Letter from South Dakota Physician

Mailed Oct. 22, 2012

Rep. Genuine Compassion
777 Headache Rd
Empathetic SD 57000

Greetings, Rep. Compassion;

SoDakNORML sent the following   letter to all members of a So. Dak. legislative committee scheduled to take   testimony on two medical cannabis issues in 2010. Dr. Traub, a Rapid City   internal medicine specialist, wrote the letter below to the committees, advocating recognition of medical cannabis in 2010. In those hearings, no   legislator mentioned the letter. We reprint it here.

To the legislature:

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 (THC).   I am hopeful that the legislative process might be able to address their   needs by reconsidering a limited legalization of marijuana for very limited   medical use, similar to that 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 marijuana.

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 in the eye, 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 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 person’s 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 — inhaling smoke from   marijuana by burning it or dessicating 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   cannaboids. 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. Disadvantages include the potential effects on the   lung including the potential for emphysema and possibly lung cancer in   long-term users. [SoDakNORML note: Recently released studies and a huge   volume of anecdotal reports suggest that known damage to lungs by cannabis   smoke is at least far, far less than expected, and, at best, cannabis smoke   appears to not damage lungs as much as most folks’ ambient environment.]

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. 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 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.

Douglas M. Traub, MD, FACP


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