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Hosted by Drug Sense

Unofficial Transcript of Testimony of Dr. Michael M. Miller

(This is an unofficial transcript of the testimony of Dr. Michael M. Miller at the Informational Hearing on April 10 2001, transcribed from microcassette recording of testimony.)

COMMITTEE ON: STATE AFFAIRS
Representatives Skindrud, chairperson,
Krawczyk, vice chairperson,
Bies, M. Lehman, Petrowski, Wood, Young, and Travis

Testimony of Dr. Michael M. Miller, representing the State Medical Society, at Informational Hearing on Medical Marijuana of State Affairs Committee on April 10, 2001.

Dr. Miller: Well thank you for ahh inviting me and accommodating my schedule, and ahh thank you for this open hearing on this matter. I'm the president of the Dane County Medical Society and an alternate delegate to the State Medical Society of Wisconsin and the AMA House of Delegates. Ahh, I'm also secretary of the American Society of Addiction Medicine and chair of ACM's public policy committee. I practice just up the street at Meriter Hospital, where I serve as medical director for the New Start drug and alcohol treatment program for twelve years. My wife and I reside in Middleton and I've practiced addiction medicine in Wisconsin for almost 18 years, so my comments today are on behalf of the State Medical Society and the American Society of Addiction Medicine, and on behalf of my patients and my family 

I'll go off the record for a moment and say that I just told my secretary as I was leaving that I'm going to go up to the Capitol and help explain that medical marijuana is an oxymoron the two terms together and I'll explain why they don't exactly fit together. And driving in this morning ummm the aahh the ahhh internet quiz on WIBA was are you in favor or not in favor of medical marijuana ahh for the benefit of patients…that's the way it was phrased.

Anyone would say they want anything for the benefit of patients. The problem with the formulation of the question is the presumption that there's demonstrated benefit from smoked marijuana as a therapeutic agent. So, if you presume that marijuana is a therapeutic agent that leads you down a path that leads you to some reasonable conclusions, 'cause no one wants to be an ogre. But we have to check on the evidence of whether smoked marijuana is ahh an effective medication demonstrated by evidence. I believe that the policies adopted by the American Medical Association and the American Society of Addiction Medicine and the State Medical Society express as well as I ever could the opinion that should guide public policy today and I've attached for you copies of those policies. There are many anecdotal reports about the alleged benefits of smoked marijuana. There are definitely evidence-based reports in the scientific literature about the benefits of pharmaceutical THC taken orally in the form of Marinol. Ahhh nausea from chemotherapy and appetite enhancement for malnourished and underweight patients with AIDS and advanced cancer are definitely circumstances where Marinol has been of use. But unless there are studies that are published in the peer-reviewed literature that would provide evidence of the safety and efficacy of smoked marijuana, it would be foolish and dangerous for Wisconsin or any governmental entity to approve the use of smoked marijuana for alleged beneficial purposes. The plight of patients with HIV infection and advanced cancers is surely tragic and patients should be embraced with compassion from family and friends from health care professionals and from the government. But there's no scientific evidence that I'm aware of that offering marijuana cigarettes to these individuals equates to compassion. Marijuana is not a benign drug. Addiction to marijuana can and does occur, disability and dysfunction do result, families can be destroyed by cannabis addiction. The risks of legalizing smoked marijuana are great and the medical evidence of its' benefits is lacking. Until such time that valid and accepted research demonstrates that the benefits of smoked marijuana outweigh the potentially tragic costs, the State Medical Society believes it should not be legalized. Umm, it believes that appropriate medical research should be considered. Umm, control of potentially addictive drugs can affect rates of use and rates of addiction in the population, ahh that control of supplies in isolation is not the best public health strategy to reduce use rates and addiction rates. Many things need to be done to increase the availability of and the access to funding for treatment for cannabis, alcohol, tobacco and other drug addictions. The most important thing the legislature can do is to pass the parity legislation that would make addiction benefits at par with health insurance benefits for other conditions. Despite the relative merits of treatment over supply control, control of access to drug supplies still is an important intervention that is overseen by governments. Loosening controls will predictably result in increased rates of use; increased rates of use are clearly correlated with increased rates of addiction in the population. The key is to have treatment available for those people who develop addiction. Removing legal barriers to the use of smoked marijuana would result in increased marijuana use in our society. It's clear to me that some, though not all advocates of medically approved smoked marijuana are looking for just that result - increases in use in our society. Removing legal barriers to the use of smoked marijuana will harm the state by increasing the prevalence of cases of marijuana addiction. Removing legal barriers to the use of smoked marijuana will not benefit the state or its citizens. There are assertions that it can, but there's no evidence that that's true. So I say why authorize, as approved medical treatment an approach that does not have proven efficacy? 

In conclusion, speaking as an individual physician, I offer for you for your consideration, my professional opinion based on years of training and experience that the term medical marijuana is an oxymoron. It's a seductive oxymoron, but it's an oxymoron nonetheless`. THC has proven medicinal benefits. In the smoked form with all the toxic things that go along with smoking the product it's not so.

So my final comments are a shot of brandy at bedtime comes a lot closer to being grandma's good medicine than a hit of marijuana comes to being good medicine for any condition. Proponents of medical marijuana want to increase the public acceptance of marijuana by lending credibility to use such as by saying that it's medically effective, medically appropriate, medically justified. These proponents have no double blind studies as evidence for their assertions smoked marijuana is (unintelligible) medicine. One can only conclude that proponents of these measures have a political position they are trying to couch as a medical position. Ahh so my suggestion is your considering legislation is wait until the science catches up. There have been some difficulties getting pharmaceutical grade plant marijuana available for researchers, and there have been tragic situations where people attempting to do legitimate medical research on smoked marijuana for patients have been blocked in their efforts to get pharmaceutical grade marijuana to use in studies so you control the dose etc., plus the side effects. Ahh it looks like we're beyond that now and people are able to do research and I think we should await the results of those studies before we authorize smoked marijuana for any supposed therapeutic benefit. 

Chairman Skindrud: Thank you sir, Umm, I guess that's ahh a question that came to my mind and you say that they are now in the process of doing studies.

Dr.Miller: Right:

I'm just going to ask you a…I don't want to argue that…I...I told everyone when they came I don't want to argue the bill or argue the point but I want to ask you a question we have morphine, we have cocaine…

Dr.Miller: Right:

Rep. Skindrud: And we use those drugs and people use those drugs today, and I'm sure if they were not legal drugs today prescribed for somebody that has a condition that we would try to legalize cocaine and morphine. 

Dr.Miller: Right.

Rep. Skindrud: Would you present a paper that was probably identical to this?

Dr.Miller: No. There's evidence on morphine and cocaine. And, and and morphine is not smoked as opium. Now smoking opium…I don't think smoking opium is in the pharmacopoeia, but taking the active opiates out of opium and then putting them in some sort of form…somebody want to update this? It clicked off. (referring to reporter's microcassette recorder) but ahh there's a difference. So ah the question here isn't do we make THC legal for medicinal use? It already is. The question is do you make the marijuana plant and getting it into the bloodstream by smoking that, do you make that legal? Okay? It's a different issue. And again coca leaf is chewed and it's not a very effective way of getting cocaine into the bloodstream, ahh you refine the product and then you can use it by a variety of means and ahh so it's a different deal. And there's tons of evidence on the benefits of morphine and cocaine and there are studies on the benefits of THC. That's not what we're debating. 

Chairman Skindrud: Representative Wood.

Rep. Wood: Thanks Mr. Chairman and my questions are designed to get information (unintelligible) the subject (unintelligible). The testimony by Miss Rickert indicated that she did not view either capsulated or liquid form of THC as a suitable alternative because one could suggest that the entire dose is there whereas smoking she can approach it from the standpoint that once the symptoms are relieved she can stop smoking. Now what is your response as a physician to that?

Dr.Miller: I really don't understand the pharmacology that would be behind such an assertion. You put the drug into the bloodstream, If you put it in through the oral route it passes through the liver, it's metabolized there as a first pass as part of its metabolic pathway. Excuse me. Absorption is slower through the G.I. tract, but once it gets into your bloodstream, then its there until its either excreted or broken down by metabolism. You can get into the bloodstream through the oral route or through an injection route or through a nasal route or through a smoked route, but once its in the bloodstream, nothing…. the route of administration does not affect the route ahh the speed of disposition. Her contention, her contention…yeah okay…

Rep. Wood: My question, I think her testimony is she could adjust the amount that was in the blood better through smoking than through taking capsules or liquid doses.

Dr.Miller: There really is actually sir; some fairly good evidence about that and the fact is that it's not accurate. You can clearly measure the THC content in the pill better, you know how many milligrams or you know the potency of it. Ummm, you know about the absorption rates, and that can be, that can be measured in drug studies. The route, now again, if you had someone testify I don't they're getting it from a place that is measuring the percentage of THC in the leaf, okay? Even places like the San Francisco marijuana co-op will tell you something about the relative strength but I don't really think they are precise about the milligram per milligram in the, in the, leaf, okay? So she has a sense of what's strong marijuana and what's weaker marijuana, and how much you need to inhale and how deep of an inhalation, how long to hold it before exhaling. Those are methods for her to adjust the dosage but they are not anywhere near as precise as measuring the dose in a pill. And and ahh some people are actually suggesting that that marijuana inhalers be developed so that a measured amount of drug put in a appliance can be inhaled through you know through the lungs. That would give a measured amount but would not give the heat, the smoke, the carcinogens, the carbon monoxide, etc. It's the combustion of the leaf that provides a lot of the toxicity. And and, no, this idea that you can titrate the dose better with a smoked vegetable than with, than with ahhh a pharmaceutical product I would disagree with. 

Chairman Skindrud: Representative Lehman.

Rep. Lehman: Yes, thank you Mr. Chair. Somewhere along those same lines is in terms of ahh her damages to the stomach lining and inability to be able to ahhh digest certain pills form drugs. Is there anything done like for diabetes are able have ahh ahh an attachment that does a drop, a controlled drop in liquid form or not?

Dr.Miller: Ahh No, I'm not aware of any intravenous delivery systems, I'm not aware of any sublingual systems, under the tongue. I'm aware of the oral product. I'm aware of the fact that people smoke the leaf. And I'm aware that some companies are working on developing an inhalation delivery system ahhh ahh an inhalation delivery system that would be like the nicotine inhaler that the drug, the tobacco companies tried to develop.

Rep. Skindrud: Representative Young.

Rep. Young: Thank you Mr. Chairman. Dr. Miller, at the end of your testimony you talked about ahh we should wait (unintelligible) for legislation on this until we get the results back on the research on ahhhh…

Dr.Miller: smoked marijuana…

Rep. Young: smoked marijuana. How far are we from, getting some some information from that research angle?

Dr.Miller: I would tend to think, I'm not personally familiar with the research, but I would tend to think it's certainly more a matter of years than months, so in order to, you know, run the studies, look at the outcomes, analyze the results etc., I don't think its going to be in the next 12 months, but I'm really not an expert to testify on the status of the research and you know the…

Rep. Young: Okay, the study comes back I don't want to say positive or negative but if it finds we should legalize it, would you support it? Support legislation?

Dr.Miller: With regard to medicinal use, right. I would. But the American Medical Association wrote a report in '97. They're going to present an update of that report ahh ahh in June. And so an updated AMA report on medical marijuana is coming out just this summer. And even that report looks at the state of the research and in the last four years there's not been enough stuff come out to ahh to warrant an opinion of the American Medical Association the approval for the medicinal use of smoked marijuana.

Chairman Skindrud: Representative Wood.

Rep. Wood: Thank you Mr. Chairman. I believe ahh I'm trying to decide how to formulate this question, but as a physician, ahh, do you believe there's any psychological advantage to placebos?

Dr.Miller: Absolutely. 

Rep. Wood: So that's in particular cases a smoked marijuana may have a psychological effect that may have some sort of positive effect on the body's functions?

Dr.Miller: Without question.

Rep. Wood: Okay thank you.

Dr.Miller: I would say that with regard to ahh to marijuana…both the use of drugs for medical therapeutic reasons and the use of substances for intoxication and euphoria are accompanied by ahhm ahh effects of the ahh mental state of the patients who use it, their expectations, ahh if people expect to get benefit or expect to get high, they're much more likely to get high or get benefit than if they didn't expect it. And so if you were wondering whether some of the anecdotal reports of patients who smoke marijuana when they have HIV disease or ah wasting from cancer or multiple sclerosis, spasticity problems etc. If you were wondering whether some of those self-reports are based on the expectation of the patient and their wanting to get better, I think that is true, and could they actually get better based on the placebo effects? Without question, and that shouldn't be scorned. 

Chairman Skindrud: Representative Petrowski.

Rep. Petrowski: Thank you Mr. Chairman. Dr. Miller, Marinol, am I saying it right?

Dr.Miller: Marinol, I think is what they (unintelligible).

Rep. Petrowski: Is that basically a form of marijuana? It's the narcotic THC, is that what we're talking about?

Dr.Miller: Yes, yes, it's a measured amount of THC.

Rep. Petrowski: Have there been studies done on this?

Dr.Miller: Yes.

Rep. Petrowski: Are the studies to do with its ahhh, its side effects as a (unintelligible) medication? Is that why this drug was developed?

Dr.Miller: Ah Why was this drug developed? I would like to think that the reason it was developed was because the drug company thought they could make a profit. And the reason they thought that, was that they thought there was a market of the people who would want THC based on the anecdotal reports of marijuana smokers that maybe it was doing something. So ahh uhh I, I am not aware of the history of Marinol with regards to whether it just came up as an idea or results of studies with rodents or the like what have you. I tend to think the hypothesis actually may have actually have come from the fact is marijuana is so widely used and its known so much to be an appetite enhancer, of course its called the munchies, okay? The fact that Mar… it's…that marijuana enhances appetite sends out a thought what if we could take THC and use it as an appetite enhancer in people who are underweight and and need to ahh eat more. Ahh and clinical trials were done and it's proved effective.

Rep. Petrowski: So people have prescribed Marinol for a number of things?

Dr.Miller: Correct.

Rep. Petrowski: When somebody is going to prescribe this, you know, there are a number of drugs they could also prescribe…

Dr.Miller: Correct.

Rep. Petrowski: Are doctors prescribing (unintelligible) Marinol?

Dr.Miller: Yes, ah some do choose Marinol. Ahhm I ahh I ahh had some stuff here on specific studies that have shown different effects and there's no doubt there are some proven benefits from Marinol.

Rep. Petrowski: Is Marinol a really expensive drug?

Dr.Miller: Ah I do not know.

Chairman Skindrudi: Ah Doctor, umm there is one paragraphs in here that disturbs me a little bit in your testimony, and when you're I'll be honest with you, and that's Dr.Miller: Ah the bottom paragraph on the very first page. 

Dr.Miller: Alright.

Chairman Skindrudi: Marijuana is not a benign drug. Addiction to marijuana can and does occur. Dysfunction and disability do result. And I think everybody in this room absolutely agrees with that. But that same thing can happen if you are on cocaine or on morphine. Why do we say this about this particular drug if it can help somebody and because that same thing can happen with legalized drugs for pain and suffering that we have now?

Dr.Miller: I believe you answered your own question. Why should we say if it helps somebody? That's the whole point. We have to have evidence that marijuana in the smoked form is more effective than placebo or more effective than other agents. Again, (unintelligible) today. Do you believe that medical marijuana should be approved for medical purposes to benefit patients? The presumption if you take the argument back is, it works, okay? With morphine, with cocaine, they work, okay? Nobody wants to say we want to keep away from people for political reasons or otherwise something that's helpful. That would be not good sense, not good policy. But there's so many presumptions of evidence that serve as the beginning of the argument, and I believe that most people forget about that that they, they basically said let's just accept that premise that it's beneficial and go from there. 

Chairman Skindrud: Again, what do we do with people like Miss Rickert here who has said that she has used it and it has helped her, I mean whether it be placebo effect or whether it be true, if it's if it's working for some people, isn't that in a sense, somewhat of a study?

Dr.Miller: Well, ahh there are provisions in ahh umm in drug control regulations that ahh talk about compassionate use (unintelligible), and ahh there are a number of states that actually have authorized compassionate use protocols, so that individuals ahhh can have their doctor submit an application for a compassionate use protocol, and ahh that is the direction that one should consider and and what I don't know is the status of the FDA or the DEA as to these protocols of smoked marijuana. I believe, I believe that they do exist in some areas, but I cannot testify to ahh (unintelligible) so if you want to do more research on that, that is the term that's applied, compassionate use protocols.

Chairman Skindrud: Representative Wood…

Rep. Wood: This is not to (untelligible) response, but it appears that ahh Miss Rickert has all of those approvals and yet is not able to get officially, the marijuana for smoking, so I'm not sure what these compassionate use protocols (unintelligible)…

Dr.Miller: Ahhhm, I can't speak to that 

Chairman Skindrud: Doctor, thank you very much for you know putting yourself in the hot seat up here, 

Dr.Miller: You bet.

Chairman Skindrud: ...and thank you very much for taking time out of your schedule today

Dr.Miller: I'm very happy to be invited. Thank you so much. 

 

Updated Tuesday, June 08, 2010

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