Medical Marijuana in Iowa?

merit-medical-marijuanaThe link http://ec4.cc/vc6327e3 takes you to an educational video produced in Iowa City during a presentation given at the Iowa City Public Library on November 19, 2013 about medical marijuana. It’s entitled “A Sensible Conversation about Medical Cannabis in Iowa.” The video has also been broadcast on local public access TV. The introduction is:

This program features Dr. Steve Jenison, the former medical director of the New Mexico Medical Cannabis Program, who presents information about the New Mexico program. Also featured are Iowans who share their personal stories. Discussion also includes information about the status of advocacy efforts in Iowa. Dr. Jenison was born in Ames, graduated from Iowa State University, and earned a medical degree from the University of Iowa. In 1999, he received the UI College of Medicine’s Distinguished Alumnus Award for Service in recognition of his work in developing a rapid diagnostic test during the Four Corners hantavirus outbreak of 1993. Sponsored by the Iowa Chapter of the American Civil Liberties Union and hosted by Senator Joe Bolkcom.

I just watched the show on TV last night. The event was well-attended by state legislators and members of the Iowa City community. I was not aware that the Iowa Board of Pharmacy had recommended just three years ago that Iowa adopt a medical marijuana program similar to that in New Mexico so that patients could have legal access to marijuana for the treatment of certain medical conditions.

Although I think the program is informative and current, even citing the recent passage of the law legalizing the recreational use of marijuana in Colorado, there was no mention of the paradoxical issue of the recently recognized Cannabinoid Hyperemesis Syndrome (CHS), which I see occasionally as a psychiatric consultant in the general hospital. It’s marked by intractable nausea and vomiting and taking a lot of hot showers, the relevant cause of which seems to be the recent use of marijuana. I found a recent review available by open access about this syndrome, which has important data about the pharmacologic complexity of cannabis that probably doesn’t get enough attention [1].

Is it just me or does the Galli review fail to recognize the significant psychiatric comorbidity in Cannabis users who suffer from CHS as compared to patients who suffer from Cyclical Vomiting Syndrome (CVS), which is also associated with similar psychiatric overlay? Look at Table 2 in which CHS is compared to CVS. It clearly identifies CHS as being distinguishable from CVS, partly on the basis of a presumed relative lack of psychiatric comorbidity in those with CHS. That’s not consistent with the literature as I read it and my experience as a clinician–there’s plenty of psychiatric comorbidity (UPMC
Physician Resources: UPMC Synergies Fall 2013
).

It’s also not consistent with the authors’ own observation earlier in the paper, in which they point out that stress can trigger “reintoxication effects” (and they say that this effect may have implications for CHS)  even if there’s been a period of abstinence from marijuana use because of the long elimination half-life of delta-9-tetrahydrocannabinol (THC). As Galli et al point out, “These characteristics of THC may have implications in Cannabinoid Hyperemesis Syndrome as these patients are chronic users of cannabis who likely have large lipid stores making them susceptible to increased cannabinoid levels in the plasma during times of stress.”

What does seem to distinguish those with CHS versus CVS is the curious penchant for spending a long time taking hot showers to counteract the nausea and vomiting. The treatment? Stop smoking marijuana.

If you can stand more detail, than try digging into one of the other open access references [2].

And what do states do about ensuring that medical cannabis dispensaries and retailers who are granted licenses to sell their products to the public are staying up to speed with the research on marijuana in order to keep safety for consumers and patients the top priority?

Well, Maintenance of Licensure (MOL) programs of course. I’m a little surprised that a corporation similar to the Federation of State Medical Boards (FSMB) has not been developed for this already. There would probably be at least as much profit for states as the increase in tax revenues ($70 million estimated for Colorado next year).

At times, I wonder if the marijuana debate is really about generating more political heat than scientific light. A medical marijuana program for Iowa is unlikely, especially given the politically cool reception it’s been getting. And what effect will the recent licensing of retail marijuana sales do to the medical marijuana market? Will medical marijuana programs become obsolete? After all, if you can buy marijuana for recreational use, why would doctors have to be involved at all in access to it?

What’s your state doing about medical marijuana?

medicalmarijuana

References:

1. Galli, J. A., R. A. Sawaya, et al. (2011). “Cannabinoid hyperemesis syndrome.” Curr Drug Abuse Rev 4(4): 241-249.

Coinciding with the increasing rates of cannabis abuse has been the recognition of a new clinical condition known as Cannabinoid Hyperemesis Syndrome. Cannabinoid Hyperemesis Syndrome is characterized by chronic cannabis use, cyclic episodes of nausea and vomiting, and frequent hot bathing. Cannabinoid Hyperemesis Syndrome occurs by an unknown mechanism. Despite the well-established anti-emetic properties of marijuana, there is increasing evidence of its paradoxical effects on the gastrointestinal tract and CNS. Tetrahydrocannabinol, cannabidiol, and cannabigerol are three cannabinoids found in the cannabis plant with opposing effects on the emesis response. The clinical course of Cannabinoid Hyperemesis Syndrome may be divided into three phases: prodromal, hyperemetic, and recovery phase. The hyperemetic phase usually ceases within 48 hours, and treatment involves supportive therapy with fluid resuscitation and anti-emetic medications. Patients often demonstrate the learned behavior of frequent hot bathing, which produces temporary cessation of nausea, vomiting, and abdominal pain. The broad differential diagnosis of nausea and vomiting often leads to delay in the diagnosis of Cannabinoid Hyperemesis Syndrome. Cyclic Vomiting Syndrome shares several similarities with CHS and the two conditions are often confused. Knowledge of the epidemiology, pathophysiology, and natural course of Cannabinoid Hyperemesis Syndrome is limited and requires further investigation. Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576702/

2. Darmani, N. A. (2010). “Cannabinoid-Induced Hyperemesis: A Conundrum—From Clinical Recognition to Basic Science Mechanisms.” Pharmaceuticals 3(7): 2163-2177. Link: http://www.mdpi.com/1424-8247/3/7/2163.

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Comments

  1. Hurl if you like marijuana!

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  2. Debates about medical marijuana are definitely about generating more heat than light. I see it as part of the society wide trend cited by Musto where drugs of abuse fluctuate between periods of wide acceptance to periods of relative prohibition. In that context you have to be really naive to believe that there is a need for widespread legitimate medical use of marijuana or that everyone trying to get a prescription for medical marijuana is using it for a legitimate medical purpose. You only have to look as far as prescription opioids.

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