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Letters to the Editor  |   August 2019
Response
Author Notes
  • Department of Psychiatry, Oregon Health and Science University, Portland 
Article Information
Addiction Medicine / Pain Management/Palliative Care / Opioids
Letters to the Editor   |   August 2019
Response
The Journal of the American Osteopathic Association, August 2019, Vol. 119, 477a-478. doi:https://doi.org/10.7556/jaoa.2019.088
The Journal of the American Osteopathic Association, August 2019, Vol. 119, 477a-478. doi:https://doi.org/10.7556/jaoa.2019.088
We thank Dr Moy for taking her time to read and respond to our February 2018 article on the routes of cannabis consumption.1 We agree that the United States is in a watershed moment for cannabis with regard to its legalization and potential medical applications. 
Although many studies have suggested potential benefits from cannabis, positive outcomes do not necessarily equate to efficacious treatments for human patients. For example, Abraxane (Celgene Corporation) was derived from the yew tree, but we do not prescribe yew tree teas for cancer patients. Instead, a compound in the yew tree was isolated, purified, and studied in randomized controlled studies. Doses, adverse effects, and potential mechanisms of action were identified, leading to the development of a medication that can be carefully prescribed.2 Regarding the quality of available evidence on cannabis, in the systematic review by Whiting et al,3 only 4 of 79 trials were determined to have a low risk for bias, and many did not reach statistical significance. Better studies are needed. 
We are encouraged by new cannabis-derived medications such as Epidiolex for the management of seizures, and we often point to Marinol (dronabinol, tetrahydrocannabinol; AbbVie Inc.) for the management of nausea and vomiting caused by chemotherapy as proof that cannabis-derived products can be used to improve patient care. We are also hopeful that cannabis might be used as a safer alternative to opioids; a cannabis-derived pain medication would be a significant boon. Olfson et al,4 however, found that cannabis use was associated with increased nonprescription opioid use and opioid use disorder. 
Herbal cannabis is not a consistent product. Studies5,6 have demonstrated that a specific plant's cannabinoid and terpene profile can shift based on soil, nutrients, light cycle, water, and grow location. The cannabis used in a specific study is unlikely to be equivalent to the cannabis found in local shops or grown in backyards. We believe the active components of cannabis should be identified, purified, and studied, as they were with the yew tree, so that physicians can prescribe medications with known doses and a clear understanding of the mechanisms of action and potential adverse effects. 
We are not promoting antiquated biases against cannabis; rather, we suggest that modern medicine requires the development of a standardized cannabis product (be it a standardized herbal product, purified compound, or something in between) to allow for nonbiased, randomized controlled studies. This process would pave the way for stronger medical evidence and safer prescribing. 
References
Peters J, Chien J. Contemporary routes of cannabis consumption: a primer for clinicians. J Am Osteopath Assoc. 2018;118(2):67-70. doi: 10.7556/jaoa.2018.020 [CrossRef] [PubMed]
Cragg GM. Paclitaxel (Taxol ®): a success story with valuable lessons for natural product drug discovery and development. Med Res Rev. 1999;18(5):315-331. [CrossRef]
Whiting PF, Wolff RF, Deshpande S, et al.   Cannabinoids for medical use: a systematic review and meta-analysis [published corrections appear in JAMA. 2015;314(5):520; 2015;314(8):837; 2015;314(21):2308; and 2016;315(14)1522]. JAMA. 2015;313(24):2456-2473. doi: 10.1001/jama.2015.6358 [CrossRef] [PubMed]
Olfson M, Wall MM, Liu SM, Blanco C. Cannabis use and risk of prescription opioid use disorder in the United States. 2018;175(1):47-53. doi: 10.1176/appi.ajp.2017.17040413
Hawley D, Graham T, Stasiak M, Dixon M. Improving cannabis bud quality and yield with subcanopy lighting. Hort Science. 2018;52(11):1593-1599. doi: 10.21273/HORTSCI13173-18
Potter DJ, Duncombe P. The effect of electrical lighting power and irradiance on indoor-grown cannabis potency and yield. J Forensic Sci. 2012;57(3):618-622. doi: 10.1111/j.1556-4029.2011.02024.x [CrossRef] [PubMed]