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Minnesota’s medical cannabis law: Variations on a national theme

Mayo Clinic psychiatrist J. Michael Bostwick revisits his research on medical cannabis, and takes a hard look at the many inconsistencies across the landscape.

Marijuana-based products are displayed at the Oregon's Finest medical marijuana dispensary in Portland, Oregon.
REUTERS/Steve Dipaola

Mayo Clinic psychiatrist J. Michael Bostwick has spent considerable time trying to make sense out of the “peculiar and misguided tumult” over marijuana in American culture. He’s not sure that he’s entirely succeeded.

His 2012 abstract published in Mayo Clinic Proceedings [PDF] took a close look at the “blurred boundaries” between medical and recreational use, and explored such topics as the relationship between psychosis and marijuana, the dangers of early use, what promise there might be in pharmaceutical applications, federal barriers to research, and why some states finally went rogue.

He had (and still has) both professional and personal reasons. The dedication to his then-17-year-old son reads: “For Gabe, whose ongoing recovery from chemical dependence inspired me to write this article.” He was trying to better understand the struggles not only of his son but also his patients, he said.

“Mostly I just realized there are more things to try to understand better,” he said in an interview this week just days after Minnesota passed its medical cannabis law. “I tried to show where the inconsistencies were. I don’t think they’ve been resolved. In fact, things are even more inconsistent than they were.”

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The landscape of more and more states deciding their own course is a bit surreal, he said — “almost like a Fellini film, isn’t it?”

MinnPost caught up with Dr. Bostwick as Gov. Mark Dayton prepared to sign Minnesota’s medical cannabis law, which was many years in the making and which brought forth law enforcement officials, health professionals, adults suffering from a multitude of severe conditions and mothers of children with seizure disorders. The latter are credited with clutching at the hearts of all of the above.

These views are Bostwick’s own, and do not necessarily represent those of Mayo Clinic.

MinnPost: It seems so unusual that people have gotten out ahead of federal regulatory authorities on a substance that they believe is providing relief from serious conditions, such as seizure disorders in children. Do you know of any comparable situation in recent medical history?

J. Michael Bostwick: No. I’m not aware of any situation where multiple states have taken the law into their own hands as it relates to drugs. It’s a popular revolution, it would appear. It does seem to be a challenge to the federal system. I’ve written and I do believe that there was no scientific evidence to support making the drug Schedule I [defined as having a high potential for abuse and no medicinal value]. And there’s really inadequate scientific evidence to justify all the uses for which it’s being proposed … the sort of evidence that’s used for making legal every other drug that we use or are prescribed.

MP: What exactly went into the 1970 conclusion that marijuana had no medicinal value?

Psychiatrist J. Michael Bostwick
Mayo Clinic
J. Michael Bostwick

JMB: There was a suggestion that it was partly driven or largely driven by concerns about “unsavory elements” entering the country who used the drug. That’s a little hard to get at, but it does appear that there were concerns that because it was popular among the Mexican immigrant population and popular among the African-American population, it was an effort to respond to that.

MP: Over the 5 millennia of its use across all of history, what are some of the more intriguing applications in your opinion?

JMB: I think it’s interesting. It’s a psychoactive drug. It’s been used in religious ceremonies like other psychoactive drugs. It’s been used for pleasure. It’s been used for a whole host of medical indications — for gastrointestinal upset, “female problems,” pain problems. It appeared in poultices, pills and extracts of various sorts. And if you look at the indications that had it on the U.S. formulary for a century until the mid-20th century, most are the same indications that are being claimed now.

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Of course medicine … 100 years or so ago was empirical and experimental, so you would try something and see if it worked: a lot of anecdotes, not too much standardization. And that seems to be kind of where we are now. There’s an article in 1937 I believe, from a British Isles doctor in India who claimed that it helped particularly with GI problems and pain problems. But a lot of the historical references don’t go into detail in a way that would fit with a modern conception of medicine.

The first reference comes from ancient China. And certainly the Chinese system is very different from the Western homeopathic system in terms of how disease is conceptualized and how it’s treated. But the point is that the substance was valued for its treatment possibilities even then.

MP: Some opponents to legalization of medical marijuana invoke the images of snake-oil salesmen and charlatans. Are those fair comparisons?

JMB: I think there’s a lot of hyperbole and a lot of rhetoric. The reality, though, is that we do have a system in the U.S. that is by and large followed by providers who are licensed to prescribe — and this is not what’s happening. The states have never been the final authority on how medication will be prescribed; we carry federal licenses. The studies that justify nearly every medication that we have are done through a federal agency. Another way to look at this would be really a challenge to the federal authority to study our drugs and regulate them.

MP: What medicinal potential do you think botanical cannabis might have?

JMB: I continue to be fascinated by the fact that since the 1970s’ demonization of the drug, nearly everything we know about the endocannabinoid system and the effect of this drug on the body has been discovered. So it’s quite striking to me that we have a law that demonizes the medication prior to there having been any knowledge of how it works. Since then, we have [learned] that there are two different kinds of receptors — one that’s psychoactive, one that’s not. We have the situation with the [cannabidiol] oil in Colorado, which specifically does not work on the psychoactive receptor, so the substance would not have psychoactive effects.

It seems to me that the science has not been married to the practice. Which is what we do. I think there are very hybrid ideas where states will study this. But again, that does not fit the standards by which we [regulate] our drugs.

MP: What about those who got “left out” of the Minnesota medical cannabis law — those who suffer from intractable pain, nausea, wasting, and PTSD?

JMB: I think the Minnesota bill is yet another variation on the variety of medical and political expediencies trying to work out some kind of compromise. I don’t think the bill ultimately fits the test of scientific logicality. It does fit an attempt to balance the concerns of police, the concerns of the governor, the concerns of various senators and representatives, and the concerns of the constituents.

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But the effect is a compromise that is not an internally logical bill.

MP: There was a lot of concern about the means of ingestion — no smoking, for example. What do you make of that?

Cannabis indica fluid extract, American Druggists Syndicate, pre-1937
Wikimedia Commons
Cannabis indica fluid extract, American
Druggists Syndicate, pre-1937

JMB: I think it’s an attempt to head off the complaints that come from recreational use, which is almost exclusively by smoking. But it’s just part of the compromise. I know I read that someone important said they thought it was “the most restrictive marijuana law in the country.” I don’t think that’s a great thing. It’s just one more variation on a theme, so that, depending on the state you’re in, the rules are completely different on what you can use it for, how much you can have, what form you can take it in. It’s all a little crazy-making.

MP: Do you share the concern about young people’s exposure to the drug?

JMB: I do share that concern, but I think the horse is way, way out of the barn. That horse has been running around for 50 years in this country. And it’s especially ironic because many of the parents of these kids and even the grandparents used heavily when they were adolescents. So it’s a bit pious and I think a bit misplaced to be talking about this drug as if it’s the first time in history that youth have misused it. It’s so ironic that even as we were declaring it a Schedule I drug, it was becoming more and more popular, in an unbridled way, through the ’70s and ’80s.

MP: Are we overlooking anything in this debate?

JMB: I think we’re overlooking reform of the process by which this substance could be studied. I’ve not yet heard anybody proposing a way to get the drug rescheduled. I’ve heard plenty of suggestions that it should be rescheduled, but I haven’t heard any actual process where that will occur. I may have missed something, but I don’t see anybody pushing to get the drug on Schedule II in a way that will actually result in that happening.

MP: How are we going to get out of this mess?

JMB: I think the way we’re going to get out of the mess is for the federal government at some point to take some leadership in terms of reclassifying and studying the drug. It’s so difficult to study … that people give up. But it makes no sense that we have all these claims and all this anecdotal evidence, and we’re not studying the drug assiduously. Instead we’re fussing and bothering. Eric Holder is telling Colorado that he won’t intervene if they give it to children or take it out of state or give it to tourists. It’s just silly. The compromises are ultimately illogical.

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In the Minnesota situation, just watching the discussion, and all the different constituencies — the boundaries were blurred. … At any given point, it wasn’t clear which constituency was coming to the fore.

We have experience with opiate and amphetamine derivatives, and no one’s saying make them illegal. They’re saying control them better, they’re saying manage them better, they’re saying put them into forms that are safer. And it’s not as if we don’t have many other substances that are working on the same reward system in the brain that are not both recreationally misused and very important treatment armamentaria.