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Looking at medical marijuana from opposite sides of the fence

She’s a major player and advocate of the state’s proposed medical marijuana legislation; he’s the country’s most outspoken opponent on the issue. 

Kevin Sabet during his Feb. 13 presentation at the Mall of America in Bloomington.
MinnPost photo by Sarah T. Williams

Heather Azzi first got interested in medical marijuana as a middle-school student in the mid-1990s when she was asked to write an English paper on alternative medicine. The teacher had in mind acupuncture and biofeedback, she said, but herbal remedies were included in the literature. She read enough, she said, to learn that “marijuana never killed anybody.”

At approximately the same time, Kevin Sabet was beginning his own personal war on drugs at the University of California, where he said he founded the improbable campus group Citizens for a Drug-Free Berkeley.

She’s now political director of a group called Minnesotans for Compassionate Care, based in St. Louis Park, and a major player in crafting — and advocating for — H.F. 1818/S.F 1641, a bill to permit the medical use of marijuana in Minnesota.

And he’s now the country’s most indefatigable and vociferous legalization opponent, director of the Drug Policy Institute at the University of Florida, co-founder (with Patrick Kennedy) of Project SAM (Smart Approaches to Marijuana) and author of “Reefer Sanity: Seven Great Myths About Marjuana” (2013).

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They are poles apart on the issues, of course. Here are some capsule summaries of (just a few) their sentiments. Sabet’s remarks are excerpted from a Feb. 13 presentation he gave at the Mall of America to group of about 300 law enforcement officials, treatment providers and health professionals. Azzi’s remarks are excerpted from an interview she granted this week as she prepared for the start of the 2014 state legislative session and another debate over medical marijuana. (They did not argue face-to-face; the construct is my own.)

On marijuana as an alternative for people with debilitating and painful conditions.

Azzi: The bill that’s been proposed in Minnesota will provide protection for patients suffering from glaucoma, cancer and [nausea from] chemotherapy, multiple sclerosis, epilepsy, and other debilitating illnesses that cause chronic pain, especially neuropathic pain, which is very resistant to treatment with other available pain medication. … Our patients in Minnesota are actually afraid. They are afraid of losing their property to drug forfeiture laws, which happens commonly, unfortunately. They’re petrified of losing their children, especially those who are administering CBD [cannabidiol, a nonpsychoactive compound found in marijuana used as an anticonvulsant] to their kids. Many are law-and-order types. They have cancer. And their doctor pulls them aside in the hallway and says, “This is something that might help you get along.” [They think to themselves] “I’m a Minnesotan, I’m an American, and I’m not going to break the law.” It’s not right for us to be putting these people into this position.

Sabet: How is it compassionate to tell Granny: You know what? You can’t go to the pharmacy, because it’s not there. You can’t talk to your doctor about it, because they don’t know a thing about it. But what I want you to do is go to that strip mall where the pizza shop used to be. You’re going to see a 300-pound bouncer who’s guarding the bulk cash and marijuana product. Don’t worry about him. Go past him, and you’re going to see a doctor or somebody in a white coat, who, for $50 cash, will look at you for two minutes and write down on a Post-it note that you should get marijuana. Then … you’re going to see the 27-year-old kid with no medical experience who’s going to sell you something called Super Silver Haze. Good luck. How is that compassionate?

On marijuana as medicine, and the issue of smoking.

Azzi: The reason we don’t have more marijuana-based medicines is because the federal government has blocked most researchers from doing the specific types of studies that would be required for licensing, labeling and marketing of marijuana as a drug. It’s basically created a perfect Catch-22: Federal officials will say that marijuana isn’t a medicine because the FDA hasn’t approved it, while making sure that the studies needed for FDA approval never happen.

It gets pretty complicated because the National Institute on Drug Abuse [NIDA] actually has control of the only legal supply of marijuana in the country for testing. Both the American Medical Association and American College of Physicians have recommended that the federal government actually consider rescheduling marijuana to facilitate research. The ACP explained that a research expansion had been hindered by a complicated approval process and limited availability of research-grade marijuana. In 2007, one of the Drug Enforcement Administration’s administrative law judges actually ruled that we should allow the private production of marijuana for research because the current supply … was inadequate. The DEA rejected the judge’s ruling. They just can ignore their own judges. … Not only have they hindered private research, but of course the federal government has shown a complete lack of interest in funding trials into marijuana’s efficacy, including into the kind of large-scale clinical trials that they typically do.

Sabet: Do we just want people to grow medicines in their back yard and sell them as such? Or have we moved on, I hope, from the late 1800s? We have medicines, I know it sounds crazy, that have labels. We actually know what’s in it. Other people have tested it. And we know what it does to you if you’re taking any other drugs. And, finally, we have a dosage. Call me crazy that we want to have a dosage level for something. You cannot dose raw marijuana. It’s a raw herbal material that varies from batch to batch — I grow it here under this light, it’s going to be different than if I grow it out there under that light. … We don’t want that in our medicines. We want standardization, so that the aspirin I get when I have a headache in Minnesota is the same aspirin I get when I have a headache in Massachusetts. I think that’s a good thing. I don’t think that’s Big Pharma. If it is, sign me up.

For the last 30 years, we’ve had a pill that has [synthetic] THC in it. A lot of people don’t like to take it … but it’s available. It was developed during the height of the AIDS epidemic. People were dying of things like AIDS wasting syndrome, Kaposi’s sarcoma – these horrible things that were related to advanced AIDS. Well, by the way, now we have antiretroviral drugs that are allowing people to live with HIV, and we have no such thing as AIDS wasting syndrome anymore. It’s an amazing public health success … But when we didn’t have that [antiretroviral drugs], we developed Marinol.

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The good news is that we’re also developing other things. Sativex, [a mouth spray] which is not a synthetic — it’s the whole extract that is put in a liquid form — whose active ingredients are THC and CBD. And because it has CBD on a 1 to 1 ratio with THC, it doesn’t get you high. That is helpful for a lot of different reasons. That doesn’t mean that if it got you high it’s not a medication. A lot of medications that help people are intoxicating. But putting CBD together with THC can be very helpful. It’s in late-stage clinical trials here.

Azzi: The science is much more complicated than it seems. First of all, smoking or vaporizing marijuana is a much more effective delivery method than pills for many patients, because the drug works instantly, its dosage is easily controlled because it’s got quick effect, and there’s no problem keeping it down since it can’t be vomited back up. ….

Sativex is not quite there yet. Worst of all is that it will likely be several years before it will be approved for use in the United States. We have seriously ill patients in Minnesota right now, and they should not have to wait for a potentially less effective drug when marijuana could be helping them now. …

Vaporizers, which have been around for several years now, basically heat the marijuana to the point where the chemical compounds are released, and the person is able to inhale those in a vapor form with no smoking involved. From my experience, that is what most patients prefer. However, with a piece of paper and a lighter, especially for patients who don’t have a whole lot of money, it’s very simple … and very cheap to administer, and readily available. Portable vaporizers are becoming more popular as time goes on, but there’s been some delay in research from the federal government in those as well, so I don’t think there is enough research yet on the safety of those systems to preclude smoking.

Fortunately, smoking of marijuana does not have many of the problems that smoking of tobacco has. Research has never shown that marijuana increases rates of lung cancer or other cancers usually associated with cigarette smoking. There was a 10-year, 65,000-patient study conducted by Kaiser Permanente in 1997, [which found that] cigarette smokers had much higher rates of cancer of the lung, mouth and throat than nonsmokers. But marijuana smokers who didn’t smoke tobacco had no such increase.

Sabet: It goes without saying that smoking anything isn’t a good idea — bronchitis, cough, phlegm production. I will say that the evidence on lung cancer is mixed. Of course, we didn’t have strong evidence for tobacco and lung cancer up until the early 1900s. We may find something later, we may not. … But certainly the evidence is there for the carcinogens that cause cancer.

On marijuana and mental health.

Azzi: There’s actually no compelling scientific evidence that demonstrates marijuana causes psychosis in an otherwise healthy individual. Overall, the evidence suggests that marijuana can precipitate schizophrenia in vulnerable individuals, but it is unlikely to cause illness in an otherwise normal person. Epidemiological data show that there’s no correlation between rates of marijuana use and rates of psychosis or schizophrenia. For example, countries that have higher rates of marijuana use don’t have higher rates of these illnesses. Research has consistently failed to find a connection between increases in marijuana use and increases in rates of psychosis. As with all medications, the physician needs to consider what is an appropriate medication in light of the individual patient’s situation. And they will suggest avoiding marijuana in a patient with family or personal history of psychosis.

Sabet: The reason why a lot of people lately have been talking about marijuana, and the reason why the National Alliance for Mental Illness is very concerned about this, and the National Institute of Mental Health is very concerned about this, is because of the link of today’s high-potency marijuana and mental illness — things like schizophrenia, psychosis, and, to a lesser extent, depression and anxiety.

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A lot people say, well, maybe people are using this to self-medicate because in the short term at least it makes them feel better. And that might be true. But the issue to me is not so much is it marijuana and then mental illness, or mental illness and then marijuana? It doesn’t really matter because it’s probably both. The issue for me is that marijuana is the common denominator there that exacerbates and makes those problems worse, whether those problems were there before or those problems came after.

I’m concerned with what policy makes marijuana more acceptable and used more. And therefore, whether somebody has a predisposition for this or not doesn’t really matter to me. What matters is that it’s making it worse.

On marijuana and teens.

Azzi: Fortunately, we actually have state-by-state data in 15 of the 20 of the medical marijuana states, so we can follow [more than] just the national trend. Generally, marijuana use has been increasing in recent years, nowhere near where it was in the 1970s, but it has been trending up. But we can’t say that’s related to medical marijuana laws in any way. In 15 of the states with before-and-after data, not one has reported a statistically significant increase in teen marijuana use. In fact 11 of those states have reported decreases. … Researchers believe the reason for that is that it’s a medicine. We teach our children that medical use is different from recreational use.

Sabet: One in 10 or 11 who start using marijuana after age 25 will eventually become addicted. For adolescents, we’re talking about 1 in 6 16-year-olds who try marijuana will at some point in their lives become addicted. … Why is it 1 in 6 when you’re an adolescent and 1 in 10 or 11 when you’re an adult? The brain is under construction from age 0 to 28. That means that anything that brain comes in contact with has the power to stick with a person for a very long time. That could be a good thing or a bad thing, like addiction.

On diversion.

Sabet: All the statistics of every single state done on medical marijuana programs show that the average user of medical marijuana is a 32-year-old white male with a history of drug and alcohol abuse; no history of cancer, HIV, ALS, Crohn’s, glaucoma, multiple sclerosis, allodynia — any of the excruciating horrible things, where I think 100 percent of people, including uniformed law enforcement, would say, whatever you need in your last six months of life, you get it.

Azzi: We’re always accused of this being some loophole-ridden proposal. The truth is, the proposed law in Minnesota was drafted very carefully to make sure there are no loopholes, real or imagined. … The Minnesota [proposed] program is modeled after the one in New Mexico, for example, where there are no claims of abuse. … Our goal is to put together the most tightly crafted, responsible and effective bill possible, with the end result of protecting suffering patients from the threat of arrest or jail for treating their illness.