Cancer and Medical Marijuana



A Note from Americans for Safe Access We are committed to ensuring safe, legal availability of marijuana for medical uses. This brochure is intended to help doctors, patients and policymakers better understand how marijuana—or “cannabis” as it is more properly called—may be used as a treatment for people with serious medical conditions. This booklet contains information about using cannabis as medicine. In it you’ll find information on:

Why Cannabis is Legal to Recommend

Overview of the Scientific Research on Medical Cannabis

Research on Cannabis and Cancer

Comparison of Medications: Efficacy and Side-Effects

Why Cannabis is Safe to Recommend

Testimonials of Patients and Doctors

History of Cannabis as Medicine

Scientific and Legal References

We recognize that information about using cannabis as medicine has been difficult to obtain. The federal prohibition on cannabis has meant that modern clinical research has been limited, to the detriment of medical science and the wellness of patients. But the documented history of the safe, medical use of cannabis dates to 2700 B.C. Cannabis was part of the American pharmacopoeia until 1942 and is currently available by prescription in the Netherlands and Canada.

Testimonials from both doctors and patients reveal valuable information on the use of cannabis therapies, and supporting statements from professional health organizations and leading medical journals support its legitimacy as a medicine. In the last few years, clinical trials in Great Britain, Canada, Spain, Israel, and elsewhere have shown great promise for new medical applications.

This brochure is intended to be a starting point for the consideration of applying cannabis therapies to specific conditions; it is not intended to replace the training and expertise of physicians with regard to medicine, or attorneys with regard to the law. But as patients, doctors and advocates who have been working intimately with these issues for many years, Americans for Safe Access has seen firsthand how helpful cannabis can be for a wide variety of indications. We know doctors want the freedom to practice medicine and patients the freedom to make decisions about their healthcare.

For more information about ASA and the work we do, please see our website at AmericansForSafeAccess.org or call 1-888-929-4367.

Is Cannabis Legal to Recommend? In 2004, the United States Supreme Court upheld earlier federal court decisions that doctors have a fundamental Constitutional right to recommend cannabis to their patients.

The history. Within weeks of California voters legalizing medical cannabis in 1996, federal officials had threatened to revoke the prescribing privileges of any physicians who recommended cannabis to their patients for medical use.1 In response, a group of doctors and patients led by AIDS specialist Dr. Marcus Conant filed suit against the government, contending that such a policy violates the First Amend-ment.2 The federal courts agreed at first the district level,3  then all the way through appeals to the Ninth Circuit and then the Supreme Court.

What doctors may and may not do. In Conant v. Walters,4 the Ninth Circuit Court of Appeals held that the federal government could neither punish nor threaten a doctor merely for recommending the use of cannabis to a patient.5 But it remains illegal for a doctor to “aid and abet” a patient in obtaining cannabis.6 This means a physician may discuss the pros and cons of medical cannabis with any patient, and issue a written or oral recommendation to use cannabis without fear of legal reprisal.7 This is true regardless of whether the physician anticipates that the patient will, in turn, use this recommendation to obtain cannabis.8 What physicians may not do is actually prescribe or dispense cannabis to a patient9 or tell patients how to use a written recommendation to procure it from a cannabis club or dispensary.10 Doctors can tell patients they may be helped by cannabis. They can put that in writing. They just can’t help patients obtain the cannabis itself.

Patients protected under state, not federal, law. In June 2005, the U.S. Supreme Court overturned the Raich v. Ashcroft Ninth Circuit Court of Appeals decision. In reversing the lower court’s ruling, Gonzales v. Raich established that it is legal under federal law to prosecute patients who possess, grow, or consume medical cannabis in medical cannabis states. However, this Supreme Court decision does not overturn or supersede the laws in states with medical cannabis programs.

For assistance with determining how best to write a legal recommendation for cannabis, please contact ASA at 1-888-929-4367.

Scientific Research Supports Medical Cannabis Between 1840 and 1900, European and American medical journals published more than 100 articles on the therapeutic use of the drug known then as Cannabis Indica (or Indian hemp) and now simply as cannabis. Today, new studies are being published in peer-reviewed journals that demonstrate cannabis has medical value in treating patients with serious illnesses such as AIDS, glaucoma, cancer, multiple sclerosis, epilepsy, and chronic pain.

The safety of the drug has been attested to by numerous studies and reports, including the LaGuardia Report of 1944, the Schafer Commission Report of 1972, a 1997 study conducted by the British House of Lords, the Institutes of Medicine report of 1999, research sponsored by Health Canada, and numerous studies conducted in the Netherlands, where cannabis has been quasi-legal since 1976 and is currently available from pharmacies by prescription.

Recent published research on CD4 immunity in AIDS patients found no compromise to the immune systems of patients undergoing cannabis therapy in clinical trials.11

The use of medical cannabis has been endorsed by numerous professional organizations, including the American Academy of Family Physicians, the American Public Health Association, and the American Nurses Association. Its use is supported by such leading medical publications as The New England Journal of Medicine and The Lancet.

Recent Research Advances While research has until recently been sharply limited by federal prohibition, the last few years have seen rapid change. The International Cannabinoid Research Society was formally incorporated as a scientific research organization in 1991. Membership in the Society has more than tripled from about 50 members in the first year to over 300 in 2005. The International Association for Cannabis as Medicine (IACM) was founded in March 2000. It publishes a bi-weekly newsletter and the IACM-Bulletin, and holds a bi-annual symposium to highlight emerging research in cannabis therapeutics. The University of California established the Center for Medicinal Cannabis Research in 2001. As of June 2006, the CMCR has 17 approved studies, including research on cancer pain, nausea control in chemotherapy, general analgesia and a proposed study on refractory cancer pain.

In the United Kingdom, GW Pharmaceuticals has been granted a clinical trial exemption certificate by the Medicines Control Agency to conduct clinical studies with cannabis-based medicines. The exemption includes investigations in the relief of pain of neurological origin and defects of neurological function in the following indications: multiple sclerosis (MS), spinal cord injury, peripheral nerve injury, central nervous system damage, neuroinvasive cancer, dystonias, cerebral vascular accident and spina bifida, as well as for the relief of pain and inflammation in rheumatoid arthritis and also pain relief in brachial plexus injury.

GW has completed Phase III studies in patients with MS neuropathic pain and spasticity, and Phase II trials on perioperative pain, rheumatoid arthritis, peripheral neuropathy secondary to diabetes mellitus or AIDS, and patients with neurogenic symptoms.

These trials have provided positive results and confirmed an excellent safety profile for cannabis-based medicines. In 2002, GW conducted five Phase III trials of its cannabis derivatives, including a double-blind, placebo-controlled trial with a sublingual spray containing THC in more than 100 patients with cancer pain. In total, more than 1,000 patients are currently involved in phase III trials in the UK.

In 2002 GW Pharmaceuticals received an IND approval to commence phase II clinical trials in Canada in patients with chronic pain, multiple sclerosis and spinal cord injury, and in April 2005 GW received regulatory approval to distribute Sativex in Canada for the relief of neuropathic pain in adults with Multiple Sclerosis. Following meetings with the FDA, DEA, the Office for National Drug Control Policy, and the National Institute for Drug Abuse, GW was granted an import license from the DEA and has imported its first cannabis extracts into the U.S., and in January of 2006 was granted permission to begin Phase III clinical trials into cancer pain.

CANNABIS AND CANCER Cannabis has been found to help cancer patients with pain and nausea, and recent research indicates it has tumor-reducing and anti-carcinogenic properties properties as well. It has proven highly effective at controlling the nausea associated with chemotherapy, and its appetite-stimulation properties help combat wasting. Cannabis can also help control the pain associated with some cancers, as well as that resulting from radiation and chemotherapy treatment.

Cannabis and chemotherapy side effects One of the most widely studied therapeutic applications for cannabis and  the pharmaceutical drugs derived from cannabinoids is in the treatment of nausea and vomiting associated with cancer chemotherapy.. Numerous clinical studies have reported that the use of cannabis reduces nausea and vomiting and stimulates appetite, thereby reducing the severity of cachexia, or wasting syndrome, in patients receiving chemotherapy treatment.

The 1999 Institutes of Medicine report concluded: “In patients already experiencing severe nausea or vomiting, pills are generally ineffective, because of the difficulty in swallowing or keeping a pill down, and slow onset of the drug effect. Thus an inhalation (but, preferably not smoking) cannabinoid drug delivery system would be advantageous for treating chemotherapy-induced nausea.”12

A 1997 inquiry by the British Medical Association found cannabis more effective than Marinol, and a 1998 review by the House of Lords Science & Technology Select Committee concluded that “Cannabinoids are undoubtedly effective as anti-emetic agents in vomiting induced by anti-cancer drugs. Some users of both find cannabis itself more effective.”13

In the last three years, there have been major advances in both cannabinoid pharmacology and in understanding of the cancer disease process. In particular, research has demonstrated the presence of numerous cannabinoid receptors in the nucleus of the solitary tract, a brain center important in control of vomiting.

Although other recently developed anti-emetics are as effective or more effective than oral THC, nabilone or smoked cannabis, for certain individuals unresponsive to conventional anti-emetic drugs, the use of smoked cannabis can provide relief more effectively than oral preparations which may be difficult to swallow or be vomited before taking effect, as the IOM report notes.

The psychoactive/euphoriant effects of THC or inhaled cannabis may also provide an improvement in mood. By contrast, several conventional medications commonly prescribed for cancer patients, e.g. phenothiazines such as haloperidol (known as “major tranquillizers”) may produce unwanted side effects such as excessive sedation, flattening of mood, and/or distressing physical “extrapyramidal” symptoms such as uncontrolled or compulsive movements.

While clinical research on using cannabis medicinally has been severely limited by federal prohibition,the accumulated data speaks strongly in favor of considering it as an option for most cancer patients, and many oncologists do. Survey data from a Harvard Medical School study in 1990, before any states had approved medical use, shows that 44% of oncologists had recommended cannabis to at least some of their patients. Nearly half said they would do so if the laws were changed. According the American Cancer Society’s 2003 data, more than 1,300,000 Americans are diagnosed with cancer each year.15  At least 300,000 of them will undergo chemotherapy, meaning as many as 132,000 patients annually may have cannabis recommended to them to help fight the side effects of conventional treatments.

As the Institutes of Medicine report concluded, “nausea, appetite loss, pain and anxiety … all can be mitigated by marijuana.”

Research on cannabis and chemotherapy Cannabis is used to combat pain caused by various cancers and nausea induced by chemotherapy agents. Over 30 human clinical trials have examined the effects of cannabis or synthetic cannabinoids on nausea, not including several U.S. state trials that took place between 1978 and 1986.16 In reviewing this literature, Hall et al. concluded that “. . . THC [delta-9-tetrahydrocannabinol] is superior to placebo, and equivalent in effectiveness to other widely-used anti-emetic drugs, in its capacity to reduce the nausea and vomiting caused by some chemotherapy regimens in some cancer patients.”17 A 2003 study found “Cannabinoids—the active components of cannabis sativa and their derivatives—exert palliative effects in cancer patients by preventing nausea, vomiting and pain and by stimulating appetite. In addition, these compounds have been shown to inhibit the growth of tumor cells in culture and animal models by modulating key cell-signaling pathways. Cannabinoids are usually well tolerated, and do not produce the generalized toxic effects of conventional chemotherapies.”18

Authors of the Institute of Medicine report, “Marijuana and Medicine: Assessing the Science Base,” found that there are certain cancer patients for whom cannabis should be a valid medical option.19 A random-sample anonymous survey conducted in the spring of 1990 measured the attitudes and experiences of oncologists concerning the antiemetic use of cannabis in cancer chemotherapy patients. Of the respondents expressing an opinion, a majority (54%) thought cannabis should be available by prescription.20

Cancer-fighting properties of cannabis More than twenty major studies published between 2001 and 2006have shown that the chemicals in cannabis known as cannabinoids have a significant effect fighting cancer cells. We now know cannabinoids arrest many kinds of cancer growths (brain, breast, leukemic, melanoma, phaeochromocytoma, et al.) through promotion of apoptosis (programmed cell death) that is lost in tumors, and by arresting angiogenesis (increased blood vessel production).

Recent scientific advances in the study of cannabinoid receptors and endocannabinoids have produced exciting new leads in the search for anti-cancer treatments.

There is growing evidence of direct anti-tumor activity of cannabinoids, specifically CB1 and CB2 agonists, in a range of cancer types including brain (gliomas), skin, pituitary, prostate and bowel. The antitumor activity has led in laboratory animals and in-vitro human tissues to regression of tumors, reductions in vascularisation (blood supply) and metastases (secondary tumors), as well as direct inducement of death (apoptosis) among cancer cells. Indeed, the complex interactions of endogenous cannabinoids and receptors are leading to greater scientific understanding of the mechanisms by which cancers develop.

The findings of these studies are borne out by the reports of such patients as Steve Kubby, whose cannabis use is credited with keeping a rare, terminal cancer in a state of remission for decades beyond conventional expectations.

Research on tumor reduction Although cannabis smoke has been shown to have precancerous-causing effects in animal tissue, epidemiological studies on humans have failed to link cannabis smoking with cancer.21,22  If smoke inhalation is a concern, cannabis can be used with a vaporizer, orally in baked goods, and topically as a tincture or a suppository.

Cannabinoids, the active components of cannabis, have been shown to exhibit anti-tumor properties. Multiple studies published between 2001 and 2006 found that cannabinoids inhibit tumor growth in laboratory animals.23-27 In another study, injections of synthetic THC eradicated malignant brain tumors in one-third of treated rats, and prolonged life in another third by as much as six weeks.28 Other journals have also reported on cannabinoids’ antitumoral potential.29-35 Italian research teams reported in 1998 and 2001 that the endocannabinoid anandamide, which binds to the same brain receptors as cannabis, “potently and selectively inhibits the proliferation of human breast cancer cells in vitro” by interfering with their DNA production cycle.36-38 Cannabis has been shown in recent studies to inhibit the growth of thyroid, prostate and colorectal cancer cells.39-41 THC has been found to cause the death of glioma cells.42,43 And research on pituitary cancers shows cannabinoids are key to regulating human pituitary hormone secretion.44-47

In 2004 an Italian research team demonstrated that the administration of the non-psychoactive cannabinoid cannabidiol (CBD) to nude mice significantly inhibited the growth of subcutaneously implanted U87 human glioma cells. The authors of the study concluded that “… CBD was able to produce a significant antitumor activity both in vitro and in vivo, thus suggesting a possible application of CBD as an antineoplastic agent (an agent that inhibits the growth of malignant cells.)”48

More recently, investigators at the California Pacific Medical Center Research Institute reported that the administration of THC on human glioblastoma multiforme cell lines decreased the proliferation of malignant cells and induced apoptosis (programmed cell death) more rapidly than did the administration of an alternative synthetic cannabis receptor agonist.49

How cannabis compares to other medications The American Cancer Society lists 269 medicines currently prescribed to treat cancer and its symptoms, and to treat the side effects of other cancer drugs. Some drugs are prescribed for pain caused by cancer, and cancer patients report pain relief with cannabis therapy. Many chemotherapy agents cause severe nausea and 13 drugs are currently prescribed to treat nausea, including Marinol, a synthetic form of delta-9-THC, one of the active ingredients in cannabis.

The newer antiemetics, Anzamet, Kytril and Zofran, are serotonin antagonists, blocking the neurotransmitter that sends a vomiting signal to the brain. Rare side effects of these drugs include fever, fatigue, bone pain, muscle aches, constipation, loss of appetite, inflammation of the pancreas, changes in electrical activity of heart, vivid dreams, sleep problems, confusion, anxiety and facial swelling.

Reglan, a substituted benzamide, increases emptying of the stomach, thus decreasing the chance of developing nausea and vomiting due to food remaining in the stomach. When given at high doses, it blocks the messages to the part of the brain responsible for nausea and vomiting resulting from chemotherapy. Side effects include sleepiness, restlessness, diarrhea and dry mouth. Rarer side effects are rash, hives and decreased blood pressure

Haldol and Inapsine are tranquilizers that block messages to the part of the brain responsible for nausea and vomiting. Possible side effects include decreased breathing rate, increased heart rate, decrease in blood pressure when changing position and, rarely, change in electrical activity of the heart.

Compazine and Torecan are phenothiazines, the first major anti-nausea drugs. Both have tranquilizing effects. Common side effects include dry mouth and constipation. Less common effects are blurred vision, restlessness, involuntary muscle movements, tremors, increased appetite, weight gain, increased heart rate and changes in electrical activity of heart. Rare side effects include jaundice, rash, hives and increased sensitivity to sunlight.

Benadryl, an antihistamine, is given along with Reglan, Haldol, Inapsine, Compazine and Torecan to counter side effects of restlessness, tongue protrusion, and involuntary movements. Its side effects include sedation, drowsiness, dry mouth, dizziness, confusion, excitability and decreased blood pressure.

Decadron (dexamethasone), a corticosteroid, is given with other chemotherapy drugs as an adjunct medication. Common side effects include increased appetite, irritation of stomach, euphoria, difficulty sleeping, mood changes, flushing, increased blood sugar, decreased blood potassium level. Possible side effects upon discontinuing the drug include adrenal insufficiency, weakness, aches, fever, dizziness, lowering of blood pressure when changing position, difficulty breathing, and low blood sugar.

Benzodiazepine drugs Ativan and Xanax are also prescribed to combat the effects of chemotherapy. Ativan causes amnesia. Abruptly stopping the drug can cause anxiety, dizziness, nausea and vomiting, and tiredness. It can cause drowsiness, confusion, weakness, and headache when first starting the drug. Nausea, vomiting, dry mouth, changes in heart rate and blood pressure, and palpitations are possible side effects.

In addition, in April 2003 the FDA approved the drug Emend (aprepitant) to help control delayed-onset nausea. It is given along with two other anti-nausea drugs. A regimen of three pills costs $250. The most common side effects with Emend are fatigue, nausea, loss of appetite, constipation, diarrhea. span>

Cannabis: By comparison, the side effects associated with cannabis are typically mild and are classified as “low risk.” Euphoric mood changes are among the most frequent side effects.  Cannabinoids can exacerbate schizophrenic psychosis in predisposed persons.  Cannabinoids impede cognitive and psychomotor performance, resulting in temporary impairment. Chronic use can lead to the development of tolerance. Tachycardia and hypotension are frequently documented as adverse events in the cardiovascular system. A few cases of myocardial ischemia have been reported in young and previously healthy patients. Inhaling the smoke of cannabis cigarettes induces side effects on the respiratory system.  Cannabinoids are contraindicated for patients with a history of cardiac ischemias.  In summary, a low risk profile is evident from the literature available. Serious complications are very rare and are not usually reported during the use of cannabinoids for medical indications.

Is cannabis safe to recommend? “The smoking of cannabis, even long term, is not harmful to health….”  So began a 1995 editorial statement of Great Britain’s leading medical journal, The Lancet. The long history of human use of cannabis also attests to its safety—nearly 5,000 years of documented use without a single death.  In the same year as the Lancet editorial, Dr. Lester Grinspoon, a professor emeritus at Harvard Medical School who has published many influential books and articles on medical use of cannabis, had this to say in an article in the Journal of the American Medical Association (1995):

“One of marihuana’s greatest advantages as a medicine is its remarkable safety. It has little effect on major physiological functions. There is no known case of a lethal overdose; on the basis of animal models, the ratio of lethal to effective dose is estimated as 40,000 to 1. By comparison, the ratio is between 3 and 50 to 1 for secobarbital and between 4 and 10 to 1 for ethanol. Marihuana is also far less addictive and far less subject to abuse than many drugs now used as muscle relaxants, hypnotics, and analgesics. The chief legitimate concern is the effect of smoking on the lungs. Cannabis smoke carries even more tars and other particulate matter than tobacco smoke. But the amount smoked is much less, especially in medical use, and once marihuana is an openly recognized medicine, solutions may be found; ultimately a technology for the inhalation of cannabinoid vapors could be developed.”

The technology Dr. Grinspoon imagined in 1995 now exists in the form of “vaporizers,” (which are widely available through stores and by mail-order) and recent research attests to their efficacy and safety.35  Additionally, pharmaceutical companies have developed sublingual sprays and tablet forms of the drug. Patients and doctors have found other ways to avoid the potential problems associated with smoking, though long-term studies of even the heaviest users in Jamaica, Turkey and the U.S. have not found increased incidence of lung disease or other respiratory problems. As Dr. Grinspoon goes on to say, “the greatest danger in medical use of marihuana is its illegality, which imposes much anxiety and expense on suffering people, forces them to bargain with illicit drug dealers, and exposes them to the threat of criminal prosecution.” This was the same conclusion reached by the House of Lords report, which recommended rescheduling and decriminalization, both of which were enacted in Great Britain in 2004.

Cannabis or Marinol? Those committed to the prohibition on cannabis frequently cite Marinol, a Schedule III drug, as the legal means to obtain the benefits of cannabis. However, Marinol, which is a synthetic form of THC, does not deliver the same therapeutic benefits as the natural herb, which contains at least another 60 cannabinoids in addition to THC. Recent research conducted by GW Pharmaceuticals in Great Britain has shown that Marinol is simply not as effective for pain management as the whole plant; a balance of cannabinoids, specifically CBC and CBD with THC, is what helps patients most. In fact, Marinol is not labeled for pain, only appetite stimulation and nausea control. But studies have found that many severely nauseated patients experience difficulty in getting and keeping a pill down, a problem avoided by use of inhaled cannabis.

Clinical research on Marinol vs. cannabis has been limited by federal restrictions, but a New Mexico state research program conducted from 1978 to 1986 provided cannabis or Marinol to about 250 cancer patients for whom conventional medications had failed to control the nausea and vomiting associated with chemotherapy. At a DEA hearing, a physician with the program testified that cannabis was clearly superior to both Chlorpromazine and Marinol for these patients. Additionally, patients frequently have difficulty getting the right dose with Marinol, while inhaled cannabis allows for easier titration and avoids the negative side effects many report with Marinol. As the House of Lords report states, “Some users of both find cannabis itself more effective.”

THE EXPERIENCE OF PATIENTS Judith Cushner, Breast Cancer In 1989, I was diagnosed with breast cancer. After a brief period of recovery from the surgeries, I was placed on an aggressive protocol of chemotherapy, which lasted for eight months. That protocol was referred to as “CMF,” because it consisted of heavy doses of Cytoxan, methotraxate, and 5 fluorouracil.

The treatment caused severe and persistent side effects which were thoroughly disabling: chronic nausea, joint pain and weakness; a debilitating lack of energy and motivation; loss of appetite and a resulting unwanted weight loss; sleep disruption; and eventually my withdrawal from social situations and interpersonal relationships. The cumulative effect of these symptoms often rendered it impossible (or painfully difficult) to take the huge number of medications essential to my treatment regimen.

Right from the start, I was given Compazine as part of my chemotherapy protocol. I took it both orally (in pill form) and intravenously, but it too caused severe adverse side effects, including neuropathy. Moreover, the Compazine provided little, if any, relief from the nausea that had persisted since my treatment began. Hoping for better results, my doctor discontinued the Compazine and prescribed Reglan. That, too, had no effect on the nausea and we decided to discontinue it after a fairly short time. By then, I had developed chronic mouth sores (also from the chemotherapy), which made it extremely painful to take pills or swallow anything. Rather than providing relief, the Reglan increased my discomfort and pain.

Yet another drug I tried was Marinol, which gave me no relief from the unrelenting nausea. If anything, taking yet another pill increased my discomfort. The pills themselves irritated the sores in my mouth. It also made me quite groggy, yet my sleep disturbance persisted, in part because my nausea and anxiety were so distracting. My doctor prescribed Lorazepam to help me sleep, but it was just one more medication with unpleasant effects of its own.

During this time, a friend of mine (who happened to be a nurse) gave me a marijuana cigarette. She had seen my suffering and thought it might help. I took her advice and it worked. I took just a few puffs and within minutes, the nausea dissipated. For the first time in several months, I felt relief. I also felt hope. I smoked small amounts of marijuana for the remainder of my chemotherapy and radiation treatment. It was not a regular part of my day, nor did it become a habit. Each time I felt nausea coming on, I inhaled just two or three puffs and it subsided.

As my nausea decreased, my ability to eat and retain food increased. I saw a marked weight gain and my energy increased. As my general health improved, my sleeping habits also improved. In retrospect, one of the greatest benefits from the marijuana was that it decreased my use of other, more disabling and toxic medications, including the Compazine, Reglan and Lorazepam.

My cancer has been in remission now for just under a year. I lived to see my son’s Bar Mitzvah, and I am proud to say that the risks I took to save my life, while technically illegal, have earned me the respect of both my children. They have learned the difference between therapeutic treatment and substance abuse, and (unlike many of their peers) that knowledge has helped them resist the temptations of recreational drugs.

My decision to use marijuana and save my own life has educated many, including my rabbi and my congregation.

-Sworn testimony by Judith Cushner in Conant v. McCaffrey, 2/14/1997

Jo Daly, Colon Cancer In 1980, I was appointed by Dianne Feinstein, then Mayor of San Francisco, to serve as police commissioner for the city of San Francisco, an office which I held for six years. On May 24, 1988, I was diagnosed with Phase IV cancer of the colon. By the time it was diagnosed, it had already spread to my ovaries and lymph nodes. My oncologist at the UCSF Hospital prescribed an aggressive regimen of chemotherapy, which lasted six months. I was given large doses of the chemicals, four hours a day, five days a week in the first week of each month.

Each day, when I returned home from the hospital following treatment, at about 5:00 p.m., my whole body turned quite warm, as if a fever were coursing through me. My fingernails even burned with heat. Invariably, I was overcome by a sudden wave of intense nausea—like a nuclear implosion in my solar plexus—and I rushed desperately for the bathroom where I would remain for hours, clutching the toilet and retching my guts out. I had no appetite. I could not hold down what little food that I managed to swallow. And I could not sleep at night.

This intense nausea persisted for the two weeks following the treatment. By the third week after treatment, the side effects of the chemicals began to wear off, and I started to feel better. The next week, however, I had to return to the hospital where the chemicals were administered once more, beginning my hell all over again.

To combat the nausea, I tried Marinol, a synthetic version of THC, one of the primary chemicals found in marijuana. However, I was often unable to swallow the Marinol capsule because of my severe nausea and retching. A friend then gave me a marijuana cigarette, suggesting that it might help quell my nausea. I took three puffs from the cigarette. One-half hour later, I was calm, my nausea had disappeared, my appetite returned, and I slept that evening.

I told my oncologist about how well marijuana quelled my nausea. My doctor was not surprised. In fact, he told me that many of his patients had made the same discovery. My doctor encouraged me to continue using marijuana if it worked. Although it occasionally produced a slight euphoria, it was not a painful sensation and I was careful never to leave the house during those rare moments.

My use of medical marijuana had a secondary, though by no means minor benefit: I was able to drastically reduce my dependence on more powerful prescription drugs that I was prescribed for pain and nausea. With the help of medical marijuana, which I ingest only occasionally and in small amounts, I no longer need the Compazine, Lorazepam, Ativan and Halcion. No combination of these medications provided adequate relief. They also caused serious side effects that I never experienced with marijuana.

—Jo Daly, former San Francisco Police Commissioner

Anonymous, Breast Cancer I have used medicinal cannabis legally in California for a year, after being diagnosed and treated for breast cancer. I have also been given prescription drugs that were not effective, that irritated my stomach, for which they wanted to prescribe more drugs. These medications were neither cost-effective nor useful, and I choose to use medicinal cannabis through a vaporizer as recommended by my physician, thereby bypassing the sometimes-harmful effects of smoking.

I, personally, would rather the federal government use their resources to go after the true criminals and terrorists that we have in our country, as opposed to persecuting the sick for whatever relief they may have from medical cannabis.

—Anonymous patient

Lyn Nofziger, Father of Cancer Patient When our grown daughter was undergoing chemotherapy for lymph cancer, she was sick and vomiting constantly as a result of her treatments. No legal drugs, including Marinol, helped her. We finally turned to marijuana. With it, she kept her food down, was comfortable and even gained weight. Those who say Marinol and other drugs are satisfactory substitutes for marijuana may be right in some cases but certainly not in all cases.

If doctors can prescribe morphine and other addictive medicines, it makes no sense to deny marijuana to sick and dying patients when it can be provided on a carefully controlled, prescription basis.

—Lyn Nofziger, former senior adviser to President Ronald Reagan

The Experience of Doctors Howard D. Maccabee, M.D. In my practice, I commonly use radiation therapy to treat the whole spectrum of solid malignant tumors. Radiation therapy is often used after surgery or chemotherapy, as a second stage in treatment. Sometimes, however, radiation therapy is used concurrently with chemotherapy, or even as the first or only modality of treatment.

I treat approximately 20 patients each day and provide follow-up care and/or consultation with another 5 or so patients a day. I currently have approximately 2,000 patients in various stages of follow-up to their initial treatment. Most of these are long-term survivors.

Because of the nature of some cancers, I must sometimes irradiate large portions of my patients’ abdomens. Such patients often experience nausea, vomiting, and other side effects. Because of the severity of these side effects, some of my patients choose to discontinue treatment altogether, even when they know that ceasing treatment could lead to death.

During the 1980s, I participated in a state-sponsored study of the effects of marijuana and THC (an active ingredient in marijuana) on nausea. It was my observation during this time that some patients smoked marijuana while hospitalized, often with the tacit approval of physicians. I also observed that medical marijuana was clinically effective in treating the nausea of some patients.

During my career as a physician, I have witnessed cases where patients suffered from nausea or vomiting that could not be controlled by prescription anti-emetics. I frequently hear similar reports from colleagues treating cancer and AIDS patients. As a practical matter, some patients are unable to swallow pills because of the side effects of radiation therapy or chemotherapy, or because of the nature of the cancer (for instance, throat cancer). For these patients, medical marijuana can be an effective form of treatment.

—Howard D. Maccabee, M.D.

Debasish Tripathy, M.D. Since 1993, I have been a physician at the UCSF Mount Zion Breast Care Center in San Francisco. My practice is devoted exclusively to breast cancer patients. I treat more than 1,000 patients. Approximately 100 of these patients are currently undergoing chemotherapy, a treatment utilizing various combinations of powerful medications. In some cases, the therapeutic dose of the medication we use is not far from the potentially lethal dose. Although chemotherapy is a widely used treatment in the treatment of many cancers, it can also cause severe adverse affects, which some patients are simply unable to tolerate. The most common adverse effects of chemotherapy are nausea and retching.

The nausea and retching associated with chemotherapy are often disabling and intractable. The severity of the symptoms and their medical consequences vary from patient to patient. In many cases, the immediate results are weight loss, fatigue, and chronic discomfort. The consequences can be far graver in patients whose health and functioning is already compromised. For example, the dangers associated with weight loss and malnutrition are greater in patients whose cancer has metastasized and attacked other parts of the body.

… I have prescribed Marinol to some of my patients and it has proven effective in some cases. However, scientific and anecdotal reports consistently indicate that smoking marijuana is a therapeutically preferable means of ingestion. Marinol is available in pill form only. Moreover, Marinol contains only one of the many ingredients found in marijuana (THC). It may be that the beneficial effects of THC are increased by the cumulative effect of additional substances found in cannabis. That is an area for future research. For whatever reason, smoking appears to result in faster, more effective relief, and dosage levels are more easily titrated and controlled in some patients.

Kate Scannell, MD Because I was a cancer patient receiving chemotherapy at the same hospital where I worked, the women with whom I shared the suite quickly surmised that I was also a doctor. The clues were obvious: the colleagues dropping by, the “doctor” salutations from co-workers and the odd coincidence that one of my suite mates was also one of my patients.

I braced myself for this woman’s question, both wanting to make myself available to her but also wishing that the world could forget that I was a doctor for the moment. After receiving my cancer diagnosis, dealing with surgery and chemo-therapy and grappling with insistent reminders of my mortality, I had no desire to think about medicine or to experience myself as a physician in that oncology suite. And besides, the chemotherapy, anti-nauseants, sleep medications and prednisone were hampering my ability to think clearly.

So, after a gentle disclaimer about my clinical capabilities, I said I’d do my best to answer her question. She shoved her IV line out of the way and, with great effort and discomfort, rolled on her side to face me. Her belly was a pendulous sack bloated with ovarian cancer cells, and her eyes were vacant of any light. She became short of breath from the task of turning toward me.

“Tell me,” she managed, “Do you think marijuana could help me? I feel so sick.”

I winced. I knew about her wretched pain, her constant nausea and all the prescription drugs that had failed her —some of which also made her more constipated, less alert and even more nauseous. I knew about the internal derangements of chemotherapy, the terrible feeling that a toxic swill is invading your bones, destroying your gut and softening your brain. I knew this woman was dying a prolonged and miserable death.

And, from years of clinical experience, I —like many other doctors —also knew that marijuana could actually help her. From working with AIDS and cancer patients, I repeatedly saw how marijuana could ameliorate a patient’s debilitating fatigue, restore appetite, diminish pain, remedy nausea, cure vomiting and curtail down-to-the-bone weight loss. I could firmly attest to its benefits and wager the likelihood that it would decrease her suffering.

Still, federal law has forbidden doctors to . . . prescribe marijuana to patients [though doctors may legally recommend it.] In fact, in 1988 the Drug Enforcement Agency even rejected one of its own administrative law judge’s conclusions supporting medicinal marijuana, after two full years of hearings on the issue.

Judge Francis Young recommended the change on grounds that “marijuana, in its natural form, is one of the safest therapeutically active substances known to man,” and that it offered a “currently accepted medical use in treatment.”

Doctors see all sorts of social injustices that are written on the human body, one person at a time. But this one —the rote denial of a palliative care drug like marijuana to people with serious illness —smacks of pure cruelty precisely because it is so easily remediable, precisely because it prioritizes service to a cold political agenda over the distressed lives and deaths of real human beings.

Washington bureaucrats —far removed from the troubled bedsides of sick and dying patients —are ignoring what patients and doctors and health care workers are telling them about real world suffering. The federal refusal to honor public referendums like California’s voter-approved Medical Marijuana Initiative is bewildering. Its refusal to listen to doctors groups like the California Medical Association that support compassionate use of medical marijuana is chilling.

In a society that has witnessed extensive positive experiences with medicinal marijuana, as long as it is safe and not proven to be ineffective, why shouldn’t seriously ill patients have access to it? Why should an old woman be made to die a horrible death for a hollow political symbol?

—Dr. Scannell is co-director of the Ethics Department of Kaiser-Permanente.

The history of cannabis as medicine The history of the medical use of cannabis dates back to 2700 B.C. in the pharmacopoeia of Shen Nung, one of the fathers of Chinese medicine. In the west, it has been recognized as a valued, therapeutic herb for centuries. In 1823, Queen Victoria’s personal physician, Sir Russell Reynolds, not only prescribed it to her for menstrual cramps but wrote in the first issue of The Lancet, “When pure and administered carefully, [it is] one of the of the most valuable medicines we possess.” (Lancet 1; 1823).

The American Medical Association opposed the first federal law against cannabis with an article in its leading journal (108 J.A.M.A. 1543-44; 1937). Their representative, Dr. William C. Woodward, testified to Congress that “The American Medical Association knows of no evidence that marihuana is a dangerous drug,” and that any prohibition “loses sight of the fact that future investigation may show that there are substantial medical uses for Cannabis.” Cannabis remained part of the American pharmacopoeia until 1942 and is currently available by prescription in the Netherlands and Canada.

Federal Policy is Contradictory Federal policy on medical cannabis is filled with contradictions. Cannabis is a Schedule I drug, classified as having no medicinal value and a high potential for abuse, yet its most psychoactive component, THC, is legally available as Marinol and is classified as Schedule III.

Even in America cannabis was widely prescribed until the turn of the century. Cannabis is now available by prescription in the Netherlands. Canada has been growing cannabis for patients there and plans to make it available in pharmacies as well. Ironically, the U.S. federal government also grows and provides cannabis for a small number of patients today.

In 1976 the federal government created the Investigational New Drug (IND) compassionate access research program to allow patients to receive medical cannabis from the government. The application process was extremely complicated, and few physicians became involved. In the first twelve years the government accepted about a half dozen patients. The federal government approved the distribution of up to nine pounds of cannabis a year to these patients, all of whom report being substantially helped by it.

In 1989 the FDA was deluged with new applications from people with AIDS, and 34 patients were approved within a year. In June 1991, the Public Health Service announced that the program would be suspended because it undercut the administration’s opposition to the use of illegal drugs. The program was discontinued in March 1992, and the remaining patients had to sue the federal government on the basis of “medical necessity” to retain access to their medicine. Today, eight surviving patients still receive medical cannabis from the federal government, grown under a doctor’s supervision at the University of Mississippi and paid for by federal tax dollars.

Despite this successful medical program and centuries of documented safe use, cannabis is still classified in America as a Schedule I substance. Healthcare advocates have tried to resolve this contradiction through legal and administrative channels. In 1972, a petition was submitted to reschedule cannabis so that it could be prescribed to patients.

The DEA stalled hearings for 16 years, but in 1988 their chief administrative law judge, Francis L. Young, ruled that, “Marijuana, in its natural form, is one of the safest therapeutically active substances known… It would be unreasonable, arbitrary and capricious for the DEA to continue to stand between those sufferers and the benefits of this substance.”

The DEA refused to implement this ruling based on a procedural technicality and continues to classify cannabis as a substance with no medical use.

Widespread public support; state laws passed Public opinion is clearly in favor of ending the prohibition of medical cannabis. According to a CNN/Time poll in November 2002, 80% of Americans support medical cannabis. The AARP, the national association whose 35 million members are over the age of fifty, released a national poll in December 2004 showing that nearly two-thirds of older Americans support legal access to medical marijuana. Support in the West, where most states that allow legal access are located, was strongest, at 82%, but at least 2 out of 3 everywhere agreed that “adults should be allowed to legally use marijuana for medical purposes if a physician recommends it.”

The refusal of the federal government to act on this support has meant that patients have had to turn to the states for action. Since 1996, voters have passed favorable medical cannabis ballot initiatives in eleven states plus the District of Columbia, while the legislatures in Delaware, Hawaii, Rhode Island, New Jersey, Vermont and Maryland have enacted similar bills.

Currently, laws that effectively remove state-level criminal penalties for growing and/or possessing medical cannabis are in place in 17 states plus the District of Columbia: Alaska, Arizona, California, Colorado, Delaware, Hawaii, Maine, Maryland, Michigan, Montana, Nevada, New Jersey, Oregon, Rhode Island, Vermont and Washington. Nearly three dozen other states have symbolic medical cannabis laws (laws that support medical cannabis but do not provide patients with legal protection under state law).

2005 U.S. Supreme Court ruling In June 2005, the U.S. Supreme Court overturned a decision by a U.S. appeals court (Raich v. Ashcroft) that had exempted medical marijuana from federal prohibition. The 2005 decision, now called Gonzales v. Raich, ruled that federal officials may prosecute medical marijuana patients for possessing, consuming, and cultivating medical cannabis. But according to numerous legal opinions, that ruling does not affect individual states’ medical marijuana programs, and only applies to prosecution in federal, not state, court.

Petitions for legal prescriptions pending The federal Department of Health and Human Services (HHS) and the FDA are currently reviewing two legal petitions with broad implications for medical marijuana. The first, brought by ASA under the Data Quality Act, says HHS must correct its statements that there is no medical use for marijuana to reflect the many studies which have found it helpful for many conditions. Acknowledging legitimate medical use would then force the agency to consider allowing the prescribing of marijuana as they do other drugs, based on its relative safety.

A separate petition, of which ASA is a co-signer, asks the Drug Enforcement Administration for a full, formal re-evaluation of marijuana’s medical benefits, based on hundreds of recent medical research studies and two thousand years of documented human use.

 

Legal Citations 1. See “The Administration’s Response to the Passage of California Proposition 215 and Arizona Proposition 200” (Dec. 30, 1996).

2. See Conant v. McCaffrey, 172 F.R.D. 681 (N.D. Cal. 1997).

3. See id.; Conant v. McCaffrey, 2000 WL 1281174 (N.D. Cal. 2000); Conant v. Walters, 309 F.3d 629 (9th Cir. 2002).

4. 309 F.3d 629 (9th Cir. 2002).

5. Id. at 634-36.

6. Criminal liability for aiding and abetting requires proof that the defendant “insome sort associate[d] himself with the venture, that he participate[d] in it as something that he wishe[d] to bring about, that he [sought] by his action to make it succeed.”Conant v. McCaffrey, 172 F.R.D. 681, 700 (N.D. Cal. 1997) (quotation omitted). A conspiracy to obtain cannabis requires an agreement between two or more persons to do this, with both persons knowing this illegal objective and intending to help accomplish it. Id. at 700-01.

7. 309 F.3d at 634 & 636.

8. Conant v. McCaffrey, 2000 WL 1281174, at *16 (N.D. Cal. 2000).

9. 309 F.3d at 634.

10. See id.. at 635; Conant v. McCaffrey, 172 F.R.D. 681, 700-01 (N.D. Cal. 1997).

Research Citations 11. Abrams D I., et al (2003). Short-Term Effects of Cannabinoids in Patients with HIV-1 Infection: A Randomized, Placebo-Controlled Clinical Trial. Ann Intern Med. Aug 19;139(4):258-66.

12. Joy JE.et al (1999) Eds. Marijuana and Medicine: Assessing the Science Base. Washington, DC: Division of Neuroscience and Behavioral Health, Institute of Medicine.

13. British Medical Association (1997). Therapeutic Uses of Cannabis. Harwood Academic Pub.

14. House of Lords, Select Committee on Science and Technology, (1998). Cannabis: The Scientific and Medical Evidence. London, England: The Stationery Office, Parliament.

15. American Cancer Society (2003). Cancer Facts and Figures 2003. http://www.cancer.org/downloads/STT/CAFF2003PWSecured.pdf

16. Gieringer D (1996) “Review of the Human Studies on the Medical Use of Marijuana”.. http: //norml.org/medical/medmj.studies.shtml. See state studies at http: //www.drugpolicy.org/

17. HallW et al (1994). The Health and Psychological Consequences of Cannabis Use, Canberra, Australian Government Publishing Service 189. http://www.druglibrary.org/

18. Guzman M (2003) Cannabinoids: potential anticancer agents. Nat Rev Cancer. 3(10): 745-55

19. Joy E (1999) op. cit., 259. (Chapter 4 of this report contains sections on nausea, vomiting, wasting syndrome and anorexia)

20. Doblin R, Kleiman MAR (1991). Marijuana as Antiemetic Medicine: A Survey of Oncologists’ Experiences and Attitudes. J Clin Oncol,; 9: 1275-1290.

21. Knox RA. (1997). “Study may undercut marijuana opponents —Report says THC did not cause cancer.” Boston Globe. January 30, p. 1(A).

22. James JS. (1997) “Medical Marijuana: Unpublished Federal Study Found THC- Treated Rats Lived Longer, Had Less Cancer.” AIDS Treatment News.. 263. http://www.immunet.org/

23. Guzman M (2003). Cannabinoids: Potential Anticancer Agents.  Nature Reviews, Cancer 3, 745 -755.

24. Blazquez Cet al (2003) Inhibition of tumor angiogenesis by cannabinoids. FASEB J. 17(3): 529-31. Epub  Jan 02.

25. Sanchez C et al (2001). Inhibition of glioma growth in vivo by selective activation of the CB(2) cannabinoid receptor. Cancer Res. 61(15): 5784-9.

26. Casanova ML et al (2003). Inhibition of skin tumor growth and angiogenesis in vivo by activation of cannabinoid receptors. J Clin Invest. 111(1): 43-50

27. Jacobsson SO et al (2001). Inhibition of rat C6 glioma cell proliferation by endogenous and synthetic cannabinoids. Relative involvement of cannabinoid and vanilloid receptors. J Pharmacol Exp Ther. 2001 Dec;299(3): 951-9.

28. Galve-Roperph I et al (2000). Antitumoral action of cannabinoids: involvement of sustained ceramide accumulation of ERK activation. Nature Medicine 6 313-319; ACM Bulletin. “THC destroys brain cancer in animal research.” http: //www.acmed.org/english/2000/eb000305.html

29. Benard J (2000). Cannabinoids, among others, send malignant tumors to nirvana. Bull Cancer 87 299-300.

30. Di Marzo V et al (2001). Palmitoylethanolamide inhibits the expression of fatty acid amide hydrolase and enhances the anti-proliferative effect of anandamide in human breast cancer cells. Biochem J.. 15(358): 249-55.

31. Molnar J et al (2000). Membrane associated with antitumor effects of crocine-ginsenoside and cannabinoid derivatives. Anticancer Res 20 861-867.

32. Ruiz L et al (1999). Delta-9-tetrahydrocannabinol induces apoptosis in human prostate PC-3 cells via a receptor-independent mechanism. FEBS Letter 458 400-404.

33. Baek S et al (1998). Antitumor activity of cannabigerol against human oral epitheloid carcinoma cells. Arch Pharm Res 21 353-356.

34. Harris L et al (1976). Anti-tumoral Properties of Cannabinoids. The Pharmacology of Marihuana, ed. M. Braude et al., 2 vols., New York: Raven Press 2: 773-776 as cited by L. Grinspoon et al., Marihuana: The Forbidden Medicine (second edition), New Haven, CT: Yale University Press (1997), 173.

35. Toxicology and Carcinogenesis Studies of 1trans-delta-9-tetrahydrocannabinol in F344N/N Rats and BC63F1 Mice. National Institutes of Health National Toxicology Program, NIH Publication No. 97-3362 (November 1996).

36. De Petrocellis L et al (1998). The endogenous cannabinoid anandamide inhibits human breast cancer cell proliferation, Proceedings of the National Academy of Sciences 95 8375-8380. http: //www.pnas.org/cgi/content/abstract/95/14/8375

37. “Pot Chemicals Might Inhibit Breast Tumors, Stroke Damage,” Dallas Morning News, July 13, 1998.

38. Di Marzo V et al (2001). Palmitoylethanolamide inhibits the expression of fatty acid amide hydrolase and enhances the anti-proliferative effect of anandamide in human breast cancer cells.Biochem J. 358(Pt 1):249-55

39. Portella G et al (2003). Inhibitory effects of cannabinoid CB1 receptor stimulation on tumor growth and metastatic spreading: actions on signals involved in angiogenesis and metastasis.FASEB J. 17(12): 1771-3. Epub 2003 Jul 03.

40. Mimeault M et al (2003). Anti-proliferative and apoptotic effects of anandamide in human prostatic cancer cell lines: implication of epidermal growth factor receptor down-regulation and ceramide production. Prostate. 56(1): 1-12.

41. Ligresti A et al (2003). Possible endocannabinoid control of colorectal cancer growth. Gastroenterology. 125(3):677-87.

42. Gomez del Pulgar T et al (2002). De novo-synthesized ceramide is in-volved in cannabinoid-induced apoptosis. Biochem J. 363(Pt 1): 183-8.

43. Gomez Del Pulgar T et al (2002). Cannabinoids protect astrocytes from ceramide-induced apoptosis through the phosphatidylinositol 3-kinase/protein kinase B pathway. J Biol Chem. 277(39):36527-33. Epub  Jul 19.

44. Gonzalez S et al (2000). Decreased cannabinoid CB1 receptor mRNA levels and immunoreactivity in pituitary hyperplasia induced by prolonged exposure to estrogens. Pituitary. 3(4):221-6.

45. Pagotto U et al (2001). Normal human pituitary gland and pituitary adenomas express cannabinoid receptor type 1 and synthesize endogenous cannabinoids: first evidence for a direct role of cannabinoids on hormone modulation at the human pituitary level. J Clin Endocrinol Metab. 86(6):2687-96

46. Rubovitch V, Gafni M, Sarne Y. (2002.) The cannabinoid agonist DALN positively modulates L-type voltage-dependent calcium-channels in N18TG2 neuroblastoma cells. Brain Res Mol Brain Res. 101(1-2):93-102.

47. Bifulco M et al (2001). Control by the endogenous cannabinoid system of ras oncogene-dependent tumor growth. FASEB J. 15(14): 2745-7. Epub  Oct 29.

48. Massi P et al (2004). Antitumor effects of cannabidiol, a nonpsychoative cannabinoid, on human glioma cell lines. JPET 308:838-845.

49. McAllister SD et al (2005). Cannabinoids selectively inhibit proliferation and induce death of cultured human glioblastoma multiforme cells. J Neurooncol. Aug;74(1):31-40.

50. Hazekamp A et al (2006). Evaluation of a vaporizing device (Volcano(R)) for the pulmonary administration of tetrahydrocannabinol. J Pharm Sci 95 (6) Apr 24: 1308-1317.

cancer_brochure.pdf

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6 comments on “Cancer and Medical Marijuana

  • Deodira

    good pointhttp://www.oiemail.net

  • Claudina

    what about sending a notification for the readers when you update the website?http://www.ojogosdomario.com

    • Jeffrey

      Hello, and thank you for your reply, We are a new Non-Profit web site, We will be posting and updating the site weekly, If you have any stories you would like to share please e-mail them to Jeffrey@imapatientnotacriminal.com You can also view & read stories on our Face Book Page, I’m A Patient Not A Criminal. We have a lot of great information.

      Thanks Again & Please share with a patient.

      Jeffrey Kennedy

  • Jeffrey

    Thank you, We will post new info weekly & sometimes daily,

    Thanks again & be safe,

    Jeffrey Kennedy

  • Jeffrey

    Thank you for your reply. Please share with patients, freinds & family.

    Thanks Again & Be Safe,

    Jeffrey Kennedy

  • Jeffrey

    Thank you for your reply, Please tell a patient, family & friends.

    Thanks Again & Be Safe,

    Jeffrey Kennedy

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