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Whilst OTC opioid issue in this article refers to the US current issue, the Australian context is beginning to catch up!

Nora D. Volkow, M.D., and A. Thomas McLellan, Ph.D.: N Engl J Med 2016; 374:1253-1263  March 31, 2016DOI: 10.1056/NEJMra1507771
 
However, two major facts can no longer be questioned. First, opioid analgesics are widely diverted and improperly used, and the widespread use of the drugs has resulted in a national epidemic of opioid overdose deaths and addictions. More than a third (37%) of the 44,000 drug-overdose deaths that were reported in 2013 (the most recent year for which estimates are available) were attributable to pharmaceutical opioids; heroin accounted for an additional 19%. At the same time, there has been a parallel increase in the rate of opioid addiction, affecting approximately 2.5 million adults in 2014. 9 Second, the major source of diverted opioids is physician prescriptions.10,  11 For these reasons, physicians and medical associations have begun questioning prescribing practices for opioids, particularly as they relate to the management of chronic pain. Moreover, many physicians admit that they are not confident about how to prescribe opioids safely, 12 how to detect abuse or emerging addiction, or even how to discuss these issues with their patients. 13
 
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Despite the pressure of anecdotal evidence prevalent in the popular press and social media, for the past two years the American Epilepsy Society has been opposed to the expanded use of medical marijuana and its derivative, cannabidiol or CBD, in the treatment of children with severe epilepsy. At this time there is no evidence from controlled trials that strongly supports the use of marijuana for treatment of epilepsy. Our position is informed by the lack of available research and supported by the position statements from the American Academy of Neurology, the American Academy of Pediatrics, and the American Medical Association.

The American Epilepsy Society has consistently advised states against acting on anecdotal evidence alone and has called for more research. The need for more research is a consistent theme from nearly every medical society in the U.S. To help advance research, the American Epilepsy Society has requested that the Federal Drug Enforcement Agency reschedule marijuana to ease access for clinical studies.

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Why is whole plant marijuana not approved? Concerns focus on abuse liability, safety and effectiveness.

Abuse liability. Marijuana has high abuse potential, no currently approved medical use and is considered unsafe. At least 4.2 million Americans have a cannabis (marijuana) use disorder, with about 30.5 percent of current marijuana users harboring this problem. Long-time heavy users can experience a robust withdrawal, reflecting adaptive changes in the brain and body caused by the drug. Shortly after use, marijuana intoxicates and impairs higher brain functions, learning, memory, planning, and decision-making. Driving skills are reduced and the risk for injuries increases. Functioning at school or at work is compromised, especially because marijuana takes so long to clear from the body, days to weeks, and much longer compared with an alcohol binge. Complex human performance can be impaired as long as 24 hours after smoking a moderate dose of marijuana and the user may be unaware of the drug's influence. For 7 to 20 days, abstinent marijuana users may have impaired attention, concentration and impulse control. The most robust, durable deficits are documented in heavy, steady marijuana users. Even after one month of withdrawal, daily, heavy marijuana smokers can manifest impaired higher brain functions. Yet the indications for marijuana are for chronic medical conditions, requiring daily or more frequent use.

Safety. There is a strong association between marijuana use and psychosis or schizophrenia, in at least four ways: (1) marijuana can produce transient schizophrenia-like symptoms in some healthy individuals; (2) in those harboring a psychotic disorder, marijuana may worsen the symptoms, trigger relapse, and negatively affect the course of the illness; (3)  susceptible individuals in the general population develop a psychotic illness with heavy marijuana use, which is associated with age of onset of use, strength of THC in marijuana,  frequency and duration of use; (4) marijuana use is associated with lowering the age of onset of schizophrenia. Among youth, marijuana use is associated with poor grades and with high school drop-out rates, with those dropping out of school engaging in high rates of frequent marijuana use. Early use of heavy marijuana is associated with lower income, lower college degree completion, greater need for economic assistance, and higher unemployment.  In sum, marijuana use is associated with an increased risk of degraded brain function, increased motor vehicle crashes, emergency department visits, psychiatric symptoms, reduced educational and employment achievement, reduced motivation, increased use of, and addiction to other drugs, and adverse health effects on the developing fetus.

Effectiveness. The FDA is not the only body that has questioned the effectiveness of marijuana. Non-government academic physicians and scientists have extensively scrutinized biomedical research (meta-analyses) on the use of whole plant marijuana for medical indications. Independently, they have concluded that there is scant, inadequate or no evidence that whole plant medicine is valuable as a first line treatment for a myriad of medical conditions claimed by the marijuana lobby.  For edibles, rigorous evidence is at zero or near-zero levels. Indeed, many specialty medical associations (Neurology, Psychiatry, Bertha K.

Bertha Madras is a professor at Harvard Medical School. 

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From the January ACP Hospitalist, copyright © 2016 by the American College of Physicians

By Mollie Durkin

After a decrease in hospitalizations related to marijuana alone from 2004 to 2007, these inpatient admissions ballooned from 11,267 in 2007 to 20,471 in 2011—an 82% increase, said Dr. Zhu, a postdoctoral associate at Duke University Medical Center in Durham, N.C.
 
This analysis considered 4 categories of marijuana use: marijuana only; marijuana and alcohol; marijuana and other illicit drugs; and marijuana, other illicit drugs, and alcohol. “Our preliminary findings indicated that both the number of cannabis-related ED visits and hospitalizations has increased since 2007, especially for visits involving cannabis use only,” Dr. Zhu said. Marijuana-related ED visits increased by 71% from 2004 to 2011, from 280,671 to 478,989, she reported. Those related to use of marijuana alone increased faster than other categories, reaching 144,566 in 2011, double the number of visits in 2004.
 
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