Dr. Traub speaks

When we took eight medical cannabis users with illnesses like MS, fibromyalgia, irritable bowel syndrome and AIDS to testify in So. Dak. legislative committees in Jan. 2009, we had already submitted the following letter of testimony from Dr. Douglas Traub -- a 30+-year internal medicine practitioner in Rapid City -- to every member of those committees.

Dear Representatives:

Thank you for the opportunity to address you on behalf of my patients with multiple sclerosis and AIDS wasting syndrome who have found relief from their symptoms by using marijuana. I am hopeful that the legislative process might be able to address their needs by considering a limited legalization of marijuana for very limited medical use, similar to what has worked in other states. I hope to point out how the drug works in relieving symptoms, why it may have advantages over currently available prescription drugs, and ask your assistance in decreasing or abolishing the criminal consequences that our patients currently face with their current surreptitious use of the drug marijuana.

Tetrahydrocannabinol (THC) is a drug derived from plant material or made synthetically and available as a capsule called dronabinol. Cannabinoids (a collective term for substances with similar structures and effects as tetrahydrocannabinol) have many effects on the brain , and often cause changes in pulse and blood pressure that medically we call sympathomimetic effects. The sympathomimetic effects include conjunctival injection, or “red-eye,” and an increase in pulse rate and fluctuations in blood pressure. It is thought that these effects arise from binding of the cannabinoids with receptors in the brain with subsequent autonomic nervous system to cause the symptoms noted above. These effects lessen rapidly with regular use of the drug. This explains why an examiner can sometimes detect when a new user of marijuana has used the drug, whereas a frequent user of the drug may escape detection on physical exam.

Cannabinoids can be found in several parts of the brain after ingestion. Areas found to have receptors for cannabinoids include the cerebellum (area at the base of the brain responsible to some degree for balance and coordination of movements), the hippocampus (responsible in part for memory and interpretation of sensory input), the frontal cortex (interpretation of visual and sensory input important for appetite, hunger and body sensations). The cannabinoids affect dopamine levels, which in the cerebellum may explain less spasticity and smoother motion in patients with multiple sclerosis. The effect of cannabinoids in the frontal cortex explain their effect on appetite and weight gain. Effects in the hippocampus may explain cannabinoids effect on forgetting painful conditions and tolerating pain. Collectively, these are some of the symptom relief mechanisms, leading patients with AIDS wasting syndrome and MS to try marijuana.

Upon hearing this explanation, some would ask, “Why not ask these patients to obtain prescriptions from their medical professionals for dronabinol, and everything will be fine, right?” Unfortunately, oral dronabinol, best-known under the brand name “Marinol,”is extensively degraded by the liver after it is absorbed from the gut. Furthermore, due to the large volume of tissues that the cannabinoid is diluted in (called volume of distribution) in the body, actual concentrations of the drug are very low after taking it orally. Ingesting several times the recommended dose may be the only method to obtain the desired symptom relief. This practice is not recommended, or safe, because of the variability of each persons reaction to cannabinoids. The only positive long lasting effect that is usually seen with the use of oral cannabinoids is their effect on the appetite.

These drawbacks to oral cannabinoids lead to another option for their use, by inhaling smoke from the marijuana by burning it or desiccating it to allow absorption of the oily, fat-soluble substance directly into the blood. Variables exist here, also, as different marijuana plants contain differing concentrations of the active cannaboid. Advantages of inhaling the marijuana smoke include allowing the patient to titrate the dose of the marijuana themselves (by smoking enough to relieve their symptoms), but disadvantages include the potential effects on the lung including the potential for emphysema and possibly lung cancer in long-term users. (Newland note: Neither of these diseases has been found, not even once, in even long-term heavy users of marijuana who do not also smoke tobacco.)

In conclusion, we in the medical profession are faced with patients with miserable symptoms, from diseases that are incurable or chronically disabling. Their symptoms, including spasticity, weight loss, and pain, can be alleviated by their use of marijuana.

The medical use of marijuana can have positive effects for our patients above and beyond those seen with medicines currently available. Work currently ongoing in fields of chronic cancer pain and hospice lend us hope that medical marijuana may allow us to offer further symptom relief for our patients.

Is medical marijuana a cure-all or wonder drug? Certainly not. It can be, however, helpful, even critical, for some of our chronically ill patients with miserable symptoms.

Please consider this explanation when considering legislation this year on the medical use of marijuana.

Sincerely,
Douglas M. Traub, MD, FACP

When the committee members commented on the testimony given, a couple of them asked why we had no testimony from doctors. (I banged my head against the wall repeatedly.)

I had asked a couple of doctors to come to the hearings. Here is the gist of what they said: "My time is much too valuable to cancel appointments with sick patients to travel to Pierre to speak to poseurs who think they know my business better than I do."