Marijuana and Medicine: Assessing the Science Base by Janet Joy, Stanley Watson, and John Benson, Jr. Washington, DC: National Academy Press; 1999. 267 pages, $39.95.
In 1997, the Institute of Medicine (IOM) was commissioned by the White House Office of National Drug Control Policy (ONDCP) to review the scientific evidence to assess the potential benefits and risks of marijuana and its constituent cannabinoids in relation to medical use. This book is a report based on that review and builds on a previous report by the IOM in 1982. This report is also available in full text online at http://www.nap.edu.
The book is organized into 5 main chapters and is preceded by an executive summary. This report addresses a key issue surrounding medical marijuana by acknowledging that analysis of the state of scientific knowledge is often obscured by political, legal, and moral controversy. By taking an evidence-based approach, the IOM hopes to address common concerns about marijuana and to examine potential medical uses.
Chapter 1 introduces the review and describes the epidemiology of medical marijuana use in the United States. Importantly, the changing legal landscape is also described. The primary reason for initiation of this review was increased interest by some parts of the electorate and some states to consider legalization of medical marijuana use. Because of the legal context, research in this field has lagged and science related to healthcare use has not kept up to current public interest.
Chapter 2 summarizes the basis of cannabinoid biology. Since 1982, there have been major advances in understanding the basic mechanisms through which cannabinoids affect physiology. Over the past 20 years, investigators have identified and cloned endogenous cannabinoid receptors, discovered endogenous substances that bind to these receptors, and also developed synthetic cannabinoids that bind to these receptors. There are now even greater possibilities to develop synthetic cannabinoids.
Chapter 3 reviews the consequences of use and abuse of marijuana. The IOM concluded that except for the harms associated with smoking, the adverse effects of marijuana use are within the range of effects tolerated for other medications. They also disprove the common misperception that the approval of marijuana for medical use will lead to increased use in the general population.
Chapter 4 describes the current and potential uses of medical marijuana. Studies in general find that the specific combination of drug effects (anxiety reduction, appetite stimulation, nausea reduction, and pain relief) of cannabinoids is "moderately well-suited" to conditions such as chemotherapy-induced nausea and vomiting and acquired immunodeficiency syndrome (AIDS) wasting, and possibly other chronic conditions such as muscle and movement disorders and epilepsy associated with neurological disorders. The IOM suggested that clinical trials of both marijuana and cannabinoid drugs should be conducted using alternative delivery systems.
Chapter 5 reviews the process of and progress in development of cannabinoid drugs. There are many regulatory and marketing challenges for pharmaceutical companies. Currently, there is only one approved synthetic cannabinoid in the United States. Dronabinol (Marinol) has been on the market since 1985. A major issue related to synthetic development is federal drug development policy and drug scheduling. Currently, marijuana is a Schedule 1 drug, which means that it is considered to have a high potential for abuse and has no currently accepted medical use. With this designation, most companies are currently reluctant to pursue development.
This book provides a balanced and objective discussion related to medical marijuana use through an evidence-based review of the science to date up to 1999. The book is clearly focused only on the medical use perspective. Other than background discussion of legal and scheduling issues, it does not extend this discussion and review to the broader societal issues related to marijuana use, such as decriminalization and legalization. One limitation of this book is that the evidence base is 6 years old. The IOM also recognized that this review is limited in its own right as it relied on the most relevant and methodologically rigorous studies available at the time, which were few in number. Ultimately, the IOM hoped that this review would provide a framework from which to interpret new information that will continue to emerge. Unfortunately, as long as marijuana remains a Schedule 1 drug with accompanying legal restrictions to use, there will most likely be less motivation for pharmaceutical companies to develop new formulations and more difficulties for researchers interested in conducting large scale clinical trials. This book is a reliable and well-researched addition to a reference library for professionals working in fields with connections to substance use, including healthcare providers, alcohol and drug counselors, policy makers, and legal counsels.
Lenora Marcellus, MN, RN
Instructor, School of Nursing, University of Victoria, CIHR Doctoral Research Trainee, Integrated Mentoring Program in Addictions Research Training, BC Centre of Excellence for Women's Health, Victoria, British Columbia, Canada