MEDICINE -- NOT POT

Last month the Institute of Medicine released a report in response to the
two-year-long wave of ballot initiatives supporting medical marijuana. It
assessed the scientific base of the claim that suffering terminally ill
people are unnecessarily deprived of a useful treatment by drug laws that
criminalize smoking.

There has never been controversy about the use of purified chemicals in
smoke to treat any illness, as witnessed by the availability of synthetic
tetrahydrocabinol (THC) since 1985. The only dispute between the drug-law
hawks and doves is the place of smoked marijuana in medical treatment. The
institute's report, balanced and firmly rooted in three decades of
scientific research, reached this conclusion:

"Although smoke delivers THC and other cannabinoids to the body, it also
delivers harmful substances, including most of those found in tobacco smoke.
In addition, plants contain a variable mixture of biologically active
compounds and cannot be expected to provide a precisely defined drug effect.
For those reasons, the report concludes that the future of cannabinoid drugs
lies not in smoked marijuana but in chemically defined drugs that act on the
cannabinoid systems that are a natural component of human physiology. Until
such drugs can be
developed and made available for medical use, the report recommends interim
solutions."

Here are the details of its interim solution:

"Short-term use of smoked marijuana (not more than 6 months) for patients
with debilitating symptoms (such as intractable pain or vomiting) must meet
the following conditions:

"failure of all approved medications to provide relief has been documented;

"the symptoms can reasonably be expected to be relieved by rapid-onset
cannabinoid drugs;

"such treatment is administered under medical supervision in a manner that
allows for assessment of treatment effectiveness;

"and involves an oversight strategy comparable to an institutional review
board process that could provide guidance within 24 hours of submission by a
physician to provide marijuana to a patient for a specified use."

The best hope for a resolution of this medical conflict would be for the
National Institute on Drug Abuse (NIDA) to fashion definitive clinical
trials of smoked marijuana vs. other standard treatments for the indications
the Institute of Medicine identified (anxiety reduction, appetite
stimulation, nausea reduction and pain relief). This was how a similar call
for legal heroin for terminal cancer pain was disposed of a decade ago. A
controlled trial conducted at Sloan-Kettering, (funded by NIDA), showed that
heroin offered no advantages compared with standard pain treatments.

If new trials were to show superiority for smoked marijuana, and if there
was no way to identify and deliver purified chemicals with less toxicity
than smoke, then I would have no objection to a carefully monitored,
medically supervised use of smoked marijuana in settings that discouraged
diversion. There is no controversy in the United States today about the
medical use of opiates (including those derived from natural opium, as is
heroin) or cocaine. The concern now is that smoked marijuana has not been
shown to be superior to other treatments for any illness.

Most supporters of medical marijuana do not understand three facts that were
made clear in the Institute of Medicine's report:

(1) "The effects of cannabinoids on the symptoms studied are generally
modest, and in most cases, there are more effective medications." In other
words, do not look for anything dramatic from this class of chemicals. This
may explain why marijuana's chemicals have produced little enthusiasm from
pharmaceutical companies.

(2) Modern medicine does not burn leaves and ask sick patients to inhale the
smoke. It identifies individual chemicals and delivers them in purified,
often synthetic, form to treat specific illnesses.

(3) Marijuana smoke is not only unstable but toxic, like tobacco smoke.
These characteristics make smoked marijuana unsuitable as a medicine.

Clinical trials will take several years, and they are expensive. The most
regrettable aspect of this process is that scarce medical research money
will be wasted on tests of the chemicals in smoke that have little medical
value. Nevertheless, the political momentum created by the marijuana
advocates has made it essential that these
clinical trials go forward to demonstrate to a skeptical public how smoked
marijuana stacks up against standard treatments.

I hope that the people who now are advocating a science-based approach to
this politicized problem, including the Institute of Medicine, understand
that these efforts, even if completely successful, will have little impact
on the pro-marijuana forces, whose only interest is free access to the drug.
They do not want clinical trials, and they do not want purified or synthetic
cannabinoids. They want smoked dope.

The writer was director of the National Institute on Drug Abuse from 1973 to
1978. He is now a clinical professor of psychiatry at Georgetown Medical School.