J. Michael Bostwick, M.D., from the Mayo Clinic in Rochester, Minn., reports that growing, mainly anecdotal literature supports the efficacy of marijuana, particularly for cases that are refractory to conventional treatments. In the United States, there are currently no vaporized inhalants as an alternative to medicinal marijuana, and oral cannabinoids are poorly suited to relieving patients' distress due to their slow onset and unreliable bioavailability. Although the patient may find the psychoactive effects of marijuana unacceptable, it may be beneficial and should be recommended if conservative treatment options have failed.

Gary M. Reisfield, M.D., from the University of Florida College of Medicine in Gainesville, and Robert L. DuPont, M.D., from the Institute for Behavior and Health in Rockville, Md., note that there is little evidence suggesting that smoked marijuana will improve nociceptive pain or other symptoms. Other effects of smoking marijuana should be considered, including cognitive side effects, the impact of smoking on pulmonary disease, and the potential impact on tumor progression. Prescription cannabinoids, which feature oral administration, chemical purity, precise dosage, and sustained action, may have similar efficacy without the potential negative side effects.

"There is little scientific basis for recommending that [a patient] smoke marijuana for symptom control," Reisfield and DuPont write.

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