Mainstream Medicine Has Endorsed Medical Marijuana

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Former Surgeon General: Mainstream Medicine Has Endorsed Medical Marijuana
By Dr. Jocelyn Elders (http://www.alternet.org/authors/9221/), AlterNet (http://www.alternet.org/). Posted March 26, 2008 (http://www.alternet.org/ts/archives/?date[F]=03&date[Y]=2008&date[d]=26&act=Go/).


A historic document from the 124,000-member American College of Physicians certifies the medical value of marijuana.
One of America's largest and most important groups of physicians has moved to cut through the clutter of political controversies over medical use of marijuana. Lawmakers and the public alike would do well to pay attention.
The American College of Physicians is the largest medical specialty organization and the second largest physician group in the United States. Its 124,000 members are doctors specializing in internal medicine and related subspecialties, including cardiology, neurology, pulmonary disease, oncology and infectious diseases. The College publishes Annals of Internal Medicine, the most widely cited medical specialty journal in the world.
In a landmark position paper released in February, these distinguished physicians are saying what many of us have been arguing for years: Most of our laws have gotten it wrong when it comes to medical marijuana, and it's time for public policy to get in step with science.
Right now, the laws of 38 states and the federal government bar use of marijuana as a medicine. Federal law classifies marijuana as a Schedule I drug, defined as having no accepted medical use and being unsafe for use even under medical supervision.
ACP's position paper urges "reclassification into a more appropriate schedule, given the scientific evidence regarding marijuana's safety and efficacy in some clinical conditions." The document goes on to call for protection of physicians' right to "prescribe or dispense medical marijuana in accordance with state law" and "strongly urges protection from civil or criminal penalties for patients who use medical marijuana as permitted under state laws."
ACP supports its position with 10 pages of scientific documentation and references. They cite data showing relief of the nausea, vomiting and wasting that can worsen the misery of cancer, AIDS and other diseases; of the pain and tremors associated with multiple sclerosis; and for relief of pain caused by a variety of other conditions. They note that marijuana in combination with some pharmaceuticals may produce more benefit than either drug alone.
ACP calls for more research, but then adds a critical point: In some areas, the efficacy of medical marijuana has already been established, and it's time for studies designed to determine the best dose and route of delivery.
The ACP position paper demolishes several myths, starting with the notion still proclaimed by some politicians that marijuana is unsafe for medical use. The College notes that the most serious objection to medical marijuana -- potential harm to the lungs from smoking -- has largely been solved by a technology called vaporization, already proven in scientific studies.
The ACP position paper also explains that there is no reason to believe that protecting medical marijuana patients leads to increased drug abuse. "Marijuana has not been proven to be the cause or even the most significant predictor of serious drug abuse," the doctors write. "Opiates are highly addictive, yet medically effective ... There is no evidence to suggest that medical use of opiates has increased perception that their illicit use is safe or acceptable."

for the entire article:
http://www.alternet.org/drugreporter/80582

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RoleSupporting Research into the Therapeutic
of Marijuana
A Position Paper of the
American College of Physicians
This paper, written by Tia Taylor, MPH, was developed for the Health and Public Policy
Committee of the American College of Physicians: J. Fred Ralston, MD, FACP, Chair; Molly
Cooke, MD, FACP, Vice Chair; Andrew A. Chang, MA, Charles Cutler, MD, FACP; MA, David
A. Fleming, MD, FACP; Brian P. Freeman, MD, FACP; Robert Gluckman, MD, FACP; Mark
Liebow, MD, FACP; Kenneth Musana, MB, ChB; Robert McLean, MD, FACP; Mark Purtle,
MD, FACP; P. Preston Reynolds; and Kathleen Weaver, MD, FACP. It was approved by the
Board of Regents in January 2008.
3
Executive Summary
Marijuana has been smoked for its medicinal properties for centuries. Preclinical, clinical, and
anecdotal reports suggest numerous potential medical uses for marijuana. Although the
indications for some conditions (e.g., HIV wasting and chemotherapy-induced nausea and
vomiting) have been well documented, less information is available about other potential medical
uses. Additional research is needed to clarify marijuana’s therapeutic properties and determine
standard and optimal doses and routes of delivery. Unfortunately, research expansion has been
hindered by a complicated federal approval process, limited availability of research-grade
marijuana, and the debate over legalization. Marijuana’s categorization as a Schedule I controlled
substance raises significant concerns for researchers, physicians, and patients. As such, the
College’s policy positions on marijuana as medicine are as follows:
Position 1: ACP supports programs and funding for rigorous scientific evaluation of the
potential therapeutic benefits of medical marijuana and the publication of such findings.
Position 1a: ACP supports increased research for conditions where the efficacy of
marijuana has been established to determine optimal dosage and route of delivery.
Position 1b: Medical marijuana research should not only focus on determining drug
efficacy and safety but also on determining efficacy in comparison with other
available treatments.
Position 2: ACP encourages the use of nonsmoked forms of THC that have proven
therapeutic value.
Position 3: ACP supports the current process for obtaining federal research-grade
cannabis.
Position 4: ACP urges review of marijuana’s status as a schedule I controlled substance
and its reclassification into a more appropriate schedule, given the scientific evidence
regarding marijuana’s safety and efficacy in some clinical conditions.
Position 5: ACP strongly supports exemption from federal criminal prosecution; civil
liability; or professional sanctioning, such as loss of licensure or credentialing, for
physicians who prescribe or dispense medical marijuana in accordance with state law.
Similarly, ACP strongly urges protection from criminal or civil penalties for patients who
use medical marijuana as permitted under state laws.
4
Background
The marijuana plant, cannabis, contains more than 60 chemical compounds, known as
cannabinoids. The main psychoactive element in marijuana is delta-9-tetrahydrocannabinol
(THC). Cannabidiol (CBD) is the second most abundant cannabinoid, but it has no psychoactive
effects. The concentration of THC and other cannabinoids in marijuana is highly variable,
depending on growing condition, plant genetics, and processing after harvest (1). This variability
in composition has hindered research on and evaluation of the drug’s medical value.
Marijuana has been smoked for its medicinal properties for centuries. It was in the U.S.
Pharmacopoeia until 1942 when it was removed because federal legislation made the drug illegal
(2). The Controlled Substance Act of 1970 placed marijuana in the Schedule I category along
with other substances deemed to have no medicinal value and high potential for abuse. Still, the
overwhelming number of anecdotal reports on the therapeutic properties of marijuana sparks
interest from scientists, health care providers, and patients. Over the past 20 years, researchers
have discovered cannabinoid receptors: CB1, which mediates the central nervous system (CNS),
and CB2, which occurs outside the CNS and is believed to have anti-inflammatory and
immunosuppressive activity (3, 4). These scientific developments have revealed much
information supporting expansion of research into the potential therapeutic properties of
marijuana and its cannabinoids.
In 1997, the White House Office of National Drug Control Policy asked the Institute of Medicine
(IOM) to review scientific evidence and assess the risks and benefits of marijuana. The IOM
concluded that scientific developments indicate marijuana and its cannabinoids have therapeutic
properties that could potentially treat many illnesses and conditions. The IOM recommended that
cannabis research should focus on the development of rapid-onset, reliable, and safe delivery
systems (5). Since the IOM report, the body of research on cannabinoids for symptom
management has grown slightly.
Potential Medical Uses of Marijuana
Appetite Stimulation/Antiemetic
The research supporting THC as an effective appetite stimulant and antiemetic is abundant. In
1986, the U.S. Food and Drug Administration approved Marinol® (dronabinol), an oral synthetic
form of THC, to treat severe weight loss associated with AIDS (HIV/AIDS wasting) and nausea
and vomiting associated with chemotherapy for patients who fail to respond to other antiemetics.
Clinical trials have demonstrated that both oral and smoked marijuana stimulate appetite,
increase caloric intake, and result in weight gain among patients experiencing HIV wasting (6–9).
Studies of chemotherapy patients with nausea and vomiting found THC to be equivalent or
superior to other antiemetics (including prochlorperazine or metoclopramide) for symptom
reduction (10). Research has also found that administration of THC along with another
antiemetic was more effective that either drug alone, suggesting opportunities for combined
therapy. The IOM concluded that cannabinoids are “modest” antiemetics but may be effective for

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those who respond poorly to other available antiemetics. THC and other cannabinoids may offer
relief not found in other drugs (11).
Glaucoma
High intraocular pressure (IOP) is a known risk factor for glaucoma. Cannabinoids have been
shown to have neuroprotective properties and to reduce IOP, pupil restriction, and conjunctival
hyperemia (12–14). Smoked or eaten marijuana and oral THC can reduce IOP by approximately
25% in people with normal IOP who have visual field changes, with similar results exhibited in
healthy adults and glaucoma patients. However, the effects of cannabinoids on IOP are shortlived,
and high doses are required to produce any effects at all. There is concern that long-term
use of marijuana could reduce blood flow to the optic nerve because of its systemic hypotensive
effects and its potential for interaction with other antiglaucoma drugs (15). In addition, the
cardiovascular and psychoactive effects of smoked marijuana contraindicate its use in glaucoma
patients, many of whom are elderly and have comorbidities. This led to the development and
testing of a topical THC, but its effect on IOP was insignificant. As a result, the IOM and
American Academy of Ophthalmology concluded that no scientific evidence has demonstrated
increased benefits or diminished risks of marijuana use to treat glaucoma compared with the
wide variety of pharmaceutical agents currently available (16, 17).
Neurological and Movement Disorders
Anecdotal, survey, and clinical trial data suggest that smoked marijuana and oral THC provide
relief of spasticity, pain, and tremor in some patients with multiple sclerosis (MS), spinal cord
injuries, or other trauma (18, 19). A recent study of patients with HIV-associated sensory
neuropathy (HIV–SN) found that those who smoked marijuana 3 times a day reported a decrease
of 34% in HIV–SN, compared with 17% in the placebo group. However, the psychoactive effects
of THC impaired posture and balance among subjects (20). CBD has some anti-inflammatory
properties and inhibits smooth muscle contractions, thus making it a potentially powerful
anticonvulsant that does not contain the psychoactive effects of THC. CBD has been indicated as
a treatment for several types of seizures and epilepsy, although human research is scant.
Preclinical trials revealed that the anticonvulsant properties of cannabinoids differ widely by dose
and between species. CBD has been shown to induce seizures in some species and to be strongly
anticonvulsant in others (21).
Analgesic
Current research on the role of various forms of marijuana as an analgesic is promising. Oral
doses of THC resulted in pain reductions similar to that from codeine among cancer patients
(22). A randomized, double-blind trial of patients with rheumatoid arthritis found that Sativex®,
an oromucosal THC spray, significantly reduced pain on movement and at rest and improved
quality of sleep (23). While studies indicate that THC has analgesic properties, there is a very
narrow therapeutic window between doses that produce useful analgesia and those that produce
unacceptable adverse effects. A recent study found that subjects who smoked 4% THC cigarettes
reported reduced pain sensations after 45 minutes. On the other hand, subjects who smoked 8%
6
THC cigarettes reported an increased sensitivity to pain after 45 minutes (24). In another study,
smoked marijuana increased sensitivity to electric shock among normal patients. The biphasic
action of THC, stimulation followed by sedation, increases then decreases pain. These properties
support the need for research to identify the specific kinds of pain that may be relieved by
marijuana and the development of a synthetic cannabinoid with few actions other than analgesia.
Adverse Effects
Acutely, smoked marijuana increases heart rate and may decrease blood pressure on standing;
however, some patients find the drug’s psychoactive effects more disturbing. Undesired effects
include impairment of short-term memory, attention, motor skills, reaction times, and the
organization and integration of complex information (25). These effects are generally more
severe for oral THC than for smoked marijuana (26).
The chronic effects of smoked marijuana are of much greater concern, as its gas and tar phases
contain many of the same compounds as tobacco smoke. Chronic use of smoked marijuana is
associated with increased risk of cancer, lung damage, bacterial pneumonia, and poor pregnancy
outcomes. Chronic marijuana use has also been linked to the development of tolerance to some
effects and the appearance of withdrawal symptoms (restlessness, irritability, mild agitation,
insomnia, sleep disturbances, nausea, cramping) with the onset of abstinence. However, these
withdrawal symptoms are mild compared with those experienced with opiates or
benzodiazepines (27). Moreover, THC, while quite potent in comparison with other psychoactive
drugs, has remarkably low lethal toxicity. This led the IOM to conclude that “except for harms
associated with smoking, adverse effects of marijuana use are within the range of effects
tolerated for other medications (28).”
Positions
As with any potential therapeutic drug, there are many factors that should be considered in
evaluating its medicinal value. These include the drug’s side effects, methods of administration,
and availability and comparability of alternatives. However, marijuana’s categorization as a
Schedule I controlled substance creates additional concerns for researchers, physicians, and
patients. As such, the College adopts the following positions on medical marijuana:
Position 1: ACP supports programs and funding for rigorous scientific evaluation of the
potential therapeutic benefits of medical marijuana and the publication of such findings.
Preclinical and clinical research and anecdotal reports suggest numerous potential medical uses
for marijuana. Unfortunately, the debate surrounding marijuana’s legalization for general use has
obscured scientific findings. Current available data suggest numerous indications for
cannabinoids, especially antiemesis, appetite stimulation, and pain relief. For patients with AIDS
or those undergoing chemotherapy, who suffer severe pain, nausea, and appetite loss,
cannabinoid drugs may provide symptom relief not found in any other medication. The data
supporting cannabinoid use for the relief of muscle spasticity and movement disorders is
promising, but further research is needed to clarify the roles of cannabinoids in treating these
conditions. For epilepsy and glaucoma, the data is much less convincing, and many of the reports
supporting marijuana use for these conditions remain anecdotal. In addition, while the
therapeutic effects of THC are well established, less is known about the effects and potential
indications of other cannabinoids. Additional research is needed to clarify both the therapeutic
properties of cannabinoids and their effects on symptom management. The IOM recommended
the following guidelines for clinical trials of marijuana for medical use:
• Clinical trials should involve only short-term use (less than 6 months);
• Clinical trials should be conducted in patients for whom there is a reasonable
expectation of efficacy;
• Clinical trials should be approved by institutional review boards; and
• Clinical trials should collect efficacy data (29).
Position 1a: ACP supports increased research for conditions where the efficacy of
marijuana has been established to determine optimal dosage and route of delivery.
To date, much of the research into the medicinal properties of marijuana has been on oral and
smoked forms of THC. The pharmacokinetics of oral and smoked THC differ greatly and
therefore have varying implications. The oral, synthetic THC has low and variable bioavailability
(30). Oral THC is slow in onset of action but produces more pronounced, and often unfavorable,
psychoactive effects that last much longer than those experienced with smoking (31). On the
other hand, smoked THC is quickly absorbed into the blood and effects are experienced
immediately. Studies have found that patients prefer the immediate effect on symptoms that
occurs after smoking marijuana (32, 33). Therefore, there may be some patient populations (e.g.,
cancer patients who experience nausea and vomiting during chemotherapy) for whom the
inhalation route might offer advantages over the currently available capsule formulation (34).
Also, many cancer and HIV/AIDS patients may prefer smoking over swallowing a pill.
However, examining the effects of smoked marijuana can be difficult because the absorption and
efficacy of THC on symptom relief is dependent on subject familiarity with smoking and
inhaling. Experienced smokers are more competent at self-titrating to get the desired results.
Thus, smoking behavior is not easily quantified or replicated (35). Other problems with smoked
marijuana include difficulty in attempting to match placebo control against smoked marijuana
(especially for those with previous marijuana experience) and the no-smoking policy of hospitals
and public facilities. Overall, the clinical utility of smoked marijuana is limited by its short
duration of action and accompanying side effects. Although the long-term effects of smoked
marijuana may not be relevant for patients with terminal illnesses or debilitating symptoms, the
residual effects of smoked marijuana are prohibitive for long-term medical use. The IOM
concluded that clinical trials of smoked marijuana should be the first step toward the possible
development of nonsmoked, rapid-onset cannabinoid delivery systems (36). Additional research
is also needed to determine optimal dosage of cannabinoid drugs for symptom management.

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Current data has shown that for some indications, particularly pain relief, there is a small margin between clinical benefit and unacceptable adverse events.
Position 1b: Medical marijuana research should not only focus on determining drug efficacy and safety but also on determining efficacy in comparison with other available treatments.
Most of the conditions for which efficacy of cannabinoid drugs has been determined already have well-established and effective treatments. However, little is known about how cannabinoids
perform in comparison with these other treatments. Because of the availability of an oral form of THC, several studies have compared the effectiveness of both smoked THC and Marinol® to
other antiemetic drugs (mainly prochlorperazine). Although the results from these studies varied, they all found that THC was as effective as prochlorperazine at controlling nausea and vomiting.
Several studies also found that the combination of THC and other antiemetics was more effective than either drug alone. Research suggests that cannabinoids may have synergistic effects that may
indicate its use as an adjunctive therapy to both antiemetics for nausea and vomiting and opioids for pain relief. Further research is needed to compare cannabinoids’ efficacy and safety with
current treatments and to examine their potential role in combination therapy for some conditions.

Position 2: ACP encourages the use of nonsmoked forms of THC that have proven therapeutic value.
The negative effects associated with long-term smoked marijuana use necessitate consideration of varying modes of cannabinoid delivery. Only 2 cannabinoid drugs are currently licensed for sale in the U.S. (dronabinol [Marinol ®] and nabilone [Cesamet ®]), and both are only available
in oral form. While useful for some, these drugs have serious limitations. The oral route of administration hampers the effectiveness of THC because of slow absorption. In addition, swallowing a pill may not be feasible for patients with severe nausea and vomiting, for whom
oral THC is indicated. To overcome the limitations of oral administration, researchers have focused on developing other nonsmoked, rapid-onset formulations.
Sativex®, an oromucosal spray of natural cannabis, was approved in June 2006 for prescription use in Canada to treat neuropathic pain in patients with MS. The manufacturer, GW Pharmaceuticals, received FDA approval to begin a U.S. clinical trial of Sativex for cancer patients in 2007.

The development of a vapor route for THC delivery offers promise for the future of medical marijuana research. A recent study found that THC administered through the Volcano® vaporizer resulted in higher plasma THC levels than smoked marijuana at both 30 and 60 minutes after
administration. It also found that exhaled carbon monoxide increased very little after vapor compared with smoking (37). Those findings, along with patient preference for the vapor method, indicate opportunities for future clinical trials. Vaporization of THC offers the rapid
onset of symptom relief without the negative effects from smoking. It allows patients to selfregulate their dosage immediately by ceasing inhalation when or if psychoactive effects become
unpleasant. Scientists are also developing a pulmonary dronabinol to be delivered with a
pressurized metered-dosed inhaler. Preliminary studies show rapid absorption, but FDA approval remains distant.

Position 3: ACP supports the current process for obtaining federal research-grade medical marijuana.
Some scientists and physicians believe the procedures for obtaining marijuana for research and publishing research findings are particularly arduous because of the debate surrounding its
legalization for general use (38). Marijuana’s designation as a Schedule I controlled substance does pose a unique challenge for researchers. The federal government is the only legal producer
of marijuana for medical research; scientists must therefore apply for both an Investigational New Drug Application (IND) from the FDA and a Schedule I license from the Drug Enforcement Administration (DEA) to receive and dispense marijuana through a designated pharmacy. The
marijuana is provided by the National Institute on Drug Abuse (NIDA) in the National Institutes of Health (NIH). Through the Drug Supply Program, NIDA arranges for marijuana to be grown
and processed through contracts with the University of Mississippi and the Research Triangle Institute. The University grows, harvests, and dries marijuana, and the Institute processes it into cigarettes. Researchers can obtain marijuana free of charge from NIDA through an NIH-approved
grant to investigate marijuana or through a separate protocol review.
Because of the high biovariability in cannabis plants, obtaining research-grade cannabis is critical to conducting well-designed clinical trials on the safety and efficacy of marijuana and its
cannabinoids. In addition, because of the drug’s widespread general use and high potential for abuse, it is imperative that the federal process is followed for obtaining research-grade marijuana and conducting clinical trials.

Position 4: ACP urges review of marijuana’s status as a Schedule I controlled substance and its reclassification into a more appropriate schedule, given the scientific evidence regarding marijuana’s safety and efficacy in some clinical conditions.
Currently, marijuana is a Schedule I controlled substance, meaning it has no medicinal value and high potential for abuse. An evaluation by several Department of Health and Human Services agencies, including the FDA and NIDA, concluded that no sound scientific studies supported
medical use of marijuana for treatment in the United States (39). This conflicts with a review by the IOM, which declared that “for patients such as those with AIDS or who are undergoing chemotherapy and who suffer simultaneously from severe pain, scientific studies support medical
use of marijuana for treatment in the United States.” The IOM also concluded that compared with other licit and illicit drugs, including alcohol, tobacco, and cocaine, “dependence among
marijuana users is relatively rare and dependence appears to be less severe than dependence on other drugs.” (40) A clear discord exists between the scientific community and federal legal and
regulatory agencies over the medicinal value of marijuana, which impedes the expansion of
research.

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The concern that marijuana is a “gateway” drug also hinders opportunities to evaluate its
potential therapeutic benefits. However, the IOM concluded that marijuana is a gateway drug
only in the sense that its use normally precedes, rather than follows, initiation of other illicit
drugs. Marijuana has not been proven to be the cause or even the most serious predictor of
serious drug abuse. It is also important to note that the data on marijuana’s role in illicit drug use
progression only pertains to its nonmedical use (41).
Dronabinol, oral THC, is classified as a Schedule III substance. Recently, the DEA proposed a
rule that would allow for classification of both synthetic and natural (derived from the cannabis
plant) dronabinol products in Schedule III. Opiates are highly addictive yet medically effective
substances and are classified as Schedule II substances. There is no evidence to suggest that
medical use of opiates has increased perception that their illicit use is safe or acceptable (42).
Given marijuana’s proven efficacy at treating certain symptoms and its relatively low toxicity,
reclassification would reduce barriers to research and increase availability of cannabinoid drugs
to patients who have failed to respond to other treatments.
Position 5: ACP strongly supports exemption from federal criminal prosecution; civil
liability; or professional sanctioning, such as loss of licensure or credentialing, for
physicians who prescribe or dispense medical marijuana in accordance with state law.
Similarly, ACP strongly urges protection from criminal or civil penalties for patients who
use medical marijuana as permitted under state laws.
Reclassification of marijuana into a more appropriate schedule would remove the legal stresses
that can affect the physician–patient relationship. Although marijuana is a Schedule I drug, 12
states currently have legislation permitting its use for medicinal purposes. Similar legislation is
pending in New York and support has been shown for legislation in Minnesota and New
Hampshire. The movement among states to permit the use of marijuana for certain conditions
was spearheaded by California's Proposition 215, which received the support of 56% of state
voters in 1996. This led to the establishment of a $3 million state-funded Center for Medicinal
Cannabis Research (CMCR) at the University of California’s San Diego and San Francisco
campuses. CMCR receives the marijuana for its research from NIDA.
Despite these state laws and initiatives, possession of marijuana is a punishable federal offense.
In 2005, the Supreme Court ruled that state laws confer no immunity from prosecution under
federal law, which does not include a medical exemption to the prohibition on marijuana
possession. This creates additional concerns for researchers, physicians, and patients. Physicians
must be selective in their wording (when discussing the substance) so as not to appear that they
are aiding or abetting patients in obtaining cannabis. In addition to the legalities, the lack of
availability and standards on dose and route of delivery present medical concerns. Physicians
cannot supervise and have very little control over their patient’s behavior. Also, the quality of the
drug is usually undeterminable.
11
Conclusion
Evidence not only supports the use of medical marijuana in certain conditions but also suggests
numerous indications for cannabinoids. Additional research is needed to further clarify the
therapeutic value of cannabinoids and determine optimal routes of administration. The science on
medical marijuana should not be obscured or hindered by the debate surrounding the legalization
of marijuana for general use.
Notes
1. National Institutes of Health, Ad Hoc Expert Group. Workshop on the Medical Utility of
Marijuana Expert Report 1997. Accessed June 7, 2007 at
www.nih.gov/news/medmarijuana/MedicalMarijuana.htm
2. Hollister L. Marijuana (Cannabis) as Medicine. Journal of Cannabis Therapuetics 2001;
1(1): 5-27.
3. Grant I, Cahn BR. Cannabis and Endocannabinoid Modulators: Therapeutic Promises and
Challenges. Clinical Neuroscience Research 2005; 5: 185-99
4. Robson P. Therapeutic Aspects of Cannabis and Cannabinoids. British Journal of Psychiatry
2001; 178: 107-15.
5. Joy JE, Watson SJ, Benson JA. Marijuana and Medicine: Assessing the Science Base.
National Academy of Sciences, Institute of Medicine. Washington, DC; 1999.
6. Hollister L. Marijuana (Cannabis) as Medicine. Journal of Cannabis Therapuetics 2001;
1(1): 5-27.
7. Woolridge E, Barton S, Samuel J, Osorio J, Dougherty A, Holdcroft A. Cannabis Use in
HIV for Pain and Other Medical Symptoms. Journal of Pain and Symptom Management
2005; 29 (4): 358-67
8. Abrams D, Hilton J, Leiser R, Shade S, Elbeik T, et al. Short-Term Effects of
Cannabinoids in Patients with HIV-Infection. Annals of Internal Medicine 2003; 139: 258-
66.
9. Beal J, Olson R, Lefkowitz L, Laubenstein, et al. Long-Term Efficacy and Safety of
Dronabinol for Acquired Immunodeficiency Syndrome-Associate Anorexia. Journal of Pain
and Symptom Management 1997; 14(1): 7-14
10. Musty R, Rossi R. Effects of Smoked Cannabis and Oral O 9- Tetrahydrocannabinol on
Nausea and Emesis After Cancer Chemotherapy: A Review of State Clinical Trials. Journal
of Cannabis Therapeutics 2001; 1(1): 29-42.
11. Joy JE, Watson SJ, Benson JA. Marijuana and Medicine: Assessing the Science Base.
National Academy of Sciences, Institute of Medicine. Washington, DC; 1999.
12. Grant I, Cahn BR. Cannabis and Endocannabinoid Modulators: Therapeutic Promises and
Challenges. Clinical Neuroscience Research 2005; 5: 185-99
13. American Medical Association. Featured Report: Medical Marijuana. Chicago, IL; June
2001 citing Merrit JC, Crawford WJ, Alexander PC, Anduze AL, Gelbart SS. Effect of
Marijuana on Intraocular and Blood Pressure in Glaucoma. Opthamology 1980; 87:222-28.
12
14. Hampson AJ, Grimald M, Axelrod J, Wink D. Cannabidiol and O 9- Tetrahydrocannabinol
Are Neuroprotective Antioxidants. Proceedings of the National Academy of Sciences USA
1998; 95: 8268-73.
15. American Medical Association. Featured Report: Medical Marijuana. Chicago, IL; June
2001.
16. Joy JE, Watson SJ, Benson JA. Marijuana and Medicine: Assessing the Science Base.
National Academy of Sciences, Institute of Medicine. Washington, DC; 1999.
17. American Academy of Ophthalmology. Complementary Therapy Assessment: Marijuana
in the Treatment of Glaucoma. Accessed on June 12, 2007 at
www.aao.org/education/guidelines/cta/loader.cfm?url=/commonspot/security/getfile.cfm&Pa
geID=1216.
18. Consroe P, Musty R, Rein J, Tillery W, Pertwee R. The Perceived Effects of Smoked
Cannabis on Patients with Multiple Sclerosis. European Neurology: 38: 44-48.
19. American Medical Association. Featured Report: Medical Marijuana. Chicago, IL; June
2001 citing Malec J, Harvey RF, Cayner JJ. Cannabis Effect on Spasticity In Spinal Cord
Injury. Archives of Physical Medicine and Rehabilitation 1982: 63: 116-118.
20. Abrams DI, Jay CA, Shade SB, Vizoso H, Reda H, Press S, et al. Cannanbis in Painful
HIV-Associated Sensory Neuropathy: A Randomized Placebo-Controlled Trial. Neurology
2007; 68: 515-21.
21. Robson P. Therapeutic Aspects of Cannabis and Cannabinoids. British Journal of Psychiatry
2001; 178: 107-15.
22. Hollister L. Marijuana (Cannabis) as Medicine. Journal of Cannabis Therapuetics 2001;
1(1): 5-27 citing Noyes R, Brunk DR, Avery DH, Canter A. The Analgesic Properties of
delta-9-tetrahydrocannabinol and codeine. Clinical Pharmacology and Therapeutics 1975;
18:84-89.
23. Blake DR, Robson P, Ho M, Jubb RW, McCabe CS. Preliminary Assessment of the
Efficacy, Tolerability and Safety of a Cannabis-Based Medicine (Sativex) in the Treatment of
Pain Caused by Rheumatoid Arthritis. Rheumatology 2006; 45: 50-52.
24. Wallace MS, et al. Dose-dependent effects of smoked cannabis on capsaicin-induced pain
and hyperalgesia in healthy volunteers. Anesthesiology 2007; 107: epub.
25. Grant I, Cahn BR. Cannabis and Endocannabinoid Modulators: Therapeutic Promises and
Challenges. Clinical Neuroscience Research 2005; 5: 185-99
26. Joy JE, Watson SJ, Benson JA. Marijuana and Medicine: Assessing the Science Base.
National Academy of Sciences, Institute of Medicine. Washington, DC; 1999.
27. Joy JE, Watson SJ, Benson JA. Marijuana and Medicine: Assessing the Science Base.
National Academy of Sciences, Institute of Medicine. Washington, DC; 1999.
28. Joy JE, Watson SJ, Benson JA. Marijuana and Medicine: Assessing the Science Base.
National Academy of Sciences, Institute of Medicine. Washington, DC; 1999.
29. Joy JE, Watson SJ, Benson JA. Marijuana and Medicine: Assessing the Science Base.
National Academy of Sciences, Institute of Medicine. Washington, DC; 1999.
30. American Medical Association. Featured Report: Medical Marijuana. Chicago, IL; June
2001.
31. Beal J, Olson R, Lefkowitz L, Laubenstein, et al. Long-Term Efficacy and Safety of
Dronabinol for Acquired Immunodeficiency Syndrome-Associate Anorexia. Journal of Pain
and Symptom Management 1997; 14(1): 7-14
13
32. Abrams D, Hilton J, Leiser R, Shade S, Elbeik, T et al. Short-Term Effects of
Cannabinoids in Patients with HIV-Infection. Annals of Internal Medicine 2003; 139: 258-
66.
33. Musty R, Rossi R. Effects of Smoked Cannabis and Oral O 9- Tetrahydrocannabinol on
Nausea and Emesis After Cancer Chemotherapy: A Review of State Clinical Trials. Journal
of Cannabis Therapeutics 2001; 1(1): 29-42.
34. National Institutes of Health, Ad Hoc Expert Group. Workshop on the Medical Utility of
MarijuanaExpert Report 1997. Accessed June 7, 2007 at
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35. Joy JE, Watson SJ, Benson JA. Marijuana and Medicine: Assessing the Science Base.
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