CMSC: Medical Marijuana, Part 2
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I had the opportunity to talk with Brenda Banwell, Tanuja Chitnis, and Allen Bowling, all medical doctors, neurologists, and speakers at the Annual meeting of the Consortium for Multiple Sclerosis Centers (CMSC), about the use of cannabis for multiple sclerosis symptoms. In particular, I posed the question if they supported the legalization of Sativex, a research quality cannabis available by prescription in Canada and elsewhere, but not in the United States. We also discussed other aspects of the use of cannabis as a treatment for MS symptoms and regulatory issues.

Cannabis and pediatric care

Dr. Brenda Banwell is chief of the Division of Neurology at The Children’s Hospital of Philadelphia. She is the principal investigator for a large study of pediatric MS patients in Canada, funded by the Canadian MS Society.

“Most of my patients don’t have pain or spasticity,” said Dr. Banwell, about her pediatric patients, but she still has strong opinions about the use of cannabis, especially for children. Pain and spasticity are two common MS symptoms that users of cannabis report having improvement from.

“The kids who come to me and ask about medical marijuana want the high in the THC side and not the medicinal side,” she said. “The indication for Sativex is not applicable to my patients.”

Adolescent brain changing pathways

She went on to further explain her concerns. “The adolescent brain and the adult brain are not the same. Among the many things that are changing in the adolescent brain are the pathways for risk to addiction and mental health. The studies show these are actively changing in the teenage years.”

“There are studies indicating at least recreational marijuana exposure during teenage years has a very different profile and toxicity risk than the same amount of exposure in a more mature brain. That’s also true in alcohol exposure, and nicotine exposure. Teenagers are risk takers to begin with,” said Dr. Banwell, stating altering their risk patterns and pathways in the brain can have lifelong consequences.

“The other side is the cognitive impact on memory, executive function and social maturation … they are all negative compared to adult exposure.

“Smoking is also an additional concern; we know smoking makes MS worse and we can conclude smoking marijuana would be much the same. The evidence is quite convincing,” said Dr. Banwell about smoking and MS. “The problem is there is a lobby to make more (medical marijuana) available, there is a lot not known.  The intoxication duration testing suggests memory is impaired a lot longer than people think it is” when using cannabis. “With alcohol you have some guidelines as to when not to drive and what amount is safe to drive after drinking. With marijuana you don’t know. There is a real worry about not having a good grasp for the safety of cannabis.”

Prescribing information

Dr. Tanuja Chitnis, Director of the Partners Pediatric MS Center, MassGeneral Pediatric Hospital, said cannabis “is challenging for physicians. We can give a license for medical marijuana, but there is modest evidence for marijuana in general. There are other drugs that can do similar things (in controlling MS symptoms), however there are people who find (cannabis) helpful or enjoy it.”

“There needs to be additional evidence in my opinion, for medical use and better control of the product that is provided, including dosing information. My sense is it would be better if regulated, then I could confidently tell my patients what it can actually be prescribed for,” said Dr. Chitnis.

Legal considerations

Dr. Allen Bowling is from Colorado, where cannabis is legal for medicinal and recreational use and more of his take on medical marijuana can be found in PART 1 of this story. “My patients do inquire about it, it’s widespread enough in Colorado.”

He said he uses cannabis as the “3rd or 4th line drug for pain or spasticity,” but it is not his first drug of choice.

I asked if these doctors ever have to discuss the legal side of using cannabis and Dr. Bowling said “we (Colorado) have the only full-time professor on cannabis law in the country. There are all sorts of legal aspects that are not well worked through. When patients bring it up to me (requesting medical marijuana) they have already done their homework to know if there are issues on their side legally.”

“For doctors there is a clunkiness to the whole process of prescribing cannabis. Because of malpractice carriers, technically we have to say it has unpredictable effects and can cause harm or death and then go through many of the side effects and drug interactions,” to satisfy the doctor’s own liability insurance requirements, said Dr. Bowling.

Inconsistent legislation

He went on to note “each state invented their own version of the (medical marijuana) law and then at the federal level.”

Dr. Bowling said his concern is the cannabis people are getting is not inspected and there needs to be oversight on the products that people are ingesting and smoking. “This is not new territory at the federal level for FDA (Food and Drug Administration) but the states don’t have the infrastructure, and don’t even have staff that knows guidelines for herbal products.” Dr Bowling’s concerns are the states have no knowledge of how to establish guidelines and testing for cannabis purity, detecting metals, pesticides and other possible contaminants. He said he thinks cannabis should not be controlled by the Drug Enforcement Agency (DEA) but could be overseen by the FDA, much like they set regulation and inspection of tobacco products.

Several sessions at CMSC focused on cannabis and its use by people with multiple sclerosis. Dr. Bowling said the need now is to ‘inform the public” about cannabis and its use and there is a “huge amount of information that should be disseminated through public health to professionals and the public.” Educating neurologists at this meeting was a good first step, and the sessions were full of health providers willing and wanting to learn more.

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