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Medicinal Uses of Cannabis
“Hemp is used in various forms, by the dissipated and depraved, as the ready agent of a pleasing intoxication. In the popular medicine of these nations, we find it extensively employed for a multitude of affections. But in Western Europe, its use either as a stimulant or as a remedy, is equally unknown.” wrote W.B. O’Shaughnessy in 1838. Over 150 years later cannabis prohibition causes the drug to be largely unknown as a remedy. In certain segments of contemporary California cultures its therapeutic properties are being independently reaffirmed and elaborated.
Until the initiation of the cannabis buyers clubs in 1992 there has been minimal opportunity for clinical research. Since removal from prescriptive availability in 1937 therapeutic experience with the drug has been minimal.
Removal of cannabis from prescriptive availability in 1937 plunged the medical and scientific community into a dark world of clinical ignorance; with prevailing realities and definitions hostage to police, prosecutors, and (unbeknownst to the public) the covert agencies. Despite continuing official stories to the contrary, “anecdotal” accounts of therapeutic efficacy could not be entirely suppressed. Under covert community contracts a synthetic d 1-9 tetrahydrocannabinol was synthesized in quantity by a federal contractor to the CIA and made available under the trade name, dronabinol (Marinol®) in 1986.
Additionally, there was legislative recognition that cannabis drugs had therapeutic potential and the California Research Advisory Panel (CRAP) was set up in 1969 . The agency was installed in the Attorney General’s office. The secretary, Edward P. O’Brien, Assistant Attorney General strictly interpreted the law and inhibited the panel from carrying out its legislative mandate of affording compassionate access. The 22 year old autocracy was unsuccessfully challenged in August 1990.
The panel, exclusive of O’Brien, attempted to publish an executive summary which, among other things, recommended the decriminalization of marijuana. The executive summary was expurgated from the annual report. UCSF professor of pharmacology, Frederick Meyers, M.D., was obliged to publish it privately.
Significant research did take place with Reese Jones, MD at UCSF proved the safety of high dose THC and marijuana which contributed to the release of Marinol as a schedule II controlled substance.
The National Organization for the Reform of Marijuana Laws (NORML) brought suit against the Drug Enforcement Administration (DEA) in 1972 to reclassify marijuana to make it available for prescription After two years of hearings and testimony down scheduling of crude cannabis from schedule I to schedule II was recommended by administrative judge Francis L. Young on September 6, 1988. The DEA appealed this and in October 1991 was told to facilitate the decision making process or better justify retention in schedule I. At this writing thirty years after the initial filing, the litigation continues- Jon Gettman's (a former director of NORML) continuing efforts of reclassification is living testimony to both governmental intransigence and persistence of opponents. In April 2002, a panel of federal judges decided that Gettman lacked standing and avoided dealing with any of the issues of the petition itself. Another victory for stipulative reality and a defeat for reason, science, medicine, and compassion. Stipulative reality is a legal or bureaucratic process that, in the case of cannabis, is largely devoid of scientific, medical, or common sense. Operational definitions run amok.
James O. Mason, M.D. Assistant Secretary for Health in May, 1991 terminated the compassionate Investigative New Drug (IND) for cannabis. AIDS activist protesters led opposition to this which resulted in the IND’s continuing until November 18, 1991 when he again announced suspension. Mason stated that cannabis has no legitimate medicinal use an that use of marijuana promoted disinhibition leading to unsafe sex.
Another claim of was that natural cannabinoids may expose immunocompromised individuals to harmful contaminants like fungi, molds, and bacteria. While there are no cases reported as yet, these were the rationalizations for his decision.
Dr Donald Abrams and a respected team at University of California, San Francisco at the San Francisco General Hospital have been finally successful in obtaining approval after 5 years delay to research the comparative utility of Marinol and cannabis in AIDS patients.
In 1992 the first Cannabis Buyers Clubs were started in San Francisco, New York, and Washington, DC with originated by gay community activists after informal meetings in Washington, DC at the 1991 annual Drug Policy Foundation conference. Of the buyers clubs, the San Francisco CBC was the largest. It grew from a few hundred to twelve thousand before it was raided and closed in August, 1996 by the California State Bureau of Narcotics.
Currently, known CBC’s are throughout the greater San Francisco Bay area operating autonomously with varying admission requirements and protocol. Since the closing of the San Francisco CBC, the procedures, for the most part, tended to be cautious and exclusive until the passage of Proposition 215.
Notwithstanding official statements that the medicinal usefulness were yet to demonstrated in opposing Proposition 215 , the Compassionate Use Act of 1996, the initiative passed 55% to 44% and became California Health and Safety Code section 11362.5. Because little preparation for the eventuality of its passage, enforcement of California marijuana laws became problematic.
While cannabis law reform activists celebrated by conspicuously “self-medicating”, institutional response was anxious perplexity. From the White Office of National Drug Control Policy, and Drug Enforcement Administration to the California Attorney General’s Office, and the California Medical Association, all trying to determine responses to the legalization of medical marijuana. Meanwhile, California marijuana law anarchy. De facto partial legalization.
Five years after the passage of this law unfortunately finds less than a substantial level of implementation and compliance throughout the state. Correspondence with 58 California counties' boards of supervisors, District Attorneys, Sheriffs', and Health Officers discloses less than a fifth of the counties have policies. www.ccrmg.org Projects.
Cannabis, however, had a ninety year history of clinical use in the U.S. since the mid 1840’s until removal from clinical availability by the Marihuana Tax Act. Neither the composition of cannabis nor human physiology has changed since removal from prescriptive availability. While archaic by contemporary reality and medical descriptions proper perspective from an era before the distortion and censorship of stipulative reality.
Pre 1937 Cannabis Therapeutic Uses
2. Appetite stimulant
4. Prophylactic and treatment of the neuralgias, including migraine and tic doloreux
9. Topical anesthetic
10. Withdrawal agent and substitute for opiate, chloral, and alcohol dependence
11. Childbirth analgesic
Unapproved Clinical Research: California Cannabis Center
Because the use of marijuana is illegal, usual institutional channels of support are blocked and funding unavailable. U.S. Analytical laboratories are forbidden to analyze specimens from extralegal sources. Notwithstanding these impediments the cannabis buyers clubs’ afford unique clinical research opportunities in therapeutic uses of cannabis. CBCs are communities of persons who seek the drug for self-medication. Gaining entry to a CBC requires proof of illness and a written referral from a physician.
Interviews at the CBC’s in San Francisco, Santa Cruz, Oakland and in my Berkeley office confirmed and elaborated upon descriptions in the pre prohibition medical, pharmaceutical and scientific literature. Clinical phenomena once known to medicine and treated by the physician are rediscovered by persons self medicating with cannabis. Additional unreported conditions are encountered.. Despite the lack of information of forgotten medical intelligence there appears to be frequent “spontaneous” discovery of medicinal utility. A typical story goes: A person in their forties “Oh yes, I did it a few times in high school but never used it again until recently and to my surprise the symptom improved!”
A pilot study of interviews with 57 San Francisco Cannabis Buyers’ Club members in 1994 was done using an outline derived from pre-prohibition medical literature citations and personal clinical observations Interviews with over 200 CBC members have led me to certain overall clinical findings:
Cannabis therapeutic effects five categories.
The author, confronted with a myriad of conditions and diseases, seeks to categorize therapeutic actions of cannabis. The five categories represent an arbitrary attempt.
1. Psychotherapeutic: Antidepressant/Anxiolytic Easement
2. Antispasmodic Anticonvulsant Appetite stimulant
3. Analgesic immunomodulator
4. Harm reduction substitute
1. Psychotherapeutic: Antidepressant/Anxiolytic Easement
Before it was taken away from physicians for prescribing in
1937 cannabis had a long history as a drug for the treatment of melancholia
or depression with and without agitation.
The ancient Greek, Indian, Persian, writings are replete with descriptions of antidepressant properties. Homer’s Odyssey describes Helen using a potion obtained from Polydamna that lifted the spirits at a morose gathering by slipping Nepenthe in the wine. Nepenthe means “against sorrow” .
Sanskrit and Hindi writings characterize cannabis:
Before the 8th century an anti phlegmatic, Circa 1050: victorious (Vijaya), and victorious in three worlds (Trailokyavijaya).
1300 A.D. in The Rajanighantu of Narahari Pandita: the light hearted (Capala), the joyful (Ananda), the rejoicer (Harsini), speech giving (vakpradatva) inspiring of mental power (medhakaritva), and a most excellent excitant (cresthadipanatva).
17th Century Materia Medica The Rajavallabha: “It creates vital energy, the mental powers, and internal heat, corrects irregularities of the phlegmatic humour, and is an elixir vitae.”
In contemporary terms a case of severe and chronic depression may have been successfully treated through self medication with cannabis.
The Persian physician Mirza Abdool Rhazes wrote: “The oldest work in which Hemp is noticed is a treatise by Hasan, who states that in the year 658 (Mahometan era)(1258), the Sheikh Djafar Shirazi, a monk of the order of Haider, learnt from his master the history of the discovery of Hemp. Haider, the chief of ascetics and self-chasteners, lived in rigid privation on a mountain between Nishabor and Romah, where he established a monastery of Fakirs. Ten years he had spent in his retreat, without leaving it for a moment, till one burning summer’s day, when he departed alone to the fields. On his return an air of joy and gaiety was imprinted on his countenance; he received the visits of his brethren, and encouraged their conversation. On being questioned, he stated that: struck by the aspect of a plant which danced in the heat as if with joy, while all the rest of the vegetable creation was torpid, he had gathered and eaten of it’s leaves. He led his companions to the spot, all ate, and all were similarly excited. A tincture of the Hemp leaf in wine or spirit seems to have been the favorite formula in which the Sheikh Haider indulged himself. An Arab poet sings of Haider’s emerald cup; an evident allusion to the rich green colour of the tincture of the drug. The Sheikh survived the discovery ten years, subsisting chiefly on this herb, and on his death his disciples by his desire planted it in an arbour about his tomb. From this saintly sepulcher the knowledge of the effects of Hemp is stated to have spread into Khorasan.” (O'Shaughnessy 1839)
In 1845 J.J. Moreau de Tours, a French psychiatrist utilized cannabis in the treatment of depression described the drug’s effects:
“It seems that nothing can hurt you in this peace of mind, that you are inaccessible to sadness. I doubt that the most unfortunate news could draw you out of that imaginary bliss, which can only be appreciated through experience. I have just attempted to give an idea of the delights that hashish produces. I hasten to add that I have presented them here in no more than raw form, as it were, and at their simplest. It will depend upon external circumstances to confer upon these feelings of happiness still greater intensity by directing them toward a determined goal and by concentrating them on a single point. One imagines what reality can add to this state of bliss and how much the joys of hashish can be enhanced by external impressions, by direct sensory excitations, or by the stirring of passions through natural causes. At that time, the rapture of hashish intoxication, taking shape and form, will assume the dimensions of delirium. This disposition of the mind, linked with another which I will discuss later, was, I feel, the fertile source from which the fanatic inhabitants of Lebanon derived that happiness, those ineffable delights for which they gladly sacrificed their lives.
It is necessary here to clarify what I have just said. It is really happiness that hashish gives, and by that I mean mental joy, not sensual joy as one might be tempted to believe. This is indeed very curious, and one can draw strange conclusions- this one among others, that all joy, all contentment, even though its cause is strictly mental, deeply spiritual, and highly idealistic, could well be in reality a purely physical sensation, developed physiologically, exactly like those caused by hashish. At least, if one relies on inner feelings, there is no distinction to be made between these two orders of sensations, in spite of the diversity of the causes to which they are related for the hashish user is happy, not in the manner of the glutton, of the ravenous man who satisfies his appetite, or even of the hedonist who gratifies his desires, but in the manner, for example, of the man who hears news that compounds his joys, of the miser counting his treasures, of the gambler whom luck favors, or the ambitious man whom success intoxicates. However, the preceding remarks were not intended to raise a psychological question. I am merely recording observations, and have no other pretension than that of being the faithful and exact historian of my sensations.”
This characterization of the antidepressant effects of the drug in contemporary contexts would be unthinkable pro drug sedition hyperbole and would never be found in any advertisement today .
Depression as one of the conditions listed for treatment appeared in general Materia Medica, or medical texts , , , Subsequent clinical use in depression is described as having variable results. Clouston in 1871 from the Cumberland and Westmoreland asylum reported on five cases of melancholy with some success in four and marked improvement in one. Villard describes similar variable results in melancholia by physicians in France.
The Indian Hemp Drugs Commission in 1894 reviewed medical literature, testimony by both indigenous medical practitioners and Western trained physicians and described cannabis to be used as a tonic to increase stamina.
Cannabis decreases emotional reactivity and intensity of affect while increasing introspection as evidenced by the slowing of the EEG after initial stimulation. The unique anti depressive effects of cannabis are experienced immediately with the alteration in cognition. Obsessive and pressured thinking give way to introspective free associations when in relaxed circumstances. Emotional reactivity is smoothed out, worries are less pressing. Used on a continuing basis, cannabis used to hold the depressive symptoms at bay. Agitated depression appears to respond to the anxiolytic component of the drug . The poorly modulated emotional control seen in bipolar disorder with its overreactive affectual responses are diminished with cannabis.
The treatment of depression with cannabis may be difficult because of differences in individual makeup, need for continuous dose levels, expense, availability, and illegality. Hostile attitudes of clinicians who are ignorant of cannabis’ therapeutic properties are a significant impediment to its appropriate use in the treatment of depression with and without anxiety. Cannabis appears to be effective both adjunctively and alone in bipolar disorders (296.6) by decreasing affectual overreactivity., In schizoaffective disorder (295.70), dysthymic disorder (300.4), and major depression (296.3) cannabis appears to lessen feelings of alienation and blocking of ideation. In any disorder cannabis’ sedative properties help with problems of insomnia (307.42).
Posttraumatic stress disorders (309.81) are particularly helped by cannabis which afford control of symptoms more effectively than other psychotherapeutic agents because of the absence of incapacitating or debilitating side effects. The modulation of mood response prevents or significantly decreases the symptoms of anxiety attacks, mood swings, and insomnia. The short term memory loss effects that may be undesirable in other contexts are therapeutic in controlling obsessive worry ignited by the triggering stimuli.
Cannabis is an especially effective in PTSD because it both modulates emotional responsivity and restores sleep. The restoration of sleep shore up the defenses that are eroded by sleep deficit. The chronic loss of sleep and insomnia (307.42) is helped. Nightmares and other sleep disfunctions are ameliorated (307.47). The PTSD is worsened by any prescribed or non medical substances that interfere with sleep like alcohol, stimulants, and SSRI medication.
With PTSD there is no such thing as an alt/ctrl/delete option for horrific memories and the goal is to optimize management through minimizing physical and emotional vulnerability. Sleep, nutrition, and regular exercise are the treatments of choice in addition to cannabis therapy. Minimizing and avoiding other psychoactive substances is part of the long term regimen. Developing and using supportive resource are other requisites for long term optimal management.
Cannabis while possibly adversely interacting with tricyclic antidepressants appears to have either no interaction with SSRI antidepressants or possibly act synergistically. A 43 year old female graphics artist reported that while fluoxetine relieved her subjective depression, she needed cannabis to stimulate the flow of ideas. Others find cannabis useful in suppressing side effects of tenseness or anorexia from the SSRI’s. Individual psychotherapy may focus on problems secondary to feelings of marginalization because of criminal status and alienation from judgmental therapists and family.
A forty year old clinical psychologist experienced recurrent major depression ( 296.3) with bouts of immobilization with sequestration, social withdrawal, and hypersomnolence. She would "shut down" and turn inward for weeks at a time. Cannabis would reverse this process and mobilize her feelings to "make her available" emotionally. Anorexia and constipation were part of the episode which was also relieved by the cannabis. The restoration of vegetative functioning as well as mood improvement also reestablishes a sense of control.
Depression frequently presents as irritability and anger which is helped by cannabis. Besides improving mood there is a restoration of emotional well being. Restoration of sleep with the paying back of the sleep debt that is a common presenting feature of depression. Cannabis is especially useful in the organically caused depression.
Another of the significant contributions to medicine by William Brooke O'Shaughnessy, M.D. was the discovery that cannabis was useful in the treatment of seizures and spasticity. So important was this discovery that his nonpareil monograph ON THE PREPARATIONS OF THE INDIAN HEMP, OR GUNJAH presented in 1839 was subtitled: THEIR EFFECTS ON THE ANIMAL SYSTEM IN HEALTH, AND THEIR UTILITY IN THE TREATMENT OF TETANUS AND OTHER CONVULSIVE DISEASES.
These findings were confirmed by Clendinning in 1843 who described efficacy in both tetanic spasticity and irritability of the central nervous system. The latter secondary to alcohol withdrawal symptoms. Christison in 1851 described two cases of tetanic muscle spasms alleviated. Willis in 1859 reported success in the treatment of “puerperal convulsions” and delirium tremens. The Ohio State Medical Society convened a committee that reported on the medicinal properties of cannabis in 1860. W.P. Kincaid reported: “I have treated four cases of epilepsy with the hemp; two were permanently benefited (at least to the present time); one temporarily, and one not at all.” Major pharmaceutical firms listed epilepsy as one of the conditions for which cannabis was indicated either alone or as an ingredient in combination preparations. The Indian Hemp Drugs Commission in 1894 listed “brain fever,” cramps, convulsions of children,...neuralgia, and tetanus.” The U.S. Dispensatory of that year lists convulsions as one of the indicated conditions recommended for treatment.
After the onset of marijuana prohibition in 1937, citations in medical literature all but disappeared and only isolated mentions in the scientific literature.
Multiple Sclerosis- One Case over three years
A 52 year old woman with advanced degrees in speech pathology, audiology, theater, secondary school teacher, and learning disabilities resource specialist has herself been disabled for 25 years with chronic progressive multiple sclerosis (340), rheumatoid arthritis (714.0), and trigeminal neuralgia (tic Doloroux) (350.1). An articulate reporter on the effects of chronic illnesses that are multi system in manifestation: Major depression, recurrent (296.3), muscle spasm (528.85), bladder hypertonicity (596.51).
At our first meeting she described her first use of cannabis as medicinal and not social at the age of forty. She discovered that smoked cannabis relieved her symptoms of depression, muscle spasm, and pain. Marinol did not relieve the symptoms. She was maintaining on klonopin 30 mg, cortisone 15 mg, daily and prilosec as needed.
One year later she described a gradual worsening of the disease but the use of cannabis to cut back on the use of drugs that are addictive and cause liver damage. She was receiving a course of 40 mg prednisone daily for a flare up in her spasticity, pain, and was grieving for her mother who died two weeks before the follow up visit. Two years follow up review of medication her use of klonopin to 1 mg at bed time and ditropan for bladder hypertonicity. She was less depressed and aware of the aggravation by klonopin used for spasticity control. Growing her own supply of cannabis, she prepared tinctures and butter extracts used daily, up from smoking x5 weekly. It was recommended that she switch to vaporizing from smoking.
Two years later the MS continues to gradually worsen She switched to vaporizing instead of smoking and increased her use of a vaporizer to daily (Vaportech). She reported her MS has worsened over the past year but that cannabis has allowed her to be more functional and mobile. The relief of depression and freedom of side effects from other medications and dependency on pain medication. She has avoided steroids and diminished her use of NSAIDs that irritate the stomach. Weekly psychotherapy helps her cope with the depression. An 18 month trial of fluoxetine was less effective than desired and decreased emotional responsivity. By contrast, cannabis improves emotional responsivity and mobility. The diminished spasticity increases mobility and stamina with her stretching exercises and overall feelings of well-being and self-confidence. MS is now an incovenience rather than the center of my life.
Three years later the MS is secondary progressive (symptomatic on a daily basis but stable and without exacerbation) now and the cannabis used daily makes an enormous difference in the quality of my life. I am more active and less depressed.
Her use of oral cooked forms require long term planning to compensate for her needs when she goes out for an evening. She has improved in that she has taken control of her spasticity through frequent PRN inhaled vaporized cannabis and supplementary oral preparations.
Consroe both described a case of epilepsy controlled by smoked marijuana and demonstrated the efficacy in blocking experimentally induced seizures in rats. Similarly, anticonvulsant activity was demonstrated in mice using various constituents of cannabis.
Findings from secret research on cannabinoids as an incapacitation agent for chemical warfare produced the useful side effect of reconfirming the use of cannabis as an anti seizure medication. Van M. Sim, M.D. then director of the Edgewood Arsenal Chemical Warfare declared: “Marijuana...is probably the most potent anti epileptic known to medicine today.” and Harold Hardman described significant hypothermogenic activity. Despite these disclosures in 1971 to date there has been no efforts to exploit these beneficial medicinal properties. Soon after Marinol (dronabinol) became available but was still a Schedule II drug, medical psychiatric consultations at a county hospital afforded the opportunity to try Marinol for some "off label" therapeutic trials. California permits use of any medication for any purpose as long as there is some therapeutic rationale.
GM, a 38 year old male with post cerebral anoxia encephalopathy ( 348.1) complicated by alcoholic encephalopathy ( 291.2) and seizures was seen by me for unpredictable and uncontrolled assaultiveness from a chronic organic personality disorder, explosive type ( 310.10). He was maintained on phenobarbital, tegretol chlordiazepozide, lithium, chlorpromazine, and diazepam. He was angry, paranoid, agitated, cursing, needing leather restraints. Marinol 5 - 10 mg TID - QID was initiated with dramatic improvement in the agitation and anger. He was significantly improved and was able to be transferred off the neurological ward to the ambulatory locked psychiatric ward.
I saw him on follow up consultation four months later and he had reverted to his unmanageable behavior and was an assault and safety risk. The psychiatric ward staff discontinued the Marinol which led to continuing problems and finally an administrative transfer back to the neurology-medical ward. Marinol was not restarted because of expense and controversy of using a synthetic marijuana.
Clinical experience with California self-medicating patients confirms the previous observations in the literature and expand the range of conditions for which cannabis provides relief. The use of inhaled cannabis in contemporary observations is different from the accounts in older medical literature in which all use was oral.
Seizure disorders ( 345x) of diverse etiologies of cerebral dysfunction including familial, idiopathic, trauma, and metabolic dysfunction are helped by cannabis. Tourette's disease and intermittent explosive disorder are controlled by cannabis. There are frequently multi system problems concurrently helped by cannabis.
S.P. a 36 year old female physician with temporal lobe epilepsy starting at age 32, severe migraine headaches, and bipolar disorder since age 9. Adopted as a baby, genetic history is lacking. She was incapacitated to the extent that she had to take a medical leave of absence during her third year of medical school. Cannabis significantly decreased her seizures and migraines. She controlled symptoms of migraine and is seizure free. She also suffers congenital hip dysplasia with traumatic arthritis ( 716.1), carpal tunnel syndrome ( 354.0) and muscle spasm. Cannabis is useful in the control of these symptoms as well. Both inhaled cannabis and moderate doses of dronabinol (synthetic THC in sesame oil) work well. Concurrent mood swings are well controlled with cannabis. ( 296.6) She experiences control of both seizures as well as the migraine ( 346.1) and muscle spasm ( 728.85).
Cannabis has been recognized as an appetite stimulant for hundreds of years in non-western medicine. Mirza Abdool Rhazes, “a most intelligent Persian physician...considers Hemp to be a powerful exciter of the flow of bile, and relates cases of its efficacy in restoring appetite..” ” “produces a healthy appetite, ..digestive, easy of digestion,.. and the digestive faculty” (quoted in O'Shaughnessy)
During its’ century long prescriptive availability before being taken off the market, stimulation of appetite was frequently described, as a secondary effect during its use as an analgesic or sedative in comparison with the opiates. McConnell in 1888 specifically described success in treating anorexia “One of the conditions in which the drug has proved useful in his hands is anorexia- loss of appetite consequent upon exhausting diseases such as prolonged fevers, diarrhoea, dysentery, phthisis, etc.”
Lees described the drug as a mild stimulant to overcome constipation and gastritis that is nervous in origin
Cannabis as an appetite stimulant- Relaxation of smooth muscle throughout the gastrointestinal tract.
Besides relieving skeletal muscle spasm, smooth muscle spasm is eased. In the gastrointestinal tract there is relaxation without atony. Peristalsis is restored, reflux relieved, small bowel spasm and hypermotility eased. Constipation and colitis are helped by cannabis. These mechanisms are, no doubt, moderated by the autonomic nervous system with supratentorial effects.
Cannabis appears to relax both smooth and skeletal muscle. The relaxation of the gastrointestinal tract is the relief of smooth muscle spasm, and immobility. Peristalsis is restored. Gastritis, ( 535.5), gastroesophageal reflux ( 530.81), pylorospasm ( 537.81), regional enteritis, Crohn's disease ( 555.9), irritable bowel ( 564.1) colitis ( 558.9), diverticulitis ( 562.1), and constipation ( 564.0) are eased.
AMW a 20 year old single college student presented with a history of recurrent severe abdominal pain starting at age 10 with a history of hospitalizations x4, exclusion diets
In the treatment of AIDS related illness ( 042) and hepatitis "C" ( 070.54) antiviral pharmacotherapy and other chemotherapy drugs cause significant anorexia ( 783.0), nausea ( 787.02), and vomiting ( 787.01).
Marinol and cannabis are both useful in the treatment of anorexia, nausea, and vomiting from both disease processes and the iatrogenic symptoms caused by other drugs like cancer chemotherapeutic or antibiotics. Marinol which is supplied only as an oral preparation frequently is less effective than the inhaled route because of the long time between ingestion and onset of effects. Additionally, the status of the gastrointestinal tract motility, and contents, affect the absorption rates of the drug. However, medicating for relief of side effects from radiation ( E929.9), chemotherapy ( V66.2), is useful for some using the oral route for premedicating.
Paradoxically, cannabis' psychotherapeutic properties are useful in the treatment of bulemia. ( 307.51) While increased normal hunger, overeating and gorging is controlled by cannabis because of decreasing the obsessive thinking, intense depression, and compulsive eating. Exogenous obesity is, reported by some, to facilitate control of compulsive eating. The same mechanism of mood modulation and control of obsessive compulsive thinking ( 300.3) and behavior may be seen with cannabis. Weight reduction treatment of morbid obesity ( 278.01) The gastrointestinal and emotional well-being are linked. Psychotherapeutic benefits are holistic in their manifestation through the normalization of vegetative functioning as well as modulation of mood and emotional reactivity.
Essential hypertension ( 401.1) benefits from the psychotherapeutic effects which decreases the muscle tension of the arterial wall.
3. Analgesic Immunomodulator
First described by O’Shaughnessy in the treatment of acute and chronic arthritis in 1839, Clendinning confirmed the findings in 4 of his 18 patients in 1843. Acute rheumatism was successfully treated by Buckingham in 1858
Clinical interviews of over 6500 members at cannabis buyers clubs and patients in my office practice lead to this generalization:
Many illnesses or conditions present with both inflammation and muscle spasm. Cannabis is both an antispasmodic and anti inflammatory.
Cannabis as a mood modulator and easement A unique medicine. The classification of cannabis is difficult since the profile of pharmacological activity is different qualitatively from other medicines. Route of administration and amount While it has sedative properties, it is different from others. Cannabis and its mental effects affect the behavior of the immune system that is a significant dimension of expression of chronic disease processes. The hypothalamic-pituitary-adrenal axis (HPA) is significantly affected by cannabis. Chronic local hyperactivity of the immune system manifests as pain, swelling, or irritation. Peripheral neuropathies (357.x) including generalize pruritis (698.9)
O'Shaughnessy's 1839 report included 4 cases of patients with severe, immobilizing, arthritis when administered cannabis became cheerful and mobile with decreased pain.
Pain management in chronic disease is a salient beneficial use of cannabis. Because of the absence of adverse or undesirable effects of the drug compared with conventional or mainstream drugs, cannabis should be considered as an initial pharmacologic intervention. Ethically, it is consistent with "Above all, do no harm." Economically, cannabis substitution optimizes long term management.
Pain, a complex phenomenon, which is a substantial aspect of chronic illness. Psychic pain without demonstrable underlying organic pathology (307.8) is mitigated. The manifestations of pain of disturbances in circadian rhythms and mobility are seen in endocrine and other organ systems. Cannabis therapy helps to control pain by both psychological and physical effects. By both mental and organic effects.
Control through integrative effects. The cognitive effect of decreased pressured obsessive thinking, amplified by sleep deficit, and a painful physical condition, is controlled by cannabis. The decreased emotional reactivity and restored sleep augment the local anti-inflammatory effects of cannabis. Subjectively, the perception of pain is altered. The source of pain is "owned" which then permits control. A leash on an angry omnipresent inner animal. The ability to accommodate and prevail over immobility and depression with the facilitation of vegetative function makes cannabis unique among analgesics.
Cannabis therapy with its enhanced control gives comparative freedom and improved quality of life to chronic pain conditions. The side effect is the increased awareness of adverse effects of many other analgesics. Cannabis optimizes coping.
Immune system effects
Gabriel Nahas, M.D. Columbia University Anesthesiology professor long time antimarijuana activist, and others have alleged adverse effects of cannabis on the immune system supposedly decreasing the immune response as represented by numbers of one of the white blood cells, the T lymphocyte. Their discredited thesis of immunosuppression caused by cannabis, nonetheless adversely affected clinical research by turning attention away from possible beneficial effects on the immune system by the drug. More recent studies show much more complex effects.
Interviews with cannabis users report that despite the irritating properties of smoke, inhaled smoked or vaporized cannabis provides relief for both chronic sinusitis ( 473.9) and asthma ( 493.9). Inhalation of cannabis utilizing a vaporizer affords better relief without the concomitant irritation. But some patients with chronic pulmonary conditions prefer the expectorant effects when smoked. Anaphylactic or other reaction to external agents ( 995.0) Generalized and local itching ( 698.9), Autoimmune musculoskeletal diseases: Lupus ( 710.0), Scleroderma ( 710.1), Dermatomyositis ( 710.3), Eosinophilia-myalgia ( 710.5), Psoriatic arthritis (696.0) and Psoriasis (696.0)
Diabetes- multiple system dysfunction
The inflammatory and dysfunction secondary to failure of the islet cells of the pancreas to produce adequate amounts of insulin.
Cannabis appears to help control elevated blood sugar by control of stress through the pituitary adrenal axis by decreasing gluconeogenesis through controlling the release of epinephrine and norepinephrine.
The diabetic neuropathies (250.6), gastroparesis (337.1) retinopathy (362.01), recurrent pancreatitis (577.1)
Cannabis appears to be a unique immunomodulator analgesic that is useful in the control of autoimmune inflammatory illnesses that include:
Autoimmune Inflammatory Illnesses
Posttraumatic Arthritis (716.1), Rheumatoid (714.0), and Osteoarthritis (715.0), Fibromyalgia fibrositis (729.1), Nail-patellar-tooth disease (756.89), Melorheostosis (733.99), Lupus (710.0), Scleroderma (710.1), Dermatomyositis (710.3), Felty's syndrome (714.1),
Asthma (473.9), chronic cough (786.2)
Cystic fibrosis (518.89), Emphysema (492.8)
Central and Peripheral Nervous System
Degenerative diseases of the CNS and PNS: Cerebral Palsy (343.9) Bell's Palsy (351.0), Multiple Sclerosis (340.0), Charcot-Marie-Tooth (356.1), Post viral encehalophathy (487.8) and neuropathies, Tic doloroux (350.1), Neuropathy, Post CNS and PNS injury pain (357.x). Parkinsons disease (332.0), Huntington's disease (333.4), Restless legs syndrome (333.99), Amyotrophic Lateral Sclerosis (335.2) Friedrich's ataxia, Syringomyelia, Reflex sympathetic dystrophy (337.2), Phantom limb pain (353.6)
Glaucoma (365.23), Intraocular hypotensive, conjunctivitis (372.9), drusen of the optic nerve (377.21) Oculomotor post congenital spastic blindness (379.5), Migraine headache (346.x) .
Gastritis (535.5), Duodenal Ulcer (536.8), Regional Enteritis & Crohn’s Disease (555.9), Colitis, Spastic (558.9) and Ulcerative (536.9), Hepatitis, Peutz-Jeghers disease (756.9).
Cystitis, Ureterospasm/calculus (592) dysmenorrhea (625.3), orchitis (608.2), epididimitis (604.xx), prostatitis (600.0)
Graves disease (242) Thyroiditis (245), Amyloidosis (277.3), Premenstrual syndrome (PMS) (625.3)
Allergic Rashes (995.0), Psoriasis (696.1), Intractable Itching (698.8), Epidermolysis bullosa (694.9) Genital herpes (054.10), Hives (708.9).
nose and throat
Meniere’s Disease (386.00), Motion Sickness (994.6), Sinusitis (461.9), Allergic Rhinitis (472.0)
Therapeutic Mechanisms of action
Clinical interviews in over 6500 cases lead me to impressions regarding how cannabis produces therapeutic effects. Therapeutic mechanism of action appears to be bimodal: both central nervous system and peripheral sites involved. Cognitive change affects the perception of pain that produces relief or amelioration. Control of emotional reactivity modulates the cognitive response to the stressor or aggravating stimulus. Obsessive thinking driven by pain or discomfort is controlled. An aching tooth increases disproportionately in size and focus of attention.
In persons with spastic conditions, the decrease in muscle tension or sympathetic nervous system activity, the physical effects appears to come before the cognitive or perceptual changes.
Route of administration is highly important because dose levels and latency of onset vary greatly. The oral route from stomach and intestines via the hepatic portal veins through the liver before systemic distribution depends upon two factors: Motility and other contents of the GI tract. An empty and relaxed stomach, a high fat meal with anxiety would produce onset variability from one hour to up to four hours. Some cannabinoids might be excreted with feces. Incaution and impatience have resulted in symptoms of overdose, though alarming, has caused no lasting sequellae. Difficulty with potency consistency has been an ongoing problem.
Chemically, cannabis is distinctly different. A thick viscous oil that has a consistency of pine pitch that is soluble in fat, alcohol, and other organic solvents but minimally in water. Unlike other psychoactive drugs (except alcohol) cannabinoids do not contain nitrogen. Cannabinoids travel in the body carried by lipoproteins and modulate immune and central nervous systems through the hypothalamic-pituitary-adrenal axis (HPA) interacting with thalamo-cortical systems. There are receptor sites for cannabinoids both in the CNS and in peripheral tissues. The non-polar lipid structure of cannabinoids when inhaled travel directly to the CNS and general circulation unimpeded by the liver and other digestive processes.
The active ingredients, the cannabinoids vaporize at 180 to 200 degrees centigrade (356 to 492 degrees F.). At this temperature there is minimal pre incineration of other components of crude cannabis. Thus there are none of the noxious breakdown products of burning- only the essential oils.
Cannabinoids, essential oils of crude cannabis, vaporize at rates that are functions of surface multiplied by temperature. Even at room temperature where there are significant quantities of product with poor ventilation there is out gassing that is sufficient to produce psychic effects.
Lipid metabolic pathway of the Eicosanoids, arachidonic acid compounds, precursors to production of Prostaglandin and decrease of release of PG. Inhibition of healing of viral skin infection may be related to pulsatile elevations in circulating cortisol. Antagonism of marihuana mental effects by indomethacin, an anti inflammatory drug with side effects of suppressing production of leukocytes also indicates the complexity of the effects of cannabis on the immune system..
Cannabinoids are transported by the phospholipid system. Non polar molecules are lipophilic and similar in structure also to prostaglandins - a mediator of inflammatory reactions. The effects are manifold:
"Prostaglandins are derivatives of fatty acids that are produced in most tissues of the body and have varying physiologic actions. Prostaglandins, thromboxanes and leukotrienes are all classified as members of the prostaglandin or eicosanoid class. The first prostaglandins were so named after their initial isolation from semen in the 1930's because they presumably were added by the prostate. Since then they have been found in most every tissue in the body.
Prostaglandins are often second messengers within cells acted upon by other hormones. There are many classes of prostaglandins with the differences being conferred by substitutions to the pentane ring of the basic 20 carbon molecular skeleton. Prostaglandins are synthesized from arachidonate in the cell membrane by the action of phospholipase A2. From here two synthetic pathways, the cyclooxygenase and lipoxygenase pathways, compete with one another to form prostaglandins and thromboxane or leukotriene, respectively. Because they are lipid soluble they can pass easily out through cell membranes.
In the cyclo oxygenase pathway, the prostaglandins D, E and F plus thromboxane and prostacyclin are made. Thromboxanes are made in platelets and cause constriction of vascular smooth muscle and platelet aggregation. Prostacyclins, produced by blood vessel walls, are antagonistic to thromboxanes as they inhibit platelet aggregation.
Prostaglandins have diverse actions dependent on cell type but are known to generally cause smooth muscle contraction. They are very potent but are inactivated rapidly in the systemic circulation and the inactive metabolites are excreted primarily in urine. Non-steroidal anti-inflammatories, such as aspirin, indomethacin and ibuprofen, inhibit the enzyme cyclooxygenase and therefore decrease prostaglandin synthesis. The anti-inflammatory corticosteroids inhibit the activation of phospholipase A2 by causing the synthesis of an inhibitory protein called lipocortin. It is lipocortin that inhibits the activity of phospholipases and therefore limits prostaglandin production.
Leukotrienes are made in leukocytes and macrophages via the lipoxygenase pathway. They are potent constrictors of the bronchial airways. They are also important in inflammation and hypersensitivity reactions as they increase vascular permeability and attract leukocytes. Indeed, the slow-reacting substance of anaphylaxis is actually a mixture of leukotrienes.
The vasoconstrictive and muscle constricting activities of prostaglandins contribute to the normal sloughing of the endometrial lining during menstruation. However, excessive production of prostaglandins in the uterine endometrium is involved in the pain, cramping, vomiting, and diarrhea of dysmenorrhea.
Prostaglandins are also involved in maintaining the patency of the ductus arteriosus in the fetal heart. The ductus arteriosus is a channel from the pulmonary artery to the aorta that closes shortly after birth. Blocking prostaglandin synthesis leads to ductal closure, a fact that has been employed in premature infants. In such cases, the administration of indomethacin can close the ductus and prevent the need for surgery. Conversely, in neonates with ductus-dependent heart deformities, prostaglandins can maintain the ductus prior to surgical correction of the deformity.
Prostaglandins have been investigated as bronchodilators but the side effects of inhalation have made this undesirable. Investigations into altering the chemical structure to avoid such adverse side effects are underway. Prostaglandins are also being studied for their effects on the cardiovascular and gastrointestinal systems."
The Body- mind Link
There appears to be a distinct physical component of the effect that is different from cognitive changes. While there is contiguity of both, physical sensation appears, at least when cannabis inhaled, to start a minute or less before the onset of cognitive changes. “I have a sense of physical release. Something that was getting tighter let go and the migraine attack was avoided.” Articulated a lawyer in his late 40’s. The decreased emotional reactivity is synergistic with cognitive changes to interdict the obsessive thinking driven by the physical discomfort mediated by emotional reaction. This appears to be the body-mind link.
A 39 year old male machinist with thromboangitis obliterans (Buerger's disease)( 443.1) reported a 17 second response time between inhaling cannabis and relief from an acute episode. He had partial amputations in his hand attesting to the seriousness of the condition. The physical event was described as preceding any mental effects by several minutes.
The initial increase in the flow of ideas appears to be related to increase in cerebral blood flow. Decreased peripheral resistance in the capillary bed of the cerebral cortex and vasodilation of the meninges. The latter may be observed by reddened eyes sclera that are extensions of the meninges.
It would appear that cannabis affects local inflammation by playing some role in the prostaglandin production and release behavior of the immune system. This would also explain relief of spasticity both in skeletal and smooth musculature.
The Mind-body link
The mind-body link appears to be altered time perception as it impinges on short term memory. This alteration of cognition then modifies the perception of pain. “The pain appears to fade into the distance” or other description of altered perception of the physical sensation is the other mechanism of cannabis analgesia. Hobart Amory Hare, M.D. in 1887 noted:
"During the time that this remarkable drug is relieving pain a very curious psychical condition manifests itself; namely that the diminution of pain seems to be due to its fading away in the distance, so that the pain becomes less and less, just as the pain in a delicate ear would grow less and less as a beaten drum was carried farther and farther out of the range of hearing.
This condition is probably associated with the other well-known symptom produced by the drug; namely the prolongation of time." Chronic inflammatory conditions like arthritis and lumbosacral disease responds well to cannabis compared with other analgesics.
Perception and reaction to pain is a biological analog of an audio feedback loop. With an audio amplifier with the microphone in front of the speaker an annoying squeal becomes intolerable as the self reinforcing sound waves increase in intensity until all other sounds are overridden and distorted. The effects of cannabis include the modulation of the emotional reactivity to the source of discomfort. With overreactivity controlled, there is both a sense of "owning" the source of pain and accepting it. Paradoxically, the acceptance confers a sense of control. The decreased emotional pressure interdicts the obsessive thinking that both focuses on the source and externalizes. Instead of "my", the source becomes "it".
(Pharmaceutical companies encourage this remunerative perception as they sell their potions to relieve "it". Unfortunately, there is no free lunch- there are usually unwanted side effects. These side effects then require other potions. "It" has expanded to include shyness, bad breath, constipation, under arm odor as we are "educated" by TV and other media.) The promotion of potions and nostrums has taken on the philosophy of "Brave New World" where the social norm was promoted by the slogan "A gram is better than a damn" as the populace was induced to medicate with Soma. Unfortunately the system is far from perfect with imperfect drugs with adverse acute and chronic effects- frequently requiring other drugs to treat the side effects.
Cannabis alters perception of both inner and outer worlds. In addition to the more holistic self-perception there are alterations of perceiving external and contextual worlds. A number of patients describe spiritual or global apperceptions or appreciation of naturalistic phenomena.
The overall element is a sense of control that derives from medicating with cannabis psychophysically from easement or modulation of emotional reactivity. Both psychological and physical disease are ameliorated. They, of course, are inseparable.
During rehabilitation the analgesic effects help with the restorative processes with promotion of mobility, pushing the physical therapy with toleration of discomfort for the necessary stretching and range of mobility exercises. The normalized vegetative functioning with restoration of sleep and the ability to focus and concentrate are salient features of cannabis therapeutics. Relief of sleep deficit with cannabis improves mobility, focus and ability to keep the source of chronic pain at bay. Opioids, by contrast, interfere with vegetative functioning including the suppression of peristalsis and evacuation. Additionally there is sedation and itching. Impairment of empathetic and emotional interactions add to emotional side effects.
Harm Reduction by substitution for more toxic drugs
Over half of 57 randomly selected San Francisco Buyers Club members interviewed used cannabis to avoid or diminish the use of alcohol, cocaine, amphetamine, and opiates.
4. Cannabis Substitution- Gateway drug back.
The substitution of cannabis for more harmful drugs- especially alcohol and opiates - is one of the early and important therapeutic applications described in pre prohibition literature. In 1843 Clendinning , a clinic physician in Edinburgh, used cannabis for the detoxification of alcoholics and opiate dependent. He also described the drug to be effective in both inflammatory and spasmodic pain. . With the invention and popularization of synthetic and purified drugs such as the barbiturates, heroin, and amphetamine, the use of cannabis drugs declined.
The use of cannabis in acute alcoholic withdrawal has yet to be reevaluated. Doubtless, there are some that have probably used the drug in this application but reports are unlikely from any American institution at this time.
Cannabis as a substitute for alcohol.
A significant number of alcoholics have discovered mood management with cannabis to be significantly less toxic than alcohol. They have been able to avoid being caught up in the enabling of a dysfunctional group to aggravate this chronic progressive serious illness. Certain alcoholics may need the additional pharmacological support to resist impulse to relapse through the use of Antabuse (disulfiram).
anxiety reduction model often utilized to explain initiation and perpetuation
of episodic drinking was found inadequate to explain motivation for alcohol
use by the alcoholic. Euphoria and elation were manifest only during the
initial phases of intoxication. Prolonged drinking was characterized by
progressive depression, guilt, and psychic pain. These unpleasant affects,
however, were poorly recalled by the alcoholics following cessation of
and constricted behavior patterns, which were present during sobriety, changed
markedly during intoxication, with increased verbalization, varied expression
of feelings, increased interaction, and frequent behavioral regression. During
inebriation, psychic defenses appeared weakened with significant reduction
of repression and reaction formation.” (Tamert and Mendelsohn 1969)
Carrot and Stick Intervention
In a county alcoholism clinic in 1968 I met a terminal chronic alcoholic woman with a lengthy history of treatment failures and non compliance. She confide to me that she was able to avoid drinking if she could smoke marijuana. I encouraged this substitution but added the use of disulfiram which prevented her drinking through threat of a severe histamine reaction if she drank. This “carrot and stick” pharmacological intervention helped her to be clean and sober for seven years before her death from breast cancer. During this period of recovery she was able to heal the painful alienated relationship with her son caused by her alcoholism.
Thirty years later at the Santa Cruz Cannabis Buyers club a 40 year old musician with a degree in engineering has been functionally disabled since his mid 20’s by a gradually encroaching chronic alcoholism. He exhibited serious medical problems including cirrhosis and peripheral neuropathy. His personality deterioration and organic mental symptoms produced continuing conflict with his girl friend (now fiancée) was on the verge of making him homeless again.
Carrot and stick therapy was implemented with an ongoing arrangement where he received three days worth of cannabis in exchange for taking his disulfiram tablet under direct observation by the CBC staff. Over one year passed but not without incident. There were incidents involving conflicts with the couple and the CBC staff that diminished in frequency and intensity as recovery progressed. At four years after cannabis substitution was begun there has been only one relapse but an underlying thought disorder masked by the alcoholism complicated his continuing recovery.
Subsequently, review of 104 patients who substituted cannabis for alcohol and other drug dependencies confirms the potential of harm reduction as a viable therapeutic strategy. Their epiphanies continue as areas for clinical study that include pain and injury that characterized their lives prior to insight that cannabis could both substitute for alcohol and other drugs.
This self selected population seeking medical protection from California marijuana came from a dysfunctional population with 61 (62%) of the families with one or more parents alcoholic or mentally disturbed. They were both exposed to abuse and abandonment. They lacked appropriate role modeling for dealing with uncomfortable feelings.
Injuries while intoxicated were significant 40 (45%) which added to the problems encountered. The additional use of NSAIDs, opioid combination, benzodiazepine produced undesirable side effects.
The therapeutic effects of cannabis on underlying emotional and mental problems were striking. After the first month of detoxification through a year of anamnesis, the restoration of sleep and mobility and emotional control are seen. Interpersonal relationships are restored as physical function and, frustration toleration, mood, and mental acuity improve. The individual is freed to trust him/herself and visualize long term goals that were heretofore unattainable.
All were able to make a transition from the intoxication - withdrawal sickness cycle. Physical dependence on and withdrawal from alcohol must be properly appreciated for its toxicity.
Clinical medical reality is represented by a bell-shaped distribution of drug interactions, covers the entire spectrum from those who should avoid the use of cannabis altogether to those who should never be without the drug. Misuse of cannabis is also a real and legitimate concern, and must be recognized as a symptom of emotional discomfort that must be treated. Cannabis itself is a tool without intrinsic moral properties. Cannabis abuse is not a primary psychiatric condition per se, but part of other conditions that may be a focus of clinical attention.
Cannabis-Related Disorders (234): Use and Induced include: Cannabis Dependence (304.30), Abuse (305.20), Intoxication (292.89), Intoxication Delirium (292.81), Induced Psychotic Disorder (292.XX) with Delusions (292.11), with Hallucinations (292.12), Induced Anxiety Disorder (292.89), and Related Disorder NOS (292.9)(Not Otherwise Specified).
Cannabis' self-medication for medicinal purposes is specifically different from cannabis related or induced disorders. The intention and results are opposite. In fact the use of cannabis may be the focus of clinical attention from a therapeutic perspective.
Development of Harm Reduction Support Groups
The milieu at the CBCs itself appears to have a salutary effect upon the healing process. Informal and videotaped clinical interviews repeatedly make reference to the CBC as a sanctuary. The cohesiveness from the illicit nature of the activity is, no doubt, a significant factor. An extension of that is the opportunity for social contact with others. The non judgmental inclusive egalitarian style of interactions are sufficiently desirable to members to linger rather than just make their purchase and leave. A familiar theme in the interviews is the feeling of sanctuary and acceptance. The therapeutic benefit from communitatis must be separated from the pharmacological benefits by future clinical research.
Psychological aspects of cannabis criminalization.
The stigma of criminality- a significant stressor is relieved and helped by the salutary effect of medicalization. In the interviews at the end of which I present my California physician’s statement that recommends and approves the use of cannabis for officially diagnosed serious illness there is frequently a genuine expression of gratitude and relief. The sense of freedom from the burden of criminal status and all that portends is one of my most satisfying experiences as a physician since medical school. All serious chronic illness alienates. And criminality increases that process of stigma. People worry about criminal status and all it portends.
Criminal status is an alienating experience which is connected with one’s self esteem. “But I’m really not a criminal!” complained a cannabis using businesswoman in her forties. And the question “Who do you think you are?” takes on a new meaning. What are your rights and expectations as an individual and who are you with regard to society? With official physician’s statement definition as a non criminal, there is a palpable sense of conciliation and feeling a reduced fear of harmful intervention by sanction. For others it provides a support and shield to fight for the right to work, freedom from losing one’s home to civil forfeiture, or custody of children.
As part of the comprehensive evaluation of cannabinoids’ impact on human physiology as part of the intelligence community’s assessment of the drug as an incapacitation agent noted that body temperature was significantly lowered at higher doses. The potential for use for preoperative hypothermia in trauma was suggested by Hardman in 1970 reporting on classified research funded by the covert community.
Tod H. Mikuriya, M.D.
Medical Coordinator, California Cannabis Buyers’ Clubs
Former Director of Marijuana Research, National Institute of Mental Health
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