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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.
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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].