DOCTORS UNLIKELY TO BACK POT VOTE

While it seems unlikely the Maine Medical Association will support a
fall referendum intended to legalize marijuana for medical purposes,
the medical field is by no means of one mind on the value and safety
of the drug.

Some doctors consider marijuana a traditional medicine that has been
swept aside and vilified unjustly. Others see it as a mind-altering
drug that has no medical benefits that cannot be found in tested and
approved prescription drugs.

In late August the Maine Medical Association's public health committee
unanimously recommended that the MMA's House of Delegates publicly
oppose the referendum, which would allow patients suffering from
persistent nausea and vomiting, glaucoma, seizures and other symptoms
to possess and use limited amounts of marijuana.

The MMA will hold its annual meeting in Bar Harbor next week, with the
House of Delegates, the governing body for the MMA's 1,680 physicians,
expected to debate the marijuana resolution Sept. 16. The MMA could
choose to remain neutral on the subject, which some medical
associations have done in other states debating legalized medical
marijuana. About 2,500 doctors have active practices in Maine.

"From a public health standpoint, it doesn't make sense to legalize
the use of this substance,'' said Dr. John Garofalo, a family
practitioner in Augusta who chairs the MMA's public health committee.
"Granted, it's supposed to be under certain limited circumstances, but
the problem we're worried about is diversion and misuse of those
exemptions.''

Marijuana is a "gateway'' drug that leads users to stronger and more
harmful illicit drugs, say Garofalo and others, and the scientific
basis for using the drug is too tentative to outweigh the risks.

But medical marijuana proponents challenge those assumptions, pointing
to a report released in March by the National Academy of Sciences'
Institute of Medicine that concluded short-term use of marijuana is
appropriate for certain debilitating symptoms - provided they meet
certain conditions - and that there is no evidence to suggest medical
availability of marijuana would increase drug abuse.

The report, which was requested by the White House Office of National
Drug Control Policy in 1997, was intended to review the scientific
evidence to assess the potential health benefits and risks of marijuana.

According to Craig Brown, campaign manager for Mainers for Medical
Rights, which has been the spearhead group behind the referendum,
medical marijuana advocates look at the report as a long-awaited stamp
of government approval for the legitimacy of the alternative treatment.

"Marijuana is not just a medicine, but the best medicine in some
cases,'' Brown said.

Indeed, an analysis published in the Journal of the American
Pharmaceutical Association in March 1998 concluded, "As a medical
drug, marijuana should be available for patients who do not adequately
respond to currently available therapies.''

If Maine voters approve the referendum, the state would join Alaska,
Arizona, California, Oregon and Washington, all of which legalized
medical marijuana by referendum. Nevada voters approved a
constitutional amendment for medical marijuana in 1998, but must
approve it again in 2000 for it to go into effect.

If passed, Maine patients would not be subject to criminal prosecution
provided they have the consent of a doctor and are suffering from
persistent nausea, vomiting or severe loss of appetite as a result of
AIDS or chemotherapy; glaucoma; severe seizures; or persistent muscle
spasms associated with debilitating diseases such as multiple sclerosis.

Patients could possess no more than 10 ounces of marijuana at any one
time and could have six marijuana plants, with no more than three
being mature enough to produce a usable drug.

Legalized medical marijuana would leave doctors in an awkward
position, said Gordon Smith, executive director of the Maine Medical
Association. Though doctors wouldn't actually be writing
prescriptions, they would need to make medical assessments for a drug
that has not been approved by the U.S. Food and Drug Administration.
Unlike with approved prescription drugs, there are no set dosages for
marijuana, which is smoked or ingested.

Dr. Rob Killian, 38, a physician in Seattle and author of Washington's
medical marijuana law which has been in effect about eight months,
said that it has improved doctor-patient dialogue about treatment options.

"The main thing we did in approving it here is just protect a practice
that's been ongoing for quite a while,'' he said. Killian ran a
hospice for two years and at times when terminal patients were
suffering with nausea or vomiting, no conventional drug worked. When
family or friends helped a patient get and use marijuana as an
alternative, Killian would have to turn his back and "disappear in
that process.''

"What happens today is that I don't have to feel like I'm abandoning
the patient,'' he said. "They still have to go out and get it
somewhere, but now it can all be aboveboard. There's no shame. You
don't feel like you have to whisper or talk about secrets.

"I don't know of any physician who uses marijuana as a first-line
treatment. Usually it comes after other normally prescribed drugs have
been used and failed to work,'' he said.

Killian now runs a private practice and specializes in treating
HIV-positive and AIDS patients, who sometimes experience "wasting
syndrome'' in which their weight declines and they have no appetite.
In Killian's experience, one of marijuana's most legitimate and
efficacious uses is slowing or reversing wasting.

The Institute of Medicine report notes that "anecdotes abound'' that
smoked marijuana is useful in treating HIV-associated weight loss, but
there have been no controlled studies published on the subject.

There is, in fact, a dearth of controlled studies on the efficacy of
marijuana in treating various diseases and conditions. If there is one
theme struck in the institute's report, it is its call for clinical
trials of marijuana.

In 1997 the American Medical Association's Council on Scientific
Affairs made similar recommendations.

But federal laws severely restrict access to marijuana, even for
scientific study.

According to Dr. Lester Grinspoon, a professor in the department of
psychiatry at Harvard Medical School and an unabashed advocate of
medical marijuana, what was known then as Cannabis indica was used
regularly as an appetite stimulant, muscle relaxant, analgesic and
anticonvulsant in the 1800s and early 1900s. Its use declined the
first part of this century largely because synthetic alternatives
became available, such as aspirin and barbiturates.

"In the United States, the final blow was struck by the Marihuana Tax
Act of 1937,'' Grinspoon wrote in a commentary published in the
Journal of the American Medical Association in 1995. "Designed to
prevent nonmedical use, this law made cannabis so difficult to obtain
for medical purposes that it was removed from the pharmacopeia.''

Under the federal Controlled Substances Act of 1970 marijuana was
confined to Schedule I, which lists drugs that have a high potential
for abuse, lack an accepted medical use and are unsafe for use under
medical supervision. Other Schedule I drugs are heroin and LSD.

Ballot initiatives in California and Arizona in 1996 for approval of
medicinal marijuana sparked a national debate over its federal
designation. In December 1996, Barry McCaffrey, director of the Office
of National Drug Control Policy, announced that any doctors who tried
to make use of the new law could lose their federal Drug Enforcement
Administration licenses for prescribing controlled substances, lose
Medicare and Medicaid reimbursement and be subject to criminal
prosecution.

Several California doctors and patients filed a class action suit
based on First Amendment grounds seeking a permanent injunction
against federal regulations that punish doctors for talking to
patients about medical marijuana. A federal judge granted a temporary
injunction allowing California doctors to recommend marijuana without
fear of prosecution, which will remain in place until the lawsuit is
settled.

Some doctors argue that debating the issue of medical marijuana is
pointless, given that its primary psychoactive substance,
delta-9-tetrahdrocannabinol, or THC for short, is now available in
synthetic form and can be prescribed by doctors.

"We have the active ingredient available in Maine - in a form that's
available to everyone,'' said Dr. Ronald Blum, president of the Maine
Academy of Family Physicians and a member of the MMA's public health
committee. "Why not use that instead of legalizing what is basically a
street drug?''

Proponents of medical marijuana chafe under the argument that
marijuana is a street drug that leads to stronger, more dangerous drugs.

"It's a fallacy,'' said Killian, again referring to the Institute of
Medicine report that concluded: "In the sense that marijuana use
typically precedes rather than follows initiation into the use of
other illicit drugs, it is indeed a gateway drug. However, it does not
appear to be a gateway drug to the extent that it is the cause or even
that it is the most significant predictor of serious drug abuse; that
is, care must be taken not to attribute cause to association.''

Although doctors have not been formally polled on the subject,
Garofalo and Blum say they have heard few Maine doctors express
support for passage of the referendum.

And ultimately, doctors will have little say in the matter as Maine
residents make their choice in November.