Grassroots Medicine

For several decades, researchers have
sought to determine whether marijuana has legitimate medical uses,
and narcotics control agencies have discouraged them from finding
out. Now a new round of federally funded research may provide
some answers—or will it? The latest skirmish between scientists
and police comes on the heels of two popular referenda, in California
and Arizona, legalizing the medical use of marijuana. But since
it remains a federal crime to grow, sell, or prescribe cannabis,
the referenda have created only a legal morass.

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Barry McCaffrey, director of the White
House Office of National Drug Control Policy, derided the propositions
as "hoax referendums," and insisted that voters had
been "duped" by deceitful ad campaigns whose real intent
was to legalize drugs. Attorney General Janet Reno announced that
prescribing or recommending marijuana was still a violation of
federal law, and that any doctors who did so could be prosecuted
and lose their license to prescribe all drugs regulated by the
Drug Enforcement Administration (DEA).

However, the medical use of marijuana
has been gaining respectability. Several states have research
programs of their own and some governors, including Republican
William Weld of Massachusetts, openly endorse medical legalization.
The editor of the prestigious New England Journal of Medicine,
Jerome Kassirer, lambasted the Clinton administration in an editorial
entitled "Federal Foolishness and Marijuana" that received
national attention. "To prohibit physicians from alleviating
suffering by prescribing marijuana for seriously ill patients,"
Kassirer wrote, "is misguided, heavy-handed, and inhumane."

In January, Director McCaffrey, finding
himself knee-deep in a debate in which he was little qualified
to participate, tried to defuse criticism with an announcement
that the Institute of Medicine (IOM) would be given $1 million
to conduct an 18-month review of the current literature on marijuana.
Later that month Harold Varmus, director of the National Institutes
of Health (NIH), announced that the NIH would convene a workshop
on the medical utility of marijuana. "We have no rationale
for not looking into it," Dr. Varmus said in a phone interview.

But the IOM conducted a similar study
back in 1982 and issued a report entitled "Marijuana and
Health," concluding that "Marijuana and its derivatives
or analogues might be useful in the treatment of glaucoma, of
nausea and vomiting brought on by cancer chemotherapy, and of
asthma. . . ." A review of the existing literature, as Kassirer
pointed out, will likely be inconclusive because no definitive
study has been done. The new IOM review, Kassirer said in an interview,
"was a political maneuver designed to move the debate off
center stage—it probably could be done in 18 days."

In February, the NIH held its workshop,
organized by the National Institute on Drug Abuse (NIDA), and
workshop participants initially promised to submit their recommendations
for further research to Varmus by the end of March. But as this
article goes to press in mid-June, three months have passed and
the recommendations have yet to be submitted.

Ever
since the 1930s and the era of "Reefer Madness," when
marijuana acquired both a countercultural stigma and allure, the
federal government has resisted attempts to legalize marijuana
for medical purposes—both by inhibiting research and by restricting
access to the drug. The government has been fearful of sending
the message that if marijuana is medically useful, it also can
be used safely as a recreational drug. The scientific issue is
unresolved, but nonetheless closed.

The medical marijuana movement emerged
with the rise of recreational marijuana use in the 1960s. Marijuana
had long been known to promote appetite, and a few studies in
the first half of the twentieth century showed that it aided in
alleviating nausea. Many chemotherapy patients found that smoking
marijuana not only relieved their nausea and vomiting better than
any of the legally available medications, but also enhanced appetite
and relieved anxiety. For many, the relief from smoking pot was
so strikingly better than from the use of Compazine, the anti-nauseant
of choice, that word quickly spread among patients and doctors
and then on to legislators.



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In a 1980 congressional hearing titled
"Health Consequences of Marijuana Abuse: Recent Findings
and the Therapeutic Uses of Marijuana and the Use of Heroin to
Reduce Pain," two prominent oncologists—Steven Sallan, then
clinical director of pediatric oncology at the Sidney Farber Cancer
Institute, and Solomon Garb, president of the medical staff at
the AMC Cancer Research Center in Lakewood, Colorado—and others
attested to the medical utility of both smokable marijuana and
its primary active ingredient, delta-9-THC. They also testified
to the difficulties in obtaining the drugs to conduct research:
While anyone could buy marijuana on the street on any given day,
Garb had to wait seven months for his research supply and knew
others who had waited up to two years.

However, marijuana remained a Schedule
I drug—a substance with potential for abuse and no medical uses.
Despite a number of petitions to move marijuana to Schedule II,
the DEA refused even to hold a public hearing on the issue. So
while the federal government resisted, states took the initiative.
By the late 1980s, 34 states had passed some form of medical marijuana
legislation. Several states organized marijuana research programs
so they could legitimately obtain synthetic THC—and in a few cases,
marijuana—from the federal government, for suffering patients.
Results from studies, though not rigorously scientific, conducted
in New Mexico, Tennessee, New York, and elsewhere, found that
smokable marijuana and THC outperformed the best available prescription
drugs, reporting success rates close to 90 percent; anecdotal
evidence suggested that smoked marijuana was more effective than
Marinol, the synthetic THC pill.

Finally, in 1985 the coalition of doctors,
patients, and marijuana activists persuaded the Department of
Health and Human Services to move Marinol to Schedule II, making
it legally available by prescription to patients. Soon after,
the DEA announced that public hearings on the rescheduling of
marijuana itself would finally
be held. Those hearings lasted two years
and culminated in the recommendation of DEA Administrative Law
Judge Francis L. Young in 1988, who wrote that

it is unrealistic and unreasonable
to require unanimity of opinion on the question confronting us.
For the reasons there indicated, acceptance [of marijuana having
a medical use] by a significant minority of doctors is all that
can reasonably be required. This record makes it abundantly clear
that such acceptance exists in the United States. . . . One must
reasonably conclude that there is accepted safety for use of marijuana
under medical supervision.

But the DEA administrator did not act
on this recommendation and marijuana remained in Schedule I.

The pro-legalization National Organization
for the Reform of Marijuana Laws (NORML) petitioned the DEA to
reschedule marijuana for review again in 1992. Denying this petition,
DEA Administrator Robert Bonner wrote in the Federal Register,
"Our nation's top cancer experts reject marijuana for medical
use." To support his claim, he cited the testimony of David
S. Ettinger, a professor of medicine at Johns Hopkins University
School of Medicine and "nationally respected cancer expert,"
who said: "There is no indication that marijuana is effective
in treating nausea and vomiting resulting from radiation treatment
or other causes. No legitimate studies have been conducted which
make such conclusions."

Bonner thus concluded, "Not one
nationally recognized cancer expert could be found to testify
on marijuana's behalf." But in a recent phone interview,
Ettinger said he had changed his position. He now believes that
in cases of intractable nausea "smoking marijuana is reasonable"
and that there are "patients for whom therapies don't work
and in that situation anything is worth trying." He also
said a study should be conducted comparing the efficacy of smoked
marijuana to Marinol.

From
the late 1980s up to the present, the federal government has appeared
content to close the book on the medical marijuana question, inhibiting
any attempts at further research of its medical utility, and limiting
research to marijuana's negative effects. In 1994 Dr. Donald Abrams,
a California AIDS specialist, submitted a research proposal to
compare smokable marijuana and Marinol because, he said, "we
have 1,100 AIDS patients in the Bay Area using marijuana [on their
own]." Abrams's draft proposal did not pass peer review,
but the FDA helped Abrams develop a revised proposal, which was
approved by several California research committees and submitted
in August 1994. After a delay of nine months, Abrams received
a letter from Dr. Alan Leshner, director of the NIDA, turning
down the proposal and leaving no room for further negotiation
over revisions. "As an AIDS investigator who has worked closely
with the National Institutes of Health and the U.S. Food and Drug
Administration for the past 14 years of this epidemic, I must
tell you that dealing with your institute has been the worst experience
of my career!" Abrams replied.

Polls show broad support for medicalization.
An ABC/Discovery Channel nationwide poll conducted in May found
that 69 percent of respondents favored permitting doctors to prescribe
marijuana. Now, after several years of relative quiet, states
and local organizations are again pursuing the issue of medical
marijuana. The California Medical Association recently backed
a bill in May that would provide $6 million for researching the
medical benefits of marijuana, and Americans for Medical Rights
is gearing up to get medical marijuana ballots placed in a half
dozen states for 1998. In addition to the California and Arizona
referenda, the state governments of Massachusetts and Washington
are creating programs to distribute marijuana to qualifying patients,
though of course these programs are contingent on federal approval.
In a sense, these could be test cases, signaling whether federal
health officials will keep an open mind about the potential medical
benefits of cannabis.


RAISING THE HURDLE

In the past, the DEA argued that marijuana
had no accepted medical use. Now the government has altered that
argument subtly, raising the hurdle for a revision in its policy.
Director McCaffrey, in testimony December 2, 1996, before the
Senate Judiciary Committee, stated, "There is no scientifically
sound evidence that smoked marijuana is medically superior
to currently available therapies
[emphasis added]."

There are, in fact, some new anti-nausea
treatments that may provide relief comparable or superior to marijuana.
For example, new anti-emetic drugs such as Ondansetron and Kytril
(trade names), are administered to patients intravenously, and
work well. But they are difficult to administer and are astronomically
expensive. In tablet form, for outpatient chemotherapy, Kytril
retails for around $86 for a daily two-milligram dose. Legal marijuana
would cost just a few cents a dose. Moreover, it is not FDA policy
to disallow one treatment simply because another, more expensive
or elaborate one is available. Dr. Robert Temple, associate director
for medical policy in the Center for Drug Evaluation and Research
at the FDA, who also attended the NIH workshop, told the New
York Times
, "FDA approval does not require that any [new]
drug be better than, or even as good as, an existing drug."
Such an action would be equivalent to the FDA denying approval
to, say, Pepcid, because Tagamet is a sufficient acid-blocking
drug.

Other Schedule I drugs have been rescheduled
because they provided relatively minor increased flexibility or
improvement in treatment. LAAM (L-alpha-acetylmethodol), a drug
now used with or in place of methadone to treat heroin addicts,
was recently moved from Schedule I to II because it can be taken
every other day compared to the required daily prescription of
methadone. This allows recovering addicts to use the day in the
middle for counseling.

Many
AIDS patients suffer from AIDS wasting syndrome, during which
they are so sick they cannot eat. Chemo-therapy and radiation-treatment
patients often suffer from extreme nausea and vomiting. All of
these patients might be candidates for marijuana therapy, to promote
appetite and relieve nausea and vomiting. Many patients smoke
marijuana that they obtain illegally because they can control
the dosage: The palliative effects occur about 45 minutes faster
and the psychoactive effects go away more quickly than when the
patients take Marinol. Ironically, the government approved Marinol
in part because it seemed less "recreational" than smoked
marijuana. But clinically, the psychoactive effects of Marinol
characteristically last nearly eight hours, while those of a comparable
dose of smoked marijuana generally last between two and four.

Moreover, for patients suffering from
extreme nausea and vomiting, the Marinol pill is not practical
because they may not be able to retain it. In the 1980 congressional
hearing on marijuana, Dr. Steven Sallan testified to the benefits
of smoking as a venue for ingesting anti-nausea medication:

There is no question in my mind that
the oral route for an anti-emetic, a pill, is the absolute worst
route for the patient who has a lot of anticipatory nausea and
vomiting. . . . The smoke route is in some ways ideal. Certainly
when we want a drug to be absolutely sure, general anesthesia,
we put it on the face, they breathe it across their lungs, it's
in their bloodstream immediately.

Dr. Lester Grinspoon, author of Marihuana:
The Forbidden Medicine
, says it may be possible to inhale
only the therapeutically effective chemicals of marijuana and
leave the tar and carcinogens behind. He attests that marijuana
can be heated to a certain point at which the cannabinoids (the
pharmacologically effective chemicals) are released, but the plant
will not actually burn. "In the future, [patients] will be
inhaling the vapors of marijuana," Grinspoon said, if the
government allows the technology to be developed. In an April
interview in the online magazine Salon, Dr. William
Beaver, professor of pharmacology at Georgetown and chair of the
NIH workshop, mentioned the possibility of developing such a delivery
system. Currently, however, paraphernalia laws forbid the production
or the sale of marijuana vaporizers.


A TROJAN HORSE FOR LEGALIZATION?

Is medical marijuana just a stalking horse? It's
true that pro-legalization organizations such as NORML play an
active role in the med ical marijuana movement. Philanthropist
George Soros and his Drug Policy Foundation, advocates of general
decriminalization, have financially backed medical marijuana initiatives.
A February 17 article in the New Republic, "The Return
of Pot" by Hanna Rosin, also characterized the raison d'être
of the medical marijuana movement as general legalization. "The
truth about the marijuana movement is . . . blindingly obvious
after a day in [Dennis] Peron's club. The movement is . . . primarily
about legalization," Rosin wrote. While the movement "may
feature billboards of the infirm . . . in the offices of its activists
you are more likely to find a different poster, a stoner classic:
The Declaration of Independence and the Constitution Were Written
on Hemp Paper
."

The reality is that the medical legalization
coalition includes pot-heads, scientists, oncologists, patients,
and social reformers. Bill Zimmerman, who coordinated California's
pro-legalization Proposition 215, says, "Some people supporting
medical marijuana initiatives are without question using it as
an attempt to legalize marijuana. Other people are supporting
marijuana policy changes out of a genuine concern for patients.
It's a free country." And while Rosin paints a pretty bleak
picture of the California marijuana scene—scrawny pot junkies
with grimy teeth using excuses of migraine headaches to legitimately
obtain their fix—she leaves out biographies of activists like
conservative notable William F. Buckley, Jr., who found marijuana's
medical illegality absurd when his sister preferred it to standard
drugs in alleviating the negative affects of her chemotherapy.
Ironically, it is marijuana's medical illegality that perpetuates
the very cannabis clubs Rosin finds contemptible. Such clubs would
largely disappear if marijuana were available by prescription.

One curious footnote to this controversy
is that the federal government is currently dispensing smokable
marijuana—to eight individuals. The Food and Drug Administration
began the Single Patient Investigational New Drug Program (commonly
know as compassionate IND) in the mid-1970s. Settling out of court
in the case Randall v. U.S., the federal government determined
it would provide Robert Randall, who suffered from glaucoma, smokable
marijuana legally. Fourteen people in all were admitted to the
compassionate IND program before its suspension in 1990 and its
closure in 1992. The FDA ended the program due to a deluge of
applications—again, the government was worried about the public
perception of liberally dispensing the drug. Nonetheless, eight
people, beneficiaries of a grandfather clause, continue to receive
federal marijuana to this day.

The
strongest argument against prescribed marijuana remains the concern
that it would remove whatever stigma marijuana retains and thus
proliferate recreational usage. Joseph Califano, president of
the National Center on Addiction and Substance Abuse (CASA), wrote
in a Washington Post op-ed attacking medical legalization:

Our children are at stake here. . .
. A state has an enormous interest in protecting children from
proposals likely to make drugs such as marijuana, heroin and LSD
more acceptable and accessible.

But would making marijuana prescribable do either? The list of dangerous and addictive drugs currently
prescribable by physicians is enormous and all of them are tightly
controlled by the DEA. Although opiates have been abused for centuries,
drugs such as codeine, morphine, and dilaudid are carefully regulated,
widely prescribed, and relieve the suffering of millions. The
use of cocaine has declined drastically from 5.7 million people
in 1985 to 1.4 million in 1994, and the drug is a prescribable
Schedule II controlled substance.

At the 1980 congressional hearing,
North Carolina Congressman Stephen Neal, the chairman of the task
force, responded to similar fears expressed by the NIDA spokesperson
in the following testimony:

I have two teenage children. . . .
They are at the prime age for exposure to these drugs. . . . It
seems to me, watching them and watching what our government has
done over the years, that we have spread a good deal of misinformation
. . . and that people, and young people in particular respond
very positively to accurate information. . . . I really think
that my own kids can understand the difference between a use of
a drug for a particular illness and its recreational use. . .
. It just doesn't seem reasonable to me we would have to sacrifice
the potential for some good use of these drugs . . . it doesn't
seem consistent. Not only that, but I think kids will see right
through it.

However, for President Clinton and
many other elected officials, the question is not so simple.

Having
spent decades branding marijuana a killer weed, the government
is caught in its own rhetoric. This administration, like previous
ones, is fearful that if it softens on the issue of the medical
use of marijuana, it risks being labeled soft on drugs. When President
Clinton began cutting the drug war budget during his first term,
he was soon confronted with harsh criticism from the right—William
Bennett wrote in a 1995 congressional testimony, "The Clinton
Administration suffers from moral torpor on this issue"—and
with claims of increased marijuana use among teens. These factors
led Clinton to announce the largest drug war budget ever for 1996.
Again in 1997, the United States has appropriated $16 billion
for the drug war budget.

It remains to be seen whether the federal government
will have the courage to allow scientists to resolve the issue
of marijuana's medical use in the face of pot's long-standing
cultural stigma. But the government will not depress recreational
marijuana use or make progress in the war on hard drugs by denouncing
referenda, threatening prosecution of doctors, and blocking legitimate
medical research. It will only make it more difficult for severely
ill people to relieve their suffering.



Related Resources



For information about medical uses of marijuana, including clinical studies, reform efforts, and related links, go to
http://www.marijuana-as-medicine.org/



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