Several factors have recently converged to make passage of a medical marijuana law in Pennsylvania a distinct possibility.
First, public opinion in the state is now overwhelmingly in favor of legalizing marijuana (cannabis sativa) for medical use. Results of a Franklin and Marshall College poll in February 2013 indicated that 82 percent of Pennsylvanians favored allowing adults to use marijuana for medical purposes if recommended by a doctor. On March 3, 2014, a Quinnipiac University poll showed support in Pennsylvania at 85 percent. When analyzed by age, gender, and political orientation groups, a minimum of 78 percent in each group supported medical marijuana.
The second key factor is development of bipartisan support for such a law in the state Legislature. Sen. Mike Folmer, R-Lebanon/York County, is a prime sponsor of Senate Bill 1182, titled the Governor Raymond Shafer Compassionate Use of Medical Cannabis Act. The other sponsors at the time of this writing include one other Republican senator and nine Democrats. In the House, Rep. Jim Cox, R-Berks), has introduced House Bill 2182, which is similar to the Senate bill but with updated language based on discussions with the Senate.
Sen. Folmer and Rep. Cox are both motivated by a desire to alleviate suffering on the part of patients with symptoms that cannot be relieved with currently available treatments.
The third factor making a medical marijuana law more likely in Pennsylvania's near future is Gov. Tom Corbett's low approval rating. Gov. Corbett does not support access to medical marijuana beyond a very limited program proposed to benefit a small number of children with a severe seizure disorder. If he is replaced by Democratic challenger Tom Wolf after this year's election, Pennsylvania will have a governor who has come out in support of a much broader medical marijuana law.
Thus, a high percentage of Pennsylvanians would trust their doctors to prescribe marijuana for medical conditions, and momentum is building to pass legislation that would allow such prescriptions to be written.
How does this issue look from the other side of the prescription pad — to the physicians who would be faced with implementing such a law?
By an act of Congress — the Controlled Substances Act of 1970 — marijuana was placed in the same category of drugs (Schedule I) as heroin: drugs with very high potential for abuse and addiction and no currently accepted medical use. In contrast, cocaine and methamphetamine were placed in Schedule II, considered to have less potential for abuse and dependency than Schedule I drugs and known to have accepted medical use. As long as this classification remains in effect, any physician who writes a prescription for marijuana risks federal prosecution and puts their career in jeopardy.
In addition, this classification has been an almost insurmountable hurdle to performing research on the potential medical benefits of products derived from cannabis. Therefore, the evidence available to physicians on the safety and efficacy of medical marijuana products does not, in most cases, rise to the level of that available for drugs that have been approved by the FDA based on clinical trials.
Nevertheless, many physicians and other health care providers in states with medical marijuana laws do write prescriptions. The reasons likely include the limitations of conventional medical treatments in alleviating suffering and treating certain diseases, the availability of some evidence for a beneficial effect from use of cannabis in certain conditions, and the perception that cannabis is a relatively safe drug compared to many FDA-approved medications.
In the interest of increasing public awareness of physician perspectives on this issue, and of stimulating involvement of the medical community in the shaping of public policy, a number of Berks County physicians were presented with the following summary of some of the most salient provisions of SB 1182 (as of mid-June) and asked for their comments.
Dr. Jason T. Bundy of the Center for Pain Control wrote:
"It is well known among pain management physicians that there are few good options to treat nerve dysfunction (neuropathic) pain. We often end up empirically trying opioids for lack of a better option, which poses significant risk to patients. Add in the prescription drug abuse epidemic that this country faces and anyone can easily understand why pain management physicians are so eager to explore non-opioid alternatives when treating patients suffering with neuropathic pain. The relevant literature suggests that cannabis can prove more effective in treating neuropathic pain than using higher dose opioids — all while incrementally decreasing the risk posed to patients.
"Therefore, I am cautiously optimistic that cannibinoid products may help a certain subset of appropriately selected chronic pain patients.
"The fact that the federal Drug Enforcement Administration still lists cannabis as a schedule I substance ... troubles me though. Assuming Pennsylvania Senate Bill 1182 passes, I plan to educate myself more on the subject, focus on best practice consensus guidelines and be guided by the anesthesiology adage 'start low and go slow' in my practice and for each patient that may receive a cannabis prescription with my DEA number on it."
Dr. Diane T. Bonaccorsi of Green Hills Family Medicine Associates indicated she would not be able to prescribe marijuana if it remained a Schedule 1 drug.
"As you are aware, Schedule I drugs are thought to have no current accepted medical use," she wrote. "That being said, I believe this is an unjustified and antiquated designation. Marijuana is currently being studied for multiple medicinal uses, from multiple sclerosis, glaucoma, ALS, fibromyalgia and depression to cancer, seizure disorders and many more. It has been a help to patients with chronic pain. I would prescribe it to appropriate patients if it were Schedule II or less."
There are probably as many physician opinions on this subject as there are physicians in Berks County, but all share the core principles that guide the decision-making of ethical physicians. The maxim to "first, do no harm" is inculcated into every medical student, and no drug prescription is written without a calculation of the risk of an adverse reaction relative to the risk of alternative treatments or no treatment for the problem at hand. This is difficult enough when evidence from well-designed, long-term clinical trials is available.
For at least some of the symptoms or disorders listed in SB 1182, the quality of available evidence is so poor that this calculation would better be characterized as a guess. Further uncertainty is injected into this calculation by the fact that cannabis contains more than 400 chemicals from 18 chemical families, and that more than 2,000 chemical compounds are released when it is smoked.
When you throw in the availability of different strains of cannabis, each with a different chemical profile, the reluctance of many physicians to prescribe "marijuana" without more research seems the only responsible position.
However, another core principle of medical practice is to use one's knowledge and skills to alleviate suffering. Indeed, the desire to relieve suffering is one of the most common motivations for pursuing a medical career. Unfortunately, almost all physicians have the experience of caring for patients with debilitating conditions that cannot be effectively treated with currently available medication (or other treatment modalities).
If a medical marijuana law is enacted in Pennsylvania, physicians will have another treatment option that is likely to benefit some of these patients, with risks that seem to be no higher, and in some cases lower, than risks posed by a number of commonly-prescribed drugs.
— Dr. Lucy J. Cairns is editor of the Berks County Medical Society newsletter Medical Record, in which this article first appeared. It's reprinted here with Cairn's and the society's permission.