Internal Medicine Of Southwest Florida Newsletter
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Medical Marijuana
The History of the Stethoscope
Healthy Dessert
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Dr. Raymond Kordonowy MD
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Issue: # 8 June/2010

We find ourselves in the real summer season.  Recently I have been hearing discussion about and seeing media pieces concerning the legalization of medical marijuana.  As a physician who has never prescribed medical marijuana (the smoking method), I decided I would educate both myself and my readers on this topic.  It was a very interesting journey and I encourage you to read this first featured piece.

Instead of another disease topic, I opted to provide a history article on the stethoscope (second article).  Last newsletter's recipe article was a hit with our readers, so I found another good dessert recipe that is very healthy.

Medical Marijuana
marijuana plant Does marijuana have any medical indication?

On June 14th I was driving to work in the morning and heard an NPR piece (yes, I am a big fan of NPR radio).  The piece was about the medical marijuana market. I found myself asking, "How has the debate of legalizing marijuana been successfully sold to the public on the merits of its use as a medication?  I am unaware of any FDA approved indication for smoking marijuana yet there appears to be a foregone conclusion by the media and public at large that there are diseases for which marijuana is indicated.

Being somewhat of an intellectually inclined person, I am irritated when incorrect premises begin an argument (take my commentary on the health care debate for instance). This business of the media discussing medical marijuana is also predicated on a false premise (or so I thought as I started my personal inquiry). I decided to research this topic and report to our newsletter readers. Let's see what I found out...
Marijuana (cannabis) appears to have originated from Central Asia and was being consumed long before man was writing things down. Archeological discoveries indicated that it had been known to be in China since at least 4000 BC! It was described by the Emperor of China, Shen Nung (he discovered tea also) for its properties and therapeutic uses in a compendium he wrote in 2737 BC. In 1839, a British physician William O'Shaughnessy discovered it in India and described its therapeutic uses for nausea, muscle relaxation,seizure control and pain relief. In 1854, cannabis was listed in the US Dispensatory and was sold freely in pharmacies of western countries. It was available as a tincture and extract in Britain for over 100 years.

It was in 1937 that the American authorities condemned cannabis for being responsible for insanity, moral and intellectual deterioration, violence and various crimes- apparently setting the stage for making it illegal and to tax it. Also in 1937 (following the lifting of alcohol prohibition) the US Government introduced the Marijuana Tax Act: a tax of $1 per ounce when used for medical uses and $100 an ounce for unapproved uses. It appears there is precedence for how we can potentially tax this product if we go back to this legislation for review.   Remember, we were in a depression in the 30's (paralleling the current severe recession) so perhaps we were looking for new tax revenue (like now)?  In 1942, cannabis was removed from the US Pharmacopoeia, thus losing its therapeutic legitimacy.

As stated in my introductory paragraph of this newsletter, there recently is all this talk of medically indicated marijuana.  In 1978, following a lawsuit filed by a glaucoma patient who was treating himself (apparently not even physician recommended), the government created a compassionate program for marijuana cigarrettes.  Twenty people were allowed to legally have marijuana cigarettes under the supervision of the National Institute on Drug Abuse following approval by the FDA for this stated program. The program was discontinued in 1991 by President Bush but in 2004 there were still 7 individuals registered and receiving government regulated marijuana. The government does have a standardized marijuana approved, allowing a few growers to provide a regulated product for ongoing medical research to look into is potential uses for disease treatment/management. The government regulates the potency and species to be used for research in order to provide consistency and a standard.  There are a wide range of cannabis species with various potencies and characteristics (hence the market for marijuana).

Cannabis has over 460 known chemicals, 60 of which are under the name cannabinoids. THC is the major psychoactive ingredient. There is now a well recognized receptor system in the body for the cannabinoid chemicals.  Our body makes at least 2 chemicals which stimulate these receptors and have effects on neurotransmission and appetite stimulation. The compounds in marijuana also stimulate these receptors and are responsible for the various effects that using this drug has on people.  The medical field hopes to have medication that takes advantage of the endocannabinoid system to decrease appetite and help with weight loss.

Officially there are no US Food and Drug Administration approved indications for smoking marijuana. There are 14 states that have decided to override the federal position on smoking marijuana for medical treatment. California was the first in 1996 and is the only one that has legalized dispensaries. The American Medical Association has weighed in on this issue as well. It is considered a schedule one substance (highest risk for abuse for which no beneficial purpose has been meaningfully proven). The American College of Physicians are on record as recommending this schedule classification be revisited and revised- mainly in order to lower the legal risk for physicians to recommend it and also to lower the barriers to promote more research into it's potential therapeutic benefits. The ACP also states that the data suggest it has less dependency potential than other drugs.

On a more harmful note, there are health hazards from the smoking delivery system and to date no adequate data regarding health benefits from smoking marijuana.  There is now a vaporizing device called the Volcano vaporizer that will liberate the chemicals of marijuana without creating smoke. This device doesn't come out and say it is for marijuana but rather it is for herbal distillate use. There are recipes for getting various herbal flavors from various plants/herbs. This sleek looking metal flask heats the plant to near burning and the volatile chemicals rise into a collection bag which has a mouth piece/opening to release the collected contents. A person can inhale the contents of the bag to receive delivery of the drug to the mucosa and lungs without the smoke.  Vaporization could be a method of delivery that merits further study. See the comments about Sativex two paragraphs below.

There are two medically approved medications that contain cannabinoid chemicals. One is a synthetic THC patented as Marinol (approved in the US in 1985) for chemotherapy related nausea in cancer patients and HIV related weight loss/anorexia.  I have prescribed Marinol and my experience with patients using it is similar to the data- it helps but has significant side effects.  There are other available products that work better and are better tolerated. You can get high from Marinol which limits its tolerance, especially in the elderly. Another FDA approved medication is an analog (similar but not exactly) of THC and is patented under the name Cesamet. Its indication is also chemotherapy related nausea in cancer patients. This product has been available in Canada since 1982.

In the interest of brevity I would like to summarize some other conditions that have been touted as being medical benefited from marijuana.  The diseases that have been reasonably studied to date and do show some benefit in terms of having effects over placebo include: 1) mild to moderate pain relief (minimal and conflicting data) 2) antispasmodic and muscle relaxant properties for certain symptoms in multiple sclerosis and spinal cord injuries, 3) promising data on Tourette's syndrome for reducing vocal and motor tics as well as behavioral and obsessive-compulsive features seen in this syndrome,  4) marginal data for epilepsy. 

There is increasing interest in possible anti-inflammatory and immunologic effects (especially on cancer cells).  The low down on glaucoma is that the drug does lower eye pressure but only for a few hours with each dose and at the cost of significant side effects.  There are many other far better products currently available for this condition. The most recently promising cannabinoid medication that is presently approved in Britain and some European countries and is being studied for approval in the US comes under the brand name Sativex.  This is an aerosolized inhaled form of THC and a second ingredient known as CBD.  It does help with cancer related pain and due to the CBD component is better tolerated and more effective for pain relief. It is produced by GW pharmaceuticals (British company). Most recently an article described at a basic science level new data that even Alzheimer's pathology might be benefited from the compounds in marijuana. Can we imagine the market for this if we find a useful way to target this disease?

I would like to summarize my conclusions of researching this rather broad topic.  Marijuana has been around for a long time and has been used medically centuries before our country was formed.  The US and other western nations did use it medicinally up until the 1930's/40's.  It was politicized and even taxed in our prior history as a nation and now it appears on the same path. There are no FDA approved indications for the smoking of marijuana and due to the health hazards of this delivery method most physicians would agree with the FDA's position.  Recreational and commercial marijuana is a topic of debate but I am bothered that the media and perhaps the public at large is accepting this idea that there actually are approved indications for smoking marijuana-there are none.  Articles that lead people to believe that there are accepted indications for medical marijuana are starting with a false/untrue premise and I simply want folks to know this.

It is my opinion that the people advocating marijuana for medical indications really are interested in legalizing it for recreational and commercial reasons.  The black market marijuana has been bred for the euphoric potency of the THC component of the marijuana plants and thus some of the medically helpful substances being studied might not actually be in the "street versions" of marijuana.The medical profession has been used as an "in" for legalizing the smoking of this recreational drug.  There are currently proven areas for which cannabis derived medications are approved and prescribed.  More study into marijuana might lead to other indications as well as better delivery systems and "mixes" that might offer better safety, tolerability, as well as effectiveness.

Laennec and the Stethoscope
 Medical Device History

Laennec"s stethoscope

The following brief history comes from excerpts from a lecture series provided by Professor Sherwin B. Nuland from Yale School of MedicineHis lecture series I obtained from a series entitled The Great Courses, Teaching that engages the mind (TM). This is a product provided by a company known as The Teaching Company.

Before we get to the story of the stethoscope we first need to recognize Giovanni Morgagni.  He wrote a 3 volume treatise titled On the Seats and Causes of Disease as Indicated by Anatomy in 1761.  His accounting of 700 autopsies correlated diseases with specific organs of the body.  From his work arose the idea of physical examination.  In 1789 a French physician named Jean-Nicolas Corvisart eventually developed the French method of physical examination that used systematically 4 methods of evaluation: looking, touching, tapping and listening.  The tapping is known as percussion and was actually was written about in its own book by a young man, the son of an innkeeper.  The father taught the young man how to use percussion to evaluate the status of their wine barrels.  The young man was named Leopold Auenbrugger and he applied this method to peoples' chests to evaluated and diagnose TB pneumonia.  His book was lost to Morgagni's epic work and thus his method didn't catch on until Corvisart found Auenbrugger's book in German text and he translated it into French. From the translation he began to perform this method to patient evaluation and subsequently systematically examined patients.  During Laennec's time the listening part of the chest examination required that the physician lay his ear against the often uncleaned chest. Amongst his accomplishments he is now known to have documented alcoholic cirrhosis.  He described the pathology of pulmonary tuberculosis and wrote a paper on valvular heart disease. 

Eventually his accomplishments became recognized and he was elevated to the position of Physician which at the time meant chief of medicine. As the chief of medicine in Paris, France he was responsible for students and their training.  He came upon a young female patient who had heart disease. In Paris in his day bathing was not common. Laennec was a modest man and apparently was intimidated by the breasts of his female patients. This buxom, young, obese lady was apparently not clean and he couldn't find it in himself to examine her yet his teaching methods required this.  The story goes that he was returning home after this experience and observed some children playing a game in the courtyard of the Louvre.  They were playing an old game even he had participated in as a child. One child was scratching one end of a 6-8 foot board with a pin and the other had his ear on the other end of the wood, listening for the scratches and translating this into words- a sort of "Morse Code",  if you will. 

Observing the kids in this way, it suddenly dawned on him that he could use a similar method to exam his female patient. He rushed back to the hospital and rolled up a notebook into a cylinder and applied one end under her left breast and the other to his ear.  He found he could hear even better than the direct ear to chest method.  He also worked wood and had a lathe.  He eventually turned a cylinder to his liking and he used this "le cylindre" as part of his examinations thereafter.  He gave it a scientific name stethoscope from the Greek "stethos" which means chest and "scope" which means "observe".  Using this device and being the avid examiner and document keeper that he was,  within 3 years of using it he had written a two volume book which in English was titled "A Mediate Auscultation".
Tasty No Guilt Dessert
South Beach Ricotta Dessert A South Beach Recipe

Last newsletter's interest in the borscht recipe was very high.  This newsletter I decided to remind our readers of a very healthy year round dessert recipe from Dr. Agatston'sfamous book.  His diet has been scientifically validated to help with metabolic syndrome, diabetes and pre-diabetes.  His diet is also cholesterol/lipid friendly and I highly recommend it as a diet appropriate for most folks.

You can go with even lower fat ricotta cheese to achieve less calories and less saturated fat. Also you can use other flavorings to provide more variety to this "pudding" type dessert.  I have found you can make them ahead of time and keep them in a ramekin (custard dish) so they are easily available for an after dinner snack. Flavorings to consider: chocolate, almond extract, lime peel, banana, berries.  If you use real fruit you won't need to add the artificial sweetener.  Having a pre-made handy dessert in the fridge will keep you from being tempted to eat something less healthy.  Storing them in the refrigerator also allows the flavoring to "stew" a bit and enhance the flavor experience (cover them though to prevent staleness).

Lemon Peel Ricotta Crème Recipe - South Beach Diet

Fast and easy to make, this is sort of a pudding made with ricotta cheese, grated lemon peel, vanilla, and sugar substitute. Good for a snack or dessert for those following the South Beach Diet.
Prep Time: 5 minutes
Cook Time: 15 minutes
Total Time: 20 minutes
1/2 c part-skim ricotta cheese
1/4 tsp grated lemon peel
1/4 tsp vanilla extract
1 pkg sugar substitute
Mix together the ricotta cheese, lemon peel, vanilla extract, and sugar substitute. Serve chilled.

Yield: 1 serving

Per Serving: 178 cal, 14 g pro, 7 g carb, 10 g fat, 6 g sat. fat, 38 mg chol, 0 g fiber, 155 mg sodium

Recipe from: The South Beach Diet : The Delicious, Doctor-Designed, Foolproof Plan for Fast and Healthy Weight Loss by Arthur S. Agatston M.D. (Ballantine Books)
Copyright 2003 by Arthur S. Agatston M.D.

I and my group wish to thank you for your patronage.  I hope the newsletter this month was informative, fresh and fun.  I wish everyone wellness and a safe summer.

Raymond Kordonowy MD
Internal Medicine Of Southwest Florida