Jonathan Kaplan, MD, MPH, makes a serious error when he states that “marijuana use for medicinal purposes is now legal in 29 states plus the District of Columbia, (MedicalEconomics.com, September 20, 2017), ignoring the fact that state laws legalizing marijuana do not in any way affect federal laws making marijuana illegal and subject to federal prosecution. President Obama instructed his federal prosecutors not to enforce federal anti-cannabis laws, but Attorney General Jeff Sessions is planning to enforce them aggressively. Those of us who disagree with the illegal status of cannabis have only two choices: Either obey the nationwide federal ban on medical marijuana, or risk becoming a test-case, and, most likely, a “marijuana martyr.”
Under federal law, marijuana is illegal to use, possess, cultivate or distribute. Sentencing guidelines for possessing even the smallest amounts range from up to one year incarceration and a 1,000 fine to up to three years in jail and a $5,000 fine.
Federal law always preempts and overrides state laws. This means that even if your state allows you to grow or sell marijuana, federal agents can still arrest you. And, if you are found guilty, you will be sentenced under the federal guidelines.
Kaplan advocates prescribing marijuana for post-op pain instead of opiates as a way to reduce opioid addiction and overdoses. However, marijuana is not indicated for post-surgical pain, and the evidence Kaplan cites of its efficacy compares marijuana to placebo, not to the potent pain relief afforded by opioid analgesics, such as hydrocodone, oxycodone or morphine. A surgeon who routinely prescribes marijuana for post-op pain instead of an opioid will quickly be sued for failing to control post-op pain with a proven-effective, FDA-approved opioid medication. In addition to civil lawsuits, physicians who fail to prescribe strong enough opioid doses to treat a patient’s pain can even face criminal prosecution. While it is true that opioid-related addiction and overdoses can be avoided by not prescribing opioids, this is analogous to avoiding hypoglycemia by not prescribing insulin when it is indicated, or avoiding bleeding complications by not prescribing blood thinners when they are indicated. Our job as physicians is to manage the risks of potentially dangerous medications when they are indicated. Even a patient with a known history of opioid abuse should not be denied treatment with opioid pain medication, when it is required, as noted in a 2014 Population Health Management study.
Kaplan also emphasizes that THC is approved by the FDA for the treatment of nausea, and its use increases appetite and weight gain. That is an argument for prescribing THC for nausea, appetite stimulation and anorexia, but it in no way excuses a physician from treating pain with an opioid, when required. Cannabis and its components, such as THC and CBD, may reduce pain when compared to placebo, but they do not achieve anywhere near the efficacy of opioid analgesics, and Kaplan could not cite any studies even comparing cannabis or its derivatives with opioids specifically for the treatment of pain.
Another seriously false misconception is that smoking marijuana is less dangerous than smoking tobacco. Physiologically, there is no reason to believe that inhaling the hot smoke from any dried plant should be more or less prone to cause lung disease. One long-term study, published in JAMA in 2012, purported that smoking marijuana was less likely to cause COPD than smoking tobacco and actually compared marijuana smokers with tobacco smokers who smoked more than 40 times as many cigarettes per day. When marijuana smokers were compared with tobacco smokers who smoked roughly similar numbers of cigarettes per day, there was no significant safety benefit for persons who smoked either substance.
Physicians can obtain guidance on how to minimize the medical and legal risks of prescribing opioids for treating pain from pain experts and from an excellent free publication by the California Medical Board titled “Guidelines for Prescribing Controlled Substances for Pain” (bit.ly/MBC-pain-guidelines).
David Louis Keller, MD, FACP
Thanks to Dr. Keller for voicing his opinion in regards to my article, “5 reasons physicians should choose marijuana over opioids” (bit.ly/Kaplan-marijuana). While productive discourse is always welcome, stating there are “serious errors” in my article is disingenuous. My citations, to name just a few, include the National Cancer Institutes and JAMA. I gladly and confidently stand behind their credentials.
Certainly anyone can find articles and sources to contradict another author’s argument. It’s ultimately up to the reader to weigh the preponderance of evidence in each argument. I will admit that Keller is well versed in stating his opinion, as he has done so in 226 other “letters to the editor” to various publications (I checked Google). I do not deny his passion, nor his research. But his opinion, based on his research, is still just that: an opinion.
As for the issue of state legalization vs. federal legalization, there is no argument here. Federal law still rules marijuana as illegal. However, as to my point, consumers are using marijuana for medical and recreational purposes in those states where it is allowed. And while U.S. Attorney General Jeff Sessions once said, “Good people don’t smoke marijuana,” it’s unclear if he will move to enforce federal law on this issue.
Ultimately, there is more than anecdotal evidence that marijuana has helped many patients with their pain associated with surgery or during cancer treatment. And I welcome their adamant defense of this alternative to opioids in subsequent letters to the editor or in the comments section of the blog.
Jonathan Kaplan MD, MPH
San Francisco, California