Tuesday, April 24, 2018
Opinion

Sanchez-Ramos: Medical use of marijuana requires more research

When the Legislature passed the Compassionate Medical Cannabis Act of 2014, it required that doctors be trained how to use cannabis preparations for a limited set of medical conditions. A member of the Florida Medical Association (FMA) asked me to help craft a course that would teach physicians proper procedures.

And that's when I began to realize the problems. To begin with, the science for the very limited kind of cannabis this law would allow (the strain called Charlotte's Web) is thin at best.

The new law allows the medical use of cannabis preparations that lack psychoactive constituents to make patients "high." Cannabis — marijuana — contains more than 70 cannabinoid compounds that vary in concentration depending on the species of the plant. One of these compounds, tetrahydrocannabinol (THC), is responsible for the plant's psychoactive effects.

Reducing or removing THC from the plant material is equivalent to removing caffeine from coffee, resulting in a substance with less likelihood of adverse effects, especially the development of dependence. Therefore, the law specifically prohibits THC levels greater than 0.8 percent of the total cannabinoid content, and allows the use of preparations rich in cannabidiol (CBD), a common component of the plant that does not make patients "high."

While developing the course with a colleague, we realized the scientific literature on medical applications of low-THC cannabis (containing less than 0.8 percent THC) was scant, compared to the extensive evidence for the therapeutic properties of marijuana with higher THC concentrations. In fact, there is no clinical trial of low-THC cannabis or cannabidiol alone that meets Class I criteria (the gold standard for demonstrating efficacy of drugs).

There have been anecdotal reports and media coverage about the anti-epileptic effects of an oily extract prepared from a cannabis strain (known as Charlotte's Web) rich in cannabidiol (CBD) and with very low levels of THC. Unfortunately, there are no high-quality clinical studies supporting the efficacy of this oil.

Clearly, there is a need for much more human research, especially since CBD has many beneficial actions in animal models of disease. In contrast, there are many Class I trials supporting the efficacy of cannabis preparations containing greater than 0.8 percent THC.

Florida voters will have a chance to modify the law on medical marijuana this November to redress the shortcomings of the Compassionate Medical Cannabis Act. Amendment 2 on the ballot — the "Florida Right to Medical Marijuana Initiative" — would allow use of cannabis with a wider range of THC concentrations to treat specific symptoms and medical conditions.

Given the high likelihood that this amendment will pass, I thought it reasonable to create a course for physicians incorporating all the clinical research findings on medical marijuana. It would be a disservice to the medical community to focus only on CBD-rich extracts from Charlotte's Web.

I submitted a draft to my colleague at the FMA expecting the leadership would embrace a more thorough scope of the course. The goal would be to lay the pharmacological groundwork for responsible, scientifically sound use of clinical cannabis preparations. I was greatly dismayed by the recently released public statement that the FMA is opposed to the amendment.

I couldn't understand how the FMA endorsed the education of physicians on use of low-THC cannabis without good clinical evidence to back up their decision, while ignoring the large body of Class I evidence supporting medical use of cannabis preparations with greater than 0.8 percent THC. The official FMA position against Amendment 2 is short-sighted and assumes the same position as the U.S. Justice Department, which classes cannabis as a Schedule 1 drug alongside heroin, LSD, MDMA (ecstasy). Schedule 1 drugs are those with no currently accepted medical use and a high potential for abuse.

Despite many legal attempts to have cannabis reclassified, the Drug Enforcement Agency and the White House Office of National Drug Policy have refused to budge. It is this very position that has hampered clinical research on cannabis for nearly half a century. And the FMA position against Amendment 2 reinforces this obstruction to clinical research at the state level.

Every physician and scientist who has reviewed the benefits and risks of cannabis to date, regardless of the THC content, has agreed on one thing: more research is needed. In particular, research is required to develop dosing protocols, using well-studied strains containing known amounts of cannabinoids for treating specific conditions.

It is possible that the official FMA position will change after the state's voters decide to pass Amendment 2 and the physician members of the FMA realize that expansion and dissemination of knowledge about the clinical pharmacology of cannabis will enhance the primary mission of all physicians to alleviate suffering and improve the quality of life of our patients.

Dr. Juan Sanchez-Ramos is a neuropharmacologist whose doctoral dissertation at the University of Chicago focused on the mechanisms of drug dependence. He is a board-certified neurologist who specializes in neurodegenerative diseases such as Parkinson's, Huntington's and Alzheimer's. He holds the Helen Ellis Endowed Chair for Parkinson's Disease Research, is director of the Huntington's Disease Center of Excellence at the University of South Florida and is medical director of the nonprofit Parkinson Research Foundation in Sarasota. In writing this exclusively for the Tampa Bay Times, he is expressing his own opinion, which does not in any way reflect the position of the University of South Florida.

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