Thursday, 19 September 2013

Marijuana For Pain: More Discussion

Today's post from (see link below) is hardly an unbiased, scientific facts-only article but is nevertheless very interesting for those who use (or are thinking of using) marijuana to help reduce their neuropathic pain. Marijuana is a proven analgesic that works well for many people with neurological pain but it's not without controversy as everybody knows. Many states in the USA are radically changing their legal approaches to marijuana as an illegal/legal drug and this article looks in some depth at the whole discussion as to whether this is a correct move or not. An interesting addition to the other discussion posts (see alphabetical list to the right of the page) about marijuana/cannabis for neuropathy.

Baby marijuana plants. Credit: A7nubis
Going To Pot: The Marijuana Sequel
By Tabitha M. Powledge Posted: September 6, 2013

In my last post, also on marijuana, I wondered why science writers hadn’t used Sanjay Gupta’s announcement of his apostasy from the anti-Cannabis contingent as a reason for examining the marijuana steamroller we are about to experience. I had been hoping for takeouts on what our present trajectory toward marijuana legalization is likely to mean for many aspects of US life, ranging from medical practice, to genetic research on people and plants, to its effects on politics–and more. But I hadn’t seen any.

The pot post appeared August 23, prompting immediate indignation from my science-writing colleagues. On an NASW listserv they protested (correctly) that, dammit, they had too written about marijuana. I see on rereading my post that their charge was understandable. I was not, of course, saying that none of them had ever written marijuana stories. That would have been featherbrained. But I was ambiguous.

What I was trying to say is that this is a pivotal moment in our nation’s weird history with Cannabis. A great many things are going to change as a result. Whatever you think of Sanjay Gupta, his about-face on marijuana was a kind of bellwether. That high-profile apology was, I thought then (and still think), a missed opportunity to examine those changes.

More marijuana revolution from (gasp!) the Justice Department

A few days after my post, on August 29, came another such opportunity, and a few writers seized it. The opportunity was the Justice Department’s decision to allow the places where pot is legal for recreation (at the moment Colorado and Washington state) to sell and regulate it even though that is against federal law.

Of the pieces on this event I’ve seen, most noteworthy was Maia Szalavitz’s at Time’s Healthland. Maia’s forthright lede sums it up: “The war on drugs may have ended today.” Maia has written far more about illegal drugs, and for far longer, than most of us. Which makes her observations noteworthy, and not just because she agrees with me that something radical is going on.

There was a predictable response to the Justice decision on marijuana from those whose oxen were gored by it. Ryan Grim tells us all about law enforcement’s protests at HuffPo. He also notes: “Local law enforcement agencies rely heavily on the drug war for funding. Police departments are often able to keep a large portion of the assets they seize during drug raids, even if charges are never brought. And federal grants for drug war operations make up a sizable portion of local law enforcement funding.”

‘Nuff said.

A couple of writers foresee that the Justice decision on marijuana could hasten pot legalization in other states that have been held back by fear that the feds would come down on them. At, Ed Krayewski lists five he thinks could be next to legalize marijuana: Oregon, Alaska, California, Maine, and Rhode Island. At HuffPo, Nick Wing agrees with that list and adds 4 more states: Arizona, Nevada, Montana, and Vermont.

The plural of anecdote IS data!

States where medical marijuana is legal–an astonishing 20 now, and counting–will be seeing increased use, and at least some of it will actually be for medical purposes. Pot prescriptions are nearly all written for pain. So in my previous post I was uneasy about the relative lack of data on marijuana’s efficacy against pain.

My fellow writers slammed me for that, too. But I’m not taking it back.

Working on this follow-up pot post, I was thinking that medical marijuana was the quintessential example illustrating the cautionary quip well known to science writers: the plural of anecdote is not data. I dug around looking for the origin of that quote and discovered, by golly, blessed be Google, that the original comment was in fact exactly the reverse. Political scientist Ray Wolfinger has claimed that the version we all know and love was actually a twist on what he told a graduate seminar during the 1969-70 school year. Which was, he said, “the plural of anecdote is data.”

Which is even more apropos for Cannabis. Because that’s what we have here: a zillion anecdotes praising medical marijuana that serve as proxies for data on its power to heal. As I observed last time, that’s not scientists’ fault. Politics has made research on real medical applications, including pain, next to impossible, as neuroscientist David Nutt and his colleagues complained last June. I don’t think that paper is open access, but you can read Maia’s piece about it, which is.

I have looked, mostly in vain, for studies that provide backup for declaring pot works on pain (or any of the other medical uses claimed for it.) I am comforted to find that I’m not alone in coming up near-empty. So august a body as the American Medical Association ran into the same absence of evidence, even though the search process they describe was far more thorough than mine.

In a 2009 report, its most recent, an AMA committee cited just 3 pain studies on marijuana, involving a total of 119 patients. One study (38 subjects) was on induced pain. The two others involved HIV-associated neuropathic pain. About half the patients reported at least 30% pain reduction from smoking weed. But the study lasted only 5 days. The AMA committee found nothing, it appears, about pot’s effects on chronic pain, although that’s the chief use for medical marijuana. Find a link to the report PDF here. Thanks to Maia for the ref.

The rest of the AMA report’s discussion on pain efficacy involved surveys.

Surveys. In short, anecdotes.

Here we have the American Medical Association declaring that yes, the plural of anecdote IS data.

Being descriptive about marijuana, and normative too

You will say this lack of data is true of other drugs in use, and I’m sure you’re right. But failure to study other drugs adequately doesn’t seem to me a justification for shrugging off the need for data on medical uses for marijuana. Why add one more oversight deficiency to the sorry list?

It’s also the case that these other ill-established drugs are not nearly as widely used as marijuana–not to mention the consumption explosion to come. This is a huge experiment we’re running here, folks. And so far as I know, no one’s keeping track of it.

Please don’t pretend I am arguing that pot doesn’t work on pain and/or that I’m hand-wringing about the march toward legalization. Nope, neither. As my philosopher colleagues used to say back in my bioethics days, my comments about the lack of marijuana research are descriptive statements, not normative ones.

If you insist on normative, I will say this: The positive anecdotes on pot appear to make it worth trying for chronic pain. The alternatives, even when they work, pose far more serious problems. Just last week The Lancet published a study claiming that opioid dependence causes the greatest health burden–meaning death as well as illness–of all the illicit drugs.

If you insist further on normative, I would also say that making pot legal (with restrictions and regulation and tax revenue) would be far better for the country than what we have now, with hundreds of thousands of people (most of them black) imprisoned for small drug offenses combined with a top-heavy and often ineffective–and extremely expensive–drug law enforcement establishment.

Not that legal marijuana doesn’t come with its own massive set of pitfalls. For a brief overview, consult “Seven Questions about Marijuana Legalization” at Dirk Hanson’s Addiction Inbox. There are, as you will see, many more than 7 questions. And they are very tough questions indeed.

Hanson says, “Moving a popular drug across the legal/illegal line is a bit like getting molecules through the blood-brain barrier: It can be done, but it had better be done with sufficient care and forethought.” Alas, it is too late for sufficient care and forethought, although I suppose we can pray that other states will absorb and take advantage of the painful lessons Colorado and Washington state are about to learn.

Will there ever be research on medical marijuana?

Even though we are way beyond the stage of sufficient care and foresight, I am still arguing that the various uses for medical marijuana should be more firmly grounded in data than they are.

I also know perfectly well that research of this kind, including clinical trials, takes time, lots of time–and that it would have to be preceded by time-consuming policy decisions in the White House, and possibly in Congress and the courts, before it ended up in another time-consuming process for making funding decisions at the National Institutes of Health and other government agencies.

In short, we will not, cannot, have this knowledge in time to inform local policy decisions and educate medical professionals before the cavalcade of Cannabis is well away. Not to mention informing patients, who are understandably impatient for the straight scoop on how best to deal with their intractable neuropathic pain and other health burdens.

Yet here we are, having launched a radical revision in official attitudes and citizen behavior toward marijuana, in the process creating an unstoppable social and legal trend. Even though these transformations are, and will be for several years at least, backed up mostly with . . . hope.

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