Herbal Cannabis as MedicineAbioculturalanalysis 

By Vanessa Mardones

11,160 words

September 2011

 

A dissertation submitted to the

Department of Anthropology and Conservation at the University of Kent-Canterbury, in association with Kew Royal Botanic Gardens,

in partial fulfillment of the requirements for the degree of

Master of Science in Ethnobotany.

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Acknowledgements

I would like to thank all the people who supported me in this research endeavor. First, I would

like to thank Anna Waldstein and Cameron Adams of the University of Kent for their

encouragement, especially during the planning phase of this project when I had reservations

about taking on the subject of a marginalized botanical medicine. I would like to thank Barbara

and Mario Mardones for their unconditional support on this journey. Thanks to Kaisang Tenzin

for the invaluable brainstorming sessions, indispensible tech support, and amazing moral

support.

For their insightful correspondence, generous guidance, and inspiring work, I would like to thank

(in no particular order) Rose Habib of CannabAnalysis Laboratory, Christine McGarvin at the

Institute for Cannabis Therapeutics (ICT), Ed Glick of Healing Flowers Center, Todd Dalotto,

Cannabis Horticultural Researcher, Buckie Minor of Full Spectrum Laboratories, Mary Lynn

Mathre of Patients Out of Time, Ethan Sommer of the Medical Cannabis Association, Zachary

Jarou of Cannalytics Laboratory, Eileen Konieczy, RN Medical Oncology, Hugo de Boer of

Uppsala University, Dr. David Baker of Barts and The London School of Medicine, Dr. Jeffrey

Raber of the Werc Shop Laboratory, Dr. Lester Grinspoon of Harvard Medical School, Dr.

Amanda Reiman of the Berkley Patients Group, Dr. Mitch Earleywine, Dr. Ethan Russo, Dr.

Julie Holland, Keith Stroup from the National Organization for the Reformation of Marijuana

Laws (NORML), Amanda Feilding of the Beckley Foundation, and Rick Doblin of the

Multidisciplinary Association for Psychedelic Studies (MAPS), and all the inspiring contributors

to Breaking Convention, Canterbury 2011.

This project was a collaborative effort and would not have been possible without the help of all

those named above, and especially those who remain unnamed, the survey participants who were

willing to share their experiences with using cannabis as medicine. It is my sincere hope that this

work will be of benefit to all those who seek access to safe and effective medicine without fear of

prosecution or imprisonment. It is time for change.

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Abstract

Subsequent to the passage of the California Compassionate Use Act (Proposition 215), a

voter initiative passed on November 5, 1996 permitting the cultivation, possession, and

use of cannabis for medical purposes in California, fifteen other US states and the

District of Columbia have followed suit and decriminalized cannabis for medicinal use. In

response to the emergence of this medical marijuana market, a number of analytic

chemistry labs have been established for the purpose of quantifying cannabinoid content

and testing for contaminants in cannabis to be used for therapy. Current literature has

shown that there are at least 80 cannabinoids in various strains of cannabis, and has also

shown that these constituents have unique pharmacological effects (Izzo et al 2009:515).

Does access to chemical analysis data quantifying cannabinoid content affect patients’

selection of medical marijuana cultivars and delivery methods? Literature review, semi-

structured interviews and a self-administered online survey of medical marijuana users

will be employed to address this research question from a biocultural perspective.

Keywords: Cannabis, medical marijuana, cannabinoids, therapeutic potential

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Table of Contents:

Acknowledgements………………………………………………………………1

Abstract………………………………………………………………………….2

Table of Contents………………………………………………………………..3

List of figures, tables, and

appendices...……………………………………………………………………..4

Introduction……………………………………………………………………..5

Background……………………………………………………………………...6

Botany of Cannabis……………………………………………………………...7

Cannabis and Culture……………………………………………………………10

Chemistry of Cannabis…………………………………………………………..12

Pharmacology of Cannabis………………………………………………………17

Cannabis as Medicine……………………………………………………………19

Social Science and Medical Marijuana……………………….…………………...21

Aims and Objectives.……………………………………………………………23

Research Question………………………………………………………………24

Methods…………………………………………………………………………24

Results…………………………………………………………………………...31

Analysis………………………………………………………………………….41

Conclusion………………………………………………………………………43

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Figures:

Figure 1: Cannabaceutical facts label…………………………………………Page 14

Figure 2: Promotional flier…………………………………………………………26

Figure 3: Number of daily responses……………………………………………….31

Figure 4: Gender distribution………………………………………………………32

Figure 5: Age distribution…………………………………………………………..32

Figure 6: Geographic distribution of respondents…………………………………..32

Figure 7: Modes of administration………………………………………………….33

Figure 8: Symptom word cloud……………………………………………………...34

Figure 9: Therapeutic applications…………………………………………………..35

Figure 10: Strain preference word cloud…………………………………………….36

Figure 11: Commonly named strains………………………………………………...37

Figure 12: Strain selection criteria word cloud……………………………………….38

Figure 13: Medical cannabis cup 2011……………………………………………….39

Figure 14: Importance placed on chemical analysis………………………………….40

Figure 15: Preference for cannabinoids……………………………………………...40

Figure 16: Cannabinoids selected for therapeutic application,

grouped by symptom code…………………………………………………...42

Tables:

Table 1: Comparison of Gas Chromatography and

High Performance Liquid Chromatography………………………………….14

Table 2: American Alliance for Medical Cannabis Survey Results…………………....22

Table 3: Symptom code and compound correlations………………………………...42

Appendices:

Appendix 1: Medical Marijuana Questionnaire……………………………………….47

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Introduction:

Medical marijuana is the subject of a greatly contested discourse at the interface of science and

society. The actors involved in the issue of medical marijuana are political, economic, and

medical. At play are issues of governance, public policy, health, education, and human rights. An

integration of all these perspectives, syncretism, is needed. Syncretism, as expressed by

ethnobotanist Luis Eduardo Luna at Breaking Convention (2011), is the integration of multiple

discourses. Due to the lack of syncretism in the discourse around medical marijuana, the current

state of patient access to safe and effective medicine, without risk of persecution, is greatly

limited. Despite the fact that scientific research has shown that cannabis is both safe and

effective in the treatment of serious human pathologies such as multiple sclerosis, glaucoma, and

cancer among many other valid therapeutic uses, and the fact that multiple medical associations

and legal precedents have recommended the rescheduling of cannabis, still, it is classified a

schedule I narcotic by the US Drug Enforcement Administration (DEA). A schedule I narcotic

is defined as a substance which has no accepted medical use, extremely high potential for abuse,

and high potential for psychological and physical dependency. International drug policies, with

few exceptions, follow the stance of the DEA on regulation of this botanical. These regulatory

policies deprive not only some very deserving patients of access to safe medicine, but also deny

the scientific community of access to germplasm for investigative studies which could shed

further light on the empirical basis for cannabinoid therapeutics.

The sociopolitical consequences of the current convention, as expressed by Feilding (Breaking

Convention 2011), are threefold. Firstly, it fosters the growth of a criminal underground for the

distribution of cannabis germplasm. Secondly, it undermines human rights and public health.

And third, it wastes billions of dollars a year enforcing the prohibition of a plant whose use, over

thousands of years, and across numerous cultures worldwide, has never led to a single

documented fatality. Many pharmaceutical drugs cannot claim such a safety profile. Feilding

concludes, saying “The war on drugs has failed.”

The shortcomings of the current regulatory policies on cannabis demonstrate the need for

syncretism in the discourse between science and society, and are the reason for selecting the

subject of this thesis: a biocultural analysis of medical marijuana.

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Background:

In the last century prior to its recent re-examination as a therapeutic herb, cannabis has largely

been relegated to the class of illicit recreational drugs. As a result, the scientific knowledge of its

chemistry and effects is far from complete. Classified as a Schedule I drug according to the

Controlled Substance Act (1970) in the US, it has been very difficult for researchers to gain

permission and access to carry out clinical studies on its effects, which in turn hinders its

acceptance as a legitimate medication.

Because its contemporary use has been largely recreational, plant breeders have selected cannabis

cultivars for attributes which may or may not be related to its medicinal effects. THC (∆-9-tetra-

hydrocannabinol), the best-known cannabinoid compound due to its psychoactive properties, is

often selected for, as well as aroma, flavor, and aesthetics (i.e. visible resin crystallization, color,

size and morphology of female inflorescence). Non-THC constituents in cannabis such as

terpenoids and other terpenophenolic cannabinoid compounds such as CBD (cannabidiol) have

pharmacological effects which merit further study, as they can have useful medicinal properties

and can also modulate the effects of THC.

Patients who are using cannabis for medicinal purposes may find the psychoactive properties of

THC undesirable, as they may be seeking to increase their ability to function in society by gaining

relief from serious ailments that would otherwise interfere with their daily lives. In such cases, a

plant which has been selected for high THC content or potent psychoactivity may be less than

desirable. For example, a patient who is seeking analgesia or relief from anxiety might prefer a

variety of cannabis with a higher CBD content, which might provide greater relief from

symptoms without impairing mental function. If this patient has the opportunity to select from a

range of cannabis cultivars which have been tested for safety, as well as for potency (cannabinoid

content and ratio), and this person has the knowledge to discern which of these choices will best

achieve the desired effect, it follows that he or she will choose the cultivar(s) best suited to treat

their pathophysiology. In other words, access to chemical analysis data allows medical marijuana

patients to apply rational criteria to the selection of cannabis cultivars for medicinal use.

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Botany of Cannabis

Cannabis originated in Central Asia and the Himalayas, where it may have been the earliest plant

to be domesticated by humans, as much as 10,000 years ago, as a “five-purpose plant”: for fiber,

oil, food, psychotropic, and therapeutic properties (Schultes 1998). Due the scope of its utility,

and its propensity for naturalization in almost any climate, Cannabis has since dispersed to nearly

every part of the globe. Its habit of escaping cultivation to naturalize in surrounding untended

landscapes led Vavilov (1926) to classify cannabis as merely semi-domesticated (in Hillig 2005).

Cannabis is a dioecious, dicotyledonous, erect annual herb of the Cannabaceae family which

exhibits extremely variable morphology. Given suitable growing conditions, some plants may

grow as much as 7 centimeters (2.5 inches) per day, and can reach a height of 6 meters (20 feet)

in a single 4-6 month growing season (Clarke 1993). Some smaller indica-type strains may barely

reach 1m at maturity. Cannabis is wind pollinated, allowing outcrossing over long distances in

wild populations and increasing potential for genetic variability.

The flowering cycle of cannabis requires an inductive photoperiod, as cannabis is short-day

flowering. During its vegetative state, cannabis can and will thrive when exposed to as much as

24 hours a day of uninterrupted sunlight. However, to induce flowering, cannabis must have a

period of uninterrupted darkness. Environmental stressors may increase the predominance of

female plants in a given wild population, and can also induce monoecious plants or

hermaphrodites in all female cultivated populations (Clark 1993).

Cannabis floral morphology is regular, 5-merous, and unisexual. Staminate (male) flowers are

cymes clustered in leafy terminal panicles which are nearly sessile, possess oblong tepals, anthers

3-4 mm, and appear to dangle in loosely clustered inflorescences. Pistillate (female) flowers are

upright spike-like inflorescences, sessile, borne in tightly clustered fascicles enveloped by bracts,

with a superior, single-celled ovary, and a filiform, cauducous style up to 7.5 mm in length,

possessing two stigmas. Protruding from the 2-6 mm long female calyx are a pair of white,

yellow, or pink pistils. The thin, membranous calyx of the female inflorescence exhibits capitate

stalked resinous glandular trichomes, which produce most of the secondary metabolites with

medicinal effects, such as cannabinoids and terpenoids. The fruit is a smooth, shiny, brown or

yellow single-seeded achene, 4-5 mm long, closely encased in bracts, and composed of 29-35%

oil, 20-24% protein, and 20-30% carbohydrates (Jansen 2006).

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Cannabis exhibits variable phyllotaxy throughout its life cycle. Leaf orientation shifts between

opposite during vegetative growth and alternate during reproductive growth. Leaves may also

appear opposite near the base of the stem but whorled or spiraling higher up. The palmately

compound leaves display a variable quantity of leaflets (between 1 and 11, generally odd

numbered) as the plants mature. In pre-floral phyllotaxy, the number of leaflets per leaf increases

from the base of the plant to the top, while in floral phyllotaxy, the number of leaflets per leaf

decreases along the height of the plant (Clark 1993). The leaflets are hairy, lanceolate, sessile, and

coarsely toothed, possessing many sessile or peltate trichomes. The stipules are free and narrowly

subulate or filiform. The stem of cannabis possesses long bast fibers from 5-40 mm in length,

which are used in a variety of industrial applications.

Like its morphology, the secondary metabolic products of cannabis are also extremely variable.

THC content can vary between <1% and up to 30% THC in dry weight, female flowers (Clark

and Watson 2006:11). Percentages of other cannabinoids are also highly variable depending on

the genetics of the strain, and also may vary due to ecology or growing conditions. Chemical

fingerprinting systems based upon gas chromatography, thin-layer chromatography, and high

performance liquid chromatography, as well as GC/mass spectrometry may be used as tools to

ascertain the geographic origins of cannabis, based on the fact that the chemical profiles of

cannabis are consistently induced by environmental factors (ElSohly 2006).

The taxonomic treatment and speciation within the Cannabis genus are problematic and have

been contested for centuries. Early taxonomists first assigned Cannabis to the Urticaceae family,

later to the Moraceae family, and currently it is assigned to its own family, Cannabaceae, along

with just one other genus, Humulus. The extreme variability of Cannabis as seen in its

morphological characteristics, geographic range, and secondary metabolites confounds

distinctions based solely on these characters. Linnaeus espoused a monotypic concept of

Cannabis, classified as a single undivided species, Cannabis sativa L. In 1785, Lamarck divided

Cannabis into two validly published species, C. sativa and C. indica Lam., based on morphological

distinctions, geographic distribution, and physiological effects. Schultes (1998) recognized a

three-species concept of cannabis, adding C. ruderalis to the genus along with C. indica and C.

sativa. Other species have been suggested, including Cannabis afghanica (Clark and Watson 2006:9).

Further suggested taxonomic classifications occur at the sub-species, varietal level.

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Analysis of genetic markers within the Cannabis genome has been used to shed light on the

question of speciation within the genus. Hillig (2005) conducted allozyme analysis of 157

Cannabis populations. This study examined single amino acid variations of enzymes which result

from DNA mutations, acting as genetic markers, and concluded from this data that the Cannabis

genus is divided into two species, C. sativa and C. indica. This conclusion further clarifies

taxomomic distinctions based on morphological and geographic characters, as C. indica is

generally much shorter and confers different subjective effects upon use.

However, it is unclear whether this bifurcation of the Cannabis genus occurred prior to or as a

result of domestication by humans, as humans have greatly influenced both the cross-breeding

and divergence of Cannabis gene pools. Investigation of cannabinoid genetics using RAPD

(random amplified polymorphic DNA analysis) to elucidate the taxonomic intricacies of cannabis

shows promise. As of August 19, 2011, a small company based in the US and the Netherlands,

Medicinal Genomics, has sequenced the Cannabis sativa genome using short-read sequencing

technology, and has made this phylogenetic data publically available via Amazon Cloud database,

allowing free access for scientists and others around the world with limited research access to this

highly regulated plant. These results, however, have not yet undergone peer review, and different

Cannabis strains can demonstrate a genomic variation as high as 1%, according to Kevin

McKernan, founder and head of Medicinal Genomics’ scientific operations (Kersgaard 2011)

The naming of cannabis cultivars or strains within the commercial industry and black market is

even more problematic than the continuing debate among plant taxonomists. Due to the

unregulated nature of the black market industry, growers or sellers may call their specimens

whatever they wish, as it suits economic or popular criteria. If a particular named strain (i.e

‘White Widow’) is currently in high demand, then any grower or vendor may sell their product by

that name, relying on the lack of information or alternatives available to buyers or patients to

allow latitude for such subterfuge. A lab manager interviewed for this project called it the “strain

name game”, and noted the difficulty it added to the problem of patients accessing reliable and

consistent botanical medicine. A current database of cannabis strains used for medical and

recreational (but not industrial) applications lists 2,463 strains (www.smokereports.com, accessed

on 26 August 2011) underscoring the scale of cultivation occurring despite current political

conventions.

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Commercial breeding of cannabis which seeks to maximize psychoactive effects focuses

cultivation efforts on the female plants, as they produce the resinous glandular trichomes

responsible for biosynthesis of the secondary metabolites producing these effects. The presence

of male plants which pollinate the female flowers is generally undesirable, as fertilization of the

female flowers diverts the plant’s production of floral products to production of achene-type

fruits, popularly called seeds, that would detract from the quality of herbal cannabis, known

sometimes by an adopted Spanish term, sinsemilla, or “without seeds”. For this reason, growers

often rely upon clonal or vegetative propagation of a female plant possessing desired attributes in

order to predictably increase germplasm resources. This helps avoid the unwanted production of

achenes, and also provides a genetically uniform crop which is generally ready to harvest sooner

than crops which are sown by seed.

Cannabis and culture

Even as the discourse surrounding medical marijuana demands syncretism to resolve conflicts

between scientific and political directives, the healing practices of the medical marijuana system in

states where it is ratified in the US embody an illustration of medical pluralism described by

medical anthropologist Young (1983) as intercalation. Intercalation describes the adoption of

traditional material medica into biomedical models, exclusive of traditional practitioners. “The

cannabinoid botanical medical care system [in the state of Washington], with physicians licensed

in biomedicine authorizing treatment with a long-utilized ethnobotanical medicine, represents an

intercalation, or intertwining, of modern medicine with traditional medicine” (Aggarwal

2008:23).

Cannabis is one of the oldest medicines known to humankind, and may have been the first plant

which was domesticated by humans (Schultes 1998). The variety of uses for which it is employed

includes food, oil, medicine, material culture, ritual use, and as an intoxicant. The etymology of

the name cannabis derives from the Greek word kannabis, from which was later derived the

English word canvas (Herrer 2000:5). Cannabis is known variously in different cultures and

depending upon its usage or preparation as ganja, bhang, hashish, dagga, marijuana, hemp. It is

considered “weed” in some cultures and a holy plant in others. Rastafari of Jamaica and Sadhus

of India as well as Mahayana and Tantric Buddhists of Tibet all use some form of cannabis as a

religious sacrament (Schultes 1998).

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Archaeological studies have uncovered evidence of cannabis in China dating back to the

Neolithic period, around 5,000 years ago (Hanus and Mechoulam 2005:23). The first written

record of its therapeutic use and properties was by the Chinese Emperor Shen Nung in 2737 BC,

where it was recommended for malaria, constipation, female disorders, beri-beri, rheumatic pains

and absent-mindedness (Li, in Ben Amar 2006:2, Schultes 1998). Classical physicians Galen and

Dioscorides recognized its therapeutic uses in their writings.

The Scythians of Central Asia have been credited with the spread of Cannabis from its origins of

domestication Westward into Europe. The Greek writer Herodotus (c. 500 B.C.E) described a

sort of sweat lodge practiced by the Scythians, in which cannabis seeds were thrown onto a

brazier containing hot stones within a confined tent of pelts stretched over a tripod frame, and

the vapors inhaled. Archeological evidence uncovered cannabis achenes in Germany dating back

to 500 B.C.E. and hemp rope at a Roman site in England dated A.D 140-180 (Schultes 1998).

Cannabis was introduced to South America in the mid- 1500’s and to North America in the early

1600’s (Schultes 1998). Cannabis use also spread to Africa, where it may be known as dagga or

kif, and has been adopted by many distinct ethnic groups for medicinal purposes including

anthrax, malaria, dysentery, and fevers. Mfengu and Hottentot use it in treating snakebites and

Sotho women use it to ease the pain of childbirth. It is also used by the Kung of South Africa,

the Pygmy and Kasai tribes of the Congo, the Kaffir, and in North Africa (Schultes 1998). The

multitude of cultures which have adopted cannabis into their pharmacopoeia and material culture

further illustrates the pluralist intertwining or intercalation of many cultures and practices

surrounding medical marijuana.

Cannabis was widely adopted in the US for both industrial and medical applications in the

eighteenth and nineteenth centuries, when it was used heavily in the textile and paper industries.

The first two drafts of the US Declaration of Independence were written on Dutch hemp paper,

and after the document was agreed upon it was then copied to parchment (Herer 2000:7).

Cannabis was listed in the United States Dispensary in 1854, and was part of the British

Pharmacopeia in both extract and tincture form for over 100 years. In 1937, the US government

introduced the Marihuana Tax Act, contrary to the recommendations of the American Medical

Association, making the use of marijuana prohibitively expensive. In 1942 cannabis was

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eliminated from the US Pharmacopeia, drastically undermining its legitimacy as a therapeutic

medicine.

Cultural factors such as ethnic and social prejudices have undoubtedly played a role in the history

of US federal policies surrounding cannabis (Holland 2010:7, Levine 2010), and subsequently

forced transactions leading to exchange of germplasm into underground markets, driving up the

purchase price for acquiring cannabis while decreasing the safety of obtaining quality medicine by

constraining many patients to purchase medical marijuana from unknown sources, potentially

containing unsafe contaminants, and also putting consumers of at risk of legal prosecution. More

recently, in the sixteen states of the US where the use of medical marijuana is currently ratified,

patients may have greater access to cannabinoid germplasm and information about its therapeutic

properties and chemical composition.

Chemistry of cannabis

Chemical analysis of cannabinoids has several important functions. It may be used in forensics

to determine the geographic source of cannabis samples (ElSohly et al 2006). It is useful in

strategic breeding and germplasm programs, for selecting cultivars with specific medicinal or

industrial properties (de Meijer 1999). Cannabis analysis can also help to identify and improve

access to therapeutic strains with specific medicinal compounds and potencies, free from

contaminants, and aid in determining appropriate dosages and achieving repeatable therapeutic

benefits. And more broadly, reliable laboratory testing of cannabis has the potential to

contribute to the scientific and social legitimacy of cannabis as a medicine.

Labs which provide cannabinoid profiling services have the potential to contribute in all these

regards and many others. However, the emergence of cannabis analysis services may be

influenced by economic potential and perceived opportunities in states that have provisions for

medical marijuana, and there is little or no regulatory oversight which monitors cannabis analysis

labs. Methods, equipment, and results of analysis may vary considerably, and the lay consumer

may need specialists’ knowledge in order to seek out a reputable lab or provider of tested

material, as well as to interpret the results generated through chemical analysis.

First and foremost, laboratory analysis is used to ensure the safety profile of products to be used

for therapy. Although there is no industry-wide standard of purity guidelines for herbal cannabis,

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labs will typically test for the presence of fungal, bacterial, and chemical contaminants. Improper

harvesting or curing methods can lead to fungal, bacterial, or other forms of biological

contamination. Cannabis may also contain residues of unsafe agricultural compounds such as

pesticides or fertilizers, and is occasionally adulterated to enhance its appearance. The Dutch

industry has applied pharmaceutical guidelines to its cannabis trade. Edible cannabis products

can be assessed using food-grade standards such as those which are applied to its cousin, Humulus

lupulus. In defining safety guidelines for inhaled cannabis, the standards which are applied to the

tobacco industry may be applicable (Minor, personal communication, 2011).

A number of key factors influence chemical analysis results. The method of sampling employed

by the grower: where on the plant the sample is taken from and when and how it is harvested,

processed, and stored, as some cannabinoids are subject to degradation upon exposure to heat,

light, or moisture. The sampling protocol employed at the lab is also important: how the sample

is prepared and extracted for analysis. Labs must also use reliable reference standards for each

cannabinoid.

The lab’s equipment affects results. Firstly the calibration and maintenance of lab equipment, but

also the choice of equipment and methods affects results. Labs may employ GC (gas

chromatography), HPLC (high performance liquid chromatography), or TLC (thin layer

chromatography) and each has advantages and disadvantages (See Table 1). Further potential

method variation occurs in the detector which is employed in conjunction with the

chromatography. GC may employ FID (flame ionization detector), TCD (thermal conductivity

detector), or MS (mass spectrometer). Because GC heats the sample during analysis, it does not

register heat-sensitive cannabinoid acids, which may be desirable in edible products. Liquid

chromatography, because it does not heat the sample, is useful for detection of cannabinoid acids

as well as other cannabinoids, but it produces significant solvent waste. TLC, which is basically a

test strip method is useful only for detecting the presence or absence of given cannabinoids, but

not the quantity or potency of these compounds.

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(Source: Miller 2011)

The number of variables which can affect analysis results illustrates the need for quality control

to ensure consistency and reliability of outcomes. Method validation is a certification process

which is voluntarily taken by a lab to ensure the methods used for analysis are accurately

accomplishing what they are intended to do. As defined by Full Spectrum Laboratory in Denver,

CO, “Laboratory validation of an analytical method is the process by which it is established by

laboratory studies, that the performance characteristics of the method meet the requirements for

the intended analytical application”. Full Spectrum has achieved method validation for their

HPLC assay parameters, consisting of nine defined components: precision, accuracy, linearity,

range, ruggedness, method detection limit, extraction efficiency, selectivity, and specificity. Labs

such as the Werc Shop in California provide a label for tested material which mimics the

structure and format of the Nutrition Facts labels which the FDA requires on packaged food

labels, providing a clear, accessible presentation of chemical data in table format for consumers

(see figure 1).

Figure 1.

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Basic pharmacognostical observations employing the human senses may be utilized by the

consumer without the use of scientific laboratory equipment. These organoleptic observations

include smell, taste, visual inspection, and tactile sensations. In evaluating cannabis, organoleptics

may be useful in identifying the presence of terpenoids, broadly speaking, as they have a distinct

odor. Visual inspection, whether unaided or under magnification, may be used for identifying the

presence, quantity, and color of trichomes, which are rough indicators of potency. Tactile

observations can determine the presence of sticky resinous secretions produced by the trichomes.

Biosynthesis of phytocannabinoids occurs in the glandular trichomes on the epidermis of the

pistillate plant, when a terpenoid compound binds with a phenolic compound. This leads to the

production of cannabigerol (CBG), which is the precursor from which over 60 of the remaining

phytocannabinoids are formed (McPartland and Guy 2004). CBG is subsequently converted via

the action of various enzymes and degradation processes into the spectrum of phytocannabinoids

which occur in the cannabis plant (McPartland and Guy 2004).

Terpenoid + phenol → CBG → CBC, CBD, THC, THCV, etc.

The most studied chemical constituents of cannabis are THC and CBD. The relative ratio of

these constituents occurring in landraces of cannabis tends towards equilibrium, while cannabis

bred for recreational consumption has a much higher THC content, and cannabis bred for

industrial uses will have THC content of <1% (Clark and Watson 2006:12). CBD is one of the

better understood non-psychotropic plant cannabinoids, exhibiting potential as an anti-

inflammatory agent, in the treatment of cancer, diabetes, and neurodegenerative diseases. THCV

(∆-9-tetrahydrocannabivarin) is also showing potential in the treatment of epilepsy and obesity

(Izzo et al 2009). The six compounds which the present study focused upon are the following:

Cannabichromene (CBC): Known pharmacological and therapeutic properties of CBC

include analgesia, anti-inflammatory, and potential antibiotic applications (Izzo et al 2009).

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Cannabidiol (CBD): A non-psychoactive phytocannabinoid, CBD provides a wide range of

therapeutic actions including anxiolytic, analgesic, neuroprotective, anti-inflammatory, and

anti-nausea properties (Izzo et al 2009).

Cannabinol (CBN): A mildly psychoactive cannabinoid, CBN occurs as a result of

degradation of THC. Its therapeutic properties include use as an anti-spasmodic and a sleep

aid (Izzo et al 2009).

Tetrahydrocannabinol (THC): The best-known cannabinoid, due to its euphoric

psychoactive properties or “high”, THC is known to have therapeutic applications in the

treatment of nausea and loss of appetite as a result of HIV, as an analgesic in cases of

neuropathic or cancer-related pain, and in the treatment of symptoms of MS (Izzo et al 2009).

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Tetrahydrocannabivarin (THCV): A psychoactive cannabinoid, THCV has been shown to

reduce food intake in mice, and shows promise in the treatment of diabetes and obesity (Izzo et

al 2009).

 

Terpenes/Terpenoids: One of the building blocks in cannabinoid biosynthesis, terpenoids are

also responsible for much of the distinctive aromas of cannabis strains, and play a role in the

ecology of cannabis, protecting the plant against biological stressors such as bacteria and fungi, as

well as environmental stressors such as UV radiation. Many other plants including Pinus spp. and

Eucalyptus spp. produce terpenes as part of their secondary metabolic processes. Structures vary,

but are composed of isoprene subunits (see below).

Pharmacology of Cannabinoids

The bioactivity of phytocannabinoids and their ability to act upon human physiology is possible

because of the endocannabinoid system. The endocannabinoid system is composed of

endogenous ligands and corresponding specific cell receptors within the human body. These

endogenous ligands are endocannabinoid compounds, such as anandamide, produced within the

human body for a range of physiological purposes, which act upon cannabinoid receptors

throughout the human nervous and immune systems. The structure of exogenous cannabinoids

such as the phytocannabinoids produced by the cannabis plant bears certain similarities to

endocannabinoids, allowing phytocannabinoids to act as ligands binding to human cannabinoid

receptors.

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The endocannabinoid system is involved in many of the human body’s physiological processes,

including modulation and regulation of neurotransmitters, pain perception, and functioning of

the cardiovascular system, liver, and digestion (Izzo et al 2009). There are two types of

cannabinoid receptors known to exist in humans: CB1 and CB2 receptors. CB1 receptors are

found primarily in the central and peripheral nervous system, and account for the majority of the

psychotropic effects of cannabinoids. CB2 receptors are found mainly in the immune system,

and exert immunomodulatory effects.

The presence of specific cell receptors which are activated by cannabinoids, whether of

endogenous or plant origin demonstrates a unique connection between the cannabis plant and

human physiology. The secondary metabolites of the cannabis plant are particularly suited to act

at cannabinoid receptor sites, allowing the cannabis plant to have a direct effect on the human

nervous system and other physiological processes. The biochemical communication between

cannabis and cannabinoid receptors in the human body suggests that the coevolution of human

physiology and the secondary metabolism of the cannabis plant may be interconnected via a

coevolutionary process, though it is difficult to know how this came to pass. Phytocannabinoids

may have initially been produced by plants as deterrents to insects, pathogens, or herbivory.

These compounds, however, became attractive to animals, notably to humans, in what Pollan

(2001) describes as “the botany of desire”. This represents an evolutionary strategy in which the

plant ensures its survival by making itself desirable to humans, thus ensuring its continued

propagation. Consequently, this has catalyzed the domestication and dispersal of the cannabis

plant by humans far beyond its native range, and has encouraged extensive selection, breeding,

hybridization, and cultivation of the cannabis plant for its effects and uses.

Modulation of the endocannabinoid system via the 80 or so phytocannabinoids synthesized by

the cannabis plant produces a wide range of pharmacological effects in addition to the well-

known psychotropic effect or “high” produced by the action of THC upon the CB1 receptors of

the brain. The bioactivity of phytocannabinoids with little or no psychotropic effects, such as

CBD (cannabidiol), CBC (cannabichromene) and THCV (tetrahydrocannabivarin) nonetheless

exert pharmacological effects upon the endocannabinoid system and present potential for a range

of therapeutic applications. CBD in particular has been well-studied, and shows activity as an

analgesic, neuroprotective, anxiolytic, and anti-inflammatory agent, as well as potential for the

treatment of diabetes, cancer, and ischemia (Izzo et al 2009). Lesser-studied cannabinoid

19  

compounds merit further investigation as to their effects, due to the widespread action of the

endocannabinoid system on human health, and the scale of therapeutic effects described

anecdotally by medical marijuana users.

Cannabis as Medicine

Each state in the US with medical marijuana provisions has its own list of acceptable or

recognized ailments which may be treated with cannabis. Some states are very restrictive in this

regard, depriving even needy patients of medication if their ailment, such as post-traumatic stress

disorder, is not recognized as one which responds to cannabis therapy. In contrast, other states’

regulatory systems may be under-structured, allowing patients with arguably tenuous

symptomatic justifications to obtain marijuana for purported medical purposes, and facilitating

extensive proliferation of commercial medical marijuana enterprises.

Much research still needs to be done on the therapeutic properties of cannabis, but is difficult to

accomplish in the US due to the restricted access to product for research, which is stringently

regulated by NIDA, the National Institute on Drug Abuse, which dictates distribution of

cannabis germplasm from the only federally-sanctioned repository in the US, the National Center

for Natural Products Research in Oxford, MS.

Despite the difficulty of gaining approval or materials to carry out controlled studies of cannabis’

clinical efficacy, in the period between 1975 and 2009 at least 110 such studies have been

published, evaluating the efficacy of cannabinoids in the treatment of a wide range of illnesses

from a sample population of over 6100 patients (Hazekamp and Grotenherman 2010). It is

important to note that these reviews of the clinical studies on cannabinoids also included

synthetic and pharmaceutically derived cannabinoids and did not exclusively examine herbal

cannabis.

The Journal of Ethnopharmacology published a meta-analysis of clinical studies on contemporary

therapeutic applications of cannabinoids in 2006, showing statistically significant potential for the

application of medical marijuana as an antiemetic, an appetite stimulant, analgesic, and in the

treatment of glaucoma, epilepsy, spinal cord injuries, Tourette’s syndrome, and multiple sclerosis

(Ben Amar 2006). A follow-up review of research conducted since 2005 was published,

confirming the evidence-base of cannabinoids’ therapeutic potential in the treatment of

20  

neuropathic and chronic pain, nausea, vomiting, and anorexia resulting from cancer treatments or

AIDS, as well as muscle spasticity and symptoms of multiple sclerosis (Hazekamp and

Grotenherman 2010).

A wide range of delivery methods exist for the administrations of cannabinoids, from

pharmaceutical products which contain a single isolated cannabinoid taken as a pill, an oral spray

or a sublingual spray, to whole herbal products and concentrates which may be smoked,

vaporized, ingested as food, tea, or tincture, or applied externally as oil, cream, salve, or essential

oil. The chemical composition of these preparations will vary depending upon the variety of

cannabis and the extraction methods employed. Chemical analysis methods employed for

assessing these products must be tailored to the type of product under investigation. The most

common form of use is combustion, either by pipe, rolled cigarette, or water pipe, but medical

practitioners are often hesitant to recommend this mode of administration, as it is difficult to

control from the prescriber’s standpoint, and carries concerns of carcinogens due to tars created

during oxidative combustion.

Practitioners are generally much more familiar with and comfortable prescribing a

pharmaceutically produced product, such as a pill or spray. Given the irregularities of the herbal

cannabis industry, this position is hardly unjustified. However, inhalation of herbal cannabis is

much easier for the patient to regulate via a process known as self-titration. Because inhalation

of cannabis’ active constituents produces effects which are nearly immediate, the user can

determine if the appropriate amount of medicine has been consumed and can adjust their dose

accordingly. However, pills and other edible cannabis products act more slowly, due to their

passage through the digestive system prior to taking effect. This delay in onset makes it difficult

for the patient to regulate dosage, and the patient may find themselves sedated or intoxicated to

an undesirable degree by the time the medicine takes effect. Additionally, whole herbal cannabis

contains a wide spectrum of compounds with synergistic and modulating effects, while synthetic

pharmaceutical preparations may contain one or two cannabinoids such as THC or CBD, and so

are extremely concentrated and lack the range of synergistic compounds which may act to

modulate THC’s psychoactive effect, and therefore may result in a greater sense of dysphoria

than use of herbal cannabis. A commercially produced nebulizer (similar to the mode employed

in many asthma pharmaceuticals) containing a full-spectrum herbal extract of a carefully selected

cannabis cultivar could integrate the standardized repeatability of a pharmaceutical with the fast-

21  

acting pharmacology which allows the patient to self-titrate, without the tar and carcinogens of

combustion.

The therapeutic effects of cannabis may differ as a result of chemotaxonomic variability and

mode of administration, but also the influence of set and setting on the subjective experience of

cannabis use must be noted. The effects of personal expectations, which are influenced by the

mindset and personality of the user and their sociocultural background, will shape their

perception and experience of cannabis use, whether for medicinal, recreational, or sacramental

purposes. Additionally it must be noted, the distinction between these uses is not clearly defined.

A patient who is using cannabis for its modulation of pathophysiology may also experience a

euphoric sense of mind which may have effects that are interpreted through meditative or

otherwise spiritual perspectives. Physical and mental effects are intertwined and largely

inseparable, although a patient’s choice of strain can influence the balance of effects experienced.

Some patients who are seeking only pain relief may choose strains which exert little cognitive

effect and act mainly on the peripheral nervous system, likely by activating CB2 receptors. Still

other patients, whose pathophysiology also includes anxiety, depression, mental suffering, or end-

of-life fears may choose a cultivar with greater perceived cognitive effect or euphoric “high”.

Social Science and Medical Marijuana

A review of existing ranking systems and surveys of medical marijuana use by practitioners and

patients was conducted to inform the present study. Several tools for selecting medicinal

cannabis cultivars were found on web sources. One key informant for this project mentioned the

M-Scale system, (http://www.m-scale.com/), established by an Oregon medical marijuana

proponent, which utilizes a standardized worksheet designed to assist patients in choosing

marijuana strains based on three categories of desired effects: health concerns, activity level, and

medicinal effects. The stated purpose of the m-Scale Project is to provide “tools and a common

language to create an effects-based system to clarify, classify and communicate the effects of

marijuana.” Upon filling out the m-Scale worksheet, the result is an “Mx” (like a marijuana Rx or

prescription) which includes an “M-number” to quantify the desired degree of activation or

sedation, as well as sub-categories with codes for other medicinal effects.

22  

Another tool for choosing strains available to medical marijuana patients provides access to data

on chemical analysis results, ranking cannabis cultivars by various parameters, and making

available information on sources for obtaining tested material. This search tool is provided by

Full Spectrum Laboratory (http://fullspectrumlabs.com) and assists clients in selecting cannabis

cultivars based on a database of tested products from dispensaries in the state of Colorado,

sorted by parameters such as name of strain, percentage of a specific cannabinoid, ratio of

cannabinoids, medicinal effects, or type of product (consumable, raw plant material, plant extract,

or body care). Test results are updated frequently, and results are only valid for a period of

several months to ensure reliability.

Addressing the question of species preferences among medical marijuana patients, a survey of

over 500 patients conducted by the American Alliance for Medical Cannabis examined stated

preferences for medical marijuana species Cannabis sativa or Cannabis indica as well as indica- or

sativa- predominant hybrids (See table 2). Twenty-five percent of respondents preferred Cannabis

indica, and the next largest response group, nineteen percent of respondents, did not know what

species or ratio they preferred. In the discussion of results, it was noted that “without laboratory

analysis of cannabinoid profiles, a scientific finding is impossible. What is evident, though, is that

most patients do know what works for them and it varies depending upon condition(s)”.

Species or hybrid

ratio preferred

Number of

respondents

Percentage of total

respondents

Indica 127 25%

Mostly Indica 66 13%

Indica/Sativa 90 18%

Mostly Sativa 64 13%

Sativa 68 13%

Don't Know 96 19%

Table 2

Another patient study of medicinal use of cannabis was conducted in the UK using a self-

administered questionnaire survey and found that 25% of patients were using cannabis for

chronic pain, 22% each were using cannabis for depression and multiple sclerosis, 21% for

arthritis, and 19% for neuropathy (Ware 2004). 68% of reported users stated that cannabis made

23  

their symptoms overall much better. 45% said that cannabis worked much better than prescribed

medications, and 34% stated that the side effects of prescribed medications were much worse.

Subsequent clinical trials have provided evidence which supports the therapeutic efficacy of some

of these patients’ anecdotal experiences. Suggesting the utility of natural use surveys for

informing clinical use studies, Ware concludes, “Patients’ reports of the effectiveness of cannabis

should not be discounted as purely anecdotal, but rather could serve as a valid indicator of target

diseases and symptoms for cannabinoid drug development” (Ware 2004).

Examining the data on clinical use of medical marijuana from a practitioner’s standpoint, a survey

conducted by the American Herbalists’ Guild found that the legal prohibitions surrounding

medical marijuana significantly limited practitioners’ clinical use of the botanical, and possibly

also their knowledge of the scope of its therapeutic potential. 90.5% of respondents cited legal

prohibition as the reason for avoiding cannabis recommendations in their practice, and 79.5% of

practitioners surveyed said that they would use cannabis in their clinical practice if legal

prohibitions did not prevent them from doing so (Romm 2011).

This review of existing popular ranking tools and patient and practitioner surveys made it

apparent that medical marijuana patients increasingly have access to information and tools to

guide them in making informed decisions in the selection of cannabis cultivars. Further, the scale

of knowledge and experience among patients who are self-medicating with cannabis may not be

reflected to a proportionate degree among practitioners due to legal restrictions, indicating that

syncretism and a greater degree of intercalation between practical use knowledge and biomedical

knowledge is needed.

Aims and Objectives

The goal of this research project was to contribute to the rationalization of herbal cannabis in

medical applications, to intercalate popular therapeutic uses among patients with biomedical

approaches and foster syncretism in the discourse surrounding medical marijuana. Until this

highly versatile and variable botanical can be better understood through evidence-based science,

it will remain a politicized drug which is evaluated based heavily on moral prejudices rather than

empirical data.

24  

In order to address this goal, the aim was to examine how the emerging practice of cannabis

chemical analysis affects peoples’ use of medical marijuana, and whether medical marijuana users

are applying rational criteria to the selection of cannabis cultivars as a result of these new

information resources. The aim in conducting this research was to investigate the choices made

by patients in the selection of therapeutic grade cannabis and their preferences for cannabinoid

compounds and strains.

The objectives were to gather data on patients’ preferences for cannabis cultivars, cannabinoid

compounds, and modes of administration for therapeutic purposes. Information on patients’

perceptions of and preferences for the therapeutic effects and uses of cannabis strains was

examined in combination with preferences for chemical compounds such as THC and CBD.

It is this author’s hypothesis that access to information on cannabinoid content informs patient

choices in the selection of medical marijuana cultivars, allowing for more precision and

predictability of therapeutic effects, and contributing in a broader sense to the rationalization of

marijuana in medical science and practice.

The Research Question(s)

Does access to chemical analysis data quantifying cannabinoid content affect patients’ selection

of medical marijuana cultivars and delivery methods? How does the quantification of

cannabinoid content in medicinal product affect patient preferences for different strains and

delivery methods in the use of medical marijuana? How does this correlate with the symptoms

for which medical marijuana is used to treat?

Methods

This project utilized a mixed methods approach, integrating quantitative and qualitative data

collection in order to address the aims and objectives of the research question. Quantitative

approaches focused on variables and values, while qualitative methods included the use of semi-

structured interviews with key informants and descriptive data collected from open-ended survey

questions. Literature review, semi-structured interviews and a self-administered online

questionnaire survey of medical marijuana users were conducted.

25  

In reviewing and designing survey research, it is important to consider the context validity:

questionnaires can create an artificial situation which may lead respondents’ stated behavior to

differ from their actual behavior (Newing 2010:54). However, in the case of cannabis, a highly

restricted botanical medicine, a natural use study such as this survey questionnaire also presents

benefits, as it circumvents the need for the lengthy and difficult permission process required by

NIDA and the DEA for a controlled study. Additionally, a natural use survey measures the

existing knowledge of experienced medical marijuana users to gather behavioral data which

would not be available through a controlled study. And so it was concluded that for the present

research, the limiting factors of using a questionnaire study were outweighed by the benefits of

using survey methods to conduct a natural use investigation.

For this paper, a self-administered questionnaire was designed to survey self-reported medicinal

use of cannabis, and the role of chemical analysis data in strain selection (see appendix 1). Key

informants were recruited from known contacts, and further participants recruited using the

snowball method. The survey design was informed by semi-structured interviews conducted by

telephone with a cannabis analysis lab director, a clinical nurse, and a cancer patient and director

of a medical marijuana non-profit organization, as well as written correspondence with a

horticulturist and several other cannabinoid scientists. Feedback on the survey design was sought

from several lab managers, and the survey was piloted by two respondents, on a PC and three

different mobile devices (a BlackBerry, an iPhone, and an Android smartphone). Once the

design was finalized, the questionnaire was distributed to patients via existing social networks

among non-profit groups, industry leaders (such as lab and dispensary managers), and

collaborating scientists in the field of cannabis research. These social networks included Patients

Out of Time, the Canadian Cannabis Coalition, the Association of Reform Networks, the

Medical Cannabis Association, and the International Association for Cannabinoid Medicines.

An online survey format was selected due to low cost and ease of data collection and distribution.

Google docs (www.docs.google.com) was selected for this purpose, as it easily integrated into

emails, facilitated sharing of results with collaborators, and interfaced well with Microsoft Excel

spreadsheets. A link to the survey, as well as PDF files of the survey and a promotional flier (see

figure 2) were sent to collaborators, who shared the link via their professional networks, listservs,

newsfeeds, and websites, while also distributing the flier at trade shows, conferences and medical

26  

marijuana dispensaries. Some collaborators requested paper copies of the survey, which were

mailed along with return postage for completed surveys.

The survey consisted of 13 items and employed a variety of question types, including binary

responses, 5-point Likert rankings, multiple choice, and open-ended questions. Basic

demographic data was collected, data on preferences, behavior, and knowledge of varieties of

cannabis, specific symptoms for which cannabis was used, modes of administration, and chemical

constituents. In designing the survey questions and layout, consideration was given to the

survey’s internal validity and question phrasing, as well as the variables and values which the

survey was intended to measure.

Figure 2.

The online format facilitated conditional structuring of the questionnaire, such that the

individual’s responses to certain questions determined the subsequent questions which were

posed. For example, if a patient responded yes to the question “Do you choose medical

marijuana strains that have been tested for cannabinoid content?” then they were subsequently

asked “What cannabinoids or compounds do you give preference to in selecting medical

marijuana strains?” while patients who answered no to the first question were not asked the

27  

second question. This method had advantages, as it limited the number of inapplicable questions

posed to a respondent, thereby favoring completion of the survey.

The questionnaire was designed to be brief and concise, in order to garner as many responses as

possible. The first several questions were formulated to gather basic demographic information

about respondents, including age, gender, and place of residence. Due to the sensitive nature of

collecting data on regulated substance use, names were kept confidential and not gathered as part

of the survey. Each survey respondent was instead identified by a unique time stamp issued at

the moment of submission.

Demographic questions:

1. What is your age? (write-in)

2. What is your gender? (Male or Female)

3. What state or province do you live in? (write-in)

Conditional formatting or question logic was utilized, which in effect acted as a filter or sorting

mechanism based on participants’ responses to certain questions. The first sorter question

determined if the survey respondent was currently a medical marijuana user. If the respondent

replied no, they were directed to the conclusion of the survey. If the respondent replied yes to

this question, then they continued to the next question.

First sorter question:

4. Are you currently a medical marijuana user? (Yes or No)

If the respondent replied that they were currently a medical marijuana user, the following

question aimed to identify the symptoms for which medical marijuana was employed. The

format chosen for this question was open-ended, as the range of therapeutic applications for

which marijuana is utilized would be too great to distill into five or six multiple choice options,

even with a write-in option for “other”. The advantage of using an open format for this question

was that there were no limitations as to how respondents could reply, and as a result allowed for

28  

unanticipated responses. Several disadvantages to using this format were difficulty in coding the

wide range of responses for later analysis, and occasional difficulty in deciphering the intended

meaning of the response due to misspelling or phrasing. Because the survey was self-

administered and contact data was not gathered for respondents, there was no opportunity to

seek clarification if a response was unclear. However, this was rarely a problem.

Open-ended question:

5. What symptoms are you using medical marijuana to treat? (write-in)

The next question was intended to gauge whether patients were seeking other modes of

conventional biomedical or alternative therapy for their symptoms. Due to health privacy

considerations, it was not asked what specific types of prescriptions or treatments patients were

using for symptom relief, simply whether or not cannabis was the only medicine employed.

Behavioral question:

6. Are you using other treatments for these symptoms? (Yes or No)

To further explore the role of medical marijuana as a therapeutic agent, respondents were asked

about their perceptions or experience of medical marijuana as compared with other available

modes of therapy.

Binary response question:

7. Do you find that medical marijuana has advantages over other treatments?

The next question was designed to gather data on mode of use. This question was posed in a

multiple choice format, where the respondent could choose as many options as were applicable,

as well as a write-in option for “other”.

29  

Multiple choice question:

8. What is your preferred form for using medical marijuana? (Choose all that

apply)

Smoke, Vaporizer, Liquid extract, Pill, Edible, External, or Other (Please specify)

Next the survey attempted to gather data on strain preferences. This question was posed as an

open-ended question, because the number of cannabis cultivars would be too numerous to list

comprehensively as a multiple choice question. As this question was write-in, it also assessed to

some degree the knowledge of the survey respondents, but it required more time in coding

reponses.

The use of the term “strain” was susceptible to varying interpretations by respondents. This is

partially due to the fact that speciation of cannabis is contested and nomenclature variable, even

within the scientific community and especially in the medical marijuana market. In this case, its

vagueness was not altogether undesirable in phrasing the survey question, as it allowed

respondents to speak to both species and cultivar preferences as they perceived the distinction.

Open-ended question:

9. What strains of medical marijuana do you prefer?

As a follow up to this question, the next question was aimed at exploring selection criteria.

Although there are some common variables that tend to influence selection (taste, smell, effect,

price, and availability), an open-ended format was chosen to allow respondents to be specific in

generating descriptions of their own personal preferences without being influenced by the

provision of multiple choice options.

Open-ended question:

10. What criteria do you use in selecting a medical marijuana strain?

30  

At this point, another sorter question was utilized as the survey began to explore the role of

chemical analysis data in respondents’ choice of medical marijuana alternatives. This sorter

question asked whether the patient chooses marijuana strains which have been chemically

analyzed. If the respondent replied affirmatively, or “sometimes”, then they continued to the

next question. If the respondent replied negatively, then they skipped the next question and went

directly to the conclusion of the survey.

Second sorter question:

11. Do you choose medical marijuana strains that have been tested for

cannabinoid content? (Yes, Sometimes, or No)

If the respondent replied “yes” or “sometimes” to this sorter question, then they were questioned

as to the importance of chemical analysis data as a selection criteria. The question was posed as a

five-point Likert ranking response, with  indicating “very important:, and  indicating “not

important at all”.

Ranking question:

12. How important to you are chemical analysis results in choosing a strain of

medical marijuana? (Very important Not at all)

The final question in the questionnaire was posed as a multiple choice question, intended to

assess which chemical compounds in cannabis the patient sought preferentially. A multiple

choice format was chosen due to the complexity involved in requiring participants to spell out

desired compounds. Although there are at least 80 known cannabinoids in cannabis, current

research has only illuminated the therapeutic properties of a handful of these. The most

commonly tested for compounds were listed in the multiple choice answers for this question.

One disadvantage to providing the names of the cannabinoids rather than allowing respondents

to write in responses is that it did not assess respondents’ knowledge of cannabinoid chemistry,

as a respondent could just check off a few options that sounded familiar, without demonstrating

31  

knowledge of the compounds and it also did not allow for freelist analysis of named compounds.

Respondents were also given the option to answer “I don’t know”, or to write in “other”.

Multiple-choice question:

13. What cannabinoids or compounds do you give preference to in selecting

medical marijuana strains?

Cannabichromene (CBC), Cannabidiol (CBD), Cannabinol (CBN),

Tetrahydrocannabinol (THC), Tetrahydrocannabivarin (THCV), Terpenes, I don't

know, Other: (Please specify)

(See appendix 1 for the complete survey)

Results

Responses were collected for a two month period between June 20, 2011 and August 20, 2011.

Response rates were initially slow but increased toward the end of the study period (see figure 3).

figure 3.   

Due to the recruitment methods employed, the online survey was distributed more widely than

anticipated. The initial intent was to survey just US medical cannabis patients, but because of the

span of social networks which collaborated in dispersing the questionnaire, responses also came

from Canada, the UK, and the EU. The paper surveys did not yield any responses. The total

number of responses was 112. These responses were filtered to include data only from

respondents who were currently medical marijuana users. This totaled 96 respondents, 30 of

whom were female, and 66 of whom were males (see figure 4). Average age (mean) of

respondents was 46 years (see figure 5 for age distribution).

32  

Figure 4. Figure 5.

The greatest number of responses, 19%, came from the state of Oregon, with 14% of responses

from Michigan and 11% of total responses from California. See figure 6 for geographic

distribution.

Figure 6.

In corresponding and speaking with key informants prior to designing the survey, it was found

that the language that is used from state to state to describe the players in the medical marijuana

industry and the connotations associated with that language seem to vary much more than

anticipated. One patient in Oregon who was interviewed for this project shared with me that the

0

1

2

3

4

5

6

20 23 26 29 32 35 38 41 44 47 50 53 56 59 62 65 68 71 74 77 80

Number o

f Respondents

Age of Respondent in Years

Age

02468101214161820

Alberta, C

anada

British

 Columbia,…

California

Colorado

Florida

France

Illinois

Iowa

Louisiana

Marlborough

Massachusetts

Mexico

Michigan

Missouri

Montana

Nebraska

New

 Jersey

New

 York

North

 Carolina

Ohio

Ontario, C

anada

Oregon

Pennsylvania

Rhode

 Island

Scotland

Spain

Sweden

Texas

UK

Virginia

Washington

Wisconsin

Number o

f Survey

 Respondents

State (US), Province (Canada), or Country (EU/UK)

Geographic Distribution

33  

word "dispensary" has negative connotations for some patients and advocates, and the term

“resource center” is used to describe establishments which aid in the distribution of cannabis for

medical use. A contact in California, of the Medical Cannabis Association, wrote in email

correspondence, “When you think of medical patients, what comes to mind for you? You should

know that the term marijuana patient [out here in California] is more political than you may

realize. The law in California allows a doctor to recommend the use of marijuana ‘for any

ailment for which marijuana provides relief.’” The need for syncretism in the discourse

surrounding medical marijuana is such that the language that is used to describe practices

becomes politically charged.

Modes of Administration

The results of inquiring of survey respondents as to preferred mode of administration (see figure

7) showed that smoking of cannabis was the preferred mode of administration in the majority of

cases. 67% of respondents preferred smoke inhalation. This is likely due to the fact that

smoking of cannabis is fast-acting, providing immediate results, and allows the patient to self-

titrate dosage. Note that respondents were instructed to choose as many modes as they liked, so

the sum total of responses is greater than 100%. Write-in responses included concentrate, juicing

fresh green leaves, encapsulated oil infusion, tea, creams, massage oil, and topical application.   

The use of the term “liquid extract” in the survey question was slightly vague, and in hindsight

could have been more specific. This term was intended to indicate a tincture, which is a liquid

extract in alcohol or glycerin. The term “tincture” was not used because it was uncertain whether

respondents would understand the meaning. However, “liquid extract” could also be interpreted

to indicate an infusion, tea, or tisane, the juice of the fresh plant, or an essential oil, and so the

term was not as specific as intended. However, several respondents wrote in “tea” and “fresh

juice” under the choice “other”, so perhaps the intended meaning was clear to some.

Figure 7. 

34  

Intended Therapeutic Uses

Figure 8.

In order to aid in visualization of reported symptoms for which cannabis was employed, a word

cloud was created, by pasting the raw text generated by survey respondents in response to the

question “What symptoms are you using medical marijuana to treat?” onto

http://www.wordle.net. Word clouds were found to be a useful tool in this project for

visualizing repeated terms, concepts, and themes in the language generated by open-ended

questions. In addition, wordle.net supplies a case-sensitive frequency tool which was employed

for measuring the number of times each specific word is used. See word cloud in figure 8.

An overwhelming majority, 80% of respondents replied “yes” to the question, “Do you find that

medical marijuana has advantages over other treatments?” while 1% replied “no”, and 3% replied

“not sure”.

The symptom for which cannabis was most commonly cited as a therapeutic agent (see figure 9)

was pain, with 67% of respondents citing its use for this purpose. This included chronic and

intractable pain of multiple etiologies. 15% of respondents specified neuralgia and neuropathies

in using cannabis to relieve their symptoms. Muscle spasms or spasticity (18%) were also

commonly cited. Migraines (11%), back problems (11%), and arthritis (8%) were other specific

forms of pain cited.

35  

The second most commonly cited symptom, at 25% of respondents, was insomnia and

sleeplessness. Other mental health symptoms such as anxiety (22%), depression (16%), stress

(10%), and post traumatic stress disorder or PTSD (10%) were also commonly cited. Many

patients employed cannabis to relieve both physical pain and improve mental health complaints.

Gastrointestinal concerns such as nausea (9%), irritable bowel disorders (8%), and appetite

stimulation (6%) were cited less frequently than physical pain or mental complaints. Central

nervous system disorders cited included multiple sclerosis or MS (4%) and epilepsy or seizures

(4%).

Figure 9.

Strain Preferences

To visualize the responses generated by the open-ended question “What strains of medical

marijuana do you prefer?”, the raw text was used to form a word cloud using wordle.net, with the

results displayed in figure 10.

0 10 20 30 40 50 60 70

Pain

Insomnia/sleeplessness

Anxiety

Muscle spasms, spasticityDepression

Neuropathy/neuralgia

Migraines

Back problems

PTSD

Stress

Nausea

Arthritis

ADHD/ADD

Inflammatory bowel disordersAppetite

MS

Epilepsy/seizures

Asthma

Fibromyalgia

Number of Respondents

Symptoms

Most commonly reported therapeutic applications

36  

Figure 10.

The total number of strains named by respondents was n=259. The number of unique strains

that were named was n= 136. The most commonly named strain was indica, which was named by

22% of respondents. Sativa was named by 17%, White Widow was named by 14%, and

Blueberry was named by 8%. Blu-berry was named once, but it couldn’t be assumed that this

was the same as Blueberry, so this was not added to the Blueberry count. Grand Daddy Purple

was named by 6% of respondents. 9% of respondents specified OG as a modifier to certain

strain names (e.g. OG Kush). This was assumed to indicate organically cultivated strains, but

strains named with modifiers were not grouped along with the same strain without the modifier.

For example, the frequency of OG Kush was measured separately from the frequency of Kush.

Similarly, if a respondent specified Kush varieties, this was not grouped with Kush, which was

taken to be a discrete strain while Kush varieties was taken to indicate hybrids of Kush. Kush

was named by 6%, OG Kush was named by 5%, and non-specific “Kush varieties” was named

once. The frequency of Purple Kush and other specific Kush varieties were also measured

separately. Other frequently named cultivars were Sour Diesel (6%), AK-47 (5%), and Super

Silver Haze (5%). See figure 11 for the top most frequently named strain preferences.

37  

Figure 11

A comprehensive cannabis strain library exists, http://www.kindgreenbuds.com, which lists

horticultural profiles for a large database of cannabis strains. Included in the strain profiles is

data on ratios of species predominance (indica:sativa, expressed as a percentage) for hybrids.

This database was accessed <8 September 2011> to determine the species predominance of the

top 10 most frequently named strains by survey respondents in order to determine if there was a

general trend indicating preference for indica or sativa predominance. Determined to be indica-

predominant strains were: Blueberry, Grand Daddy Purple, OG Kush, and Kush. Strains which

were determined to be sativa predominant were White Widow, Sour Diesel, and AK-47. Super

Silver Haze was found to be a 50:50 hybrid, so it was not included in determining preference for

indica or sativa-rich strains. In examining the top 10 most frequently named strains, it was found

that 47% of respondents specified a preference for an indica or indica-predominant strain, and 40

% of respondents specified preference for a sativa or sativa-rich strain. This is in comparison

with the previously cited survey conducted by the American Alliance for Cannabis Therapeutics

which found that 31% of respondents preferred indica or indica-rich hybrids while 26%

preferred sativa or sativa-rich strains for therapeutic purposes.

0 5 10 15 20 25

Indica

Sativa

White Widow

Blueberry

Grand Daddy PurpleKush

Sour DieselAK‐47

OG KushSuper Silver Haze

Green CrackIndica‐SativaBlue Dream

Haze

Jack HererLemon Skunk

New York City DieselNorthern lights

Purple KushSuper Lemon Haze

Number of respondents

Most Commonly Named Strains

38  

In the present results, 15% of respondents addressed their perception of the subjective

therapeutic differences between sativa-predominant and indica-predominant strains, saying that

sativa was uplifting, anti-depressive, energizing, useful for fatigue or exhaustion and better for

daytime use, while indica was said to be useful for pain, lack of appetite, insomnia, and generally

for nighttime use, but impeded daytime function. Similarly, 7% of respondents addressed their

preferences for CBD and THC while discussing strain preferences, with parallels noted between

the therapeutic effects of CBD and indica-dominant strains for pain and insomnia.

4% of respondents commented upon the fallibility of nomenclature which exists in the

commercial medical marijuana market, saying things like “strains are made up words,” “in Ohio,

you get what the street offers,” and “the black market doesn't tell you what you're getting and I

hate that.”

3% of respondents volunteered germplasm source information, specifying the seed company or

source which provided the specific strains they preferred. Several respondents also discussed

hybrid strains which they had selectively crossed to meet their own preferences.

General criteria in cannabis cultivar selection which was listed by respondents in answer to the

open-ended question, “What criteria do you use in selecting a medical marijuana strain?” was

again depicted using a word cloud with the results shown in figure 12.

Figure 12.

39  

20% of respondents stated that smell, aroma, or fragrance was a criterion they used in strain

selection. 15% specified taste, flavor, or palatability in strain selection criteria. 18% stated that

effects, effectiveness, or efficacy was a criterion in strain selection. Related criteria such as

potency and results were also frequently mentioned, by about 10% of respondents. Availability

was also mentioned by 5% of respondents. In semi-structured phone interviews, it was stated

that patients in the state of Oregon are “self-selecting for strains that work for them”, and that

selection of cannabis cultivars occurs through a combination of trial and error, availability, and

social networking (Glick, personal communication, 2011). Another interviewee in Oregon stated

the significance of social gatherings such as the Medical Cannabis Cup in shaping the cannabis

market by formalizing social networking and in turn facilitating the exchange of information and

novel germplasm (McGarvin, personal communication, 2011). Begun only recently in San

Francisco, California in 2010, the Medical Cannabis Cup has since occurred in Denver, Colorado,

and will occur in Detroit, Michigan in October 2011 (see figure 13), all states in the US which have

provisions for medical marijuana. Similar to the Cannabis Cup in Amsterdam, at the Medical

Cannabis Cup, medical marijuana strains are evaluated for their merits and awarded accordingly

with a cannabis cup.

Figure 13.

Patients’ use of Cannabinoid Analysis Information

18% of respondents felt that chemical analysis of cannabis was very important. 3% of

respondents felt that chemical analysis was not important at all. See figure 14.

40  

 

Figure 14.

The most commonly sought cannabinoid, by 80 % of respondents, was THC. Nearly as highly

sought was CBD, sought by 70% of respondents. Note that patients listed as many cannabinoids

as they liked in this mutiple-choice question, so the sum total of responses is greater than 100%.

44% of respondents also selected for terpenes, and 39% for CBN in choosing medical marijuana.

See figure 15.

Figure 15.

20, 18%

15, 13% 15, 13%

7, 6%

3, 3%

0

5

10

15

20

25

1‐VeryImportant

2 3 4 5‐Not at all

Number o

f Respondents

Importance Placed on Chemical Analysis

9, 15%

43, 70%

24, 39%

49, 80%

16, 26%

27, 44%

0

10

20

30

40

50

60

CBC CBD CBN THC THCV Terpenes

Number o

f Respondents

Preference for Cannabinoids

41  

Analysis

The under-regulated nature of the medical marijuana industry presented several limiting factors in

the execution of the present study. The inconsistency of popular nomenclature can be a critical

limiting factor in identifying patient preferences for cultivars. The lack of standardization of

medicinal marijuana products makes it difficult to accurately assess potency and cannabinoid

content of germplasm employed for therapeutic purposes. And lastly, patients’ access or lack

thereof, to accurate information about cannabinoid properties, to strains with known

chemotaxonomic profiles, and especially the lack of patient choice altogether in states where

cannabis use is not ratified, limits the ability of the present study to measure knowledge and its

effect on choice. Because patients may not always have access to consistent, tested cannabis and

cannabis products, selection of cultivars can sometimes be guided more by availability of product

or incomplete information. However, in US states where medical marijuana use is decriminalized,

increasing access to chemical analysis data and the tools to apply this information for

cannabinoid strain selection suggest that many patients may apply rational criteria to strain

selection.

The potential for correlations between reported symptoms and cannabinoid preferences was

examined. The data on reported therapeutic applications (see figure 9 above) was coded into 4

categories:

1. Pain of multiple etiologies

2. Mental Health (including ADHD, depression, anxiety, PTSD, and insomnia)

3. Gastrointestinal health (including appetite, nausea and irritable bowel disorder)

4. Other neuropathy (including MS and epilepsy)

The four symptom codes and six cannabinoid compounds measured in the survey were cross-

referenced. See results displayed in table 3 and figure 16.

42  

Table 3.

Figure 16.

The results of examining natural use patterns of cannabis as medicine indicate that cannabis is

used most frequently for pain of multiple etiologies as well as mental health complaints. The

compounds patients sought most for pain were THC and CBD, with 70% of pain patients

seeking cannabis high in THC, and 63% seeking cannabis high in CBD. The compounds which

were most sought by patients with mental health complaints were again CBD and THC, with

48% choosing cannabis strains tested to contain CBD, and 45% choosing strains high in THC.

Compound

Symptom Pain Mental GI Other Pain Mental GI Other Pain Mental GI Other

Total reported 8 6 3 1 38 29 14 2 22 17 10 3

Percentage 13% 10% 5% 2% 63% 48% 23% 3% 37% 28% 17% 5%

Compound

Symptom Pain Mental GI Other Pain Mental GI Other Pain Mental GI Other

Total reported 42 27 15 4 15 9 4 0 23 13 9 2

Percentage 70% 45% 25% 7% 25% 15% 7% 0% 38% 22% 15% 3%

CBC CBD CBN

THC THCV Terpenes

8

6

3 1

38

29

14

2

22

17

10

3

42

27

15

4

15

9

4 0

23

13

9

20

5

10

15

20

25

30

35

40

45

Pain Mental GI Other

Number o

f Respondents

Therapeutic Application

Cannabinoids Selected for Therapeutic Application

CBC

CBD

CBN

THC

THCV

Terpenes

43  

Conclusions

Because patients are selecting the strains of cannabis which yield the desired results for specific

therapeutic complaints, targeted investigation of specific strain properties is recommended

(including indica/sativa predominance, cannabinoid content), as indicated by frequent patient

reports of anecdotal therapeutic success with a particular strain. Controlled use studies which

further explore therapeutic indications resulting from natural use studies such as the present

survey are needed, for example in the application of herbal cannabis for the treatment of pain

and mental health complaints, and may be used to inform clinical use protocols of medical

marijuana. Continued chemotaxonomic and genetic analysis of cannabis cultivars is greatly

needed to resolve discrepancies and debates in popular and scientific nomenclature and to aid in

the development of standard naming conventions for cannabis.

Modes of administration which de-emphasize cultural associations and assumptions surrounding

cannabis merit further investigation. A nebulizer for inhalation, juicing fresh plant matter for

consumption, utilizing cannabis essential oils, external applications, and employing cannabis

strains which are high in non-psychotropic cannabinoids such as CBD, CBN, and terpenes could

all offer potential therapeutic benefit without the emphasis on smoking cannabis for its THC

content.

The trend towards decriminalization of medical marijuana at the state level in the US continues to

be a contentious issue. Policies which regulate the licensing and distribution of medical

marijuana are founded as much on moral and political considerations as they are on scientific

data, a deficiency which the present research attempted to address by examining the link between

rational criteria (chemical composition) and user behavior (selection of medical marijuana

cultivars and modes of administration). Because of the complexity of issues involved in the use

of medical marijuana, this survey can have ramifications for public health policy, government

regulations, economics and trade, medical anthropology, horticulture, and phytotherapy. The

data gathered may also inform policy recommendations for public interest or activist groups.

It is apparent that syncretism among all these discourses continues to be much-needed to address

the complexity of issues surrounding the problem of medical marijuana. Although there is some

intercalation of medical models exemplified by the growing state-level US medical marijuana

44  

system and biomedical research priorities, still the restriction of cannabis as a Schedule I drug

continues to impede the full potential of scientific research contributing to the safety and efficacy

of cannabis as medicine.

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Appendix 1: Survey 

Medical Marijuana Research Survey

By filling out the following brief (five minute) survey, you will be participating in a graduate research project aimed at examining the use of chemical analysis services among medical marijuana patients. The survey responses will be coded for confidentiality, and results will be used in writing a master's thesis. What state do you live in?

What is your gender?

Male Female

What is your age?

Are you currently a medical marijuana user?

Yes

No

What symptoms are you using medical marijuana to treat? (List all that apply)

Are you using other treatments for these symptoms?

Yes

No

Do you find that medical marijuana has advantages over other treatments?

Yes

No

What is your preferred form for using medical marijuana? (Choose all that apply) Smoke Vaporizer Liquid extract Pill Edible External Other: (Please specify)

Survey continues on the other side →

48  

What strains of medical marijuana do you prefer? (List all that apply) What criteria do you use in selecting a medical marijuana strain? (List all that apply) Do you choose medical marijuana strains that have been tested for cannabinoid content?

Yes No Sometimes

How important to you are chemical analysis results in choosing a strain of medical marijuana?

What cannabinoids or compounds do you give preference to in selecting medical

marijuana strains? (Check all that apply)

Cannabichromene (CBC) Cannabidiol (CBD) Cannabinol (CBN) Tetrahydrocannabinol (THC) Tetrahydrocannabivarin (THCV) Terpenes I don't know Other: (Please specify)

  Your participation is much appreciated!

Please return completed surveys to the lab or care center where you picked it up. Responses will be kept confidential and used to compile data toward a graduate thesis in ethnobotany for the University of Kent - Canterbury, U.K. For results of the study, or to participate further, contact cannanalysis@gmail.com.

Thank you for taking the time to complete this survey.