By Steven Patiemo

The use of marijuana as a medicine is remarkably uncontroversial at the bedside of a cancer patient or a child suffering from convulsions who might be helped. As this consensus has grown into broad public acceptance, many state legislatures have leapfrogged federal prohibition and the Federal Drug Administration process to allow medical use of cannabis. But they have usually failed to translate compassion into safe, effective health care. Until recently, when New York got it right.

The Compassionate Care Act, passed by the New York State Legislature last month and signed into law by Gov. Andrew Duomo on July 5, introduces simple yet profound reforms by banning marijuana smoking and mandating individual dosing of medical cannabis in all other forms, such as capsules and vaporization. By treating medical marijuana like other medicines, New York shifted the debate into the mainstream of modem medi­cine and set a much-needed national standard of care.

New York’s ban on smoking, the most common method of tak­ing cannabis, has drawn head­lines and criticism from some medical-marijuana advocates. But as public policy, the ban is good science and an act of common sense. Cannabis has four times the tar of tobacco, and similar carcinogenic and respiratory risks. There is also the risk of secondhand smoke to caregivers and loved ones. State health-care systems should not be in the business of sanctioning smoking of anything, for any reason. Less noted but arguably of greater significance is New York’s mandating of individual metered dosing-i.e., requiring the stan­dardization of fixed-dose levels and safety monitoring for both the actual dose and purity. Metered dosing is the standard of care in modem medicine, allowing doctors to prescribe precise amounts based on the patient’s response, and reducing the chance of adverse drug interactions. Without metered dosing, doctors are reduced to having their patients “buy and try” cannabis and hoping for the best.

Given the impossibility of allowing smoking in a clinical setting, the liability inherent in uncontrollable dosing, and a reluctance to send patients to what still seems to many like a “headshop” to pick up medicine, relatively few doctors currently recommend cannabis. Individual metered dosing will give physi­cians the tool they need to ad cannabis to their treatment arsenal.
Metered doses can also be produced to medical standards­ something that is missing and has caused many problems in other state medical cannabis pro­grams. Like any raw plant, can­nabis may contain molds, fungi, bacteria, insect matter, growth enhancers, pesticides and other contaminants that are dangerous to patients, and the potencies of cannabinoid medicines vary widely. Cannabis produced in metered doses is easily tested for contaminants, and the potency of all active ingredients, for in­ stance, and sterilized for safety essential public-health safe­guards.

The dosing requirement delivers other benefits, too. Individually packaged doses of cannabis in bar-coded, medical-grade packaging are easily tracked using standard inventory controls. Currently, most medical marijuana is distributed in a bulk form that is indistinguishable from the street drug, presenting a serious risk of diversion. Moving to a medical supply-chain model makes sense from a business, public safety, regulatory and law-enforcement point of view.

New York’s proposal also addresses the Drug Enforcement Administration position that state medical-marijuana pro­grams don’t meet the standards of modem medicine because they lack “standardized composition or dosage.’

Finally, dose standardization is the key to improving the qual­ity of care for patients in the future. Without it, we have not
been able to gather sufficient reliable clinical data on the effectiveness of medical marijuana. After almost two decades since California became the first state to legalize medical cannabis, we still have relatively few scientifically meaningful findings.

As the Compassionate Care Act is rolled out over the next 18 months, the New York health­ care system will begin to benefit from a growing trove of medical data that can be used eventually to advance the science and clinical practice of cannabinoid medi­cine everywhere. Meanwhile, the introduction of smokeless cannabis in dosage form will immediately ease human pain and suffering and help to move medical marijuana from the underground economy to the mainstream of the nation’s health-care system.

Dr. Patiemo is a professor at the Duke University School of Medicine and deputy director of the Duke Cancer Institute. He is also chairman of the medical advisory board of PalliaTech, Inc., a New York phytomedical technology company.