May, 2018


By Michael J. Katin, MD

This year may see a major leap ahead in the effort to have marijuana readily available throughout the United States. As of the start of 2018, not only do 29 states have provisions for medical use of marijuana and 9 more states and the District of Columbia have legalized its use, but 12 more states are addressing approving either medical use, recreational use, or both. In comparison, 33 states have Republican governors and 26 of these states have both Republican governors and Republican-controlled legislatures! Cynics might debate the significance of the term, "altered states," based on this. It should be noted that 50 states and the District of Columbia have already approved the medical use of alcohol to treat depression and heartache and to stimulate self-confidence, although this had not proven to be consistently effective.

It is interesting that approval of marijuana as "medical" has not been backed by research that would have allowed endorsement by the FDA; in fact, in 2009 the Family Smoking Prevention and Tobacco Control Act gave the FDA the authority to keep families from smoking. This seriously reduced the number of ashtrays needed per house, since smoking as a family was discouraged and family members now needed to take turns. It also gave the FDA the power to regulate the content, marketing, and sale of tobacco products. There is no such federal legislation regarding marijuana, since....it's illegal! At least since the Uniform State Narcotic Drug Act, submitted in 1932, passed in 1934, and adopted by all states in 1935, which was two years after alcohol prohibition was repealed. A devious but brilliant stratagem, the Marihuana Tax Act of 1937 placed a tax of $1 per year for any medical or $3 for any business activity involving marijuana; the dilemma was that if one paid the tax he or she was admitting to an illegal activity, and not paying the tax submitted that person to extreme penalties for evading taxes. It's too bad this was such a rare example of government genius that putting an effort to prevent World War II was out of the question. http://erj.ersjournals.com/content/31/2/280

The rehabilitation of marijuana has occurred through the idea that it has medicinal benefits and, once the availability has been legalized for some members of the public, it has become now legitimized for all members of the public in one state after another. Well, maybe not all members of the public, since the minimum age everywhere seems to be 21. The Minimum Drinking Age Act of 1984 set 21 as the minimum age for use of alcohol throughout the country. This resulted in only 11% of eighth-graders, in a survey in 2012, reporting using alcohol in the past 30 days. Fortunately, while waiting to age from 18 to 21 to be able to drink or buy marijuana, one can operate a forklift, join the military (age 17 with parental permission), go to movies rated NC-17, and vote...oh, and buy tobacco products, except in California, Hawaii, New Jersey, and Oregon and, after July, in Maine.

Considering that marijuana was legitimized because of its medical benefits, it may be worthwhile comparing its value to another entity that has been around for years and whose medical benefits have been also subject to derision: radiation therapy.

Medical Marijuana Radiation Therapy
Makes people feel better +++++ ++
Paid by insurance +++ (but often after
peer-to-peer appeals)
Recipient willing to pay cash +++
Mechanism of action well-defined ++ +++
Can be misused +++ +++
More easily obtained in big cities +++ ++++
Previously associated with disreputable persons ++++ ++++
At the mercy of uninformed government decisions ++++ ++++
Can cause nausea under certain circumstances ++
Cheaper in other countries ++++ +++

But wait!!! What if these could work together, like surf and turf, sturm und drang or Trump and Pence? These two outcasts have, in fact, already been found to have synergism. In 2011, Ashutosh Shrivastava et al. described that cannabidiol could induce programmed cell death in several human breast cancer cell lines in vitro by the mechanism of coordinating cross-talk between apoptosis and autophagy. Of particular interest to radiation oncologists was the discussion that cannabidiol could increase generation of reactive oxygen species. In 2014 a publication by Katherine Scott et al. from the University of London proved that cannabidiol and delta nine tetrahydrocannabinol substantially enhanced effectiveness of radiation therapy in killing orthoptic murine glioma cells in vitro. Although this was inexplicably ignored by the Nobel Prize Committee, it provides a background for a proposal in 2017 to use nanoparticles to transport cannabinoids to tumor sites to avoid psychologic effects on the rest of the organism. The combined benefit of cannabinoids and radiation therapy was again discussed in a paper published only a few days ago, by Sayeda Yasmin-Karim et al. from Harvard, this time showing an advantage in treating human lung cancer (from cell line A549), Lewis lung cancer LLC-1 , and pancreatic adenocarcinoma PANC-02, transplanted into brave volunteer mice; treatment with 4 gray plus 2 micrograms of cannabidiol was considerably more effective in killing tumor cells than 4 gray of radiation therapy alone. Please temporarily overlook the finding that 5 micrograms of cannbidiol alone was more effective than 4 gray of radiation therapy alone.

It is always difficult to predict the future, but the outcome can benefit radiation oncology one of two ways. First, persons who want to offer medical care to the general population and want to make a decent income will tend to go into the cannabis industry rather than medical school, reducing the number of physicians coming out of training and making us more valuable per capita. Second, it is a matter of time before large cannabis dealers will want to acquire radiation oncology equipment as part of a seamless centralized one-stop treatment center Getting that established may take some work, but the less efficient systems will be weeded out. It would be helpful to reefer to previous experiences with combining treatment techniques, and there's no question that problems will be able to be hashed out. This could be the ultimate joint venture.

Either way, it looks like high times ahead for our specialty.

Emanuel Countdown: Dr. Ezekiel Emanuel's biographies list his birth year as 1957 but, interestingly, do not list a birth date. He has expressed that he does not wish to live past his 75th birthday. Giving him every benefit of the doubt, he will have his 75th birthday no later than December 31, 2032. Including May 1, 2018, this leaves 5,359 days to his goal.