What has come over this country? Some 60 percent of Michigan voters decided to swing in favor of a proposal regarding the use and cultivation of marijuana. The new law will permit physician approved use of marijuana by registered patients with debilitating medical conditions — ignoring the fact that physicians cannot prescribe marijuana without breaking federal law. The law also will allow registered individuals to grow limited marijuana for personal consumption. In essence, Michigan has made a decision about medical practice that physicians in general do not accept.

This isn’t particularly surprising since numerous other states have already gone through a similar process and since a number of physicians are growing increasingly vocal regarding their desire to prescribe marijuana. Why though? Why is this drug — which is supposedly of medical value for nausea or pain under certain circumstances — invoking so much fervor on the part of the populace? There are many medications not available to the public — some because they are dangerous; some because they do not represent a value for the pharmaceutical industry; and some because they have not yet been fully studied. I didn’t see any of these medications on state ballots in November.

Let’s see how a medication gets approved in those cases where approval isn’t a result of mass hysteria:

1) Obtain thorough prospective placebo-controlled studies demonstrating superior outcome from the test drug beyond that obtained by placebo and equal or superior outcome from the test drug when compared against other available interventions.
2) Determine, through intensive study, the risks of use of the test drug, ensuring that such risks are no more than they are for other equally efficacious drugs.
3) Determine, if the risk of use is higher for the test drug than for other available treatments, if the benefit of use is also higher such that a physician might say that the benefit of prescribing this drug is so high that the increased risk is acceptable.

So, we need to know that: marijuana is efficacious for certain medical conditions; it carries an acceptable risk level given the available benefit; and a certain method of taking marijuana has the best risk:benefit ratio. For example, an oral cannabinoid might be far more useful or far less risky than smoked marijuana.

There is one additional piece to the puzzle since, in this case, we’re talking about an addictive substance. There are enormous issues regarding availability; we know, for example, that opioids, sedatives and stimulants are all readily accessed and used by a significant percentage of the public without prescription. Stimulants, for example, are highly controlled yet are widely used without prescription. We also need to know about the risk of marijuana prescriptions to the unprescribed population. That is, if we can help one person but cause risk to 25 at the same time, perhaps it’s not worth helping the one person.

One might speculate that marijuana, though currently unable to be prescribed, is already widely available and that legalizing prescribing would not result in any significant increase in use. The history of Prohibition suggests that this supposedly intuitive argument doesn’t hold water. During Prohibition, there was significant use of alcohol but use dramatically increased after Prohibition ended. There are undoubtedly many for whom the legal barrier represents a significant deterrent.

• Available drug is of questionable purity
• Available drug comes through illegal channels, sometimes with inherent risk
• Available drug might include pesticides and/or other unknown substances
• User might be arrested, lose a job or be unacceptable for a new position

If all those obstacles disappear, imagine the number of people who have not used who might now try the substance.
Massachusetts voters joined their friends in Michigan in November, in this case approving decriminalization of small amounts of marijuana. Apparently, the voters in Massachusetts didn’t care that 56 percent of teens admitted for substance treatment in their state were using, primarily, marijuana. They ignored the medically relevant dangers of the potent marijuana currently available. They bought into the argument that reduction in law enforcement of widespread marijuana use would result in better availability of law enforcement for other more serious issues.

We don’t have any good studies to demonstrate significant value from smoked marijuana. That’s not to say there is no value, but simply that such value hasn’t been demonstrated to the level that we demand of prescribed medication. We have an enormous literature detailing the risks of marijuana use; such risks are likely not going to be present in an end-of-life treatment scenario. Rather, the risks will be present to the adolescents coming into the home of this scenario and finding marijuana just as easily as they now find opioids and sedatives. The risk here is significant. Also, we have not yet determined that the risk is worth the benefit, since there may be many other ways of providing cannabinoids in a manner that are non-addictive and of no interest to those not prescribed the drug, yet still providing useful anti-pain and anti-nausea efficacy.

In the midst of widespread economic hardship, all of us will be very busy with new patients, all as a result of the public’s lack of interest in scientific credibility and increasing desire to forget about their own economic difficulties, perhaps through the use of a more readily available chemical. What is it about marijuana that has the majority of this country willing to ignore all the data reflecting the significant harm caused by that drug? Why is this even a political issue up for general debate? I’m happy to hear feedback at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

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