STRIKE A BALANCE IN THE MARIJUANA DEBATE

Everyone seemed to declare victory when a study on the medical use of
marijuana was issued last month. Advocates for legalizing such use said the
report aided their cause by concluding that the compounds in marijuana do
have some potential as medicine. Their opponents, on the other hand, cheered
the report's conclusion that the harmful effects of smoking far outweigh
potential benefits for most patients. In reality, both sides are right. The
study -- which we led for the Institute of Medicine -- firmly concluded that
the active compounds in marijuana do have potential as medicine. But that
future does not involve smoking.

Scientific hair-splitting? Hardly. To date it has been nearly impossible to
separate scientific evidence about marijuana's potential from larger
societal concerns about its use. But doing so may be the key needed to
advance the rancorous debate that has engulfed this issue since medical
marijuana began to appear on state ballot initiatives in the mid-1990s.

Those who have followed the debate may be surprised to learn that in the
scientific realm, we found remarkable consensus that marijuana's components
have potential to relieve symptoms such as pain, nausea and vomiting, and
the poor appetite associated with wasting in AIDS or cancer. For most
symptoms there are more effective drugs already on the market, but
physicians encounter patients who do not respond well to standard
medications, or who need additional therapies. These patients could benefit
from new drugs based on cannabinoids, the active components in marijuana.

Marijuana's future as medicine rests in developing new ways of delivering
these cannabinoids -- including the most common one, THC. Presently there is
only one such drug on the market. Marinol, a THC capsule, is approved by the
Food and Drug Administration for treatment of nausea and vomiting associated
with chemotherapy, as well as poor appetite and weight loss associated with
AIDS.

However, some who have used Marinol complain that it takes effect slowly,
and its results are variable. Sufferers of pain, nausea and vomiting
obviously need fast-acting medication. For that reason, we recommend that
clinical trials move forward with the goal of developing a rapid-onset,
non-smoked delivery system, such as an inhaler. This type of device could
deliver precise doses without the health problems associated with smoking.

Admittedly, an inhaler could take years to produce. What do we do right now?

In deciding whether marijuana should be smoked as medicine, society must
weigh the reality of this crude drug-delivery system against the benefits it
might bestow. Chronic smoking of marijuana increases a person's chances of
developing cancer, lung damage, and problems with pregnancies, including low
birth weight. Therefore, it simply is not an acceptable long-term option.
Smoking should be allowed only for short-term use among patients with
debilitating symptoms, or who are terminally ill and do not respond well to
approved medications.

Even in these cases, marijuana use should be limited to carefully controlled
settings. Patients who are prescribed marijuana should be enrolled in
short-term clinical trials that are approved by an oversight strategy such
as institutional review boards, and involve only those patients most likely
to benefit. They should be fully informed that they are experimental
subjects and are using a harmful drug-delivery system, and their condition
should be closely monitored and documented under medical supervision.

These clinical trials of smoked marijuana should not be designed to develop
it as a licensed drug, but should be a stepping stone to the development of
new, safe delivery systems of cannabinoids. There is no evidence that using
marijuana in controlled settings -- or cannabinoids in the form of drugs
such as Marinol -- will lead to increased illicit drug use throughout
society.

Our review of the science behind marijuana and cannabinoids convinces us
that the debate so far has been miscast. Rather than focusing on drug
control policy, the medical marijuana debate should really be about the
promise of future drug development. Mining the pharmaceutical promise of
cannabinoids will require the same kind of drug development that brought us
any number of pain-killing drugs prescribed by physicians today. With public
investments in research, or enough incentives to convince private companies
to develop these drugs, the perceived need to smoke marijuana to alleviate
symptoms could vanish.