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bs_bs_banner Pain Medicine 2013; 14: 799–801 Wiley Periodicals, Inc. Ethics Forum Medical Marijuana: A Viable Tool in the Armamentaria of Physicians Treating Chronic Pain? A Case Study and Commentary Marijuana Is Not Good Medicine Because of legislation in some states to permit prescribed “medical marijuana,” herbal cannabis in various forms is now being distributed by dispensaries to large numbers of individuals with a wide variety of medical conditions. This cannabis is not, in most cases, standardized or qualitycontrolled; the dosage forms do not provide a known and reproducible dose, and data on efficacy and adverse events are not being collected in a reliable manner [1]. Furthermore, controlled substances are drugs that have recognized abuse potential, and marijuana remains a federally Schedule I drug because it is widely abused in the United States and around the world. When physicians recommend use of scheduled substances, they must exercise great care. The current pattern of physicianauthorized “medical marijuana” use in the United States is far from the standard established for medicine. The particular case of a patient in his 30s with a history of polysubstance addiction complaining of moderate to severe chronic pain—which has been legitimized through history, physical examination, and diagnostic imaging— who requests authorization for medical marijuana from your medical practice illustrates this point. The use of medicinal marijuana for this patient will undoubtedly lead to some short-term relief of pain, anxiety, and general distress while the individual is under the influence of cannabis. This is to be expected, as cannabis, like most other drugs of abuse, causes a state of euphoria and distress relief during the period of the influence of the central nervous system (CNS) drug. We also know, as physicians, that tolerance to the CNS-induced euphoria of marijuana and other Scheduled drugs develops with long-term use, leading in many cases to abuse and dependence on the drug [2]. In the case of marijuana, this tolerance also leads This particular individual, with a history of polysubstance dependence, will be no exception. Rather, he will be much more likely to relapse with the other drugs of abuse to which he has been addicted [4] and still remains vulnerable to triggers for his addictions. Relapse with these drugs of abuse has a very high likelihood of leading to morbidity and/or mortality that would arguably be iatrogenic if the physician authorized medicinal marijuana for his chronic pain. There is no scientific evidence that the effect of marijuana in diminishing pain is related to any specifically identified analgesic effect. That it unequivocally does produce a short-term CNS euphoria, which alleviates some pain centrally, best explains its mechanism for both reducing pain short-term during the period of influence as well as causing the euphoria associated with addictive drugs of abuse. Additionally, there is no scientific evidence that long-term use of medicinal marijuana is either effective or safe for the treatment of chronic pain. In this particular case, and more generally, there are many analgesic medications available to patients and physicians that have been proven and established in the practice of medicine, through sound scientific clinical research, to be more effective and safer for the treatment of chronic pain than medical marijuana. GREGORY BUNT, MD Daytop Village, Inc., New York, New York, USA References 1 American Society of Addiction Medicine. Public Policy Statement on Medical Marijuana, 2010. Available at: http://www.asam.org/docs/publicy-policy-statements/ 1medical-marijuana-4-10.pdf?sfvrsn=0 (accessed March 29, 2013). 2 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Washington, DC: American Psychiatric Association; 2013. 3 Vanyukov MM. Substance-specific symptoms and general liability to addiction. Am J Psychiatry 2012; 169:1016–8. 4 De Vries TJ, Shaham Y, Homberg JR, et al. A cannabinoid mechanism in relapse to cocaine seeking. Nat Med 2001;7:1151–4. 799 Downloaded from http://painmedicine.oxfordjournals.org/ by guest on October 19, 2016 THE CASE: You are a physician—specialty not important, as so many different specialists and generalists treat chronic pain. A patient in his 30s with a history of polysubstance addiction walks into your office, complaining of moderate-to-severe chronic pain—which has been legitimized through history, physical examination, and diagnostic imaging. This patient lacks the resources to receive anything beyond pharmacological treatment. He requests authorization for medical marijuana (it is assumed that you are practicing in a state in which medical marijuana is legal). Do you provide him with authorization or not, and on what basis do you make your choice? many individuals to seek other drugs of abuse that may be more potent, i.e., the “gateway effect” [3].