Journal of the California Cannabis Research Medical
of Pharmaceuticals is a Recurring Theme From Patients
By Jeffrey Hergenrather, MD
Despite the many advances in medical science in elucidating the causes and
treatments for many diseases there remain many conditions that fall into
the category of “etiology unknown.” For these, physicians continue to offer
the best treatments that are available to alleviate the pain and suffering
where there is little hope for cure.
In many cases the conventional treatments are as problematic as the diseases
themselves. Patients who have chosen cannabis as an alternative treatment for
these conditions often confide to cannabis specialists that they have been
able to quit or reduce their use of pharmaceutical drugs. It is a recurring
theme, and a significant one.
Brief reports on two such cases follow.
Systemic lupus erythematosus
Patient MG is a 34-year-old woman who has had systemic lupus for over 10 years.
Her lab findings include positive ANA, positive RNP antibody, positive platelet
antibodies, and hypocomp-lementemia. Her abnormalities include low grade fevers,
fatigue, arthritis, arthralgias, cutaneous manifestations, persistent leukopenia
Evaluation and treatment by two rheumatologists resulted in the repeated advice
to use immunosuppressive drugs including Plaquenil and prednisone to modify
her immune system disease. She did this for many years with multiple adverse
effects. Subsequently, she discovered the medicinal use of cannabis, initially
for pain control and depression, then later as an immune system modulating
medication. Over the past two years she has discontinued all pharmaceuticals
while relying on cannabis only. She has not had an exacerbation and reports
that she hasn’t felt as well for many years.
Patient PE is a 22-year-old man who has had Crohn’s disease for more than six
years. His lab findings include leukocytosis and biopsy confirmed Crohn’s colitis.
His abnormalities included weight loss, anorexia, nausea, abdominal cramping
pains and diarrhea along with recurring bouts of rectal bleeding and signs
Evaluation and treatment by his gastroenterologist resulted in the repeated
advice to have his colon surgically removed and the use of immunosuppressive
drugs including azathioprine and prednisone to modify his immune system disease
along with several others medications.
Over the past three years he began regular use of cannabis with an immediate
marked improvement in his symptoms of anorexia, nausea, cramping and diarrhea.
He has been able to reduce his dependence on prednisone to 1/4 of his former
effective dosage. He reports that he feels much better now than he did before
beginning the regular use of cannabis.
And he did not have to have his colon removed at age 22.
Though these two cases are quite different, they both share the distinction
of being diseases of unknown etiology, deleterious inflammatory reactions,
and frequently treated with steroids and immunosuppressive drug therapy.
Very little is known about the role that cannabis and endocannabinoids play
in the immune system except to note that the human immune system, especially
the spleen and white blood cells, are loaded with cannabinoid receptors. An
immunomodulating effect can not only be postulated, it is confirmed with the
evidence that white cell recruitment is blocked by cannabis in rheumatoid
arthitis joints. In the cases noted above, it is very encouraging to find
the patients experiencing such beneficial clinical improvement without
Letter from a Soldier
Is Cannabis Recommended for
Hello Dr. Mikuriya.
I have recently returned home from Iraq. This was my second tour. I only had
about 4 months between the two tours. When I returned home, I noticed I didn’t
feel the same. My wife was the first one to talk to me about it. She said
I am acting a little different. I didn’t think much of it. Until I went back
to Atlantic City. We went out and I got shaky around a big group of people
and needed to leave the casino. I also am at a high state of alertness and
I startle at certain noises. My tolerance is also very low, I get angry very
easily. Not violent, I still have control but very agitated.
I also have trouble sleeping and sometimes I have to take a sleeping pill or
Nyquil to go to sleep. I went to my doctors and they sent me to a place on
base that helps with PTSD. Right now they have me in a group with others, talking
about our experiences. And they are going to prescribe something for my anxiety
and sleep disorder. I don’t feel comfortable taking these drugs because of
the side effects and maybe addictiveness of them.
I am not sure if you would recommended medical marijuana for this or not. Plus
I am still in the service so I am not sure even if I did get a prescription
if I would be allowed to use it. I do get out in 6 months and I am afraid what’s
going to happen once I get out, as far as medical goes.
Thank you for your time. Please respond at your earliest convenience.
Dr. Mikuriya responds:
Thank you for your service to the country.
Thank goodness I have never been exposed to your kinds of reality. Before medical
school I was a psychiatric corpsman in the Army at the Brooke Army Medical
Center psychiatric locked ward where enlisted men, officers, and dependents
were evaluated and administratively referred.
Cannabis would indeed be useful in managing symptoms of PTSD. This has been
known for over a century in the medical profession but forgotten because of
its legal status since 1937. The Israeli army, however, recently disclosed
that it is evaluating cannabis in the treatment of PTSD.
There are, unfortunately, a couple of problems. A positive drug test for the
presence of THC metabolite would be the end of your military career. The second
problem is that if you were prescribed Marinol, a schedule III drug, the Army
would declare the test positive and it would not be reviewed by any medical
review officer. Were it reviewed, the prescription for Marinol would explain
the presence of the metabolite and the test reported as negative.
The VA system is also precluded from utilizing cannabis or cannabinoids by
both cost and prohibitory rules.
The problem with sedatives, both prescribed and over-the-counter, is the side
effects when used chronically. Hangovers, dullness, sedation, constipation,
weight gain, and depression are common consequences.
Problems managing the symptoms of hyperalertness, insomnia, and nightmares
are not just ineffectually controlled but the ugly side effects of drugs become
Avoid alcohol! Both primary effects and interaction with other medications
practically guarantee more problems. Nothing worse for aggravating irritability,
insomnia, nightmares, and running up a sleep deficit that increases symptoms.
Unfortunately, you can’t alt-ctrl-delete
the horrific experiences.
Unfortunately, you can’t alt-ctrl-delete the horrific experiences.
You must focus your efforts on decreasing your vulnerability to these
indelible memories. Fatigue and pain are conditions to be minimized.
A regular exercise regimen to release tension and retain a sense of
control and intactness will help cope.
I don’t know what sources exist in your world for treatment of PTSD. There
is some institutional awareness of PTSD and efforts are exerted to make services
available. Skillful debriefing of a small group may be useful but I strongly
recommend against medication and alcohol for this chronic condition. You are
stuck with these memories forever but how you respond is the issue.
Medically, cannabis is the treatment of choice for PTSD but definitely would
spell the end of your military career. If you elect not to medicate with cannabis,
the regular exercise regimen, avoidance of drugs and alcohol, and a specialized
debriefing is the least worst response to this chronic psychiatric disorder.
Tod Mikuriya, MD
Letter to a Chief Probation Officer
By Philip A. Denney, MD
I have recently had a number of requests for information about my patients
who use medicinal cannabis while under court supervision. My discussions
with your deputy probation officers reveal a great deal of confusion and
misunderstanding about this issue.
As you know, a majority of California voters approved the Compassionate Use
Act in November 1996 which became codified as Health and Safety code 11362.5.
The Act allows the use of cannabis as medicine “upon the written or oral recommendation
or approval of a physician.”
The use of medicinal cannabis has been addressed by the California Supreme
Court in People v. Mower (2002), and its use while under court supervision
has been addressed by the California Appellate Courts in People v. Tilehkooh
(2003) and People v. Spark (2004).
The Mower Court stated “as a result of the enactment of section 11362.5(d),
the possession and cultivation of marijuana is no more criminal —so long as
its conditions are satisfied— than the possession and acquisition of any prescription
In Tilehkooh, the Court held that a trial court erred in refusing to allow
a defendant to present a compassionate-use defense at a probation revocation
hearing where one of the trial court’s reasons for finding the defense inapplicable
was that the defendant was not ‘seriously’ ill.’”
Lastly, the Spark court found “the question of whether the medical use of marijuana
is appropriate for a patient’s illness is a determination to be made by a physician.
A physician’s determination on this medical issue is not to be second-guessed
by jurors who might not deem the patient’s condition to be sufficiently ‘serious.’”
I have been informed by your staff that the current county medical marijuana
policy requires that the physician who recommends or approves the use of medicinal
cannabis be the patient’s primary care physician or see the patient by referral
of same. There is no legal basis for this requirement.
In addition, the recommending or approving physician must reveal the nature
of the patient’s medical illness. Again there is no legal basis for divulging
this sensitive and private information, particularly in light of the above
rulings, which make a patient’s specific diagnosis irrelevant.
The dose of cannabis is not addressed in the statute. It is strongly implied
that the determination of dosage is left to the discretion of the physician.
In practice the dose of cannabis varies widely and depends on many factors
including current level of symptoms and quality, availability and price of
cannabis. My experience is that the vast majority of patients use one ounce
or less of medical cannabis per week. This figure could be considerably less
if affordable, high-quality medicine is available or somewhat more if only
low-quality medicine is available.
The frequency of cannabis use varies widely as well. Most patients use cannabis
two to four times daily.
I recommend that my patients use the highest quality medicine available in
the lowest amount needed to relieve symptoms. I further recommend that my patients
cultivate cannabis for their own medicinal use and avoid the “black market” entirely.
In summary, when asked to reveal protected health information to the county
probation department, I will provide, upon the patient’s written authorization,
a copy of my physician’s statement recommending/approving medicinal cannabis
use. This statement includes the patient’s name, date of birth, current address,
and my physician’s and surgeon’s certificate (license) number; it expires one
year from the date of issue. I believe the physician’s statement includes sufficient
information to determine a patient’s status as a lawful medicinal cannabis
user. I do not believe that it is appropriate to reveal the nature of a patient’s
medical condition or diagnosis. Finally, I believe the appropriate dose of
cannabis for most patients to be up to one ounce of cannabis per week and advise
my patients to cultivate for their own use.
I trust that this information is helpful and is taken in the spirit of cooperation
with which it is intended. I would be pleased to discuss these issues with
you further if necessary.
Philip A. Denney, MD