Medical Cannabis, support for the forbidden medicine.

From the book Marihuana, the Forbidden Medicine By Lester Grinspoon and James B. Bakalar. Copyright © 1993 Yale University.

Cannabis has become one of the most widespread and diversified of plants. It grows as weed and cultivated plant all over the world in a variety of climates and soils. The fiber has been used for cloth and paper for centuries and was the most important source of rope until the development of synthetic fibers. The seeds (or, strictly speaking, akenes - small hard fruits) have been used as bird feed and sometimes as human food. The oil contained in the seeds was once used for lighting and soap and is now sometimes employed in the manufacture of varnish, linoleum, and artists' paints. The chemical compounds responsible for the intoxicating and medicinal effects are found mainly in a sticky golden resin exuded from the flowers on the female plants. The function of the resin is thought to be protection from heat and preservation of moisture during reproduction. The plants highest in resin therefore grow in hot regions like Mexico, the Middle East, and India. When the reproductive process is over and the fruits are fully ripe, no more resin is secreted.

The cannabis preparations used in India often serve as a folk standard of potency. The three varieties are known as bhang, ganja, and charas. The least potent and cheapest preparation, bhang, is produced from the dried and crushed leaves, seeds, and stems. Ganja, prepared from the flowering tops of cultivated female plants, is two or three times as strong as bhang; the difference is somewhat akin to the difference between beer and fine Scotch. Charas is the pure resin, also known as hashish in the Middle East. Any of these preparations can be smoked, eaten, or mixed in drinks. The marihuana used in the United States is equivalent to bhang or, increasingly in recent years, to ganja.

The marihuana plant contains more than 460 known compounds, of which more than 60 have the 21-carbon structure typical of cannabinoids. The only cannabinoid that is both highly psychoactive and present in large amounts, usually 1-5 percent by weight, is (-)3,4-trans-delta-l- tetrahydrocannabinol, also known as delta-1-THC, delta-9-THC, or simply THC. A few other tetrahydrocannabinols are about as potent as delta-9-THC but present in only a few varieties of cannabis and in much smaller quantities. A number of synthetic congeners (chemical relatives) of THC have been developed under such names as synhexyl, nabilone, and levonatradol. The other two major types of cannabinoid are the cannabidiols and the cannabinols. It appears that the plant first produces the mildly active cannabidiols, which are converted to tetrahydrocannabinols and then broken down to relatively inactive cannabinols as the plant matures.

The recent discovery of nerve receptors in the brain stimulated by THC (and the cloning of the gene that gives rise to these receptors) suggests that the body produces its own version of the substance. The receptors are found mainly in the cerebral cortex, which governs higher thinking and in the hippocampus, which is a locus of memory. A native of central Asia, cannabis may have been cultivated as long as ten thousand years ago. It was certainly cultivated in China by 4000 B.C. and in Turkestan by 3000 B.C. It has long been used as a medicine in India, China, the Middle East, Southeast Asia, South Africa, and South America. The first evidence for medicinal use of cannabis is an herbal published during the reign of the Chinese emperor Chen Nung five thousand years ago.

Cannabis was recommended for malaria, constipation, rheumatic pains, absentmindedness, and female disorders. Another Chinese herbal recommended a mixture of hemp, resin, and wine as an analgesic during surgery. In India cannabis has been recommended to quicken the mind, lower fevers, induce sleep, cure dysentery, stimulate appetite, improve digestion, relieve headaches, and cure venereal disease. In Africa it was used for dysentery, malaria, and other fevers. Today certain tribes treat snake bites with hemp or smoke it before childbirth. Hemp was also noted as a remedy by Galen and other physicians of the classical and Hellenistic eras, and it was highly valued in medieval Europe.

The English clergyman Robert Burton, in his famous work The Anatomy of Melancholy, published in 1621, suggested the use of cannabis in the treatment of depression. The New English Dispensatory of 1764 recommended applying hemp roots to the skin for inflammation, a remedy that was already popular in eastern Europe. The Edinburgh New Dispensary of 1794 included a long description of the effects of hemp and stated that the oil was useful in the treatment of coughs, venereal disease, and urinary incontinence. A few years later Nicholas Culpeper summarized all the conditions for which cannabis was supposed to be medically useful.

But cannabis did not come into its own in the West as a medicine until the middle of the nineteenth century. During its heyday, from 1840 to 1900, more than one hundred papers were published in the Western medical literature recommending it for various illnesses and discomforts. It could almost be said that physicians of a century ago knew more about cannabis than contemporary physicians do; certainly they were more interested in exploring its therapeutic potential.

The first Western physician to take an interest in cannabis as a medicine was W B. O'Shaughnessey, a young professor at the Medical College of Calcutta who had observed its use in India. He gave cannabis to animals, satisfied himself that it was safe, and began to use it with patients suffering from rabies, rheumatism, epilepsy, and tetanus. In a report published in 1839, he wrote that he had found tincture of hemp (a solution of cannabis in alcohol, taken orally) to be an effective analgesic. He was also impressed with its muscle relaxant properties and called it an anticonvulsive remedy of the greatest value.

O'Shaughnessey returned to England in 1842 and provided cannabis to pharmacists. Doctors in Europe and the United States soon began to prescribe it for a variety of physical conditions. Cannabis was even given to Queen Victoria by her court physician. It was listed in the United States Dispensatory in 1854 (with a warning that large doses were dangerous and that it was a powerful narcotic). Commercial cannabis preparations could be bought in drug stores. During the Centennial Exposition of 1876 in Philadelphia, some pharmacists carried ten pounds or more of hashish (4).

Meanwhile, reports on cannabis accumulated in the medical literature. In 1860 Dr. R. R. M'Meens reported the findings of the Committee on Cannabis Indica to the Ohio State Medical Society. After acknowledging a debt to O'Shaughnessey, M'Meens reviewed symptoms and conditions for which Indian hemp had been found useful, including tetanus, neuralgia, dysmenorrhea (painful menstruation), convulsions, rheumatic and childbirth pain, asthma, postpartum psychosis, gonorrhea, and chronic bronchitis.

As a hypnotic (sleep-inducing drug) he compared it to opium: Its effects are less intense, and the secretions are not so much suppressed by it. Digestion is not disturbed; the appetite rather increased; ... The whole effect of hemp being less violent, and producing a more natural sleep, without interfering with the actions of the internal organs, it is certainly often preferable to opium, although it is not equal to that drug in strength and reliability. Like O'Shaughnessey, M'Meens emphasized the remarkable capacity of cannabis to stimulate appetite.

Interest persisted into the next generation. In 1887, H. A. Hare recommended the capacity of hemp to subdue restlessness and anxiety and distract a patient's mind in terminal illness. In these circumstances, he wrote, The patient, whose most painful symptom has been mental trepidation, may become more happy or even hilarious. He believed cannabis to be as effective a pain reliever as opium: During the time that this remarkable drug is relieving pain, a very curious psychical condition sometimes manifests itself; namely, that the diminution of the pain seems to be due to its fading away in the distance.

In 1890, J. R. Reynolds, a British physician, summarized thirty years of experience with Cannabis indica, recommending it for patients with senile insomnia and suggesting that in this class of cases I have found nothing comparable in utility to a moderate dose of Indian hemp. According to Reynolds, hemp remained effective for months and even years without an increase in the dose. He also found it valuable in the treatment of various forms of neuralgia, including tic douloureux (a painful facial neurological disorder), and added that it was useful in preventing migraine attacks. Very many victims of this malady have for years kept their suffering in abeyance by taking hemp at the moment of threatening or onset of the attack. He also found it useful for certain kinds of epilepsy, for depression, and sometimes for asthma and dysmenorrhea.

Doctor J. B. Mattison, urging physicians to continue using hemp, in 1891 called it a drug that has a special value in some morbid conditions and the intrinsic merit and safety of which entitles it to a place it once held in therapeutics. He reviewed its uses as an analgesic and hypnotic, with special reference to dysmenorrhea, chronic rheumatism, asthma, and gastric ulcer, and added that it has proved an efficient substitute for the poppy in morphine addicts. One of his cases was a naval surgeon, nine years a ten grains daily subcutaneous morphia taker ... [who] recovered with less than a dozen doses.

The use of cannabis in treating drug addiction had already been reported in 1889 by E. A. Birch. He treated a chloral hydrate addict and an opiate addict with pills containing Cannabis indica and found a prompt response in both cases, with improved appetite and sound sleep. But for Mattison the most important use of cannabis was in treating that opprobrium of the healing art - migraine. Reviewing his own and earlier physicians' experiences, he concluded that cannabis not only blocks the pain of migraine but prevents migraine attacks.

As he noted, the medical use of cannabis was already in decline by 1890. The potency of cannabis preparations was too variable, and individual responses to orally ingested cannabis seemed erratic and unpredictable. Another reason for the neglect of research on the analgesic properties of cannabis was the greatly increased use of opiates after the invention of the hypodermic syringe in the 1850s allowed soluble drugs to be injected for fast pain relief; hemp products are insoluble in water and so cannot easily be administered by injection.

Toward the end of the nineteenth century, the development of such synthetic drugs as aspirin, chloral hydrate, and barbiturates, which are chemically more stable than Cannabis indica and therefore more reliable, hastened the decline of cannabis as a medicine. But the new drugs had striking disadvantages. Five hundred to a thousand people die from aspirin-induced bleeding each year in the United States, and barbiturates are, of course, far more dangerous yet.

One might have expected physicians looking for better analgesics and hypnotics to have turned to cannabinoid substances, especially after 1940, when it became possible to study congeners (chemical relatives) of THC that might have more stable and specific effects. But the Marihuana Tax Act of 1937 undermined any such experimentation. This law was the culmination of a campaign organized by the Federal Bureau of Narcotics under Harry Anslinger in which the public was led to believe that marihuana was addictive and caused violent crimes, psychosis, and mental deterioration.

The law was not aimed at medical use of marihuana - its purpose was to discourage recreational marihuana smoking. It was put in the form of a revenue measure to evade the effect of Supreme Court decisions that reserved to the states the right to regulate most commercial transactions. By forcing some marihuana transactions to be registered and others to be taxed heavily, the government could make it prohibitively expensive to obtain the drug legally for any other than medical purposes. Almost incidentally, the law made medical use of cannabis difficult because of the extensive paperwork required of doctors who wished to use it.

In September 1942 the American Journal of Psychiatry published The Psychiatric Aspects of Marihuana Intoxication, by two of the study's investigators, Samuel Allentuck and Karl M. Bowman. Among other things, Allentuck and Bowman wrote that habituation to cannabis is not as strong as habituation to tobacco or alcohol. Three months later, in December, an editorial in the Journal of the American Medical Association described Allentuck and Bowman's article as a careful study and mentioned potential therapeutic uses of cannabis in the treatment of depression, appetite loss, and opiate addiction. But in the next few years that journal's editors were induced to change their minds under government pressure.

Although virtually no medical investigation of cannabis was conducted for many years, the government did not entirely lose interest. Shortly after one of us (L.G.) published a book on marihuana in 1971, a chemist who had read it told us that his employer, the Arthur D. Little Company, had been given millions of dollars in government contracts to identify military uses for cannabis. He said they had found none but had come across important therapeutic leads. He visited us to discuss the economic feasibility of developing cannabinoid congeners commercially, but he could not give us the evidence because it was classified.

• Until 1883, more than three quarters of the world's paper was made from Hemp fibre.
• In Elizabethan times, farmers were fined for not growing Hemp.
• 80% of English wood pulp is imported, destroying the forests and their delicate eco-systems in Canada and Scandinavia.
• A Hemp crop produces nearly 4 ( four) times as much raw fibre as an equivalent-sized tree plantation.
• Trees take approximately 20 years to mature. Hemp takes 4 months.
• Hemp needs no pesticides because it is unpalatable to insects.
• Hemp needs no herbicides because it grows too quickly for any weed to compete.
• Hemp cloth repels up to 95% of UV rays when woven into a tight construction.
• Hemp is more water absorbent than cotton and has 3 times the tensile strength.
• Hemp paper does not need chlorine bleach, which heavily pollutes rives near wood-pulp paper mills.
• Environmentally-sound Hemp paper is stronger, finer and longer-lasting than wood-based papers.
• Hemp paper is used for bank notes and archives.
• "You would have to smoke at least a field of this stuff to even get a smile" said Mr. Scott.
• "The earliest-known woven fabric was apparently of Hemp, which began to be worked in the eighth millennium ( 8,000-7,000 BC)" say Columbia History of the world 1981.
• For more than a thousand years before the time of Christ until 1883 AD, Cannabis/Hemp was our planet's largest agricultural crop and most important industry for thousands upon thousands of products and enterprises, producing the overall majority of the earth's fibre, fabric, lighting oil, paper, incense and medicines, as well as being a primary source of protein for humans and animals alike.
• The war between America and Great Britain in 1812 was mainly about access to Russian Hemp.
• Napoleon's principle reason for tragically invading Russia in 1812 was also due to Russian Hemp supplies!
• Hemp uses the sun more efficiently than virtually any other plant on the planet.
• Hemp can grow in virtually any climate and soil condition, and is excellent for reclaiming otherwise-unusable land.
• The word 'linen', until the early 1800s meant any coarse fabrics made from Hemp or flax.
• Cannabis oil was mentioned by name in the Bible. Apparently, etymologists at Hebrew University, Jerusalem confirmed that 'kineboisin' (also spelled 'kannabosm") referred to cannabis used in a holy ointment. See Exodus 30:23. N.B. King James mistranslated the word as 'calamus' in his version.
• Hempseed oil is said to burn the brightest of all lamp oils, and has been used since the days of Abraham. Scythians used to purify and cleanse themselves with Hemp oil, which made their skin "shining and clean".
• Much of the world's paper was made from Hemp until about 1850. Since the 1900s, all newspapers and most books and magazines were printed on wood-pulp paper. Cheap throwaway paper, fitting in with a disposable economy.
• Our forests, what is left of them, are being cut down 3 times as fast as they can grow.
• Hemp offers a valuable and sustainable fuel of the future, "growing oil wells". Hemp has an output equivalent to around 1000 gallons of methanol per acre year (10 tons Biomass/acre, each yielding 100 gal. methanol/ton). Methanol used today is mainly made from natural gas, a fossil fuel. Methanol is currently being studied as a primary fuel for automobiles, hopefully reducing CO2 levels.
• Henry Ford dreamed that someday automobiles would be grown from the soil. The Ford motor company, after years of research produced an automobile with a plastic body. Its tough body used a mixture of 70% cellulose fibres from Hemp. The plastic withstood blows 10 times as great as steel could without denting! Its weight was also 2/3 that of a regular car, producing better economy. Henry Ford was forced to use petroleum due to Hemp prohibition. His plans to fuel his fleet of vehicles with plant-power also failed due to Alcohol prohibition at the time.
• Green Rizla papers are made from Hemp! Hemp Paper the interesting fact about how it is made.
• Hemp seed does not contain the anti-nutrient trypsin inhibitors as found in soy milk.

The medicinal use of cannabis in the ancient world has been well documented (Abel 1980). In the United States, cannabis was first mentioned as a medicinal drug in 1843 and by 1852 it was included in the US dispensatory list of medicines. It was thought to be beneficial in the treatment of 'neuralgia, gout, tetanus, hydrophobia, cholera, convulsions, chorea, hysteria, depression and insanity' (Wood & Bache 1854, cited in Abel 1980, p182). In Australia, tincture of cannabis was used in medicine until the 1960s, when it was declared a prohibited drug (Cartwright 1983).

Since the introduction of legislation prohibiting the recreational use of cannabis, its use for medicinal purposes has, in most Western countries, not been popular. However, recently the therapeutic benefits of cannabis have received close attention in the United States. In 1991, Doblin and Kleiman conducted an anonymous survey of the members of the American Society of Clinical Oncology measuring the attitudes and experiences of American oncologists concerning the use of cannabis to treat nausea in cancer chemotherapy patients. They found that, of those oncologists who replied to the survey (43 per cent), more than 44 per cent of them reported recommending the illegal use of cannabis for the control of nausea to at least one cancer patient. Some 48 per cent said that they would prescribe cannabis to some of their patients if it were legal (Doblin & Kleiman 1991).

Cannabis has been used as an anti-emetic in the treatment of AIDS patients and as a painkiller for those suffering from chronic pain (Grinspoon 1991). It has also been regarded by some medical practitioners as being effective in reducing intra-ocular pressure in glaucoma patients (Caswell 1992) and in treating epilepsy (Cartwright 1983), Huntington's chorea (Moss et al. 1989) and Parkinsonian tremor (Frankel et al. 1990).

Those in favour of rescheduling the drug argue that, for some, the denial of cannabis as a medicine is particularly cruel. Grinspoon argues that 'sick people are forced to suffer anxiety about prosecution in addition to their anxiety about the illness ... Doctors are afraid to recommend what they know to be the best treatment because they might lose their reputation or even their licence' (Grinspoon 1991).

The Australian medical community has not been as enthusiastic about the therapeutic benefits of cannabis although many argue that where the drug has been demonstrated to be effective its use should be permitted. A study done at the Royal Children's Hospital in Melbourne found that THC (the psychoactive ingredient in cannabis) was an effective anti-emetic for some children undergoing chemotherapy (Cartwright 1983). Dr Lorna Cartwright, a lecturer in Pharmacology at Sydney University stated:

I think there are probably better drugs for medical uses. The point is, though, I think it should be allowed to be used for conditions in which it has been shown to have effect, such as for glaucoma, for children having chemotherapy and for epilepsy. I always feel that if something is good even for a small percentage of patients, it should be allowed to be used (cited in Caswell 1992, p498).

The position in Australia is different from that in the USA in that in this country there is no legislation or binding administrative ruling specifically stating that no medical use exists for cannabis.21 Neither does the United Nations Single Convention on Narcotic Drugs, to which Australia is a party, specifically forbid the medical use of cannabis. In fact the Convention recognises that some otherwise illicit drugs may have medical purposes and states that cannabis use should be 'subject to the provisions of this Convention, to limit exclusively to medical and scientific purposes the...use and possession of drugs' (Article 4(1) (c)).

Given that the United Nations Conventions do not specifically proscribe the medical uses of cannabis, introducing legislation that allowed the use of the drug for medical purposes in Australia would be relatively simple. Clauses authorising the therapeutic use of the drug could simply be inserted into relevant drug legislation and therapeutic products scheduling. Politically, however, such a change in policy could be difficult. As an illicit drug, cannabis has a negative image and is seen as an being an inherently dependence producing, damaging drug that has no possible benefits. Recognition of the medical benefits of the drug may challenge this dominant view of cannabis.