Medical marijuana's last taboo
■ It's increasingly accepted as a remedy for adults with serious health issues. Now the question is: Should doctors recommend the substance to children?
Seattle physician Leslie R. Walker, MD, has patients as young as 10 who request medical marijuana. They often want the drug to ease alleged chronic pain, curb insomnia or enhance their ability to focus.
Dr. Walker has never given in to patients' demands for medical marijuana. But she's among the doctors worried by the growing number of young people who are seeking the substance for so-called health reasons.
“What's concerning is children are coming into the doctor now and saying, 'My back hurts. Can you write me a recommendation for a medical marijuana card?' ” said Dr. Walker, chief of Adolescent Medicine at Seattle Children's Hospital.
She doesn't believe in recommending the drug to youths, but there are some health professionals who do recommend the substance.
In Arizona, for instance, 29 people younger than 18 are active medical marijuana cardholders, according to the state's Dept. of Health Services. Arizona is one of the few states that report online the ages of its cardholders.
Although that constitutes a small percentage of the more than 36,000 Arizona residents using cannabis for health reasons, some medical experts say this is just the beginning.
They worry that as more states approve medical marijuana laws and the concept of medicinal marijuana becomes more mainstream, an increasing number of youths will attain the drug for health purposes.
Eighteen states and Washington, D.C., permit doctors to recommend marijuana for certain conditions, which can include anorexia, cancer, Crohn's disease, inflammatory bowel disease, migraines, seizures and severe pain, according to the Marijuana Policy Project. The Washington-based nonprofit is the nation's largest marijuana policy reform organization.
Only Connecticut and Delaware prohibit the use of medical marijuana by youths younger than 18, according to the Marijuana Policy Project. Delaware's policy, however, has not yet been enacted.
Eleven states have pending legislation legalizing medical marijuana, and two of those states — Illinois and New Hampshire — probably will enact the measure this year, said Paul Armentano, deputy director of NORML, a Washington-based lobbying organization working to legalize marijuana.
“The history of medicine is just filled with stories of therapies that appeared promising initially and later were found to have devastating consequences,” said Sharon Levy, MD, MPH, chair of the American Academy of Pediatrics Committee on Substance Abuse. “That's what's really frightening about this idea of medical marijuana” for young patients.
DID YOU KNOW:
18 states permit doctors to recommend medical marijuana; laws are pending in 11 other states to legalize it.
The key concern is there are limited data on how the drug impacts the developing brain. Health professionals also said youths could become addicted to cannabis; raise their risk for mental conditions, such as anxiety; and have motor vehicle crashes due to impaired driving.
Because the Drug Enforcement Agency classifies marijuana as a Schedule I drug, which means it has a high potential for abuse and no known medical benefits, the substance is not regulated by the Food and Drug Administration. As a result, doctors don't have information on the contents of medical marijuana, and there are no dosing instructions.
The American Academy of Pediatrics doesn't “recommend medical marijuana under any circumstances for children,” said Dr. Levy, director of the Adolescent Substance Abuse Program at Boston Children's Hospital. The AAP's Committee on Substance Abuse is developing a new policy statement for marijuana that will express its position more clearly, she said.
Complicating matters is the potential liability risk for doctors who recommend medical marijuana to a young patient who later develops a mental health problem or gets in a car crash, said Stuart Gitlow, MD, MPH. He is president of the American Society of Addiction Medicine and a member of the American Medical Association Council on Science and Public Health.
“Certainly there are arguments that the person would have gotten into a car crash” or developed a mental condition even if cannabis was not recommended, Dr. Gitlow said. “But given the known risks associated with the drug … the physician would have very little to stand on in trying” to defend himself.
Marijuana as medicine
There is growing support for medical marijuana in the public at large. Proponents, such as Armentano of NORML, highlight the drug's therapeutic use in adults, including reducing chronic pain and decreasing spasms in people with multiple sclerosis.
NORML's website references a study of 38 adults showing that both high and low doses of inhaled cannabis reduced neuropathic pain of diverse causes among people who were unresponsive to standard pain therapies. The findings were published June 9, 2008, in The Journal of Pain.
Because of marijuana's lack of toxicity and no reported cases of lethal overdose, “cannabis as a therapeutic agent appears to be … in some cases a safer substance than many conventional pharmaceuticals,” Armentano said.
Although there are little data on how the drug affects people younger than 18, NORML supports doctors' cautious recommendation of medical marijuana for children and teens who have a health condition that warrants use of the substance, he said.
“The reality right now is that doctors have the discretion to recommend a litany of approved pharmaceuticals to young people, [many of which] were never tested in research and development in young people,” he added.
Seattle adolescent medicine specialist Yolanda N. Evans, MD, MPH, agrees that the lack of data on many pediatric prescription drugs is troubling. That's why she tries to identify nonmedical forms of treatment, such as exercise or massage for patients with chronic pain, rather than prescribing medication right away.
“I don't think cannabis is the answer for pediatric patients,” said Dr. Evans, assistant professor of pediatrics at the University of Washington School of Medicine.
Medical marijuana use “is different for adults, because they don't have the same risks that go along with the developing brain,” she said.
Researchers have found that the human brain continues to develop into the mid- to late 20s, which means exposure to neurotoxins during that period can permanently alter the brain's structure and function.
A study of more than 1,000 people born in 1972 and 1973 found that persistent cannabis use, starting in adolescence and persisting for more than 20 years, was associated with neuropsychological decline. Cessation of cannabis didn't fully restore neuropsychological functioning, said the study in the April 23, 2012, issue of Proceedings of the National Academy of Sciences.
Those findings were contested by a recent study published online Jan. 14 in the same journal. That study used simulation models to show that socioeconomic status might account for the downward IQ trend seen in the April 2012 PNAS study.
“The message inherent in these and in multiple supporting studies is … regular marijuana use in adolescence is known to be part of a cluster of behaviors that can produce enduring detrimental effects and alter the trajectory of a young person's life — thwarting his or her potential,” said Nora D. Volkow, MD, director of the National Institute on Drug Abuse, in a statement.
Responding to patient requests
When patients request a recommendation for medical marijuana, Dr. Walker asks why they want it and inquires if they already use the drug. She said every patient who has asked for a recommendation either already was using the substance or didn't have a condition that she thought warranted it.
In declining requests, she explains the dangers of marijuana use, which can include an increased risk of developing anxiety, depression and a brief psychotic reaction, according to NIDA.
Dr. Walker tells the individual, “I do not think that what you're concerned with will be helped by marijuana.” She then tries to help the patient develop a treatment plan to address their health issue.
Patients, and sometimes their parents, get upset when she doesn't fulfill the request for medical marijuana. But “I never had anyone scream and say, 'I'll never come back again,' ” Dr. Walker said.
Where the situation gets particularly difficult for physicians is when they're faced with extreme cases, such as children with cancer who are experiencing severe pain from the disease or from chemotherapy, said Dr. Gitlow, of the American Society of Addiction Medicine. Parents sometimes ask the doctor for a medical marijuana recommendation to try to ease the child's suffering.
“My heart goes out to those parents,” he said. “But I don't believe” medical marijuana is the answer.
In those situations, Dr. Levy, of Boston, encourages physicians to tell parents that even though marijuana could help their child's nausea, it could be toxic to their brain and negatively affect them for life.
She said more research is needed into developing cannabinoids as pharmaceutical products. Cannabinoids are the components of marijuana that have shown medical benefits.
In 2009, the AMA adopted policy calling on the government to review the status of marijuana as a federal Schedule I controlled substance in an effort to facilitate clinical research on the use of medical marijuana. A Schedule II classification would allow the drug to be used for medical purposes, but it still would be tightly restricted. The AMA policy stresses that this should not be viewed as an endorsement of state-based medical cannabis programs, of the legalization of marijuana, or that scientific evidence on the therapeutic use of cannabis meets the current standards for prescription drug products.
“There are definitely [negative] effects of marijuana” on children and adolescents, Dr. Levy said. “The fact that they've been hard to describe doesn't mean that they're not there.”