Compassionate Care New York | 347.781.5435 voice | compassionatecareny@gmail.

com
June 5, 2014
Dear Senator Savino and Assemblyman Gottfried:
The members of NY Physicians for Compassionate Care are extremely grateful to your
leadership in sponsoring legislation that would allow patients in need to gain legal access to
medical cannabis.
We are aware that some of your colleagues want you to accept restrictions on the smoking of
marijuana. It might be reasonable, as you have proposed, to limit smoking of the flowers to
people 21 years of age and over (hopefully with some exceptions for critical need). However, we
want to give you the scientific arguments to use to counter the medically unsound proposals that
you:
1) exclude smoking altogether,
2) or that you limit smoking to only a metered-dose vaporizer approach.

1. Medical basis for including the smoking route for medical cannabis.
In 1999, the White House-commissioned Institute of Medicine of the National Academy of
Sciences spent two years reviewing the scientific data then available with respect to potential
benefits of medical marijuana. The study team found substantial consensus among experts in
the relevant disciplines on the scientific evidence about potential medical uses of marijuana.
The study team concluded that, nausea, appetite loss, pain and anxietyall can be mitigated by
marijuana. The study team did not exclude smoked marijuana from its conclusions, noting
instead that there are even some limited circumstances in which we recommend
smoking marijuana for medical use. See Janet E. Joy, Stanley J. Watson, Jr., and John A.
Benson, Jr. Marijuana and Medicine: Assessing the Science Base, Division of Neuroscience and
Behavioral Research, Institute of Medicine (Washington, DC: National Academy Press, 1999).
In the past ten years, the findings of that report have been corroborated by numerous peer-
reviewed, randomized, double-blind controlled studies of smoked marijuana published in highly
respected and credible medical journalsthis despite little federal support for and significant
federal obstruction of medical marijuana research. These studies prove the safety and efficacy of
smoked marijuana for chronic, neuropathic pain. The following is a brief sample of such studies
(each of which used smoking as the method of ingestion):
Abrams D, et al. Cannabis in painful HIV-associated sensory neuropathy: a randomized
placebo-controlled trial. Neurology 68 (2007): 515-521.
Wallace M, Schulteis G, Atkinson JH, et al. Dose-dependent Effects of Smoked Cannabis
on Capsaicin-induced Pain and Hyperalgesia in Healthy Volunteers. Anesthesiology 107
(2007):785-796.
Ellis R. et al. Smoked medicinal cannabis for neuropathic pain in HIV: a randomized,
crossover clinical trial. Neuropsychopharmacology 34 (2009): 672680.
Wilsey B. et al. A randomized, placebo-controlled, crossover trial of cannabis cigarettes in
neuropathic pain. Journal of Pain 9 (2008): 506-521.


Compassionate Care New York | 347.781.5435 voice | compassionatecareny@gmail.com

Another issue with the non-smoking approaches is that most of them will utilize extracts of the
cannabis plant, rather than whole plant material.
The problems:
Extracts may leave out therapeutically important terpenoids that are needed for the full
medical cannabis entourage effect produced by whole plant botanical material; and
Extracts may be too potent for some patients to tolerate, compared to the whole plant
botanical material (this is due in part to the THC becoming more concentrated, and in
part because the terpenoids that strongly modulate the effects of the cannabinoids may
be reduced or absent from the extract).

2. The medical and socioeconomic reasons to not limit smoking to only a
metered-dose vaporizer device (vape) approach
(a) Medical objections to the metered-dose vape approach:
One of the bases for this proposal is the assumption (proven incorrect) that medical
cannabis causes emphysema and/or airway tract cancers. Both assumptions have
been disproven by clinical studies published in the peer-reviewed literature (see
references below).
The companies that process the plant material for these metered-dose devices will
find it in their economic interest to limit the number of strains of cannabis to just a
few select strains that they arbitrarily select. It is highly unlikely that they would
make available the scores of strains that are needed for the different cannabis-
responsive diseases, because they will have to process each of those strains and
that will cut into profits. This would make it impossible for patients to gain legal
access to the types of strains that they need, be it one of scores of subtypes of the
sativa and/or indica varietals that are found to be effective. Physicians and patients
should be the ones deciding on what strains to use not private companies.
At least one of the private companies that we are aware of, in this vape sector, has
proposed that the cannabis material be irradiated - so as to inactivate any pathogens
(molds, fungi, etc.) growing on the plants. Irradiation causes DNA in the cells to
clump into what is called adducts, some of which can be carcinogenic. That is why
we can tell you, as physicians, that this is an unproven long-term safety paradigm.

(b) Socioeconomic objections to the metered-dose vape approach:
The companies and the elected officials who have proposed this approach are clearly not
taking into account the many thousands of patients in New York who are of limited
financial means, and cannot afford either (i) the vape pens themselves (which would
probably cost a few hundred dollars) or (ii) the metered-dose ampules containing the
cannabis bud material. It is axiomatic that whenever companies process a product,
they have to charge more for the processed product than for the unprocessed product.
Therefore, what would be an excellent business model for these private companies,
would turn out to be horrendous (and unfair) for patients with fatal or debilitating
diseases who happen to be of limited means (because of being working poor, because

Compassionate Care New York | 347.781.5435 voice | compassionatecareny@gmail.com
their disease has left them unable to work, or because of medical bankruptcy from the
costs of their or their childs illness). These people will not be able to afford either the
processed product or the devices for using it and they will be forced to either go to the
black market and risk being arrested, or to suffer needlessly.
In conclusion, the proposals to exclude smoking altogether or to limit smoking to metered-dose
vaporizer devices run counter to the sound medical practices that have been recognized and
promulgated by this nations highest scientific body The Institute of Medicine of the National
Academy of Sciences.
We hope that this medical information will give you some sound arguments to make to your
colleagues, to counter their push for compromises that do not have a sound medical basis.
References on the absence of an association for emphysema and/or cancer in chronic marijuana
smokers:
M. Pletcher, E. Vittinghoff, R. Kalhan, et al., (2012) Association Between Marijuana
Exposure and Pulmonary Function Over 20 Years," JAMA, 307(2):173-18.
Russo, E., Mathre, ML., Byrne, A., Velin, R., Bach, P., Sanchez-Ramos, J., and Kirlin,
KA. (2002). Chronic Cannabis Use in the Compassionate Investigational New Drug
Program: An Examination of Benefits and Adverse Effects of Legal Clinical Cannabis.
Journal of Cannabis Therapeutics (JCT): 2(1): 3-57.
Tashkin et al. Marijuana Use and the Risk of Lung and Upper Aerodigestive Tract
Cancers: Results of a Population-Based Case-Control Study. Cancer Epidemiology,
Biomarkers & Prevention (2006).
Bloom JW, et al. Respiratory effects of non-tobacco cigarettes. Br Med J (Clin Res
Ed). 1987 Dec 12;295(6612):1516-8.
Aldington S, et al. Effects of cannabis on pulmonary structure, function and
symptoms. Thorax. 2007 Dec;62(12):1058-63.


Chair, Howard Grossman, MD

Co-Chair, Sunil Aggarwal, MD, PhD
New York Physicians for Compassionate Care

Member, Richard M. Carlton, MD


NY Physicians for Compassionate Care is group of more than 600 physicians from across New York
who support the use of medical marijuana to alleviate the suffering of patients living with serious illness
or debilitating conditions.