Tag: medical marijuana

08/3/15

Is the Cart Before the Horse?

11088571_sSenators Dianne Feinstein and Charles Grassley wrote a brief article for Time that highlighted the effectiveness of CBD oil, a product derived from cannabis, in treating the debilitating seizures of a little girl. Her father, an ER doctor, said it took just 36 hours to see profound changes. However, CBD (cannabidiol) oil is not approved by the FDA; and there is no guarantee that the formulation of each batch will be the same. A one-month supply can cost up to $2,500; and the girl’s parents are forced to pay $100 per bottle if they want to verify the contents. “Simply put, we need to know more about CBD, and the only way to gain that knowledge is to remove barriers to research.”

The Time article has a 16-minute video linked, which reviews the issue in more detail and mentions some of the problems with the current state of regulation and research into medical marijuana. I’ve written several other articles on the legalization of marijuana and have a concern that the current practice of state-by-state approval is creating greater problems for the legitimate use of medicinal cannabis products; problems that must be addressed by federal action. The potential for CBD products should be fast tracked to confirm their medicinal use.

Currently, medical marijuana products are typically high in THC, the psychoactive cannabinoid in marijuana, and low in CBD. Compared to CBD, THC has limited medical benefits. But it is the only “therapeutic” agent in the vast majority of medical marijuana products. It seems this crucial and basic understanding of medical marijuana is not widely known or understood. It may be that many “medical” marijuana users don’t care. But it begs the following question—is the current process of state-by-state approval just a “smoke screen?” Is what is actually happening with medical marijuana just the first stage of national legalization of recreational marijuana use?

There is real, legitimate potential for the use of cannabis-based medicines. But they should pass through the same FDA gauntlet that other medicines have, even though the process itself in not perfect. It was put in place because of past abuses and the resulting dangers to public consumers from other so-called miracle cures. Let’s not ignore the past and repeat its mistakes.

The June 23/30 2015 issue of JAMA, The Journal of the American Medical Association, contained several articles related to medical marijuana. Three of them are reviewed below. They address both the potential benefits and consequences with medical marijuana. One article raises the concern embodied in the title of this article: are we putting the cart before the horse in rushing to approve medical marijuana without taking the time to scientifically assess its pros and cons?

Vandrey et al. in a JAMA research letter reported on edible cannabis products that they purchased from three randomly selected dispensaries in three cities: Los Angeles, San Francisco, and Seattle. Of the 75 different products purchased from 47 different brands, only 17% were accurately labeled with respect to their THC content. Twenty-three percent were underlabeled (contained more THC than claimed on the label); and 60% were overlabeled (contained less THC than claimed on the label). Some of the overlabled products contained negligible amounts of THC.

The non-THC content of tested products was generally low. Forty-four products (59%) contained detectable levels of CBD. But only 13 had their CBD content labeled. Four products were overlabeled and nine were underlabeled.

Whiting et al. did a systematic review and meta-analysis, “Cannabinoids for Medical Use,” of randomized clinical trials of cannabinoids for various conditions: nausea and vomiting due to chemotherapy, appetite stimulation in HIV/AIDS, chronic pain, spasticity from multiple sclerosis or paraplegia, depression anxiety disorder, sleep disorder, psychosis, glaucoma or Tourette syndrome. They used a methodology designed to reduce the risk of publication bias in their analyses.

The study concluded there was moderate-quality evidence for the use of cannabinoids (smoked THC and nabiximols) to treat chronic pain and spasticity. There was low-quality evidence to support using cannabinoids for nausea and vomiting due to chemotherapy, weight gain in HIV infection, sleep disorders and Tourette syndrome. There was very low quality evidence for improvement in anxiety as assessed by a public speaking test. There was some evidence that cannabinoids (mainly nabiximols) were associated with an improvement in sleep. There was no evidence showing that cannabinoids helped in the treatment of depression or glaucoma.

Cannabinoids were also found to be associated with increased risk of short-term adverse events such as: dizziness, dry mouth, nausea, fatigue, drowsiness, euphoria, vomiting, disorientation, confusion, loss of balance and hallucination. The two studies that assessed the association between psychosis and cannabis found no difference in mental health outcomes, but they were judged to be at high risk of bias. There were no identified studies of long-term adverse events of cannabinoids, even when the searches were extended to lower levels of evidence than established in the initial methodology.

Doctors D”Souza and Ranganathan wrote an editorial for the same issue of JAMA, “Medical Marijuana: Is the Cart Before the Horse?” They raised the same concern Whitling et al. found, namely that for most of the indications that qualify by state law for medical marijuana, the supporting evidence for its use is of poor quality. “For most qualifying conditions, approval has relied on low-quality scientific evidence, anecdotal reports, individual testimonials, legislative initiatives, and public opinion.” So state and federal governments should support and encourage research so that high quality research on medical marijuana can be done for the conditions for which the existing evidence is insufficient or of poor quality.

They also noted how there are inconsistencies from state to state in how conditions are qualified for medical marijuana use. One example noted was that posttraumatic stress disorder was approved as a qualifying condition in some, but not all states. Unlike most FDA-approved drugs, marijuana has over 400 compounds; and there isn’t a uniform composition of the cannabis preparations. “Given the variable composition, patients will have to experiment with different strains and doses to achieve the desired effects,” a process known as titrating. The patient is looking for the personal Goldilocks dose—not too high and not too low.

While the acute adverse effects are known, the effects of repeated exposure, as would occur with medical marijuana needs further study. The risk of addiction, and a smaller risk of psychotic disorder were discussed. The interaction of marijuana with other drugs concurrently prescribed needs further study. They suggested that medical marijuana be added to monitoring databases along with opioids and benzodiazepines, so doctors would have a more complete understanding of the medication profile of their patients.

The human endocannabinoid system is involved in a variety of physiological processes such as appetite, pain-sensation, mood and memory. And there are two known cannabinoid receptors, CB1 and CB2. THC is a direct “fit” with the CB1 receptor, while another cannabinoid, cannabinol fits with CB2. The receptors are predominantly found in the brain (CB1) and the immune system (CB2). Cannabidiol (CBD) does not directly fit with either receptor, but has powerful indirect effects that are still being studied. See this graphic representation of the human endocannabinoid system.

“Emerging evidence suggests that the endocannabinoid system is critical in brain development and maturation processes, especially during adolescence and early adulthood.” This ongoing development of the system during adolescence then raises questions on what age exposure to medical marijuana is justifiable. Brain development continues until the age of 25. “Changes in the endocannabinoid system have been linked to affective, behavioral, cognitive and neurochemical consequences that last into adulthood.”

In conclusion, if the states’ initiative to legalize medical marijuana is merely a veiled step toward allowing access to recreational marijuana, then the medical community should be left out of the process, and instead marijuana should be decriminalized. Conversely, if the goal is to make marijuana available for medical purposes, then it is unclear why the approval process should be different from that used for other medications. Evidence justifying marijuana use for various medical conditions will require the conduct of adequately powered, doubleblind, randomized, placebo/active controlled clinical trials to test its short- and long-term efficacy and safety. The federal government and states should support medical marijuana research. Since medical marijuana is not a life-saving intervention, it may be prudent to wait before widely adopting its use until high-quality evidence is available to guide the development of a rational approval process. Perhaps it is time to place the horse back in front of the cart.

07/27/15

Clearing Away the Medical Marijuana Smoke

© lunamarina | stockfresh.com
© lunamarina | stockfresh.com

There have been some studies that demonstrate potential medicinal benefits of marijuana use, but they often don’t meet the clinical trial standards used by the FDA to approve medications for human consumption. With the state-by-state movement to legalize marijuana progressing, there is a need for quality scientific research into the potential medical benefits of marijuana. Although marijuana has been used recreationally and medicinally for centuries, the mechanics of how it works are not clearly understood. This is partly because there are over 400 different chemicals in cannabis. THC, the psychoactive ingredient in cannabis, was just isolated in the 1960s. What follows are reviews of some articles that look at the benefits and the concerns with medical marijuana.

Marijuana has been used as a folk medicine as far back in time as five thousand years ago. The first medical use likely occurred in Central Asia and spread from there to China and India. The Chinese emperor Shen-Nung is known to have prescribed it in 2800 BC.  Between 2000 and 1400 BC it came to India, and from there to Egypt, Syria and Persia. The Greeks and Romans valued marijuana as hemp for ropes. Europeans ate its seeds and used its fibers to make paper. An urban legend falsely held that the U.S. Constitution, Declaration of Independence, and Bill of Rights were written on hemp paper. All three were actually written on parchment.

An Irish doctor, W. B. O’Shaughnessy, working in Calcutta in the 1830s, wrote a paper on the medical uses of cannabis, which were strikingly similar to those known today—vomiting, convulsions and spasticity. By 1854, the medical use of cannabis was listed in the US Dispensatory. Nineteenth-century physicians had cannabis tinctures and extracts for ailments from insomnia and headaches to anorexia and sexual dysfunction. “Cannabis-containing remedies were also used for pain, whooping cough, asthma, and insomnia and were compounded into extracts, tinctures, cigarettes, and plasters.”

The above short history on the history of medical marijuana was taken from an article by J. Michael Bostwick, “Blurred Boundaries: The Therapeutics and Politics of Medical Marijuana.” He noted how the term medical marijuana refers to botanical cannabis, which contains hundreds of compounds—including the two most often used medicinally, THC and cannabidiol (CBD). Synthetic cannabinoids are produced in a laboratory. Botanical cannabis attracts the notoriety and controversy—because it is the same substance used recreationally by “stoners” to get high.

Bostwick noted how the recreational and medical marijuana use of marijuana is not always distinct, which has medical implications for both seasoned and naïve users. For example, naïve users may decide to stop using medical marijuana because of the psychoactive effects of the THC. Although most users will experience a mild euphoria, a few experience dysphoria, anxiety and even paranoia.

As cannabis strains are bred that amplify THC content and diminish counteracting cannabidiol, highs become more intense but so do degrees of anxiety that can rise to the level of panic and psychosis, particularly in naive users and unfamiliar stressful situations.

The Bostwick article reviewed the often-blurred relationship between medical and recreational users. He discussed a Canadian study that found medical cannabis use often followed recreational use; and that most medical users continued using marijuana recreationally.  Another study of 4100 Californians found that medical users preferred inhaling their medication. Smoked cannabis has a more rapid response and is easier to titrate so that users get the analgesic effects without the higher levels favored by recreational users seeking the high. Given some of the medical problems from smoking marijuana, using vaporizers or nasal sprays may be an effective alternative delivery system.

Doctor Robert DuPont, in his book The Selfish Brain: Learning from Addiction, referred to marijuana as “a crude drug, a complex chemical slush.” Marijuana and hashish contain over 420 different chemicals, falling into 18 different chemical families. THC and cannabidiol (CBD), are only two of sixty-one cannabinoids, chemicals found only in the marijuana plant. THC is highly soluble in fats, and this quickly passes the blood-brain barrier. The factor, plus the fact that it is insoluble in water, means that it is trapped in bodily organs like the brain and reproductive glands, remaining there of days or even weeks afterwards.

Grant et al. reviewed evidence on the medicinal usefulness of marijuana in “Medical Marijuana: Clearing Away the Smoke.” They noted that most of the studies on the efficacy and safety of cannabinoids for pain and spasticity have occurred since the year 2000. A series of randomized studies at the University of California Center for Medicinal Cannabis Research (CMCR) found that cannabis significantly reduced pain intensity. A significantly greater proportion of individuals reported at least 30% reduction in pain on cannabis; the threshold of decreased pain intensity generally associated with improved quality of life. Medium doses of 3.5% THC cannabis cigarettes were as effective as higher dose (7% THC).

Oral preparations of synthetic THC (dronabinol, Marinol) and a synthetic THC analogue (nabilone, Cesamet) are legally available. Studies suggest that dronabinol significantly reduces pain. The effects on spasticity are mixed: “there may be no observable change in examiner-rated muscle tone, but patients report significant relief.” There has been less research done with nabilone, but there have been reports of modest analgesia. Dronabinol and nabilone are FDA-approved for control of acute and delayed nausea and vomiting from cancer chemotherapy.

Alternative delivery systems for cannabis include vape-pens, sublingual devices, and others that use a metered spray device. The advantages to such systems seem to be the use of known cannabinoid concentrations, predetermined dosing portions, and time-out systems that may help prevent overuse.

There are side effects, which are dose-related in terms of severity. Grant et al. reported that they seem to decline over time and are of mild to moderate severity. “Reviews suggest the most frequent side effects are dizziness or lightheadedness (30%-60%), dry mouth (10%-25%), fatigue (5%-40%), muscle weakness (10%-25%), myalgia [muscle pain] (25%), and palpitations (20%).” There is little data on a timeline of adverse or therapeutic effects. There have been concerns that rapid tolerance to adverse effects may indicate a corresponding tolerance to beneficial effects. But studies of oral sprays in multiple sclerosis report that you can reduce the incidence and severity of adverse effects by downward self-titration without loss of analgesia.

There are additional adverse effects, including some psychiatric side effects, especially with cannabis having high concentration of THC. See the original article for more specifics. The longer-term health risks of medicinal cannabis are unclear; most of the current evidence is based upon non-medical use. Some medical professionals indicate that effective medicinal use of cannabis requires significantly less marijuana than is typically consumed by recreational users.

In “The Current Status of Medical Marijuana in the United States,” Doctor Gerald McKenna noted how the majority of medical marijuana users in Hawaii claim they have chronic pain. He said a main problem in getting the medical profession to support the use of medical marijuana is that it is not widely used medicinally in a non-smoking form. “Authorizing use by inhalation of a drug with an unknown number of co-drugs contained in the same raw form is not supportable.” He said that supporting the use of medical marijuana by inhalation because users prefer it is akin to supporting the inhalation of any other drug taken orally. His impression is that medical marijuana laws have been passed “to bypass the illegality of marijuana.”

He did recommend removing marijuana from Schedule I controlled substance so research could be done more easily. “Until that research is done, stating that marijuana is useful for treating chronic pain, anxiety, post-traumatic stress disorder, depression, and other health conditions remains anecdotal and conjectural.”

It has become clear that the federal government needs to modify its resistance to reclassifying marijuana’s Schedule I Controlled Substance status to allow more quality research into its use and to fund that research. Otherwise, the current circus of inconsistent regulations from state to state, and unverified claims about the medicinal benefits of marijuana will have us back in the days of patent medicines, as far as marijuana is concerned. Further reflections on medical marijuana can be found in: “Let’s not Get Ahead of Ourselves,” “Is the Cart Before the Horse?” and “Marijuana Peek-a-Boo.”

06/15/15

Let’s Not Get Ahead of Ourselves

© iqoncept | stockfresh.com
© iqoncept | stockfresh.com

At the 249th annual meeting of the American Chemical Society, Andy LaFrate, the president and director of research of Charas Scientific presented the results his lab found on its analysis of marijuana. Average potencies are around 20% THC. He said that they have seen potency values approaching 30% THC. “As far as potency goes, it’s been surprising how strong a lot of the marijuana is.” But an unexpected consequence of that breeding for higher THC potency has been the lowering of CBD levels in many marijuana strains. CBD is the cannabinoid often touted for its therapeutic value. And unlike THC, CBD does not get people high.

There’s a lot of homogeneity whether you’re talking medical or retail level . . . One plant might have green leaves and another purple, and the absolute amount of cannabinoids might change, which relates to strength. But the ratio of THC to CBD to other cannabinoids isn’t changing a whole lot.

LaFrate said in a video, “Marijuana Testing Yields Fascinating Results,” that a lot of the time the CBD concentration is very low, sometimes too low for their equipment to detect.  The lack of CBD means that many of the hundreds of strains of marijuana actually are very similar, chemically. A lot of the medicinal benefits attributed to THC are actually from CBD, one of the 85 different cannabinoids that can be isolated from cannabis. Some of the most well known ones with known or presumed medicinal properties are reviewed in this crash course, Cannabinoid Profiles , by SC Laboratories and Weedmaps. The video makes the potential for medical marijuana sound exciting and almost limitless. But one thing seemed to be said over and over again—more research needs to be done.

LaFrate also looked for biological and chemical contaminants in the marijuana they tested and the results were surprising. “You’ll see a marijuana bud that looks beautiful. And then we run it through a biological assay, and we see that it’s covered in fungi.” He was startled to find just how dirty a lot of it was. Marijuana is a natural product, so there will be some microbial growth on it, said LaFrate. So the questions become: What’s a safe threshold? And which contaminants do we need to be concerned about?

Contaminant testing is not mandatory yet, but should be soon in Colorado. LaFrate noted that many samples had fungi or bacteria. Some marijuana products tested have butane, used to strip and concentrate THC from the plant. Other samples had heavy metals. He added that when you’re dealing with something like marijuana that’s been under prohibition for the last eighty years, scientific testing gives the consumer confidence that this is something that is safe. It seems that the state-by-state approval strategy of medical marijuana dating back to California has contributed to this issue with contaminants.

Not only can there be purity and contaminant concerns with cannabis, but the majority of the available varieties of cannabis are high in THC, the primary psychoactive ingredient, and low in CBD, the primary medicinal ingredient. Weedmaps provides a graphic of the eight known cannabinoids “that effect you most” with information on the claimed medicinal properties of the eight cannabinoids. A quick look shows that THC, “the most abundant and widely known” cannabinoid in marijuana has limited medicinal properties: it is an analgesic, it reduces vomiting and nausea, it suppresses muscle spasms and it is an appetite stimulant. The only medicinal property unique to THC in the chart is its appetite stimulant properties.

In contrast, cannabidiol (CBD) “may hold the most promise for many serious conditions.” And it’s the second most common in marijuana. In the CBD video found in Cannabinoid Profiles, Josh Wurzer, the Laboratory Director for SC Laboratories said when SC Laboratories began testing marijuana strains a few years ago, most plants were high in THC, typically 10% to 20%, with 1 to 1½ percent CBD. Now they are seeing strains with between 8 and 15 percent CBD and a concurrent 5 or 6 percent of THC. The higher CBD content occurs through the activation of a recessive gene in the cannabis plants. Wurzer said cannabis breeders have to find plants with the high CBD gene locked away and breed them. “The only way you can know if it is high in CBD is to test it.”

There was an experiment at the Institute of Psychiatry at Kings College, London, that looked at the relationship of the effects of the two main ingredients in cannabis, THC and CBD. You can see a video of a reporter participating in the experiment here. Her mixture of THC and CBD left her with the giggles: “No matter how hard I tried to take the experiment seriously, it all seems hilarious.” But with pure THC, it was a different story. “It’s horrible. It’s like being at a funeral . . . Worse . . . It’s just so depressing. You want to top [kill] yourself.”

On THC and CBD mixture, she said she seemed flippant; on pure THC, she just didn’t care. With pure THC, she was suspicious, introverted; “weird.” Every question seemed to have a double meaning. She felt morbid. “It’s like a panic attack.” The researchers used the Positive and Negative Syndrome Scale (PNASS), a standard test to measure changes in psychotic symptoms. On the PNASS sub scale used, changes above four was clinically significant; what would be associated with schizophrenic psychosis. She scored fourteen. The effects were temporary.

The suggestion is that high levels of THC “can play havoc with your mind.” Individuals with no history of mental illness and no predisposition to schizophrenia don’t seem to be at long-term risk of THC triggering this reaction. But is seems that CBD has a counteractive effect on the paranoid and psychotic effects of THC. Here is a link to several studies on the positive effects of CBD on schizophrenia found on Project CBD.

There is also an SC Lab/Weedmaps video on the problem with overmedicating with cannabis. The pro medicinal marijuana panel noted that there is a tendency to overmedicate because of the largely nontoxic effects of cannabis. “It’s really safe to take a large dose. And you don’t get a lot of hangovers.” But you do get psychotoxicity (perceived harm).  Bonni Goldstein, MD, the CannaCenters Medical Director said she recommends a process of titrating up—starting with a low dose and waiting to see what the effects are before you add more.

A second panel member, Mike Corral, the co-founder and agricultural Director of W.A.M.M (WO/Men’s Alliance for Medical Marijuana), said that in talking to researchers, medically effective doses are measured in micrograms; a gram should medically last as much as a week. “Invariably, we see people smoking, three, four, five, six, seven grams a day. We come from a stoner culture.” He said that he had no problem with people getting stoned, but that wasn’t medical use. He also thought there should be full legalization to separate the recreational and medicinal users.

Another panel member, Michael Backes, the Founder/Director of Cornerstone Research Collective, said: “Just because something has a drug safety profile that’s favorable, like cannabis does, doesn’t mean there aren’t potentially some issues.”  He noted that one of things they learned from a cannabis pain study is that there was a “sweet spot” of dosage for cannabis, “and you don’t want to go past it.” The graphic within the video read: “Just as a patient who underdoses, one who overdoses will not have their symptoms relieved, therefore exceeding the ‘sweetspot’ is a waste of medicine.”

He said people have to respect their dose more. You could use cannabis in an overdosage for years, with little changes that you don’t notice, because they accumulate over time. Although cannabis is a very nontoxic substance, it is pharmacologically active, “and you’ve got to respect it.” He noted that 10% of individuals will develop a dependency issue, and then he wondered how you counsel people who you know are doing too much. “And how do you convince them “Hey, it’s time to back off?’”

Marijuana legalization continues to move forward on a state-by-state basis, which creates problems in a number of ways. As the above information pointed out, there is not a good system of quality control and contaminant testing available yet, even in Colorado. The majority of marijuana strains available, including those for medical marijuana, appear to be high in THC (the primary psychoactive cannabinoid) and lower in CBD (the primary medicinal cannabinoid). Current dosing practices, according to a panel of pro-medical cannabis individuals, are too high for medicinal purposes and could over time, lead to health problems like “dependency issues.” A cannabis strain high in THC and low in CBD could trigger symptoms associated with schizophrenia.

Before marijuana is legalized in more states, it seems advisable to make some federal changes. First, marijuana should be reclassified as a Schedule II controlled substance. This would make the desperately needed research on the medicinal properties of cannabis easier to do. Second would be to appropriate more funds into medical marijuana research. Third would be to fund the development of marijuana strains that are much higher in CBD and lower in THC. Fourth would be using the established process of clinical trials with the FDA for confirming treatment possibilities for cannabinoids.

Legalization polls  (see this Pew Research Center poll) that distinguish recreational marijuana use from medicinal marijuana use show that more Americans in favor of legalization fall into the medicinal camp. These suggestions would be consistent with the poll’s findings. Legalizing medical marijuana without these steps puts us back to the days of patent medicine. Medical marijuana should be treated like all other substances proposed as medicinal treatments for humans. Let’s not make the mistake of treating marijuana as a special case that doesn’t need to go through the same approval process for all other proposed medical treatments.

04/20/15

Medical Reform or Medicinal Con?

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© lightwise | 123RF.com

In my home state of Pennsylvania, the legislature is considering the legalization of medical marijuana. At least one activist believes it will happen in 2015: “We have the votes for it. It’s going to happen this term.” Jon Delano of KDKA cited Jay Costa, the Democratic Senate leader, as saying the medical marijuana bill is likely to be approved this spring. Legislation has been introduced in the Senate and gone to committee. “And it is very likely over the course of the next couple of months it will pass through the Senate and make its way over to the House.”

The new governor, Tom Wolfe, has publically said he would support medical marijuana in PA: “I believe that doctors who can now prescribe some of the most potent drugs in the world should be able to prescribe medical marijuana.” The problem seems to be in the State House, which is currently holding hearings on its own legislation. Tony Romeo with CBS Philly reported that law enforcement stressed the need for strict regulatory control if medical marijuana was legalized. Republican Matt Baker, chair of the House Health Committee said:

I am very cynical and skeptical about moving forward with this. And I think there are a lot of unresolved issues, and when you talk with the medical groups and the scientific community, they’re very, very concerned about us putting on white coats and trying to play doctor here.

Polls indicate that most Americans support the legalization of medical marijuana. More than half of the US population now lives in a state where marijuana in some form (medical or recreational) is legal. But take some time to really review this compilation of surveys on marijuana legalization on PollingReport.com. Several polls by organizations like the Pew Research Center, Gallup, and CBS News show a changing trend of Americans over time to agreeing that marijuana should be legalized, when the question is put as: “Do you think the use of marijuana should be made legal, or not?” All three organizations reported results that were essentially the same as the October 2014 Gallup poll—51% said yes to legalization; 47% said no to legalization.

But now look further down at a nationwide poll by the Pew Research Center taken in February of 2014, when the question answers had more options. There the question was: “Which comes closer to your view about the use of marijuana by adults? It should be legal for personal use. It should be legal only for medicinal use. OR, It should not be legal.” The results were: 39% said marijuana should be legal for personal use; 44% said it should be legal for medicinal use; 16% said it should not be legal; 2% were unsure or refused to answer.

Then the Pew Research Center published their newest poll on legalizing marijuana on April 14, 2015. This survey reported that 53% of Americans favored legalization, while 44% opposed legalization. Millennials (18-34) had the strongest support for legalization, with 68% in favor and 29% opposed. Among those who said marijuana should be legal, 78% did not think the federal government should enforce federal laws in states that allow its use. Conversely, among those who think marijuana should be illegal, 59% said there should be federal enforcement.

The most frequently cited reasons for supporting legalization are its medicinal benefits (41%), the belief that it is no worse than other drugs (36%) and its potential for tax revenue (27%). The most frequently mentioned reasons why people oppose legalization were that it hurts society and is bad for individuals (43%), and it is a dangerous, addictive drug (30%). So it seems that the Pew Research polls suggest there is more support for the use of medicinal marijuana than recreational marijuana.

Returning now to the compilation of results on Pollingreport.com there are some further interesting results in two other polls. In a CNN/ORC Poll done in January of 2014 the legal, not legal dichotomy gets most Americans saying marijuana should be legalized. And there is support for decriminalization measures as well. However, there are two other interesting results. 88% percent of the people polled think that marijuana should be able to be legally prescribed for medical purposes by their doctor. When asked if Colorado’s legalization of recreational marijuana was a good idea, a bad idea, or if you want to wait and see what happens before deciding, 33% thought legalization was a good idea; 29% thought is was a bad idea; and 37% wanted to wait and see what happens before they decide!

A Fox News Poll taken in February of 2013 asked if you thought that most people who smoke medical marijuana truly need it for medical purposes or just want to smoke marijuana; 30% said they truly needed it; 47% thought they just wanted to smoke it; 12% said it depended upon the person; 11% were unsure. Although there aren’t many well-accepted medical uses for marijuana as this point in time, there are some.

A 2007 study in the journal Neurology showed that marijuana is effective in reducing neuropathic pain in HIV patients. Live Science also reported marijuana, when combined with opiates, led to dramatic levels of pain relief. It has been helpful in reducing stiffness and muscle spasms in MS (Multiple sclerosis). It appears useful for reducing nausea induced by chemotherapy. Medical marijuana has been touted as a treatment for glaucoma, but other drugs are more effective.

Legalizing medical marijuana now will not just legitimize its medicinal use for these generally accepted conditions, it would permit the medicinal use of marijuana whenever the individual has been given a prescription for it by a doctor. Without reliable, scientifically replicated studies of the claims for medical marijuana efficacy, we would be returning to the times of patent medicine, where medical marijuana is claimed to treat almost anything and everything. The CNN polled opinion that medical marijuana users didn’t really need it, but just wanted to smoke it would then come true.

Sensible use of medical marijuana should follow the established procedures for all medicinal substances—approval by the FDA. As the medical usefulness of marijuana for a condition is demonstrated through this process, it would then become a FDA approved medicine.  I realize that once marijuana reaches this bar of approval, it would then be available for off label use for other medical conditions. But it would also then be REGULATED like all other medical treatments. The current process of state-by-state legislative approval of marijuana for medical purposes circumvents this regulative process. It was established to protect American citizens from the fiascos of past medical treatments that turned out to be ineffective at best and harmful at worst.

Reform must start at the federal level. Given that marijuana has been a Schedule I controlled substance, its availability for the kind of medical research needed to gain FDA approval has to be increased. So a first step would be changing its status from a Schedule I controlled substance to that of Schedule II. The reclassification would make it easier to do the needed research on its legitimate medical uses. I’d suggest delaying the approval of medical marijuana in Pennsylvania and the other states where it is not yet legal until research demonstrating its medical usefulness has gone through the FDA clinical trial process. This would delay the approval of medical marijuana, but it would establish a more stable path forward for the legitimate medical use of marijuana. Debates for the off label medical use could occur alongside those now going on for other classes of FDA approved drugs such as antipsychotics and antidepressants.

Incidentally, there was a bill introduced in the U.S. Senate to reclassify marijuana from Schedule I to Schedule II, the Compassionate Access, Research Expansion and Respect States (CARERS) Act. While it is gaining support, key leaders in both parties have reservations. As the Motley Fool pointed out, the proposed loosening of federal restraints comes just as a new study of the effects of heavy marijuana use on long-term memory in adolescents was published. I hope that if ongoing research demonstrates the need for further restrictions on the medicinal use of marijuana, there would be public and legislative support for that as well.

I suspect this suggestion would not be acceptable for many medical marijuana activists because their final goal is not just the medicinal legitimization of marijuana. Acceptance of medical marijuana may be the first steppingstone towards the legalization of recreational marijuana. As the polls show, there seems to be wider support for the medical use of marijuana than for the recreational use of marijuana. So press for the medical use of marijuana now, and then recreational approval at a future date.