Marijuana Medical Handbook

by Tod Mikuriya, M.D.

DRAFT

Sedative Effects

Continued Use exhibits a much more controlled pattern of mood management through a mild stimulation with low repeated inhaled doses. Modulation of emotional reactivity appears to be another significant desired effect of cannabis. The net effects for the continuing moderate user are a unique combination of mood elevation with a decrease in anxiety that is easily controlled.

Antidepressant

The ancient Greek, Indian, Persian, writings are replete with descriptions of antidepressant properties:

Homer's Odyssey describes Helen using a potion obtained from Polydamna that lifted the spirits at a morose gathering by slipping Nepenthe in the wine. Nepenthe means "against sorrow" .

Samscrit and Hindi writings characterize cannabis:

Before the 8th century an anti phlegmatic, Circa 1050: victorious (Vijaya), and victorious in three worlds (Trailokyavijaya).

1300 A.D. in The Rajanighantu of Narahari Pandita: the light hearted (Capala), the joyful (Ananda), the rejoicer (Harsini), speech giving (vakpradatva) inspiring of mental power (medhakaritva), and a most excellent excitant (cresthadipanatva).

17th Century Materia Medica The Rajavallabha: "It creates vital energy, the mental powers, and internal heat, corrects irregularities of the phlegmatic humour, and is an elixir vitae."

In contemporary terms a case of severe and chronic depression may have been successfully treated through self medication with cannabis.

The Persian physician Mirza Abdool Rhazes wrote:"The oldest work in which Hemp is noticed is a treatise by Hasan, who states that in the year 658 (Mahometan era)(1258), the Sheikh Djafar Shirazi, a monk of the order of Haider, learnt from his master the history of the discovery of Hemp. Haider, the chief of ascetics and self-chasteners, lived in rigid privation on a mountain between Nishabor and Romah, where he established a monastery of Fakirs. Ten years he had spent in his retreat, without leaving it for a moment, till one burning summer's day, when he departed alone to the fields. On his return an air of joy and gaiety was imprinted on his countenance; he received the visits of his brethren, and encouraged their conversation. On being questioned, he stated that: struck by the aspect of a plant which danced in the heat as if with joy, while all the rest of the vegetable creation was torpid, he had gathered and eaten of it's leaves. He led his companions to the spot, all ate, and all were similarly excited. A tincture of the Hemp leaf in wine or spirit seems to have been the favorite formula in which the Sheikh Haider indulged himself. An Arab poet sings of Haider's emerald cup; an evident allusion to the rich green colour of the tincture of the drug. The Sheikh survived the discovery ten years, subsisting chiefly on this herb, and on his death his disciples by his desire planted it in an arbour about his tomb. From this saintly sepulcher the knowledge of the effects of Hemp is stated to have spread into Khorasan."

In 1845 J.J. Moreau de Tours, a French psychiatrist utilized cannabis in the treatment of depression described the drug's effects:

"It seems that nothing can hurt you in this peace of mind, that you are inaccessible to sadness. I doubt that the most unfortunate news could draw you out of that imaginary bliss, which can only be appreciated through experience.

I have just attempted to give an idea of the delights that hashish produces. I hasten to add that I have presented them here in no more than raw form, as it were, and at their simplest. It will depend upon external circumstances to confer upon these feelings of happiness still greater intensity by directing them toward a determined goal and by concentrating them on a single point. One imagines what reality can add to this state of bliss and how much the joys of hashish can be enhanced by external impressions, by direct sensory excitations, or by the stirring of passions through natural causes. At that time, the rapture of hashish intoxication, taking shape and form, will assume the dimensions of delirium. This disposition of the mind, linked with another which I will discuss later, was, I feel, the fertile source from which the fanatic inhabitants of Lebanon derived that happiness, those ineffable delights for which they gladly sacrificed their lives.

It is necessary here to clarify what I have just said. It is really happiness that hashish gives, and by that I mean mental joy, not sensual joy as one might be tempted to believe. This is indeed very curious, and one can draw strange conclusions- this one among others, that all joy, all contentment, even though its cause is strictly mental, deeply spiritual, and highly idealistic, could well be in reality a purely physical sensation, developed physiologically, exactly like those caused by hashish. At least, if one relies on inner feelings, there is no distinction to be made between these two orders of sensations, in spite of the diversity of the causes to which they are related for the hashish user is happy, not in the manner of the glutton, of the ravenous man who satisfies his appetite, or even of the hedonist who gratifies his desires, but in the manner, for example, of the man who hears news that compounds his joys, of the miser counting his treasures, of the gambler whom luck favors, or the ambitious man whom success intoxicates.

However, the preceding remarks were not intended to raise a psychological question. I am merely recording observations, and have no other pretension than that of being the faithful and exact historian of my sensations." This characterization of the antidepressant effects of the drug in contemporary contexts would be unthinkable pro drug sedition and would never be found in any advertisement.

Depression as one of the conditions listed for treatment appeared in general Materia Medica, or medical texts , , ,

Subsequent clinical use in depression is described as having variable results. Clouston in 1871 from the Cumberland and Westmoreland asylum reported on five cases of melancholy with some success in four and marked improvement in one. Villard describes similar variable results in melancholia by physicians in France. The Indian Hemp Drugs Commission in 1894 reviewed medical literature, testimony by both indigenous medical practitioners and Western trained physicians and described cannabis to be used as a tonic to increase stamina,

Cannabis decreases emotional reactivity and intensity of affect while increasing introspection as evidenced by the slowing of the EEG after initial stimulation. The unique sedative effects of cannabis then begin to prevail. Obsessive and pressured thinking give way to introspective free associations when in relaxed circumstances. Emotional reactivity is smoothed out, worries are less pressing. The alteration of time perception relieves the "hurry sickness".

Analgesic Effects

Two thousand years ago Chinese used cannabis in high doses to induce a state of altered consciousness to permit major surgery. The analgesic effects of cannabis, which are less potent than the opiates, appear in part to be from decreased affective reactivity, which is modulated by altered time perception.

"During the time that this remarkable drug is relieving pain a very curious psychical condition sometimes manifests itself; namely, that the diminution of pain seems to be due to its fading into the distance, so that the pain in a delicate ear would grow less and less as a beaten drum was carried farther and farther out of the range of hearing.

This condition is probably associated with the other well known symptom produced by the drug, namely, the prolongation of time." Cannabis was mentioned in most general medical texts as an analgesic but with lesser potency than the opiates.

Different types of pain respond differently to cannabis. Review of clinical literature discloses two general categories that respond affirmatively: Intermittent spasmodic pain and inflammation. (See table 1)

Migraine Headache is a specific type of pain for which cannabis was first described to be useful by J. Russell Reynolds . After some thirty years clinical experience after this initial observation, he described "Migraine: very many victims have for years kept their sufferings in abeyance by taking hemp at the moment of threatening, or onset of the attack." In Osler's medical text it was the treatment of choice for migraine headache. The most recent (and last) mention of cannabis for the treatment of migraine was from Morris Fishbein, M.D., Editor of the Journal of the American Medical Association in 1942.

Cannabis was compared with alcohol in cross-cultural comparisons in India. Daru vs Bhang. G. Morris Carstairs described differences in emotional reactivity: contrast of cannabis comparable effects of alcohol intoxication that increases emotional reactivity. Cannabis cools the passions. Alcohol inflames them. I have never heard of a pot room brawl.

Physical Effects:

Reddened Eyes: Increased Blood Circulation to the Brain

Moreau in his description of the clinical pharmacological effects on the brain were to increase blood circulation during effects of the drug.

The phenomenon of dilated eye blood vessels with cannabis intoxication has been described extensively in writings on the drug. The meninges, the membrane covering the brain, covers the external eye. (except for the corneal area) The reddened eyes represent a general increase in cerebral blood flow (CBF). This increase in blood circulation is due to decreased peripheral resistance from dilation of the capillaries in the cerebral cortex. CBF changes reflect mental effects; increased CBF: stimulation of cognition, decreasing CBF: sedation. Chronic heavy users appear to have decreased CBF when deprived of the drug.

Circulation and Heart Rate

Increased heart rate is due to central nervous system modulation of the tenth cranial nerve (the vagus nerve). There are no direct effects on the heart's electrical conduction system nor general peripheral vasodilation. Heart rate increase is dose related but not greater than moderate exercise.

Orthostatic hypotension which takes place with some cannabis users is due to a transient lag in changes in the muscle tension in artery walls when standing up after sitting or lying down. It is a feeling of faintness or dizziness that is relieved by sitting or reclining. This phenomenon is due to effects of interfering with the reflex response readjusting the muscle tension in arterial walls. Again, mediated through the vagus nerve.

Glaucoma

Hepler and Frank in 1971 serindipitously discovered that Marijuana smoking significantly lowered pressure in the eyeball in 9 of 11 normal subjects. Frederick Blanton, M.D. , A Florida ophthalmologist in private practice read about Hepler and Frank's findings and tried cannabis in the form of marijuana spiked brownies and marijuana cigarettes in 100 administrations with positive results as compared to pilocarpine. In his series of 20 glaucoma patients their intraocular pressure was dropped from an average of 25 to 18 mm Hg*. (Which is from the moderately elevated to a normal value) Rather than being greeted by his colleagues and the medical profession he was censured by his county medical society and suspended for 6 months. The Hepler and Frank team in a legal controlled study at U.C.L.A. confirmed Dr Blanton's findings.

Robert Randall, a sufferer of glaucoma, after his arrest for cultivation for personal use, successfully sued the federal government on the basis of medical necessity and is currently maintained on cannabis supplied by the National Institute on Drug Abuse. He continues to hold his symptoms at bay through smoking marijuana but if he attempts to stop experiences characteristic symptoms of "halo" effects around lights and eye pain. These symptoms cease when he starts inhaling marijuana smoke again.

Asthma

The contradictory properties of irritation to the throat and lungs causing bronchitis and the antiasthmatic effects acknowledged by the Indian Hemp Drugs Commission:

"In asthma and bronchitis inhalation of ganja smoke appears to be very frequently prescribed; while on the other hand, there is evidence which tends to indicate that both affections may be induced by charas or ganja smoking indulged in as a habit."

In Western medicine where the smoked route was rarely employed cannabis was described as effective in controlling asthma and cough. Since cannabis Prohibition the same seemingly paradoxical properties have been confirmed.

Topical Effects

Cannabis resin, with the consistency of pine pitch, insoluble in water is irritating to tissues although it has some topical anesthetic properties. The crude plant also has bactericidal properties.

Tracheobronchial Tree and Lungs

Because the most common route of administration is the smoked route irritation to these organs is a safety concern. The additional products from burning are undeniably irritating. Animal experiments indicate that cannabis is different from tobacco in its irritating effects on the lungs. The frequently heard coughing fits of the cannabis smoker give irrefutable involuntary vocal testimony to this undesirable side effect from smoking cannabis.

Topical Applications

Aside from contact dermatitis in hemp harvesters and processors at high levels of exposure, some allergenic individuals react similarly to exposure to small amounts of cannabis.

The powdered crude plant is moistened and applied to arthritic joints.

Concentrated cannabis resin is topical anesthetic. Applied directly to a nerve, the electrical impulses are inhibited. It was mentioned as used on dental caries for treatment of pain.

Prior to removal from the market it was combined with salicylic acid, a proteolytic agent, and collodion to keep it in place for callus removal on feet.

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Although cannabis is water insoluble powdered cannabis has been moistened and applied as a poultice to arthritic joints.

Cannabis powder has also been used as a topical antiseptic applied to wounds to promote healing and prevent infection.

The antibiotic properties of cannabis appears to be in the cannabidiolic acid and cannabidiol

Increased Appetite

Cannabis has been recognized as an appetite stimulant for hundreds of years in non-western medicine. Mirza Abdool Rhazes, "a most intelligent Persian physician...considers Hemp to be a powerful exciter of the flow of bile, and relates cases of its efficacy in restoring appetite.." " "produces a healthy appetite,..digestive, easy of digestion,..and the digestive faculty" .

During its' century long prescriptive availability before being taken off the market, stimulation of appetite was frequently described, as a secondary effect during its use as an analgesic or sedative in comparison with the opiates. McConnell in 1888 specifically described success in treating anorexia "One of the conditions in which the drug has proved useful in his hands is anorexia- loss of appetite consequent upon exhausting diseases such as prolonged fevers, diarrhoea, dysentery, phthisis, etc."

Appetite Stimulant

Antidiarrheal

Laxative

Lees described the drug as a mild stimulant to overcome constipation and gastritis that is nervous in origin

Antiemetic

Anticonvulsant

With the introduction of cannabis to Western medicine in 1838

Consroe and Sandyk 507

TABLE 1

Reported Effects of Marijuana Treatment on Features of Neurological Disorders Described in the 19th Century and Possible Contemporary Analogies to These Neurological Disorders

Disorders of the Contemporary Effect of

19th century disorders marijuana

Convulsions: recurrent. Tonic-clonic seizures: Benefit

general, tonic. clonic generalized epilepsy

Convulsions: petit mal Absence seizures:

generalized epilepsy No effect

Spasms of torticollis torticollis;

and Dystonic movements: spasmodic No effect

writer's cramp writer`s cramp

Rheumatic chorea:

Choreic movements: Sydenham`s Benefit;

generalized chorea chorea:

Huntinpton`s chorea no effect

Tremor of paralysis agitans Resting tremor: No effect

Parkinson`s disrase

I

Tonic painful spasms; jerky Spasticity and Ataxia: Benefit

movements of spinal sclerosis

spinal cord injury: no effect

multiple sclerosis

Pain of neuropathy. Sustained pain: No effect

e.g. sciatica

neuropathic pain Pain of neuropathy Paroxysmal pain, trigeminal neuralgia neuropathic pain Benefit

Migraine headache Migraine headache Benefit

Analgesic

ANTIINFLAMMATORY- Systemic

First described by O'Shaughnessy in the treatment of acute and chronic arthritis in 1839, Clendinning confirmed the findings in 4 of his 18 patients in 1843. Acute rheumatism was successfully treated by Buckingham in 1858

Non-Steroidal Anti-Inflammatory Drug:

Similar chemical structure to steroids

[Insert chemical structure diagram]

Lipid metabolic pathway of the Eicosanoids

Release of Prostaglandin and decrease of PG production.

Inhibition of healing of viral infection

Antagonism of marihuana effects by indomethacin

Post traumatic Arthritis

Auto immune Diseases

Nail Patellar Tooth

Charcot Marie Tooth

Drusen of Optic Nerve

Cough Suppressant

Clendinning in 1843 described 18 cases of whom 6 presented with cough- both acute and chronic that responded favorably to cannabis. In addition to mention in most Materia Medica and general medical literature as an antitussive, cannabis was included in proprietary cough medicine like Piso's cough cure that were available until 1937.

Antiasthmatic effects are described with both oral and smoked routes of administration although the bronchitis from chronic use was recognized as an undesirable side effect.

It was recognized to be useful "in some cases of Spasmodic Asthma"

Antipruritic

Chronic and acute itching appear to respond well to cannabis and is mentioned in several general medical texts. Grinspoon and Baklar in Marijuana Forbidden Medicine reports a case of self-medication with marijuana for intractable itching.

Alcohol, Opioid, and Sedative Substitute

Harm reduction through substitution

Clendinning also must be credited with substituting cannabis for opium dependence in 4 of the 18 cases reported. Mattison in 1891 described cannabis as treatment of choice for the treatment of opiate and alcohol dependence and cautioned the practitioner to think twice before resorting to prolonged opiate use for pain: "Would that the wisdom which has come to their professional fathers through, it maybe, a hapless experience, might serve them to steer clear of narcotic shoals on which many a patient has gone awreck.

Indian hemp is not here lauded as a specific. It will at times, fail. So do other drugs. But the many cases in which it acts well, entitle it to a large and lasting confidence."

Withdrawal and Substitute For Alcohol, Opioids, Sedatives, and Nicotine

Three of Clendinning's cases were withdrawal from alcohol dependence . Birch in 1889 and Mattison described cannabis as useful in withdrawal from and substitute for chronic chloral and chronic opium dependence. Reed described cannabis for the treatment of nicotinism

Febrifuge

The mention in the 17th century Persian medical text Makhzan-el-Adwiya as "imparting a gentle heat, and then a considerable refrigerant effect." The Indian Hemp Drugs Commission took note: There is a large body of evidence showing that hemp drugs, both as smoked and as drunk, are used as a febrifuge or preventive of diseases common in malarious tracts or arising from bad water." Cannabis continues to be used in contemporary Ayurvedic Medicine to treat malarial fever.

Clendinning in 1843 described effectiveness in the treatment of four cases of febrile illness.

While this property of cannabis went largely unnoticed by Western medicine, it was rediscovered in the classified Army research done from 1954 - 1959 reported by Van M. Sim, M.D., chief of the Edgewood Arsenal research program in an interview: "The tetrahydrocannabinols also are capable of lowering the body temperature three to four degrees centigrade under conditions of severe hyperpyrexia." While Dr Sim is credited with getting the findings declassified, at this writing there has been no clinical follow-up.

Sedative

The sedative and sleep inducing properties of cannabis were described in both general and medical literature as the end phase after an initial stimulation.

Edes while unsuccessfully treating headache relieved a patient of nightmares. As late as 1937 it was officially described by the American Medical Association as being "...the average physician will readily admit that Indian hemp is employed in various preparations for internal use as a sedative and antispasmodic" Hindu and Persian writings give many different accounts of the biphasic effects of the drug. The legendary nepenthe in Greek mythology may have been cannabis.

Uterine stimulant and contracting agent

Hashish was discovered in an ancient tomb in Israel; a woman who ha apparently died in chilbirth . Used in Africa by the smoked route. Studied by Christison , Willis , Dey, Stille" , Grigor , and Batho all reported help with uterine dysfunction as well as stimulation of labor. Treatment of dysmenorrhea and premenstrual syndrome (PMS) .

Aphrodisiac and sexual aid

While controversial, the alleged aphrodisiac properties are mentioned frequently in the Indian literature, there have never been any definitive studies. A book was devoted to the sexual power of marijuana. Sex and drugs continue to have continuing and complex relationships.

Psychological Research Tool

With the development of the philosophy and psychology of the individual with scientific methodology in the mid 19th century, the study of effects of cannabis on the mind were diverse. O'Shaughnessy's opening of a medical transcultural portal with his 1838 monograph, On the Preparations of the Indian Hemp, or Gunja (Cannabis Indica) Their Effects on the Animal Systems in Health, and Their Utility in the Treatment of Tetanus and Other Convulsive Diseases a timeless paradigm of modern scientific method. Review of the literature, social observation, animal studies, healthy human studies, and effects with diseases. Psychotropic effects of cannabis were a salient aspect of this drug which was new to western medicine. This basic primary knowledge disseminated throughout medical and lay literature saw a diverse application of cannabis' effects on the mind.

John Stuart Mill suggested using cannabis for the recall of forgotten memories.

Moreau de Tours described study of the effects to mimic mental illness, self administration to experientially understand pathologic mental states of dementia, mania, and delusional conditions suffered by patients. He also recommended personally experiencing the effects of therapeutic drugs in order to be a more empathetic and effective clinician. Self-study through the effects of cannabis was not only acceptable but necessary for a proper understanding of the drug.

Bell proposed its use in the treatment of mania, dementia, and melancholia and cited Moreau's model of simulation of different forms of mental disorder.

Kubie and Margolin described cannabis as useful in recovering repressed memories during dissociative mental states caused by the drug. Rolls and Stafford-Clark described success with the use of a single session cannabis experience in the treatment of a case of depersonalization where pentobarbital and methamphetamine narcosynthesis had failed.

These properties of cannabis and the disruption of cognition at higher dose were evaluated as chemical weapons by the secret government research from 1947 through 1977 . It was an original candidate as an aid in interrogation designated the "Truth Drug" TD

Therapeutic Power of Cannabis: A General Theory

Effects of any drug are more than the pharmacology. The effects include the set (or expectations), setting, physical and psychological makeup of the user. The set and setting includes the culture which is expressed in its language. Semantics and pharmacology define the drug.

The Indian Hemp Drugs Commission reviewed Other beneficial effects:

"The drugs are said to be cheering in their effects, and to be prized by many on this account. An interesting illustration of this may perhaps be found in the popular belief existing in many parts that these drugs protect against cholera and other epidemic diseases. One very intelligent witness, who had seen much of this use, explains it to as due to the stimulating and inspiriting* nature of the drugs."

This semantic attitudinal component is synergistic with the pharmacology of the drug in producing its therapeutic effects. This affirmative "popular belief" may be seen as a factor that favorably affects the physiology of the user including the immune system in optimizing its resistance to stress. Psychogenic factors play a significant role in the mediation of the immune response.

Linguistically the Sanskrit and Hindi references are to the attributes of healing, strength, and success:

Vijaya victorious

Trailokyavijaya victorious in three worlds

Indracana Indra's food

Jaya victorious

Virapattra leaf of heroes

Capala the light hearted

Ajaya the unconquered

Ananda the joyful

Harsini the rejoicer

vakpradatava speech giving

medhakaritva inspiring of mental power

creshadipanatva a most excellent excitant

With these product images of cannabis the set and expectations are not of forbidden deviance or illicit sensual pleasure implicit in the contemporary argot- marijuana.

The fact that medical marijuana was "discovered" despite the heavy prohibitionist censorship and pejorative semantics in descriptions of characteristics of the drug attests to the significant and strong pharmacological component of the therapeutic effects of cannabis.

I am left with the question as to the relationship between social, psychological, and physical elements; the sequence, and eventual accomodation. At this writing the salient problem is a generalized ignorance within the medical and scientific communities resulting from unavailability for clinical use- a serious case of disuse atrophy. The vaccuum of clinical experience with cannabis has been filled by poisonous fiction. Medline, the computer data base of medical and scientific abstracts and listings memorializes (if memorialize can be said of volatile and evanescent data bases) the absence of therapeutic applications. This temporocentric window of a decade or less on the topic of cannabis is a poisonous memory hole. Drug policy based upon this structurally mandated ignorance is harmful and stupid. A social form of dementia. This ignorance is then defended by the policy makers as they make wrongheaded and harmful decisions that perpetuate these policies. These are collective delusional behaviors. The courts, prosecutors, and police play an excessively active role in facilitating and perpetuating- if not actively perpetrating this social illness. On the tricentennial of the Salem Witch Trials Satan is alive and well; fed on the demonology of Prohibition. William Bennett, first recent Drug Czar designate of the United States, proclaimed Satan as etiology of drug woes.

Marijuana, Hashish, Cannabis, or Hemp?: What's in a Name?

Only with reluctance I have chosen to utilize the term marijuana over cannabis or hemp drugs because of its contemporary meanings. Etymologically, one sees this distinction in the 1839 paper by O'Shaughessey

"The term "marihuana" is a mongrel word that has crept into this country over the Mexican border and has no general meaning, except as it relates to Cannabis preparations for smoking. It is not recognized in medicine..." testified William C. Woodward, M.D., lobbyist for the American Medical Association before congress at hearings for the 1937 Marihuana Tax act that ended the medicinal use of cannabis after a century's availability.

But one finds this in medical and scientific literature not listed under marijuana- but under cannabis or hemp drugs.

Notwithstanding the availability of one of the active principles, delta 1, 9 tetrahydrocannabinol (dronabinol) dissolved in sesame oil, (Marinol) since 1986 as a schedule II drug with approved applications as an antiemetic for side effects of cancer chemotherapy and since 1993 for AIDS wasting syndrome. The numerous other medicinal uses of cannabis- or hemp drugs remain largely undocumented and unreported (including use of Marinol for applications not authorized under federal law but permitted under California law) The chilling effect of policies of the federal Drug Enforcement Administration and its precursors since the removal of cannabis from the U.S. Pharmacopeia and National Formulary in 1940 continues to maintain the fiction that cannabis drugs have no medicinal uses.

Unfortunately this harmful fiction has devastating consequences for the many patients with serious painful debilitating and lethal conditions. The poisonous immoral, illicit and illegal image of marijuana has caused numerous sufferers to reject efficacious treatment with cannabinoids.

When in consultations with elderly patients in proffering Marinol to patients for anorexia, nausea, and vomiting, an occasional victim rejects the "pot" pill "because it is wrong", I curse the deluded ignorance of our contemporary medical and scientific realities distorted by putting prosecutors and police in charge of medical decisions. Sick? Call a cop.

The Future of Marijuana lies in the Past

Our contemporary font of knowledge of the therapeutic uses of cannabis is poisoned by official moralistic lies and censorship. Besides the immediate toxicity of inappropriate withholding of the drug, the resulting loss of credibility of these statements by those with personal experience diminishes trust and belief in the sources. Thus the clinical research reported by medicine before marijuana prohibition in 1937 becomes even more important.

Contemporary perseverative voices claiming "We don't know enough to proceed further!" merely articulate their ignorance of the existing clinical literature.

Just below the layer of fouled and distorted information of the present lies a convincing body of objective clinical information on therapeutic attributes of the drug.

Cannabis in Western Medicine

Introduced to Western medicine by Sir William B. O'Shaughnessey, M.D. in 1839 , he acknowledged both medical and non-medical uses and confirmed previous observations cited in earlier literature: "...the kind of mental excitement it produces depends on the temperament of the consumer." an observation described in 1695 in Rumphius Herbarium Amboinense . O'Shaughnessy, not confining himself to the minimal information in contemporary Western medical literature, turned to Ayurvedic, Persian, and Arabic systems for additional descriptions:

The pre-synthetic era pharmaceutical industry confronted problems with wide variations in potency of different preparations of cannabis. The descriptions of inadvertent overdose with the drug are the most numerous in medical literature of the 19th century.

A clinical protocol whose applicability transcends time and technologic innovation is that of Sir J. Russell Reynolds, M.D., F.R.S. in 1890:

"The dose should be given in minimum quantity, repeated in not less than four or six hours, and gradually increased by one drop every third or fourth day, until either relief is obtained, or the drug is proved, in such case, to be useless."

This patient, prudent, and cautious regimen by this physician to Queen Victoria's court summarized his thirty years of clinical experience with the drug. The Reynolds Protocol should be used whenever possible.

Patience is of prime importance since it compensates for idiosyncratic sensitivity, lengthy onset time when taken orally, and variability in potency of the preparation.

In the 1800's, Transportation, storage, handling, shipping, and processing problems caused significant variation in potency from one sample to another. Today, the illicit market for cannabis produces similar variability.

Unlike a century ago, a salient issue is the availability of the crude drug in quantities adequate for continued personal therapeutic trial.

A Legal Cannabinoid: Marinol

Marinol* Roxane Laboratories, Inc. , a synthetic single tetrahydrocannabinol dissolved in sesame oil (dronabinol) in doses of 2.5, 5.0, and 10.0 milligram soft gelatin capsules may be quite useful in some cases. A schedule II drug requiring a triplicate prescription, it is restricted for use in nausea and vomiting for side effects in cancer chemotherapy, and (since 12/93) AIDS wasting syndrome.

In my clinical experience with Marinol it has been useful not only in these indicated conditions and also in the treatment of depression, insomnia, agitation, muscle spasm, migraine headache and pain.

For others, Marinol is either ineffectual or produces undesirable side effects. With some who experience side effects it is due to improper administration.

Route of Administration: Inhalation vs Oral.

If at all possible, the oral route is preferable since the throat and lungs are not irritated by the drug. The clinical medical literature and pharmaceutical catalogs prior to the removal of cannabis in 1937 indicates the oral route was the medicinal standard. While crude powdered cannabis was available through pharmacies that could be smoked, it was apparently minimal compared with the use of tinctures (alcoholic solutions of cannabis) and extracts (cannabis resin). In addition, cannabis was added to sedative mixtures that would contain combinations of other plant extracts and bromine salts.

Advantages of the oral route

* No irritation to throat and lungs

* Stable levels of the drug

* Lengthy period of action

Disadvantages of the oral route

* Difficult to estimate dosage with single doses

* Once eaten, the dose cannot be adjusted

* Slow onset of effects

* Dependent on activity and content of stomach and small intestines

* Lengthy period of action

* Slow wearing off of effects

* Inefficient use of the drug

With an empty stomach in a relaxed situation, effects may start in a an hour or so. The length of action is related to the dosage or sensitivity. With a small dose some three or four hours, with a large dose twelve or more hours.

The intensity of mental effects is directly dose related.

Inhalation: Smoking

Smoking, while traditionally associated with social or recreational use, may be desirable for certain users but unsuitable for others.

The advantages to inhalation are:

* Rapid onset of effects- a minute or less

* Accurate adjustment of dose

* Fast disappearance of effects

* Efficient use of drug

* Not effected by contents of stomach or intestines

* Not impeded by liver

* Difficult- if not impossible to overdose

Smoking: Minimizing Harm

Pharmacologically, as with most things there is no free lunch; smoked crude cannabis is undeniably irritating to the throat and lungs. If the user opts for the smoked use of cannabis reducing harm is possible.

The stronger, cooler and cleaner the better.

The more potent the cannabis, the less the throat and lungs are exposed to irritating impurities as fewer puffs are needed for the desired effects. The further away from the mouth and throat, the cooler the smoke which decreases irritation both by the heat, itself, and by the mix of compounds carried in the smoke. Bubbled through water, water soluble irritants are lessened.

Irritation from smoked cannabis can be minimized by using a water pipe which will absorb some of the unwanted impurities and cool the smoke. The cooler the smoke, the less irritation. The use of hand rolled cannabis cigarettes "joints" add additional impurities from the burning paper. The small burnt down end of the joint, a "roach" has the hottest and most irritating mix of impurities.

Irritation from hot, impurity laden smoke from the roach can be diminished by holding the stub away from the lips with a tube made from a rolled up paper. Better yet; use a pipe instead.

Pipes

The further from the throat and lungs, the cooler. A pipe with a long stem is better than a short stem.

Water Pipes

Water pipes (and bongs) must provide adequate scrubbing of the smoke with a minimum of "dead space" inside the vessel.

Smoking techniques

In countries where cannabis is inexpensive and available like Morocco and Nepal the cannabis smoker lights a pipe and smokes it much like a tobacco pipe with a medium sized breath with immediate exhaling. (and in Morocco tobacco is added) Coping with scarce and expensive cannabis, the United States and European cannabis smokers learn techniques to maximize the efficiency of using the drug. The smoker exhales as much as possible before taking in the puff of carbureted smoke with a puff of air following to push it past the "dead space" of the throat, trachea, and bronchi. The breath is then held for some five seconds before exhaling.

Irritation from low grade cannabis is felt immediately but irritation from high resin cannabis has a delay of a few seconds before the irritation is felt. The user thinks "this wasn't so harsh" before the fit of coughing begins as the receptors in the lungs respond to the irritation by the resin. (This delay may be from topical anesthetic properties of cannabis resin slowing the transmission of signals from receptors to the nervous system.) The user then adjusts by increasing the dilution of the smoke with air on subsequent puffs. Continuing adjustment is needed because of the variability of the quality and potency of the illicit plant. Even long time experienced users still may be seen with fits of coughing from inhaling too concentrated puffs of smoke. Heavy cannabis smokers suffer a chronic bronchitis from this irritation. "As in long-continued and excessive cigarette smoking considerable bronchial irritation and chronic catarrhal laryngitis may be induced, so to may a similar condition be caused by excessive ganja (buds of the female plant without seeds) or charas (hashish) smoking..."

Variable Potency

Unless there is access properly stored large supplies that will last for long periods, the chronic cannabis user can expect this variability. While the medicinal cannabis user of a century ago may have had to put up with variability, under cannabis prohibition today must cope with variability in addition to expense and scarcity.

Because of the rapid onset of effects through the inhaled route self adjustment of dose (autotitration) is easy. The user stops when the desired state is attained and waits until the effect starts to wear off before taking another puff.

Smoking Behavior: Set and Setting

Expectations and circumstance are important in the effects of cannabis. The effect of the drug will be different in different situations. Sitting alone or with friends in a safe and private place versus speeding down the highway at the wheel of a car with a police cruiser pulling up from behind, lights flashing, would produce different effects.

Since we are not islands unto ourselves one must consider the effects of smoking upon others which are not without consequences. Putting oneself and others at risk are not responsible behavior. Operation of any complicated machinery like driving a car under the influence of cannabis is a poor idea.

Detection and capture

As long as cannabis is illegal being caught and punished is far more dangerous to one's well-being than any of the effects of the drug. Depending on one's circumstance, it may be the end to a career path, employment, or reputation. The poisonous personal effects from social sanctions should not be minimized. Cannabis users must be discreet to avoid these most harmful of side effects of ignorance and viciousness that will befall if found out. Knowledge of cannabis use can easily be used for blackmail in a Prohibition society.

Side stream Exposure

Your throat and lung irritation is undesirable. Exposing others to these effects without agreement is even less desirable. If you didn't like or were allergic to the smoke you wouldn't want it inflicted upon you. Cannabis smoke tends to be less noxious than tobacco smoke because there is less of it. Ten times as expensive, the cannabis smokers take fewer puffs and hold their breath for better absorption. Smokers of high potency cannabis take even fewer puffs with less resultant exhaled smoke. Avoid smoking in a closed or poorly ventilated space.

Passing the Pipe, Joint- and Maybe Disease

While passing the joint or pipe may be a primal social behavior that add to feelings of acceptance and help the relaxing effects of the drug, the user is exposed to all saliva borne infectious diseases in the group.

How can one minimize this not so obvious but real risk in cannabis use?

Don't share with others. Either smoke solo or pass up the pipe or joint when it is passed your way. "No thanks, I have a cold and don't want to give it to you" should be an acceptable reason.

Don't let the pipe or joint touch your lips. Hold it so as to inhale in such a way as not to let it touch. This may take some practice. Others may think you are a bit strange. If you must use a joint, put it in your own personal holder that is not shared.

[insert picture of hand with joint or holder]

Sterilize the mouthpiece of the pipe for a second with flame or wipe it with an alcohol pad.

Vaporization; Safer Inhalation of Cannabinoids

The unique physical property of consistency like pine pitch and lack of water solubility of the active principles of cannabis pose unique problems for administration.

Heating cannabis to a temperature where the drug portion of the plant turns into a vapor which can be inhaled without burning is safer than smoking. Vaporization avoids exposing the throat and lungs to the irritating and toxic products of combustion of the crude plant. In the 5th century BC, Herodotus' description of the Scythians throwing cannabis atop a fire in an enclosure and inhaling the vapors may be a an early description of vaporization- or an inexact translation confusing smoke for vapor.

Tetrahydrocannabinols, Cannabidiols, and cannabinols vaporize in the range of 400* Fahrenheit; below their ignition point. These resinous portions come to a boil and condense into tiny particles which are dispersed in a fine air emulsion that is then inhaled. Vaporization devices have been around since the sixties but, because of their inefficiency (and illegality as drug paraphernalia), have never become popular.

Prototype Vaporizers

Cigarette lighter element & chamber

Powdered cannabis is placed in a thin layer on the heating element which is heated until white vapor appears in the chamber. The vapor is inhaled through a tube in the floor of the chamber (made from a small glass jar or bowl).

Shrink tubing heater

Powdered cannabis is placed on a small mesh brass screen in glass funnel with rubber or plastic tubing for inhalation. A hand held electric heater with a small fan used for heating shrink tubing on electronic parts is calibrated with a thermometer held in the stream of hot air. (400 degrees Fahrenheit).

Heated wire and extracted resin

Cannabis resin with the consistency of pine pitch is placed dropwise on the end of an iron or steel wire which is then applied to a hot soldering iron or glowing charcoal. The ensuing puff of vapor is captured by a large drinking straw placed close above the point where the droplet is applied inhaled through the straw. The application is timed with the beginning of the taking in of a breath.

Charcoal pellet and heat exchange chamber

Utilized by the Premier cigarette by the Phillip Morris Co. developed and test marketed in 1989 before dropped after protests from nicotine prohibitionists and poor sales. This device it was claimed could be converted from using enclosed the nicotine pellet to other drugs- namely crack cocaine.

Effects: Physical and Mental

The Bell shaped curve

Reactions to cannabis products vary from totally beneficial and necessary for life, to harmful, dangerous, and to be avoided. They can be life saving to life threatening. An AIDS wasting patient whose appetite is restored or a person violently allergic or sensitive to smoke

Dose Relationships

The combination of individual sensitivity with amount taken add up to the effects experienced. Route of administration also affects the results. Effects both in terms of intensity and length are directly related.

Dose and Route of Administration

The inhaled route avoids overdose since the rapid onset of effects permits the user to cease intake of the drug when the level of drug effect is reached. The oral route with it's slow onset and variable absorption after eating does not allow this fine degree of control in the case of a single dose.

Site of action

Unlike other sedative compounds, cannabinoids have their effect in the upper portions of the brain with physical effects mediated downward, rather than affecting lower centers of the brain as with alcohol, barbiturates, or benzodiazepines.

While the existence of receptor sites have been identified in homogenates of rat brains using radioisotopes, precise anatomic sites have not been located in humans.

The limbic system is a prime candidate as an area that lies below the cerebral cortex and plays a significant role in mediating connections with upper and lower centers within the central nervous system.

[insert diagram of limbic system]

Effects on the central nervous system

Brain Wave Effects

Cannabis' effects on the electroencephalogram (EEG) are a biphasic stimulation and sedation that are mediated by dose, set, setting, physiology, and personality. Initially, there is a speeding up of brain wave activity and a reactive slowing as the drug effects wear off. The higher the dosage, the more intense the effects and longer the experience. As the effects wear off, the stimulation gives way to sedation. The buzzing ideation of the beta state gives way to introspection, then dream imagery of alpha and theta frequencies moving towards sleep. With continuing low level use, the effects are less intense but more frequent in need to take inhaled drug.

Stimulation of both beta and theta frequencies.

Beta waves, high frequency (>14 Hz) reflect the increased cognitive activity subjectively experienced as a "flow of ideas" that characterize the onset of cannabis mental effect. The distortion of time with this "speeding up of thoughts" causes subjective perception that there is a slowing of time.

Theta waves, low frequency (4-7 Hz) are seen with visual imagery. These images break through a background of thinking and disrupt the train of thought. The thinking is distracted by these intrusions which then modify thought content to varying degrees, depending on dose, expectations, setting, and personality.

Adverse Effects of Cannabis

As with any drug, cannabis is a tool. There will always be individuals that experience adverse consequences from any drug use. The abuse of cannabis has been recognized for millennia. These problems were described by O'Shaughnessey during his observations in India in 1839 which included references in the Persian medical literature. With widespread non medical use of the drug for the past thirty years, psychiatrists have developed classifications of cannabis presented in the latest Diagnostic and Statistical Manual, Revision IV (DSM-IV)

Intoxication/Overdose

Overdose is most common by the oral route since the time from taking the drug until the experience of effects begin is from one to three or more hours. Inexperienced and ignorant first time users will have an unforgettable experience.

The effects of overdose have been numerously described in general, clinical, and scientific literature. Cannabis overdose comprises the majority of listings in the Surgeon General's List, 19th century precursor of the Indicus Medicus. American literary accounts in books: FizHugh Ludlow's Hasheesh Eater and An Essay on Hasheesh by Victor Robinson M.D. are expressly devoted to cannabis. Descriptions of experience with the drug as part of travel to areas of indigenous use may be found in English and European literature over the past three centuries. Scientific and medical descriptions of effects of cannabis overdose have been numerous extensive. Before and after its removal in 1937.

The effects of overdose are from the stimulation and sedation of the central nervous system. Stimulation with a flooding of ideas and images that are vivid and rapidly changing. Attention and concentration are markedly impaired. Time perception is significantly altered with minutes seeming like hours. There may be distortion of spatial perception.

Secondary physical effects, aside from a speeding up of the heart rate from the central nervous system stimulation, are remarkable in their absence. The acceleration of the heart rate is generally no more than that associated with mild to moderate exercise.

Cannabis-Induced Disorders

292.89 Cannabis Intoxication

A. Recent use of cannabis.

B. Clinically significant maladaptive behavioral or psychological changes (e.g., impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal) that developed during, or shortly after, cannabis use.

C. Two (or more) of the following signs, developing within

2 hours of cannabis use: (1) conjunctival injection (2) increased appetite (3) dry mouth (4) tachycardia

D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Specify if:

With Perceptual Disturbances: This specifier may be noted when hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium. Intact reality testing means that the person knows that the hallucinations are induced by the substance and do not represent external reality. When hallucinations occur in the absence of intact reality testing, a diagnosis of Substance-Induced Psychotic Disorder, With Hallucinations should be considered.

292.81 Cannabis Intoxication Delirium

292.11 Cannabis-Induced Psychotic Disorder, With Delusions Specify if With Onset During Intoxication

292.12 Cannabis-Induced Psychotic Disorder, With Hallucinations Specify if With Onset During Intoxication

292.89 Cannabis-Induced Anxiety Disorder Specify if: With Onset During Intoxication

Continuing or chronic use.

Use or abuse? Cannabis, like any other drug, is a tool. Properly utilized with realistic expectations and awareness of its properties, cannabis is a safe and effective medicine. Improperly used with unrealistic expectations and ignorance, adverse effects may result. The onset of unwanted effects may be obvious or insidious. The general etiology is some emotional discomfort for which cannabis is taken to relieve producing undesirable consequences from using the drug itself.

Paranoia and delusional thinking are not uncommon effects of cannabis both acute and chronically. In the acute experience it appears to be from the perceptual distortions of space, time and feelings of detachment.

In chronic use paranoid and delusional thinking appear to be the consequences of the suppression of feelings, The dulling of feelings may alienate the cannabis users from others by diminishing empathetic capabilities. This emotional insensitivity then results in conflict through misperception. Misperception results from the dulling of affect that is important contextual collateral information source. An effective relief of emotional distress then becomes an impediment to relationships with the cannabis user. Feelings are an integral dimension of social perception that convey important contextual information. Cannabis, as an effective sedative and antidepressant, has this undesirable side effect when misused. The relief afforded by the drug may be paid for by complications caused by avoiding dealing with the causes of the emotional pain as well as diminished functioning while under its influence.

Cognitive impairment by continuing or overuse of cannabis creates a form of mild dementia that may persist for up to several weeks after discontinuing the drug. Individuals sensitive to the drug report a persistent "hangover" that diminishes the ability to pay attention and concentrate. The onset may be insidious, subtle, and gradual. This condition is reversible with abstinence from cannabis.

304.30 Cannabis Dependence

A maladaptive pattern of cannabis use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

(1) tolerance, as defined by either of the following:

(a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect

(b) markedly diminished effect with continued use of the same amount of the substance

(2) withdrawal, as manifested by either of the following:

(a) the characteristic withdrawal syndrome for the substance

(b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

(3) cannabis is often taken in larger amounts or over a longer period than was intended

(4) there is a persistent desire or unsuccessful efforts to cut down or control cannabis use

(5) a great deal of time is spent in activities necessary to obtain cannabis (e.g., visiting multiple dealers or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

(6) important social, occupational, or recreational activities are given up or reduced because of cannabis use

(7) cannabis use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance

305.20 Cannabis Abuse

A. A maladaptive pattern of cannabis use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

(1) recurrent cannabis use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; cannabis-related absences, suspensions, or expulsions from school; neglect of children or household)

(2) recurrent cannabis use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by cannabis use)

(3) recurrent cannabis-rclatcd legal problems (e.g., arrests for cannabis-related disorderly conduct)

(4) continued cannabis use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, forgotten promises)

B. The symptoms have never met the criteria for Cannabis Dependence for this class of substance.

232.9 Cannabis-Related Disorder Not Otherwise Specified

The Cannabis-Related Disorder Not Otherwise Specified category is for disorders associated with the use of cannabis that are not classifiable as one of the disorders listed above.