A Michigan traffic safety law that prohibits the operation of a motor vehicle by persons who possess any presence of THC in their blood, regardless of whether or not they are behaviorally impaired by the substance, may not be strictly applied to state-qualified medical cannabis patients. So decided the Michigan Supreme Court on Tuesday in the case People v Koon.
In a unanimous opinion, the Court determined that legal protections extended to state-qualified patients under the Michigan Medical Marihuana Act, enacted by voters in 2008, supersede the state’s zero tolerance, internal possession law. As a result, the Court determined that state prosecutors must establish that authorized patients charged under the statute are actually impaired by their cannabis use in order to gain a DUI criminal conviction.
According to the syllabus of the Opinion:
“The MMMA [Michigan Medical Marihuana Act] does not define what it means to be ‘under the influence,’ but the phrase clearly contemplates something more than having any amount of marijuana in one’s system and requires some effect on the person. Thus, the MMMA’s protections extend to a registered patient who internally possesses marijuana while operating a vehicle unless the patient is under the influence of marijuana. The immunity from prosecution provided under the MMMA to a registered patient who drives with indications of marijuana in his or her system but is not otherwise under the influence of marijuana inescapably conflicts with MCL 257.625(8) [the state's zero tolerance per se DUI law], which prohibits a person from driving with any amount of marijuana in her or system.”
The state’s zero tolerance per se drug law remains applicable to non-patients. Under such laws, motorists are guilty per se (in fact) of a criminal traffic safety violation if they engage in the act of driving while detectable levels of certain controlled substances or, in some cases, their inert metabolites (byproducts) are present in the defendants’ blood or urine. Proof of actual impairment is not a requirement for a conviction under the law.
To date, ten states — Arizona, Delaware, Georgia, Illinois, Indiana, Iowa, Michigan, Rhode Island, Utah, and Wisconsin — have enacted legislation imposing zero tolerance per se thresholds for the presence of cannabinoids and/or their metabolites. (State-authorized medical cannabis patients in Arizona and Rhode Island are exempt from prosecution under these per se statutes unless the state can provide additional evidence of psychomotor impairment.)
Five additional states impose non-zero-tolerant per se thresholds for cannabinoids in blood: Montana (5ng/ml — law takes effect on October 1, 2013), Pennsylvania (1ng/ml), Ohio (2ng/ml), Nevada (2ng/ml) and Washington (5ng/ml). Most recently, Colorado lawmakers approved legislation stating that the presence of THC/blood levels above 5ng/ml “gives rise to permissible inference that the defendant was under the influence.” State-qualified patients in Colorado, Montana, and Nevada are not provided legal exemptions from these statutes, although legislation is presently pending in Nevada to do so.
Such caution is similarly expressed by the United States National Highway Transportation and Safety Administration, which acknowledges: “It is difficult to establish a relationship between a person’s THC blood or plasma concentration and performance impairing effects. … It is inadvisable to try and predict effects based on blood THC concentrations alone.”
A 2013 review of per se drugged driving laws and their impact on road safety found “no evidence that per se drugged driving laws reduce traffic fatalities.”
The National Organization for the Reform of Marijuana Laws is pleased to announce that it is now providing educational content to the editors of The Answer Page, Inc. The Answer Page, Inc. is an online medical educational resource founded in 1998 that provides daily education to healthcare professionals in 120 countries. TheAnswerPage (online at TheAnswerPage.com) uses the Socratic question-and-answer teaching method. The content for the website is primarily written by academic clinicians respected in their fields. All content is peer-reviewed and referenced from current texts and recent literature.
TheAnswerPage now features educational content in the area of medical marijuana. The editorial team of TheAnswerPage states: “Medical marijuana may be controversial, but it is now an important area of study in healthcare. Doctors and healthcare professionals must understand the medical, legal, social and political issues to best respond to their patients’ questions and attend to their needs.”
The medical marijuana ‘lecture series’ begins with an introductory primer to the cannabis plant. The following week focuses on five distinct cannabinoids and their therapeutic potential.
“NORML recognizes that physicians and health care professionals desire balanced information regarding the safety and efficacy of cannabis as a potential therapy,” NORML’s Deputy Director Paul Armentano said. “NORML is pleased to provide its expertise to TheAnswerPage to assist health care professionals better understand and navigate this important public health issue.”
Subscribers to TheAnswerPage receive continuing medical education (CME) credit by reading the content and completing an industry-unique Interactive Crossword Puzzle. The clues are structured to reinforce the educational material, and links are provided to the related content. Subscribers have personal educational accounts that organize their earned CME credit and allow clinicians to download, email or print CME certificates for credentialing and licensing.
TheAnswerPage.com has over 50 interactive crossword puzzles posted, for earning CME credit. New content and crosswords are posted daily.
TheAnswerPage‘s medical cannabis content is available at the ‘syllabus;’ select the pull down menu option: “Medical Marijuana — Medical, Legal, Social, and political Issues.” Free registration to the site is required.
Investigators at the University of California, Davis Medical Center conducted a double-blind, placebo-controlled, crossover study evaluating the analgesic efficacy of vaporized cannabis in 39 subjects, the majority of whom were experiencing neuropathic pain despite traditional treatment. Subjects inhaled cannabis of either moderate THC (3.53 percent), low dose THC (1.29 percent), or zero THC (placebo). Subjects continued to take all other concurrent medications as per their normal routine during the 3- to 4-week study period. Spontaneous pain relief, the primary outcome variable, was assessed by asking participants to indicate the intensity of their current pain on a 100-mm visual analog scale (VAS) between 0 (no pain) and 100 (worst possible pain).
Researchers reported: “Both the low and medium doses proved to be salutary analgesics for the heterogeneous collection of neuropathic pain conditions studied. Both active study medications provided statistically significant 30% reductions in pain intensity when compared to placebo.”
They concluded: “Both the 1.29% and 3.53% vaporized THC study medications produced equal antinociception at every time point. … [T]he use of low doses could potentially be prescribed by physicians interested in helping patients use cannabis effectively while minimizing cognitive and psychological side effects. Viewed with this in mind, the present study adds to a growing body of literature supporting the use of cannabis for the treatment of neuropathic pain. It provides additional evidence of the efficacy of vaporized cannabis as well as establishes low-dose cannabis (1.29%) as having a favorable risk-benefit ratio.”
Previous clinical trials have indicated that inhaled cannabis can safety and effectively relieve various types of pain, particularly neuropathy — a hard-to-treat nerve condition often associated with cancer, HIV, spinal cord injury, diabetes, multiple sclerosis, and other conditions. These include the following double-blind, placebo-controlled (FDA gold-standard) studies:
Ware et al. 2010. Smoked cannabis for chronic neuropathic pain: a randomized controlled trial. CMAJ 182: 694-701.
Wilsey et al. 2008. A randomized, placebo-controlled, crossover trial of cannabis cigarettes in neuropathic pain. Journal of Pain 9: 506-521.
Ellis et al. 2008. Smoked medicinal cannabis for neuropathic pain in HIV: a randomized, crossover clinical trial. Neuropsychopharmacology 34: 672-80.
Abrams et al. 2007. Cannabis in painful HIV-associated sensory neuropathy: a randomized placebo-controlled trial. Neurology 68: 515-521.
Wallace et al. 2007. Dose-dependent Effects of Smoked Cannabis on Capsaicin-induced Pain and Hyperalgesia in Healthy Volunteers Anesthesiology 107: 785-796.
Separate clinical trial data also reports that inhaled “cannabis augments the analgesic effect of opioids” and therefore “may allow for opioid treatment at lower doses with fewer side effects.”
Since 1999, US sales of opiate drugs have tripled in number and in 2010, a record-setting 254 million prescriptions for opioids were filled in the United States — enough to medicate every American adult around the clock for a month. (In particular, the manufacturing of the drug Oxycodone has increased from 8.3 tons in 1997 to 105 tons in 2011, an increase of 1,200 percent.) Overdose deaths from the use of prescription painkillers are also now at record levels, totaling some 15,000 annually — more than triple the total a decade ago.
Full text of the study, “Low-dose vaporized cannabis significantly improves neuropathic pain,” appears in The Journal of Pain.
Three quarters of medical cannabis consumers report using it as a substitute for prescription drugs, alcohol, or some other illicit substance, according to survey data published in the journal Addiction Research and Theory.
An international team of investigators from Canada and the United States assessed the subjective impact of marijuana on the use of licit and illicit substances via self-report in a cohort of 404 medical cannabis patients recruited from four dispensaries in British Columbia, Canada.
Researchers reported that subjects frequently substituted cannabis for other substances, including conventional pharmaceuticals. Authors reported:
“Over 41 percent state that they use cannabis as a substitute for alcohol (n=158), 36.1 percent use cannabis as a substitute for illicit substances (n=137), and 67.8 percent use cannabis as a substitute for prescription drugs (n=259). The three main reasons cited for cannabis-related substitution are ‘less withdrawal’ (67.7 percent), ‘fewer side-effects’ (60.4 percent), and ‘better symptom management’ suggesting that many patients may have already identified cannabis as an effective and potentially safer adjunct or alternative to their prescription drug regimen.”
Overall, 75.5 percent (n=305) of respondents said that they substitute cannabis for at least one other substance. Men were more likely than women to report substituting cannabis for alcohol or illicit drugs.
Authors concluded: “While some studies have found that a small percentage of the general population that uses cannabis may develop a dependence on this substance, a growing body of research on cannabis-related substitution suggests that for many patients cannabis is not only an effective medicine, but also a potential exit drug to problematic substance use. Given the credible biological, social and psychological mechanisms behind these results, and the associated potential to decrease personal suffering and the personal and social costs associated with addiction, further research appears to be justified on both economic and ethical grounds. Clinical trials with those who have had poor outcomes with conventional psychological or pharmacological addiction therapies could be a good starting point to further our under- standing of cannabis-based substitution effect.”
Previous studies have similarly demonstrated cannabis’ potential efficacy as an exit drug. A 2010 study published in the Harm Reduction Journal reported that cannabis-using adults enrolled in substance abuse treatment programs fared equally or better than nonusers in various outcome categories, including treatment completion. A 2009 study reported that 40 percent of subjects attending a California medical cannabis dispensary reported using marijuana as a substitute for alcohol, and 26 percent used it to replace their former use of more potent illegal drugs. A separate 2009 study published in the American Journal on Addictions reported that moderate cannabis use and improved retention in naltrexone treatment among opiate-dependent subjects in a New York state inpatient detoxification program.
Full text of the study, “Cannabis as a substitute for alcohol and other drugs: A dispensary-based survey of substitution effect in Canadian medical cannabis patients,” appears online in Addiction Research and Theory. NORML Advisory Board Member Mitch Earleywine is a co-author of this study.
Arizona Superior Court Judge: State-Licensed Dispensing Of Medical Cannabis Is Not Preempted By Federal LawDecember 18, 2012
A 2010 voter-approved Arizona state law authorizing “the local cultivation, sale, and use, of medical marijuana” is not preempted by the federal Controlled Substances Act, according to the Superior Court of Arizona, Maricopa County.
The ruling, issued earlier this month by Superior Court Judge Michael Gordon, allows for the establishment of state-licensed medicinal cannabis dispensaries within Arizona — the first of which opened its doors last week. State-licensed medical marijuana facilities now operate in several states, including Colorado, New Jersey, New Mexico, and Maine.
A majority of Arizona voters approved the AMMA in 2010. Under the law, qualified patients may possess and, depending on where they reside, cultivate cannabis. The program also mandates the state to license citizens to form not-for-profit dispensaries to grow and dispense cannabis. AMMA requires that each of the state’s 126 Community Health Care Analysis Areas permit at least one dispensary operator. Maricopa County’s prosecutor sought to block the establishment of local dispensaries by claiming that AMMA was preempted by federal anti-drug laws.
Writing for the Court in White Mountain Health Center, Inc. v. Maricopa County, Judge Gordon declared that nothing in the Arizona Medical Marijuana Act circumvents federal law since Justice Department officials, if they wished to do so, could still continue to locally enforce the Controlled Substances Act. “No one can argue that the federal government’s ability to enforce the CSA is impaired to the slightest degree [by Arizona’s medical marijuana law],” Gordon opined, adding that the new law “affirmatively provides a roadmap for federal enforcement of the CSA, if they so wished to” since the statute requires patients and proprietors to register their activities with the state.
Judge Gordon further suggested that Arizona’s law did not conflict with the federal lawmakers’ intentions when they enacted the federal Controlled Substances Act. He declared, “Instead of frustrating the CSA’s purpose, it is sensible to argue that the AMMA furthers the CSA’s objectives in combating drug abuse and the illegitimate trafficking of controlled substances.”
He concluded: “The Court rejects … arguments that the [law] violates public policy simply because marijuana use and possession violate federal law. Eighteen states and the District of Columbia have passed legislation permitting the use of marijuana in whole or in part. The Court will not rule that Arizona, having sided with the ever-growing minority of States, and having limited it to medical use, has violated public policy.”
Maricopa County Attorney Bill Montgomery is appealing Judge Gordon’s ruling.
Arizona regulations regarding patient access and dispensary operations is available from the Arizona Department of Health Services here.