IRA FLATOW, HOST:
Next Tuesday, marijuana
will have its day in court because the United States Court of Appeals
is set to hear arguments about the drug’s therapeutic and medicinal
effects. But some doctors, like one of my next guests, disagrees with
the government’s ban on medical use of marijuana, pointing to the drug’s
ability to suppress nausea, stimulate the appetite, relieve pain,
improve sleep, even fight cancer cells, in test tubes at least.
Is
the science on cannabis compelling enough to convince federal
officials? And have we done the rigorous science on marijuana that’s
required of all drugs to get it to your pharmacy? Dr. Donald Abrams is
chief of oncology at San Francisco General Hospital. He’s also a
professor of medicine at the University of California in San Francisco.
He joins us by phone. Welcome to SCIENCE FRIDAY, Dr. Abrams.
DR. DONALD ABRAMS: Thank you, good to be here.
FLATOW:
You’re welcome. Dr. Bertha Madras is professor of psychology –
psychobiology, I’m sorry, in the Department of Psychiatry at Harvard Med
School in Southborough, Massachusetts. She joins us by phone. Welcome
to SCIENCE FRIDAY.
DR. BERTHA MADRAS: Thank you, good afternoon.
FLATOW:
Good afternoon to you. Dr. Abrams, do you think it’s time? Do you think
the evidence is there that the federal government should OK cannabis
for general use?
ABRAMS: Well, I mean, let’s
take a step back. Cannabis was on the formulary of the United States
until 1942, when it was removed. So cannabis, which has been a medicine
for thousands of years in other parts of the world, was available in
this country, again, until ’42, when it was taken off our pharmacopoeia.
So yes, I think that the Institute of Medicine in their last report in
1999 suggested that cannabis and cannabinoids, their active components,
have use in treatment of nausea, vomiting, pain and loss of appetite.
And
as a cancer doctor, I see patients every day, people who are
benefitting from the use of cannabis. The problem is the government does
not allow cannabis to be studied as a therapeutic agent because the
only legal source is the National Institute on Drug Abuse, and they have
a congressional mandate only to study substances abused as substances
of abuse. So that’s a bit of a catch-22.
FLATOW: Dr. Madras, would you agree with that?
MADRAS:
Frankly I disagree, and here are my reasons why. Number one is, yes,
marijuana was removed from the pharmacopeia in the late 1930s, in fact,
but because it was found that the safety and efficacy issues did not
reach the bar that was necessary for drug approval.
The
fact that Dr. Abrams claims that we cannot study cannabis in scientific
studies is disingenuous because the Center for Medicinal Cannabis
Research, of which he’s a part of, in California, has conducted and has
received millions of dollars from the California Legislature to study
smoked marijuana as a medicine.
And as of
today, I have looked at their site. They have precisely four published
manuscripts on the medicinal uses of cannabis for which the Proposition
15 approved marijuana and a number of other publications that bear no
relationship to these clinical trials.
So the
clinical trials can go on. The marijuana is available for them.
Cannabinoids are being studied and synthesized at horrendously large
rates by medicinal chemists, and yet…
FLATOW:
I have to interrupt you. We’ll get back to you, Dr. Madras. We have to
take a break. Stay with us. Also Dr. Abrams, we’ll be right back after
this break. I’m Ira Flatow, this is SCIENCE FRIDAY from NPR.
(SOUNDBITE OF MUSIC)
FLATOW:
This is SCIENCE FRIDAY. I’m Ira Flatow. We’re talking this hour about
legalization of cannabis and the use of cannabis, otherwise marijuana,
in research studies. When I interrupted Dr. Bertha Madras, she was
talking about the fact that there were lots of studies in California and
plenty of samples of cannabis to get if you needed to study it. Dr.
Abrams, how do you answer that?
ABRAMS: Yeah,
so the Center for Medicinal Cannabis Research was set up in California
for that reason, to fund studies to look at the potential effectiveness
of cannabis. And I did two, one that demonstrated in patients with HIV
and painful nerve damage cannabis was better than placebo in relieving
their pain.
And I also did a study funded
actually by NIDA because it was a safety study to show that it was safe
for patients on chronic opiates to add cannabis to their regimen. It did
not change the level of opiates in their bloodstream, and if anything,
it may have improved their pain relief.
FLATOW: So you think there’s enough evidence, then, that the courts should approve it?
ABRAMS:
Well, no, you know, again, evidence, that’s what I’m saying. It’s
difficult to do clinical trials looking at cannabis as a therapy because
of the catch-22 that NIDA, you know, is preferentially supplying their
cannabis to studies that look at its danger.
So
the evidence, you know, clinically the evidence is there, and I do
disagree that the reason that it was removed from the pharmacopeia, the
American Medical Association in 1937, after the introduction of the
Cannabis Tax Act, was – stood alone in saying that there is no evidence
that cannabis is dangerous and that this act would impede the ability to
research it for its effectiveness.
And then
it was removed from the pharmacopeia and subjected to Schedule 1, and,
you know, the main target in this country’s failed war on drugs.
FLATOW: So you think there are not enough resources to conduct the clinical studies that would be needed?
ABRAMS:
Well, not many people want to study cannabis. It’s sort of a difficult
thing in your career because, you know, I think the more – science is
not driving the train, that’s what I’ll say. I mean, the more evidence
that people accumulate – we now have three studies demonstrating
cannabis’ utility in peripheral neuropathy, which is a very challenging
medical condition to treat.
Oftentimes people
are put on opiates, and then their life is one string of opiates after
another. Better – cannabis, this is a flower we’re talking about it.
It’s a flower. It’s not a dangerous substance like the opiates that I
prescribe and others prescribe for patients living with cancer and pain.
FLATOW:
Dr. Madras, would you acknowledge that cannabis and cannabinoids have
some therapeutic effects like Dr. Abrams mentioned?
MADRAS:
I acknowledge that cannabinoids may have some therapeutic effects. I
disagree with Dr. Abrams vehemently on the thought that one’s hands are
tied in doing the science. Once again, the Centers for Medicinal
Cannabis…
ABRAMS: Oh don’t repeat yourself on that, that’s silly.
MADRAS: Had all money available to do with – and they have…
ABRAMS: Three million dollars a year for three years.
MADRAS:
But let me please finish. They had to cancel five studies because they
could not recruit enough patients. One of the criteria for recruiting
patients is that they had to be experienced marijuana users. How many
elderly cancer patients in this day and age are experienced marijuana
users? They also are not allowed to drive because there was fear of
liability in case they got into a car accident because they were under
the influence.
So there – so what Dr. Abrams
should say is that there was money, there was cannabis available for the
studies. Why did five of the major studies that they had proposed at
the onset of this program, why were they canceled?
FLATOW: Dr. Abrams, any answer?
ABRAMS:
Well, I mean, you know, again, all of my studies were done in the
in-patient clinical research center so we could observe the patients and
make sure they weren’t diverting this Schedule 1 substance. And cancer
patients, I don’t think, are that enthusiastic about spending, you know,
some of the remaining days of their lives in the hospital doing a
research study.
Plus there was always a
concern that the cannabis that NIDA provides is not particularly potent
and that because we live in California, where we’ve had cannabis
available as a medicine for patients since 1996, if patients really
wanted to use it, they could.
And as a cancer
doctor, ma’am, many patients in my age group, who grew up in the ’60s
and ’70s, with cancer are cannabis-experienced people. So that is not a
problem. The problem is the closing of the dispensaries now by the
federal government in California, when we voted for it in 1996, is not
allowing my elderly patients access to their medicine.
MADRAS:
And NIDA provides marijuana cigarettes at 3.5 and seven percent THC. Do
you think that you need more than that, especially considering one of
the studies that came out of the CMCR that said that at seven percent
the side effects were quite above the boundary of acceptable side
effects, meaning psychoactive dizziness, confusion and so on?
So
my feeling is that the doses that are available for this research are
in fact available, but once you get into seven percent or six percent
cannabis, you do have side effects that have to be reported in clinical
trials, far beyond that boundary of what are…
ABRAMS:
Yeah. Again, I hate to disagree with you, but the cannabis available in
dispensaries averages from 10 to 15 percent, and legal cannabis in The
Netherlands is 14 percent that you get from the pharmacy. So three and
seven percent is not a huge amount, and I think patients need to
self-titrate.
It’s very different from other
medicines, you know, where you tell the patient try it and see what
works for you. You know, if it…
MADRAS: But that’s not how the FDA works.
ABRAMS: Well, of course not. This is not…
MADRAS:
The FDA requires and insists that one does a window of therapeutic
efficacy compared with a window of a side effect profile that may render
a drug unacceptable in the market. And if you do a full-dose response
curve, you will find that past a certain percentage of THC, a person is
quite incompetent.
ABRAMS: Well, that’s
absolutely correct, same with alcohol. You know, I mean, I personally
believe that this is a flower, and it should be regulated like tobacco
or alcohol. And, you know, trying to get FDA approval for a medicine
that’s been a medicine for thousands of years and was on the U.S.
pharmacopeia until 1942, when it was removed by an act of Congress
submitted by a racist, you know, what are we doing in this country.
This is a flower. We’re spending $4 billion a year on the war on drugs and incarcerating 180,000 Americans.
MADRAS: Well, you know, ephedrine from the ma huang plant…
ABRAMS: Oh, you could give me all the examples you want. I’m not in favor of cocaine, either.
MADRAS: Pardon? Most of our medications, at least 30 percent, are originally derived from plants.
ABRAMS: Right.
MADRAS:
The active ingredients were isolated, such as cocaine, such as
digitalis, such as aspirin, such as morphine. They were isolated. They
were studied in isolation in order to determine how fast they get into
the brain, how fast they get into the blood…
ABRAMS: That’s the Western pharmaceutically dominated paradigm, you know…
MADRAS: And also what the…
FLATOW: I’m going to jump in here. I’m going to jump in, and I’m going to ask…
ABRAMS: There are thousands of years of research where people use the whole plant as medicine.
FLATOW: Dr. Abrams, do you think it’s possible to create studies that would satisfy the FDA requirements?
ABRAMS:
I’m sorry, I do not. I continue to do this work, but I don’t think that
this is going to happen in my lifetime unless other people start
looking at the ridiculousness of our current policies in this country.
I’m sorry.
FLATOW: Ridiculous meaning what?
ABRAMS:
Well, this is a flower. You know, I grew up in the ’60s and ’70s. I
went to Brown University and Stanford University School of Medicine.
Cannabis was my substance of choice, not alcohol. And I’m very happy
with the person that I’ve become today, and I would be very different if
alcohol was what I used for relaxation.
FLATOW: Dr. Madras, have you done studies on cannabis?
MADRAS:
I have done a few limited studies on isolated cannabinoids, not in
patients, in preclinical research. I have studied the literature
extensively because I am very interested in the scientific issues, not
as much the political issues.
FLATOW: Well, do you believe that the studies…
ABRAMS: Science does not drive the politics…
MADRAS: I believe…
FLATOW: Dr. Madras, do you believe that studies can be done that would satisfy the FDA?
MADRAS: I certainly do.
ABRAMS: Oh, my goodness.
MADRAS: I think that…
FLATOW: And who would do them?
MADRAS: Well, (unintelligible)…
ABRAMS: Good question.
MADRAS: …and I have no, you know, full disclosure, I have absolutely no outside funding from any sources.
FLATOW: So who should do this? Who should get the funding to do this?
MADRAS: So drug companies – RGW Pharmaceuticals in England, they’ve approved an inhaled form of…
ABRAMS: It’s not inhaled, dear. It’s sprayed under the tongue.
MADRAS:
…THC combined with cannabidiol, which does not have psychoactive
effects but therapeutic effects and different types of formularies that
can deliver a reasonable bolus of active…
FLATOW: Well, Great Britain…
MADRAS:
…ingredients to the brain would satisfy the FDA. At this point, the
real issue is the relationship between psychoactive effects and
therapeutic effects. The faster a drug gets into the brain, the more
addictive it – more…
ABRAMS: No. Don’t start with addictive.
MADRAS:
…addictive potential and the more its psychoactive effects. And this
is the problem with a substance such as marijuana smoke. The other issue
is: Do we want smoked marijuana as a delivery system for medications?
It has between 60 and 80 cannabinoids in it of uneven quantities because
every one produces different ratios…
FLATOW: OK.
MADRAS: …of all of them.
FLATOW:
I have to stop you from filibustering. Let me get another question in
here. Dr. Abrams, for people who already have problems, health problems,
what about the smoking issue? Isn’t smoking a bad solution?
ABRAMS:
Yeah. My friend and colleague Donald Tashkin at the University of
California, Los Angeles has spent 40 years of his career doing studies
for NIDA looking for the danger of inhaling cannabis and basically finds
that chronic users may have a little bronchitis. Actually, it appears
from his (unintelligible) study of 1,365 patients with aerodigestive
malignancies in Los Angeles that regular cannabis use decreased the risk
of lung cancer. A recent study in young people followed for 20 years
show that those who regularly use cannabis had better pulmonary function
tests than those who didn’t.
So there are
other ways to deliver cannabis than smoking, and we’ve investigated a
vaporizer, and vaporization is now widely used by patients here in
California as a smokeless delivery system. But in my opinion, smoking is
not that dangerous, either, and I’m sure that will get some
disagreement from my colleague.
FLATOW: A lot
of people think that it’s the high that you get from smoking marijuana
that is the therapeutic effect. Is that correct?
ABRAMS:
I think that the cannabinoids – we have two receptors in our bodies,
the CB1, which is in the brain, and the CB2, which is in the immune
system. And the activation of these receptors causes chemical reactions
in cells which have many different effects besides the psychoactivity.
As my colleague said, another cannabinoid, cannabidiol is very potently
analgesic and anti-inflammatory without being psychoactive. So the
concern that there’s 60 or 70 other cannabinoids in the plant is exactly
something, I think, is a good thing.
As a
student of traditional Chinese medicine, a medicine that’s been
practiced for 5,000 years, they frequently use the whole plant instead
of following the Western pharmaceutically industry dominated paradigm of
isolating the active component, make it into a pill that people swallow
and charging large amounts of money. So I think that the cannabinoids,
as well as the other components of the plant – terpenoids and flavonoids
– all have the potential for medical benefits.
FLATOW:
All right. Let me remind everybody that this is SCIENCE FRIDAY from
NPR. Let me ask you, Dr. Madras, one more time, do you think there are
studies that can be done in the United States that would convince the
FDA, and who would do them?
MADRAS: I think
there are studies. I think we have to, A, alter the delivery system to
remove smoke. Marijuana smoke has ammonia up to 20 times greater than
tobacco smoke. It has hydrogen cyanide and nitric oxide and some
aromatic amines that are three to five times higher in marijuana than
tobacco smoke. And there are many other problems associated with
marijuana smoke. So what are the criteria? One should change the method
of delivery…
FLATOW: Who will do…
MADRAS: …and (unintelligible)…
FLATOW: Who will do the study? Ma’am. Ma’am, who will do the study?
MADRAS: …(unintelligible) change the method of delivery as well as study and…
FLATOW: Dr. Madras, who will…
MADRAS: …focus on single cannabinoids.
FLATOW: Dr. Madras, who will do these studies?
MADRAS: Well, there are pharmaceutical companies that are quite interested in…
FLATOW: Have they – will they…
ABRAMS: It’s a flower. Nobody can patent a flower.
FLATOW: Will they…
ABRAMS: Nobody can patent a flower. They’re not going to make any money.
FLATOW: Who’s going to…
MADRAS: They can patent methods of delivery. They can patent single isolated cannabinoids. They can (unintelligible)…
ABRAMS: And they’ve done that. We have that on the market.
MADRAS: They can (unintelligible).
ABRAMS: That’s called dronabinol and nabilone. Those are available for patients. I’ll tell you, as a cancer doctor, I’m…
MADRAS:
Yes. Generic drugs are very, very lucrative for companies such as Teva
Pharmaceuticals. They can be made as generics as well.
FLATOW: Who will? Can is a large population. Who is doing it and will do it and pay for it?
ABRAMS:
Can I – there’s no answer to that, so I can just say as a cancer doctor
now for 30 years in a state where we have tolerance to the use of
cannabis as medicine, that a day doesn’t go by when I don’t see a cancer
patient who has nausea, loss of appetite, pain, depression and
insomnia. And I could recommend one medicine to that patient and instead
of writing prescriptions for five or six different pharmaceuticals that
may interact with each other or with the patient’s chemotherapy. And
this is a medicine that my cancer patients can grow if they want to.
I
ask all of my patients: What brings you joy? And the percentage of
people living and, in fact, dying with cancer who tell me gardening
brings them joy is not insubstantial because bringing life out of the
ground is a pleasure. And if this life that people bring out of the
ground is also their medicine, why don’t we let them have it? The number
of patients who come to me saying they were given narcotics and at
their – the end of life and they can’t communicate with their family,
and then they wean themselves off of their opiates with cannabis so that
they could have a more pleasurable interaction in their final days of
life. Why do we deny people this medicine?
MADRAS:
Well, why is it that the recommendations currently are that serotonin
5-HT3 antagonists are much better at preventing chemotherapy-induced
nausea than marijuana?
ABRAMS: Yeah, I’m not going to – it’s not a question about ranking, but I think…
MADRAS: Why is that there are so many alternatives now to smoking marijuana, sending the wrong message to kids…
ABRAMS: I hope you never have to repeat chemotherapy.
MADRAS: …than what you’re claiming? I’m afraid…
ABRAMS:
Right. But what about Melissa Etheridge? She’s the one that went
public, saying she could not have tolerated her chemotherapy for her
breast cancer if she didn’t use cannabis. We have many medicines, but if
they don’t work and cannabis does, why deprive people of their
medicine?
FLATOW: All right. I have to stop
it right there. Dr. Bertha Madras, professor of psychobiology at the
Department of Psychiatry at Harvard. Dr. Donald Abrams, chief of
oncology, San Francisco General Hospital. Thank you both for taking time
to be with us.
ABRAMS: Sure.
FLATOW:
We’re going to take a break. After the break, tracking the ozone hole.
It’s not just over Antarctic anymore. Stay with us. I’m Ira Flatow. This
is SCIENCE FRIDAY from NPR.
