FEDERAL FOOLISHNESS AND MARIJUANA

The advanced stages of many illnesses and their treatments are often
accompanied by intractable nausea, vomiting, or pain. Thousands of patients
with cancer, AIDS, and other diseases report they have obtained striking
relief from these devastating symptoms by smoking marijuana. (1) The
alleviation of distress can be so striking that some patients and their
families have been willing to risk a jail term to obtain or grow the
marijuana.

Despite the desperation of these patients, within weeks after voters in
Arizona and California approved propositions allowing physicians in their
states to prescribe marijuana for medical indications, federal officials,
including the President, the secretary of Health and Human Services, and
the attorney general sprang into action. At a news conference, Secretary
Donna E. Shalala gave an organ recital of the parts of the body that she
asserted could be harmed by marijuana and warned of the evils of its
spreading use. Attorney General Janet Reno announced that physicians in any
state who prescribed the drug could lose the privilege of writing
prescriptions, be excluded from Medicare and Medicaid reimbursement, and
even be prosecuted for a federal crime. General Barry R. McCaffrey,
director of the Office of National Drug Control Policy, reiterated his
agency's position that marijuana is a dangerous drug and implied that
voters in Arizona and California had been duped into voting for these
propositions. He indicated that it is always possible to study the effects
of any drug, including marijuana, but that the use of marijuana by
seriously ill patients would require, at the least, scientifically valid
research.

I believe that a federal policy that prohibits physicians from alleviating
suffering by prescribing marijuana for seriously ill patients is misguided,
heavy-handed, and inhumane. Marijuana may have long-term adverse effects
and its use may presage serious addictions, but neither long-term side
effects nor addiction is a relevant issue in such patients. It is also
hypocritical to forbid physicians to prescribe marijuana while permitting
them to use morphine and meperidine to relieve extreme dyspnea and pain.
With both these drugs the difference between the dose that relieves
symptoms and the dose that hastens death is very narrow; by contrast, there
is no risk of death from smoking marijuana. To demand evidence of
therapeutic efficacy is equally hypocritical. The noxious sensations that
patients experience are extremely difficult to quantify in controlled
experiments. What really counts for a therapy with this kind of safety
margin is whether a seriously ill patient feels relief as a result of the
intervention, not whether a controlled trial "proves" its efficacy.

Paradoxically, dronabinol, a drug that contains one of the active
ingredients in marijuana (tetrahydrocannabinol), has been available by
prescription for more than a decade. But it is difficult to titrate the
therapeutic dose of this drug, and it is not widely prescribed. By
contrast, smoking marijuana produces a rapid increase in the blood level of
the active ingredients and is thus more likely to be therapeutic. Needless
to say, new drugs such as those that inhibit the nausea associated with
chemotherapy may well be more beneficial than smoking marijuana, but their
comparative efficacy has never been studied.

Whatever their reasons, federal officials are out of step with the public.
Dozens of states have passed laws that ease restrictions on the prescribing
of marijuana by physicians, and polls consistently show that the public
favors the use of marijuana for such purposes. (1) Federal authorities
should rescind their prohibition of the medicinal use of marijuana for
seriously ill patients and allow physicians to decide which patients to
treat. The government should change marijuana's status from that of a
Schedule 1 drug (considered to be potentially addictive and with no current
medical use) to that of a Schedule 2 drug (potentially addictive but with
some accepted medical use) and regulate it accordingly. To ensure its
proper distribution and use, the government could declare itself the only
agency sanctioned to provide the marijuana. I believe that such a change in
policy would have no adverse effects. The argument that it would be a
signal to the young that "marijuana is OK" is, I believe, specious.

This proposal is not new. In 1986, after years of legal wrangling, the Drug
Enforcement Administration (DEA) held extensive hearings on the transfer of
marijuana to Schedule 2. In 1988, the DEA's own administrative-law judge
concluded, "It would be unreasonable, arbitrary, and capricious for DEA to
continue to stand between those sufferers and the benefits of this
substance in light of the evidence in this record." (1) Nonetheless, the
DEA overruled the judge's order to transfer marijuana to Schedule 2, and in
1992 it issued a final rejection of all requests for reclassification. (2)

Some physicians will have the courage to challenge the continued
proscription of marijuana for the sick. Eventually, their actions will
force the courts to adjudicate between the rights of those at death's door
and the absolute power of bureaucrats whose decisions are based more on
reflexive ideology and political correctness than on compassion.

Jerome P. Kassirer, M.D.

References

1. Young FL. Opinion and recommended ruling, marijuana rescheduling petition. Department of Justice, Drug Enforcement Administration. Docket 86-22. Washington, D.C.: Drug Enforcement Administration, September 6, 1988.

2. Department of Justice, Drug Enforcement Administration. Marijuana scheduling petition: denial of petition: remand. ( Docket No. 86-22. ) Fed Regist 1992;57( 59 ):10489-508.