California’s Proposition 215, also known as the Compassionate Use Act, was the first law in the US that stipulated that individuals could legally possess and use marijuana if recommended by their physicians.
Cannabis (Cannabis sativa) was used for medicinal and religious purposes long before it gained its current status as the most commonly used recreational illicit substance in the US.1 In recent years, there has been rising interest in its potential therapeutic value, with resulting pressures to legalize its use. The medical and legal communities have simultaneously found themselves at an important decision point in the history of this well-known substance.
In 1996, California became the first state to pass a law allowing individuals to possess small quantities of marijuana for their own medical use. This law, known as Proposition 215 or the Compassionate Use Act, stipulated that a physician may “recommend” the use of marijuana for the treatment of “cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis, migraine, or any other illness for which marijuana provides relief.”2 A total of 15 states have since followed suit, although the specific medical diagnoses for which marijuana may be “recommended” varies broadly amongst them.3
Although Proposition 215 implies that marijuana be used as a medical treatment, regulations surrounding its use are much less rigorous than the FDA monitoring of regular prescription medications. Most state laws do not stipulate the means by which individuals can access the substance, which leads to significant heterogeneity of the marijuana used by patients. Some procure their marijuana through dispensaries (which themselves can vary greatly in terms of their crops), while others grow their own supplies. These disparate means of accessing marijuana complicate the evaluation of the quality, purity, and potency of cannabis. This results in physicians recommending a substance for which the dose cannot be standardized and where quality control becomes an impossible task. It is also important to note that medical marijuana is the only therapeutic agent approved to be delivered by means of smoking, and thus does not fall under the regulation of the FDA.4
Another area of ambiguity involves the medical diagnoses for which cannabis is recommended as a treatment. Although initially intended to treat cancer and AIDS-related symptoms such as nausea and pain, these indications comprise only a small fraction of the reasons cited for the prescription of medical marijuana patient identification cards. In fact, musculoskeletal pain (30.6%), insomnia (15.5%), and anxiety (13%) were the most common cited reasons.5 Yet another conundrum faced by physicians is their duty to educate their patients on the medical use of marijuana. The process of informed consent requires that a discussion about the benefits, risks, and alternatives for any proposed treatment must occur in order for the patient to make an informed decision. Those recommending medical marijuana must comply with these standards. However, there are no studies investigating the long-term effects of smoked medical marijuana use.6 Coupled with the paucity of well-designed studies investigating the therapeutic benefits of marijuana, it becomes impossible for physicians to educate their patients about the pros and cons of medical marijuana use.
Marijuana’s current status as a Schedule I Substance by the federal government further impedes research efforts to resolve these issues, since investigators who wish to study marijuana’s potential therapeutic benefits must face strict and often cumbersome regulations and restrictions imposed by the Drug Enforcement Agency.7 Along with other political considerations, this poses an important obstacle for investigators who wish to expand our understanding of the potential uses and risks of cannabis. The important question of whether the benefits of medical marijuana outweigh its risks thus remains unanswered.