Medical Marijuana Research Support: Gilead, Tobira Pro: Bilal - - PowerPoint PPT Presentation

9/30/2016 1

Debate

Medical Marijuana

Pro: Bilal Hameed , MD Con: Rupal Shah, MD

Disclosures

I did not inhale !!

Research Support: Gilead, Tobira

Debating

“You have to learn the rules of the game. Then you have to play better than anyone else.” Albert Einstein

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Marijuana

“Very few drugs, if at all, have such a tangled history as a medicine. In fact, prejudice, superstition, emotionalism, and even ideology have managed to lead cannabis to ups and downs concerning both its therapeutic properties and its toxicological and dependence- inducing effects.”

Brazilian psychopharmacologist E. A. Carlini

Toxicon 2004;44:461–7.

Marijuana History

smoke, vapor, ingestion, oil: 60 active ingredients known as cannabinoids

• 2737 BC – Sheng Neng, Emperor of China, touted

cannabis tea for Rx of gout, rheumatism, malaria and poor memory

• Use spread in Asia, Middle East, Africa and India, for

pain and stress relief

• W. B. O’Shaughnessy, an Irish physician working in

Calcutta in the 1830s recommended cannabis—pain, vomiting, convulsions, and spasticity

Global Cannabis Use?

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Marijuana History is US

• Federal Bureau of Narcotics pushed

for the congressional passage of the 1937 Marihuana Tax Act

• In 1942, it was removed from the US

Dispensatory

• In 1970 US Congress finally declare it

to have no medical value

• Use of cannabis received official

legitimacy by its listing in the US Dispensatory in 1854

Green – medical and recreational use legal Light green – medical use legal Yellow – decriminalized Red - Illegal

• Recreational Marijuana is now legal in Oregon, Washington,

Alaska, Colorado & DC

• Medical Marijuana is legal in 23 states & DC

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Scope of the Issue

• Marijuana was the most prevalently used illegal substance

in the US in 2010 (US Dept of HHS)

• 190 million people consumed cannabis in 2007 worldwide

(United Nations estimate)

• 40% of teenagers have tried marijuana / 20% are current

users (CDC)

The Facts

Many of our Founding Fathers grew cannabis and smoked it regularly

US Politicians who have ‘admitted’ to using or were known to use marijuana include mayors, governors, members of the House of Representatives, and Presidents (list not complete): George Washington, Benjamin Franklin, Thomas Jefferson, Abraham Lincoln, James Madison, John F Kennedy, Jimmy Carter, Bill Clinton, Al Gore, George W. Bush, Jeb Bush, Newt Gingcrich, Joseph P. Kennedy II, Ed Koch, Andrew Como, Bruce Babbitt, Michael Bloomberg, Bill Bradely, Paul Cellucci, Richard Lamm, John Edwards, John Kerry, Sarah Palin, Arnold Schwarzenegger, Jesse Ventura, Barack Obama… Many Queen Victoria used cannabis for childbirth pain Queen Elizabeth II used cannabis for menstrual cramps

Public Opinion About Marijuana

Middle-aged parents are now more likely to smoke weed than their teenage kids

Source: SAMHSA/CDC

Regular Marijuana Use in 2014 Age 12-17 yrs: 7% Age 35-44 yrs: 8 %

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Where Candidates Stands on Marijuana? Lifetime Dependence of Marijuana

Lifetime dependence risk

• Marijuana: 9%
• Nicotine: 32%
• Heroin: 23%
• Cocaine: 17%
• Alcohol: 15%

Robson P. Expert Opin Drug Saf 2011.

Cannabis: Not a New medicine

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Studies on Medicinal Cannabis Effects:

Whiting et al (2015) meta-analysis

# RCTs # Reports # Patients 28Chronic Pain 63 2454 28Nausea and vomiting due to chemotherapy 37 1772 14Spasticity due to multiple sclerosis/paraplegia 33 2280 4HIV/AIDS 4 255 2Sleep Disorder 5 54 2Psychosis 9 91 2Tourette syndrome 7 36 1Anxiety disorder 1 24 1Glaucoma 1 6

Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for Medical Use: A Systematic Review and Metaanalysis.

• JAMA. 313:2456-2473, 2015

Meta-Analysis

• Moderate-quality evidence to support the use of

cannabinoids in:

– chronic pain – spasticity

• Low-quality evidence suggesting that

cannabinoids were associated with improvements in:

– nausea and vomiting due to chemotherapy – weight gain in HIV infection – sleep disorders

Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for Medical Use: A Systematic Review and Metaanalysis.

• JAMA. 313:2456-2473, 2015

No Increase in Lung Cancer in Marijuana Smokers

• Pooled analyses 6 case-controlled studies – US,

Canada, UK, New Zealand - 2,100 lung cancer cases and 3,000 controls

• Provided little evidence for an increased risk of

lung cancer among habitual or long-term cannabis smokers

• Even when data was analyzed based on

intensity, duration, consumption and age of initiation, no significant association was found

Zhang et al. International Journal of Cancer; 136, (4): 894–903, Feb 2015 .

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Blurred Boundaries

• Recreational vs medical use
• Benefit vs harm of use
• Lab research and pharmacologic application vs

federal restrictions

• State vs federal law

Rules are not based on scientific evidence but

• n political ideology and gamesmanship

Marijuana and Transplant

What to do now that Marijuana is legal in some states?

Marijuana Policy for Liver Transplant

34% of Canadian centers consider marijuana as a contraindication to transplantation, compared with 70% of US centers

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Marijuana Policy for Liver Transplant

• 56% responded from 102 active adult liver transplant centers
• 70% of transplant centers have an existing policy
• 47% identified marijuana use as a “controversial characteristic”
• 46% consider current recreational use as absolute contraindication
• 11% consider medicinal use as absolute contraindication

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Ranney et al

Marijuana users have similar survival rates to non-users

0.00 0.20 0.40 0.60 0.80 1 .00 P rob a b ility

• f A

dvan ced F ib ros is 87 72 64 56 40 31 22 17 14 1 potcat_aprigte15 = >= Weekly 54 45 33 27 20 17 11 9 7 potcat_aprigte15 = < Weekly 142 93 70 54 39 31 24 16 14 1 potcat_aprigte15 = Non-User Number at risk 2 4 6 8 10 12 14 16 18 Time since study entry (years) Non-User < Weekly >= Weekly xxxxxxxxxxxxxxx xxxxxxxxxxxxxx xxxxxxxxxxxxxxx

Marijuana Use Is Not Associated With Progression to Advanced Liver Fibrosis in HIV/HCV coinfected Women

Kelly, EM et al. Clin Infect Dis 2016. Slide provided by Dr. Kelly 575 women Median of 11 years 56% no THC use 25% < weekly use 12% weekly use 7% daily use

Marijuana Use Does Not Predict Outcomes On The Liver Transplant Waitlist

• Retrospective cohort of adults evaluated for

transplant from 1/2012 to 12/2013 at UCSF

• 884 adults evaluated and 585 (66%) were

listed

• Median follow up of 1.4 years
• Prevalence of marijuana use was 48%
• 7% being current users and 41% prior users

Kotwani et al. AASLD abstract accpeted 2016.

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Marijuana Use Does Not Predict Outcomes On The Liver Transplant Waitlist

KM survival estimate for time to death/delisting on the liver transplant waitlist (N=585) Kotwani et al. AASLD abstract accepted 2016.

Recreational Marijuana Use Is Not Associated With Worse Outcomes After Renal Transplantation

Greenan G et al. Clinic Transplant 2016.

What Should be Your Transplant Center Policy?

• Don’t ask, don’t tell…
• Ask, and if yes for medical marijuana – allow use

attempt enforcement of not smoking- use other routes

• Ask, and if yes, for medical or recreational - propose

abstinence for a defined period of time (eg. 6 mo.)

• Don’t list anyone who currently uses or historically

used marijuana – Very harsh!

UCSF Liver Transplant Policy in 2015

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Lets Clear the Smoke

• Seven states prohibit denying transplant to

medical marijuana users solely based on their use

• f the drug
• Very little evidence shows that marijuana predicts

worse transplant outcomes

• Transplant professionals should attempt to

determine whether marijuana use negatively impacts a patient’s life and how it may influence behavior or mask mental health issues

How We Do We Move Forward?

• Need separate policies on medicinal use versus

recreational

• Large scale clinical trials, administered via several

routes

• Need to re-schedule class of marijuana , need

regulated dispensaries and pharmacies

• We cannot make decisions about transplant on case

reports

Future Studies

• University of California, San Diego - Center

for Medicinal Cannabis Research (CMCR)

• Established in 2012 as a program to oversee an
• bjective, high quality medical research that

will enhance understanding of the efficacy and adverse effects of marijuana as a pharmacological agent “ Learn from yesterday, live for today, hope for

• tomorrow. The important thing is not to stop

questioning.”

Thank You