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Bailey Deitch

Deitch 1
Professor Doran
ENC 2135
1 November 2016
Should Medical Marijuana Be Legalized in America?
Definitions
Neuropathic pain- Chronic pain usually comes from a tissue injury.
Botanical marijuana-The natural marijuana plant
Cannabinoid-THC, CBD or other chemical compound derived from the marijuana plant or
synthetically produced artificial marijuana that are secreted from the cannabis plant and
believed to have healing properties, ie relieve pain, spasticity, etc.
Chronic pain- Long-term pain
Acute pain- Short-term pain
Spasticity-Altered muscle performance accompanied by paralysis
Cannabis- the botanical marijuana plant
Medical cannabis (MC)- the use of the Cannabis sativa plant or cannabinoids as medical therapy
to treat disease or alleviate symptoms
Cannabinoids- drugs that can be taken in herbal form, extracted naturally from the plant, gained
by isomerization of cannabidiol, or manufactured synthetically
Prescribed cannabinoids- Legal FDA-approved drugs made from synthetically produced
cannabis, exxamples: dronabinol capsules, nabilone capsules, oromucosal
RTC-Randomized Controlled trials
AE- Adverse Effects
MS- Multiple Sclerosis
CINV-Chemo-induced nausea and vomiting

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THC-Active ingredient found in marijuana plant that has psychotropic effects, ie hallucinations
Cannabidiol (CBD)- the other active ingredient in cannabis marijuana plant that does not have
psychotropic properties
Cannabinoid system-an internal system that has receptors that react with THC and CBD. Doctors
can also manipulate with drugs to alter effects of drugs.
RCT-Randomized controlled trial
Cannibinoids-chemicals in marijuana that produce pharmacologic effects in the body
OTC- Over-the-counter
HIV/AIDS- Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome
FDA-Food and Drug Administration
Drug-Free Action Alliance (DFAA)- Drug-Free Action and Alcohol and Drug Abuse Prevention
Association of Ohio
MML-Medical Marijuana Legalization

Thesis
The landscape of America is changing right before our eyes. Twenty-three states and
Washington, DC have now legalized medical cannabis (Metts 178). More tolerant attitudes and
a decreased perception of risk will likely influence this years election on November 8, 2016
(Chu 44). Several states, including Florida will be voting, many for the first time, on whether or
not to legalize medical cannabis. Based on an extensive review of research, medical cannabis
should not be legalized nationally until the safety and efficacy of designated disease states have
been proven and all risks to patients have been identified and controlled.
Introduction

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Marijuana has been smoked, drank, eaten and burned for thousands of years (Metts, et
al 179). According to Bostwick, The Greeks and Romans used cannabis as medicine and to
make rope; medieval Europeans ate the seeds and made the fibers into paper; and the Chinese
emperor used it for pain over 5,000 years ago (173). Since drafting the U.S. Declaration of
Independence on paper made from marijuana, the drug has experienced as many highs and lows
in America as the actual effects of the drugs (172). Interestingly, Maa and Figi reminds us that
marijuana was widely available in America from the time it was placed on the U.S. Dispensary
as an OTC medicine in 1854 until 1941 when access was limited and regulated following the
Marijuana Tax Act, before finally being made illegal in 1970, on the basis that it provided no
medical benefit and a high risk of addiction (784).
According to Bostwick, physicians in several states are now recommending marijuana
for many of the same ailments it was compounded for in the past, including: pain,
nausea/vomiting, spasticity and convulsions, due to recent MMLs at the state level (179).
However, an article, entitled Medical Marijuana: A Treatment Worth Trying, written by Metts, et
al, for the Journal of Family Practice claims that double blind studies to evaluate the safety and
efficacy of cannabis are scarce because marijuana is not legally available due to the federal
classification of the drug as a Schedule I Controlled Substance (180). As a result, cannabis
studies often use synthetic FDA-approved cannabinoids because they are readily available and
legal, and doctors can prescribe them, unlike the recommendations that they are only allowed to
give for marijuana (Bostwick 181). The Drug-Free Action Alliance (DFAA) claims that greater
marijuana support than ever has not ceased the debate among researchers as to whether or not it
is safe and effective, or changed the mind of the FDA.
Medical Marijuana and Pain

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According to the article, Cannabinoids for Medical Use by Whiting et al, in the Journal
of the American Medical Association, a recent meta-analysis reviewed 28 studies for the effect
medical cannabis had on alleviating chronic pain and reported a 30% reduction of neuropathic
pain and cancer pain when cannabinoids were compared to the placebo (2460). One study
showed smoked THC as having the greatest benefit, but the study was bias and did not reach
statistical significance (2467). A second article, entitled Medical Marijuana for Pain: What the
Evidence Shows, written by Steven A. King for Psychiatric Times report four out of five
patients experienced a decrease in pain with cannabinoids when compared to a placebo (5). The
validity is questionable in both of the studies because researchers failed to report that 70% were
at risk for bias, only 57% were appropriately blinded, statistical significance was not obtained,
and pain was measured using a Visual Analog Scale intended for evaluating acute pain, not the
chronic pain being investigated (Whiting, et al. 2460). However, the researchers report
moderate-quality evidence to support medical marijuana for chronic pain (2467).
Medical Marijuana and Multiple Sclerosis
The American Academy of Family Physicians, the American College of Physicians and
the Institute of Medicine call for additional research before fully endorsing the controversial
drug, but claim to recognize the potential marijuana has for treatment of pain and other illnesses
(Metts, et al 178). Whiting, et al, found cannabinoids, including smoked cannabis extract, to
decrease MS pain associated spasticity when compared to a placebo in seven out of eleven trials
they examined as part of a 70-year MS follow-up study (2463). With further scrutiny, Metts, et
al points out that the Academy of Neurology recently confirmed that cannabis extract may be
beneficial in treating patient-centered measures of spasticity associated with MS, despite the fact
that pain levels were self-reported, and the study lacked appropriate measures for evaluating

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chronic pain (181). Based on this data, the authors claim moderate-quality evidence to support
marijuana for the treatment of MS (2463).
Medical Marijuana and Sleep
Additional diseases have also been evaluated for a response to MC treatment and
therapeutic intervention. As part of the meta-analysis review, Whiting, et al, examined sleep and
Tourette syndrome and discovered low-quality evidence to support synthetic cannabinoids
helped with sleep and/or tics, when compared to a placebo, but identified amitriptyline to work
better than cannabinoids for sleep (2464). There was also low quality evidence noted for no
effect on psychosis, very low quality evidence noted for no effect on depression or anxiety, and
no evidence to support cannabis differed from cannabinoids in promoting sleep (2467).
Examining further, the international group of researchers found no difference between the
placebo and cannabinoids on measures of intraocular pressure in patients with glaucoma, in a
trial of six subjects (2464). Interestingly, all cases using cannabinoids were associated with a
much greater risk of short term adverse events (AE), serious AE, withdrawals due to AE, and a
number of specific AEs to include: balance problems, confusion, dizziness, disorientation,
diarrhea, euphoria, drowsiness, dry mouth, fatigue, hallucinations, nausea, somnolence and
vomiting (2467). This review of diseases noted above, does not support medical marijuana as
treatment for these conditions due to a lack of valid and reliable evidence and the presence of
AE.
Medical Marijuana and CINV
Physicians have been prescribing medical cannabis for chemotherapy-induced nausea and
vomiting patients since 1999 when a study gave cancer patients hope by reporting therapeutic
benefits and relief of nausea and vomiting with smoked marijuana (Bostwick 173). However, a

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study in 2001 by Tramer, et al, found prescribed cannabinoids to be more effective for treating
CINV, but severe side effects caused many to exit the study (qtd. in Metts, et al 181). As a
result, the Natl Cancer Network does not recommend any form of cannabinoids as treatment of
CINV, due to the adverse reactions, medical and legal concerns, and the availability of safer and
more effective drugs for the treatment of CINV (Metts, et al 182).
Medical Marijuana and Weight Gain
When examining appetite and weight gain in HIV/AIDS patients, Whiting, et al, found
low quality evidence to suggest greater weight gain among patients who took one of two
synthetic cannabinoids when compared to smoking marijuana or being given a placebo (2467).
Because this evidence is low-quality, questions remain about the efficacy of synthetic
cannabinoids in stimulating appetite (2467). Investigating further, Metts, et al examined two
additional RCTs and found FDA-approved synthetic cannabinoid, megesterol to work better
than the only other approved cannabinoid for weight gain, dronabinol, in one study (182). The
second study was terminated when no difference in appetite, quality of life, or toxicity was
observed (182).
Evaluating marijuana has been a challenge because it contains 60 active cannabinoids
including THC, CBD, and the recently discovered endogenous cannabinoid system found in the
body that reacts with external cannabinoids by manipulating the effects of the drug to obtain a
specific response (Metts, et al 179). Bostwick reminds us, in Blurred Boundaries, an article
published in the Mayo Clinic Proceedings, that one of the two main cannabinoids found in
marijuana, THC is psychotropic and causes hallucinations, CBD, the other is thought to have
antipsychotic properties (174). Interestingly, many experts believe it is the low concentration
of THC and/or the ratio of THC to CBD that may contribute to the positive therapeutic effects

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that have been observed when researching the effect of medical marijuana on illness (Maa and
Figi 785).
Marijuana and Seizures
In an article written for Epilepsia, entitled The Case for Medical Marijuana in Epilepsy,
Maa and Figi report, a unique ratio of very low THC to high CBD controlled seizures in a
young girl from Colorado (784). This formula, known as Charlottes Web, decreased her
seizures from 50/day to one every 2-3 months using 4mg CBC per pound of body weight (785).
This research is misleading with respect to marijuana and seizures, according to Paige Figi, who
claims to have reviewed everything before treating her childs disease with marijuana (783784). In fact, a study done by Keeler and Reifler reports smoking marijuana to cause
convulsions (qtd. in Maa and Figi 784). Understanding the discrepancy may involve the
complexity of the plant and the mode of administration because heat alters properties and
ingestion has to pass through digestion also affecting the drug, but most likely it is a combination
of both, and includes the endocannabinoid system (784-785). The seizure debate has existed
since Carlini discovered in 1973 that CBD acts as an anti-convulsant in cats, but remains a
mystery today for lack of human trials (qtd. in Maa and Figi 784).
Differing Views Among Experts
According to the online report by the Drug-free Action Alliance, additional research is
needed before the FDA, whose approval is required for legalization, would change their current
position, as being against MML, despite the limited evidence to support therapeutic benefits of
medical cannabis. Kaplan mentions a more stern approach taken by Yale professors in an article
she wrote for the Lost Angeles Times, and quotes them as saying, state approved medical
marijuana laws are based on low-quality evidence, anecdotal evidence and testimonials,

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questioning as to whether or not legislation is a backdoor approach to legalize recreational weed
and condemning its place in medicine (qtd. in Kaplan). Their argument, imagine if all
medicines were legalized in this way and voters determined which antibiotics to approve, (qtd.
in Kaplan). Based on beliefs like these, held by the most respected doctors in the world, it is
essential for patients, voters and physicians to understand the facts before using or
recommending medical marijuana.
Legalization and Illegal Access
Most patients who are given medical cannabis experience severe adverse events (AE),
beyond the preferred state of euphoria (Whiting, et al 2464). Although these reactions are of
great concern, the health officials question the impact legalized marijuana will have on public
health, beginning with the risks and dangers to teenagers. According to Freisthler, et al, states
that allow marijuana distribution through dispensaries have more residents using it (171). An
article, entitled, The Effects of Medical Marijuana Laws on Illegal Marijuana Use, written by
Yu-Wei Luke Chu and published in the Journal of Health Economics, recently revealed evidence
of more residents seeking first time treatment for substance abuse in states that had recently
passed MML when compared to states without MML (44). Interestingly, Andrea Barthwell,
former Deputy Director of the National Drug Council Policy says, children entering drug abuse
treatment often report they thought pot was medicine and good for them (qtd. in Chu 43). She
adds that by characterizing the use of illegal drugs as quasi-legal, state-sanctioned, legalizers
destabilize societal norms that drugs are dangerous (qtd. in Chu 43). Voters must take the
opinions of experts like these very seriously because the ten to twenty percent increase in
arrests reported in states after legalizing marijuana, suggest a positive legislation effect on illegal
marijuana use (Chu 44). Other factor showing the dangers of marijuana in teens are supported

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by upcoming evidence in this report, but are not limited to the all to common amotivational
syndrome seen on television.
Teenagers
It is not surprising that teenagers endure the greatest risks from marijuana because they
are the primary users of the drug (Bostwick 175). A 2011 study conducted by Wall, et al, found
MML to be associated with a lower perceived risk and higher prevalence among juveniles (qtd.
in Chu 44). Three out of four teens already report having someone elses marijuana (Metts, et
al 183) and the results of a survey in Ohio support teenagers believe MML makes it easier for
them to start using, despite admitting that marijuana is harmful (Schwartz, et al 549).
Ironically, the results of the U.S. National Household Survey report an increase in use among
12-20 year olds in the year after MML was passed (Hall and Lynksey 1769). It should not be
surprising that the FDA, Deputy Director, and others make provocative statements and take
drastic measures to keep adolescents and teenagers away from marijuana and other drugs.
Although the risk to users drop significantly after the age of 18, one in six users who started in
their early teens will become addicted, compared to one in eleven users who start much later
(Bostwick 177). These statistics are alarming, but frightening are the risks of mental illness,
psychosis and schizophrenia, that the author addresses (Bostwick 175). Although the risks to
teenagers are more severe than adults, critics point out that most only experience mild
perceptual changes while using marijuana (Bostwick 177).
Adverse Events and Risks
Despite the reputation of marijuana as being a harmless, non-addictive drug with
medical benefits and addiction rates significantly lower than other drugs, like alcohol, tobacco,
heroin and cocaine, risks do exist in teenage marijuana users, and more severe than in adult

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users (Bostwick 175). The risks include, but are not limited to mental illness, the potential of a
gateway drug, brain development interference, academic failure, delinquency, memory deficits,
reduced attention span, abnormal social behavior and mood and anxiety disorders, and addiction
when use is initiated in adolescence and early teenage years (Bostwick 175-176). In fact, one in
six of early marijuana users will become addicted, much greater than one in eleven who begin
using after the age of 18 (Bostwick 177).
When examining psychosis and schizophrenia, Bostwick refers to several studies that
support the association of psychosis and early marijuana use in teenagers:

although moderate users over 18 are immune to cannabis-induced psychoactive


adverse effects. These conditions do exist and are why marijuana is sometimes
viewed as a potential cause, aggravator or masker of psychosis, depression, and
anxiety and other psychiatric illnesses, to include schizophrenia, sometimes seen
in heavy pubertal users. The question whether or not marijuana causes
schizophrenia remains unanswered and is not supported by the results of an
Australian study identifying an increase in cannabis use but not a corresponding
increase in schizophrenia. However, another study found that cannabis
precipitated the onset of the disease in patients with a potential for disease, and
exacerbated the symptoms in those who already had it. Most users will experience
only mild perceptual changes while using, but in individuals with a potential for
psychosis, the more they smoke, the more likely they are to develop
schizophrenia, as seen in a 27 year Dutch follow-up study revealing those who
used cannabis more than 50 times during youth, were 7 times more likely to get

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schizophrenia if they were predisposed to the condition. Among psychosis-free
individuals, a Dutch study reported 8% of non-users developed psychotic
symptoms compared to 2.2% of users developing psychosis (177-178).

Although small, these statistics are significant and of great concern to patients, caregivers,
physicians, parents and teenagers alike. Despite any evidence of health benefits to teenagers,
these numbers should take precedence over using marijuana to treat diseases that have better
options available and the promise of better medications available in the near future.
Contraindications for Marijuana Use
Marijuana is not for everyone. The increased risk of addiction and psychosis, in young
marijuana users is evidence that it should not be prescribed or recommended to teenagers.
According to Metts, et al, the benefits should always outweigh the risks in all patients (183).
Kaplan reminds us that, the FDA encourages physicians to ensure all other legally approved
methods of treatment have been exacerbated, leaving no other available options. According the
Metts, all patients should be screened thoroughly and red flags assessed to identify risk factors
that would eliminate them as a potential candidate for medical cannabis. A primary reason to
restrict MC is whether or not the patient is using recreational marijuana, because there is a
common overlap among MML and recreational users that may indicate a cannabis abuse
disorder (Metts, et al 184). Other reasons to not recommend MC as treatment are: pregnancy,
safety-sensitive job, less than 25 years old, dyscognition, concurrent use of opioids and/or
alcohol abuse (Metts, et al 184). No medication exists without side effects. A drug that is so
controversial that requires a comprehensive list of warnings, side effects and the potential to

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harm youth should be cautiously, carefully and thoroughly researched before being made
available to patients.
Marijuana and Child Neglect
The risk to children and teens is often not brought on by themselves. A common question
in everyday discussions is whether or not MML patients have difficulty holding jobs or caring
for their children, especially with storage and disposal of medical marijuana of great importance.
Incidentally, in an article entitled, Child Abuse and Neglect, written by Freisthler, et al,
references a study performed by Thurstone et al, that found parents using marijuana in Colorado
believed that marijuana use improved their parenting skills by allowing them to relax, preventing
them from yelling at or hitting their children (qtd. in Freisthler, et al 171). Fernandez-Serrano
et al, reminds us that marijuana impairs attention span, short term memory and motor
coordination which may interfere with parents ability to appropriately care for themselves and/or
their children (qtd. in Freishler, et al 171). Another study conducted by Wang et al, reported an
increase in poisonings from ingestion in children 12 years old and younger in MML states (qtd,
in Freisthler, et al 171). The same study found more frequent physical abuse to children by
parents using medical marijuana and a strong relationship in a parents physical abuse of their
children and proximity and amount of dispensaries around their home (qtd. in Freisthler, et al
171). The effect that marijuana has on youth is profound and dangerous and could cause an
epidemic if ignored or as more states legalize medical marijuana.
There are substantial claims associating other public health claims to medical marijuana,
however, as previously mentioned, studies are limited due to the illegalization of the drug.
Additional research must be carried out to disclose the health and safety risks of medical
marijuana before legalizing further.

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Pharmacologic Measures
According to Bostwick, botanical cannabis may be justifiable for experienced users
with terminal illness and a tolerance for its psychoactive effects, particularly while awaiting new
drugs that will soon be available that may even discontinue the need for medical marijuana(178179). As mentioned in the article by the Drug-Free Action Alliance, hastily approval of medical
marijuana might hinder new effective FDA-approved drugs that Bostwick believes might
obviate the need for marijuana as doctors use them to increase the efficacy by manipulating the
endocannabinoid system (180).
Conclusion/Call to Action
There is a substantial body of evidence to support medical marijuana should not be
legalized nationally until additional studies have been conducted and repeated, providing positive
therapeutic results in treating specific designated diseases, with minimal adverse effects to
subjects. Addiction and psychosis, including schizophrenia are very serious side effects, and
medical marijuana should not be legalized as long as there is an association between the two and
marijuana. Based on a limited number of studies with low- moderate evidence linking marijuana
to promising therapeutic effects of treating pain, MS and epilepsy additional studies may prove
beneficial. Funding should be made available to conduct these trials and marijuana should be reclassified to allow reputable institutions legal access to use in scientifically approved randomized
controlled trials. Funding should also be available to continue education programs informing
adolescents and teens of the risks and dangers of using marijuana in early pubescent years
because these programs have been shown to curb appeal. Pharmaceutical companies should
eagerly and anxiously work towards developing new drugs used to manipulate the
endocannabinoid system in an attempt to replace medical marijuana. The FDA and other

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professional medical organizations should remain open-minded to new research. Marijuana
should not be legalized through voter or legislative initiative and should be evaluated in the same
scientific manner as any other drug, with clinical trials undergoing close scientific peer-reviewed
scrutiny. Medical marijuana patient screenings should be enforced and monitored and
dispensaries should be closely regulated in states where with MML. Parents receiving medical
marijuana should be educated. A cautious mind should be exercised to closely monitor the views
of those who are responsible for overseeing the legalization of drugs in this country. Lastly, one
must consider the consequences if we live in a society that encourages you to be high. What is
your vote?

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Works Cited
Bostwick, J. Michael. "Blurred Boundaries: The Therapeutics and Politics of Medical
Marijuana." Mayo Clinic Proceedings, Vol. 87, No. 2, Elsevier, Feb. 2012, pp. 172-186.
Chu, Yu-Wei Luke. "The Effects Of Medical Marijuana Laws On Illegal Marijuana Use."
Journal Of Health Economics, Vol. 38, Aug. 2014, pp. 43-61. Academic Search Complete, Web,
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Drug-Free Action Alliance and Alcohol and Drug Abuse Prevention Association of Ohio.
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