A little background:

I am a physician and I usually lean libertarian in my thoughts. I personally do not care what a fellow American wants to eat, drink, smoke, do, etc. As such, before looking into this amendment, I expected myself to not care whether it passed or didn’t. As I looked into this subject, I was surprised at my conclusions.

My conclusions:

Marijuana, as it is currently, should not be viewed as a medicine – the current scientific level of evidence is highly inadequate and does not support medicinal use of marijuana.
This amendment is bastardizing the medical community and my profession specifically, for which I am a bit personally offended now that I know and understand more on the subject.

The facts:

Re: use as an antiemetic: There are only 4 studies who compared cannabinoids vs alternatives, they were highly variable in results, and demonstrated frequent side effects (Ref 1)
Re: use for epilepsy: There are only 4 randomized controlled studies with only 48 people and found insufficient evidence. No reliable conclusions on efficacy can be drawn. (Ref 2)
Re: use to reduce morbidity and mortality with HIV/AIDS: There are 7 studies with evidence lacking for efficacy and safety (Ref 3)
Re: use for neurological disorders: Here there is a little bit more evidence as oral cannabis extract is effective for spacticity and central pain, though THC and nabiximols were not. Nabiximols were effective for urinary dysfunction. (Ref 4)
Re: use for tremor: Found ineffective (Ref 4)
Re: use for pain: There is no evidence of effectiveness for acute pain. None of the 5 head to head studies showed superiority of cannabinoids to diphenhydramine, codeine or amitriptyline for pain relief. For pain relief, a daily dose of 10mg THC is necessary, though doses over 15mg results in considerable adverse effects (Ref 4)
Re: use for glaucoma: Current evidence shows probably not effective in reasonable doses
Re: use for insomnia: a small study showed improvements in patients with fibromyalgia
Adverse effects of marijuana use: Addiction (17% in adolescence/9% all users), MVA, chronic bronchitis, diminished lifetime achievement, altered brain development, schizophrenia, depression/anxiety (Ref 5)
Withdrawal effects: Irritability, difficulty with sleep, anxiety, cravings, dysphoria (Ref 5, 6)
Science has demonstrated that the part of the brain that regulates planning for complex cognitive behavior, personality expression, decision making and social behavior — is not fully developed until the early to mid-20's. It has also shown that marijuana delays/stunts this development.
There are currently multiple cannabinoid medications who have met standards and are in use (dronabinol, nabilone, nabiximols) indicated for chemo induced nausea and vomiting

Medical Profession Positions:

AAFP: …usage should be based on high quality, patient-centered, evidence-based research and further studies into the use of medical marijuana and related compounds. Request FDA change from Schedule 1 drug to Schedule 2 so it can be studied and evidence gathered.

FMA: Opposes Ammendment 2

American Psychiatric Association: "There is no current scientific evidence that marijuana is in any way beneficial for the treatment of any psychiatric disorder...

AAP: Oppose legalization of marijuana. Support research into marijuana's potential therapeutic role

ACP: Support research into marijuana's potential therapeutic role.

AMA: AMA urges that marijuana’s status as a federal Schedule I controlled substance be reviewed with the goal of facilitating the conduct of clinical research and development of cannabinoid-based medicines, and alternate delivery methods. This should not be viewed as an endorsement of state-based medical cannabis programs, the legalization of marijuana, or that scientific evidence on the therapeutic use of cannabis meets the current standards for a prescription drug product

ACA: ACA does not advocate the use of inhaled marijuana or the legalization of marijuana.

My thoughts now:

The [scientific evidence is extremely weak regarding marijuana as a medicine]. To be intellectually consistent, no one can currently claim that marijuana has a medical use. At best, the LOE is level 3 with a SOR C. (see here for definition)
Marijuana warrants further study, and thus [should be changed from a Schedule 1] controlled substance
Should evidence mount for medical use, it [should be subjected to the standards of all medications] and regulated by the FDA
[No current medication exists in a smoked form] due to potential risks and unknown dose range
This amendment is a veiled attempt to [make recreational use legal through whoring of the medical profession] and community. I do not like this. I am against it.
As for recreational use: I do not care if a person wants to use it. As a physician, I recommend against it. [Given the scientific body of evidence surrounding delayed/stunted brain development, diminished lifetime achievements, 8-10 point decrease in IQ associated with marijuana use, and increased rates of ADHD, inattention, depression and anxiety] - I would advocate for a [minimum age of 22 or 23 for recreational use] to allow as much brain maturation before marijuana use would diminish it.
In researching this, I found a resourcewho seems to have taken a wise, prudent, and intellectual approach to this issue. I recommend browsing this site.

References:

Thanks to Dr Keehbauch for an excellent lecture on this helping me to present my evidence in a logical manner and helping point me to evidence based references.

1 Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD007786

2 Cochrane Database of Systematic Reviews. 2012; 6: CD009270.

3 Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD005175.

4 Koppel BS, Brust JCM, Fife T et al. 2014 Neurology. 82:1556-1563

5 N Engl J Med. 2014 Jun 5;370(23):2219-27.

6 Adverse health effects of marijuana from NEJM blog