Hits and Misses: What's the best way to take medical marijuana?
May 04, 2006
Ryan Grim, Slate
Medical-marijuana users, take heart. So what if the Food and Drug Administration told the nation last month that marijuana has no medical benefits? You've read about the widespread scoffing that followed, and the 1999 Institute of Medicine study that concluded marijuana might in fact ease some debilitating conditions. The ongoing debate is not just about whether medical marijuana works. It's about the best way to take it.
Choosing a marijuana delivery method involves weighing legality, safety and ease of use, and effectiveness. Back in 2004, when I was a staffer at the Marijuana Policy Project, an organization based in Washington, D.C., that works to legalize and regulate marijuana use, I met dozens of patients who used varying methods of marijuana consumption. Since I don't have any medical training, I brushed up on the latest technology by speaking to medical-marijuana patients including Angel Raich, who will be forever remembered by first-year law students as the plaintiff in the Supreme Court case Gonzales v. Raich; Philippe Lucas, president of the Vancouver Island Compassion Society and one of about 1,200 legally registered medical marijuana patients in Canada; and Alison Myrden, another Canadian patient. The reviews of the various delivery methods are based on what they told me about their experiences.
Security (10 possible points): Will using this product land you in jail? A legally prescribed product gets a 10. Everything else is rated based on the chances of getting arrested.
Safety (5 possible points): Might this product give you lung cancer or a respiratory ailment like bronchitis? Because many medical-marijuana patients already have cancer or seriously debilitating illnesses, this won't matter to everyone. For more on attendant health risks, here's the medical journal BMJ's take.
Portability and Ease of Use (10 possible points): Can a sick or disabled person easily carry the product around or out of the house? And is preparation doable if you have a limited range of motion? Products that must be taken orally lose 5 points since many medical marijuana users suffer from nausea, which makes swallowing a pill or eating a brownie decidedly unappealing.
Medical effectiveness (25 possible points): The most important measure—How well does the product reduce pain and nausea, increase appetite, or enable sleep? Do the side-effects outweigh the benefits? Points are awarded for the nature of the beneficial effect, and how rapidly and predictably it sets in.
RANKINGS (worst to first)
Marinol, a synthetic version of Delta-9-Tetrahydrocannabinol, or THC, the main active ingredient in marijuana, is legal with a prescription. It's also resoundingly unpopular. First off there's t he problem of taking a pill if you're throwing up. ("I felt nauseated but was hungry at the same time, which is a stupid concept," Raich reports.) Worse, Marinol takes a long time to kick in, often more than an hour. And once it does take effect, the feeling patients get can be an overwhelming high that leaves them disoriented and unable to function. Marinol's manufacturer warns of "dizziness, feelings of exaggerated happiness, paranoid reaction, drowsiness, and thinking abnormally."
"Marinol doesn't work," says Raich. "I took the lowest dose possible and I got really, really sick from it. My heart felt like it was beating so hard I called my doctor." According to Lucas, the intensity of the effect comes from taking the pill orally. In the kidney, he says, the THC converts to a form four times stronger than when it's inhaled. "That's why people get so bloody stoned."
Portability and Ease of Use: 5
Medical Effectiveness: 2
Value : 22
For the same reason that Marinol disappoints, many patients have reservations about brownies and other baked goods made with marijuana. Effects are often delayed for more than an hour, and like a pill, brownies are an inconvenient remedy if you're nauseated. On the other hand, patients I met while at the Marijuana Policy Project were adept at controlling dosages; cooking marijuana with butter and spreading it on toast or muffins was one way to consume small amounts.
Though medical marijuana is legal under state law in 11 states, even in those jurisdictions a patient can be arrested by the feds. The patients I knew appreciated baked goods for their discretion; it's a rare cop who will collar an elderly woman for a batch of brownies.
The patients I interviewed generally described baked goods as similar, but superior, to Marinol. Whereas Marinol is only synthesized THC, baked marijuana contai ns all the active ingredients of marijuana. "I eat it and drink it in tea," says Myrden, who lives with muscular dystrophy and a painful facial malady. Tea takes effect more quickly, but "eating lasts a lot longer. I can be up and running for six to eight hours."
Portability and Ease of Use: 5
Medical Effectiveness: 11
Putting marijuana into pill form eliminates the advantages of absorbing the drug through inhalation, which include increased dosage control and rapid onset of effect. The British-based GW Pharmaceuticals has devised a compromise by creating a full marijuana extract—THC and everything else—that is sprayed under the tongue. It is available on a limited basis in Britain and Spain but has been fully approved only in Canada, where Myrden says she was the first patient to use it. But not so happily. "Within a month, I was up to 50 sprays a day and still not getting relief for the pain in my face," she says. At about $3 a spray—51 sprays per vial—such use adds up. Another downside: Savitex is made from only one strain of marijuana, while doctors and patients find that different strains work best for different ailments.
Overall, patients gave the maker of Sativex an "A" for effort but felt the product fell short. Though onset of effect was faster than with brownies and Marinol, the method still lagged behind inhalation.
Security: 10 (in Canada—it's not available in the United States)
Portability and Ease of Use: 10
Medical Effectiveness: 15
Value: 40 for Canadians. For U.S. patients, it won't be available for at least a few years—and, sorry, Rep. Barney Frank, D-Mass., doesn't bring any back with him.
Pipes, bongs, and bubblers
Pipes, bongs, and bubblers have attractive qualities that come with the benefits of inhalation, such as easy control of dosage and quick onset. At the same time, they can be cumbersome. Myrden says she uses pipes occasionally with the help of a partner, but because s he has lost use of her right hand, she has difficulty manipulating them on her own.
The conventional wisdom about bongs and bubblers—which draw smoke through water before it reaches the lungs—is that the water acts as a filter of unwanted tar and other noxious chemicals. Not so, says Lucas. "It cools down the smoke and nothing else. There really is no filtering effect." For those patients who thought they were getting cleaner, purer smoke by pulling tubes instead of smoking a joint, well, sorry.
Portability/Ease of Use: 8
Medical Effectiveness: 23
The June issue of the Journal of Pharmaceutical Sciences will include a study on the medical effectiveness of the Volcano, a vaporizer that patients use to get the beneficial elements of marijuana while avoid ing the smoke. Marijuana need not be burned to release its medicinal components. When the plant is heated to a degree short of combustion, its active ingredients become vapor and are released without the accompanying smoke. The Volcano traps those vapors in a bag, which patients can then inhale from. The device takes the traditional vaporizer—basically a heat-gun, a metal plate or bowl, and a tube—to another level of safety, mechanization, and price. At $539, it's far and away the most expensive marijuana-delivery method.
According to the journal article, with a Volcano, "The final … uptake of THC is comparable to the smoking of cannabis, while avoiding the respiratory disadvantages of smoking." You would think that would be good news for the Volcano's manufacturer, Storz & Bickel, a German company. Officially, at least, you'd be wrong. The Volcano may be "a safe and effective cannabinoids delivery system" according to the researchers. But ac cording to the company, it is not a "medical device" at all. The lead American sales representative for Storz & Bickel said he hadn't heard of it.
Regardless, the patients I spoke to all had good things to say about the Volcano. "It's patient friendly. It's easy to maneuver," says Raich. "If you're someone who is fairly disabled and somebody who has mobility problems, the Volcano is right for you."
Portability and Ease of Use: 6
Medical Effectiveness: 24
The joint is the delivery method of choice Alison Myrden and Irvin Rosenfeld, a Ft. Lauderdale stockbroker. Rosenfeld, 53, doesn't have to roll his joints: Every 25 days the federal government mails him a canister filled with 300 joints as part of a program overseen by the FDA. He has been smoking marijuana every day for 35 years, he says, 23 of them legally. (The FDA killed the program in 1991, but patients already enrolled were grandfathered in; many of them were cancer or AIDS patients, and death has cut their numbers to fewer than 10.)
The joint's drawback is the amount of the drug that is lost. Lucas estimates that 50 to 70 percent of marijuana's active ingredients disappear into the air as the joint burns while the patient isn't smoking it. And while it burns, it gives off a strong scent of marijuana that can threaten patients' freedom if they are not one of the few legal users.
On the good side, joints allow patients to regulate their intake and facilitate a rapid onset of effects. "Nothing else works fast enough for me," says Myrden, who smokes 25 to 30 joints a day. Lucas' cannabis club owns a Volcano, but he still considers the joint the gold standard of delivery methods. "Smoking is the one that everyone is trying to catch up to," he says. For patients worried about the consequences of smoking, Lucas has a suggestion: "I guess theoret ically they could use cigarette filters, but I haven't seen those sav e a lot of lives."
Portability and Ease of Use: 10
Medical Effectiveness: 24