Will medical-marijuana initiative ease their pain?

Is marijuana a safe and effective medication?

Medical practitioners, drug-prevention specialists and even scientists give
very different answers.

Some claim there is no research. Others claim there is, but say it's not
good research. Still others believe there's good research - but disagree
about whether it shows marijuana is dangerous or safe and effective.

Yet another group claims that while there isn't good research, there are
very good stories.

When it comes right down to it, emotion, not science, divides many people
on Initiative 692, which would legalize the use and possession of marijuana
by patients with terminal or chronically debilitating conditions.

Research, including new work in pain relief and brain-cell protection, is
promising but still inconclusive. And medical marijuana, like abortion, is
an issue that brings out deeply held beliefs.

On one side are the advocates, such as Dr. William O. Robertson, a
pediatrician and medical toxicologist who is a past president of the
Washington State Medical Association.

"I'm biased," concedes Robertson. "I think patients should be enabled to
make a choice. If they really believe this stuff is going to work, I have
to say, why not give it to them?"

Compared to smoking cigarettes, getting drunk on alcohol or even taking
many other medications, "the risk is trivial," he says. "Will it make life
more tolerable for patients whose lives are simply miserable? I strongly
believe that it will."

On the other side are opponents, many of whom believe marijuana is harmful
to human beings physically, psychologically and socially.

"Prescribing a smoked, psychoactive weed for conditions for which we
already have excellent legitimate medicine borders on malpractice," argued
Wayne Roques, a Florida drug-prevention consultant, in a column in
Alcoholism & Drug Abuse Week.

Prescribing marijuana, he argues, is like prescribing a pint of whiskey to
treat depression. "Compassion that harms is cruelty," he concluded.

These days, many people know patients who have used marijuana. But the
questions linger:

What are the facts? What is the research?

First, a snippet of history.

Once upon a time, the leafy green stuff called marijuana was legal. The
only plant known to contain cannabinoids such as THC, marijuana had common
medicinal uses. In the early 1900s, Sir William Osler, the father of modern
medicine, proclaimed it as "probably the most satisfactory remedy" for
migraine.

As concern about recreational drug use grew, Congress passed the Controlled
Substances Act in 1970. Marijuana was placed in the most restrictive
category, Schedule I.

Schedule I drugs, by definition, have no accepted medical use, a high
potential for abuse, and cannot be used safely even under a doctor's
supervision. For researchers, the classification made marijuana extremely
difficult to obtain.

In 1988, a federal administrative law judge recommended moving marijuana to
a less restrictive schedule.

In its natural form, the judge ruled, marijuana is "one of the safest
therapeutically active substances known to man. . . . One must reasonably
conclude that there is accepted safety for use of marijuana under medical
supervision."

He was overruled by the federal Drug Enforcement Administration.

But a growing number of patients, families and medical people began
claiming marijuana helped combat nausea, pain or other conditions.

Were these anecdotes nothing but hot air, like rumors in the '70s that
peanut butter would cure genital herpes? Or were these the stories of human
guinea pigs, much like the six soldiers who first received penicillin,
whose experiences were early evidence of a valuable medication?

For years, the demand for research slammed into the government's lock on
legal marijuana.

"The government says you need studies," says Dr. Lester Grinspoon, a
Harvard medical school psychiatrist and author of "Marihuana: The Forbidden
Medicine." "But then they will not release it to be studied clinically."

In the past year, however, two noteworthy events took place.

First, the National Institutes of Health (NIH) convened a panel of neutral
medical experts to review all available data - a "Workshop on the Medical
Utility of Marijuana." The panel's report was issued last year.

Then, the NIH awarded money - and marijuana - to a California researcher to
study marijuana's safety for HIV-positive patients.

Dr. Donald Abrams, an oncologist at the University of California at San
Francisco, was elated after earlier futile attempts to get approval for
research. "I've got one million dollars and 1,400 joints," he chortled.

The two-year study will look at the safety of smoked marijuana and Marinol,
a synthetic version of THC, marijuana's main active ingredient, when taken
with a commonly prescribed anti-HIV drug by patients.

So far, one of Abrams' biggest problems is potential study subjects balking
at the requirement that they give up marijuana for 30 days.

"They say that's how they keep their pills down."

Personal testimonials

Anecdotes may be convincing, and there's no doubt a placebo effect can take
place, but physicians must insist on scientific data when it comes to
marijuana, argues Dr. Peter Marsh, past president of the Washington State
Medical Association (WSMA).

"In actual fact, there is no data" on marijuana's claimed medical
usefulness, he told delegates to the recent WSMA convention. The
organization voted not to endorse Initiative 692.

Much of the research on smoked marijuana was conducted in the '70s, Abrams
says, and involved a small number of subjects, poor quality research and
flawed methodology.

In recent years, anecdotes, more than data, have driven the medicinal
marijuana movement.

There's the story of Ralph Seeley, a Tacoma lawyer who died last year of
bone cancer. Painting a vivid picture of lying in his own vomit after
chemotherapy, Seeley sued the state, arguing that he had a constitutional
right "to be free of unnecessary suffering." The state Supreme Court didn't
agree.

But the ruling hasn't stopped the anecdotes.

Patients, including dangerously thin AIDS patients, it seems, get the
"munchies" just like recreational users. They tell stories of hasty trips
to the bathroom detoured by a toke or two into meandering raids on the
refrigerator.

Another patient, Margaret Denny, a 48-year-old former teacher from Maple
Valley, began using marijuana, smoked and in tea, about five years ago.

Severely injured in a 1979 head-on collision that required multiple
surgeries, she was often disabled by pain and nausea. Some medications left
her so zonked she couldn't function. Others had scary side effects such as
destroying a patient's liver.

Finally, a doctor suggested she try marijuana, and she did.

She resumed life, earning a degree in computer programming. "If it hadn't
been for marijuana, I wouldn't have been able to go back to school," she
said. "It works the best of anything I've tried."

Reefer madness?

But is smoking marijuana safe?

In a 1996 NIH memo rejecting one of Abrams' earlier research proposals,
government-selected reviewers enumerated a long list of perceived dangers.

Among them were smoking-related respiratory risks, possible DNA damage,
injuries resulting from intoxication and immune-system inhibition. They
also listed mental and "neurobehavioral" effects such as anxiety and anger.

It's true that test-tube and animal studies hint that marijuana may harm
lungs and immune systems. Other research has associated it with short-term
mood disorders as well as temporary elevations of heart rate.

The NIH panel also noted that the few studies on smoked marijuana used
young, healthy male volunteers, suggesting little about possible dangers to
older, sicker patients.

Since large numbers of HIV and AIDS patients now smoke marijuana, further
research on lung and immune-system effects is necessary, concludes Dr. John
Morgan, a pharmacology professor and co-author of "Marijuana Myths,
Marijuana Facts: A review of the Scientific Evidence."

However, there is now no basis for "dire warnings of immune damage," he and
co-author Lynn Zimmer conclude.

Morgan and Zimmer note that immune-impaired patients risk contracting a
lung disease caused by a fungus. Studies also show marijuana impairs
lung-clearing cells.

Although marijuana's effects are "much less pronounced" than those of
tobacco smoke, Morgan adds: "Smoking isn't good for your lungs."

For the most part, however, test-tube and animal studies haven't translated
into findings on actual patients. Studies simply haven't found proof of
lasting physical or genetic damage in long-term, heavy marijuana smokers.

Some observers also note that Marinol was given FDA approval almost 15
years ago and is available by prescription for nausea.

Many who look carefully at marijuana say the most striking finding is how
safe it is.

"There has not been a single recorded death from overdose of marijuana in
recorded history," Grinspoon says. "There aren't many drugs you can say
that about."

The NIH panel agreed, noting that there is no known lethal dose.

May be useful in several areas

Even if it's safe enough, is there proof marijuana helps patients? It
appears to have potential medical usefulness, warranting further study, in
several areas, the NIH panel concluded.

- -- Nausea and vomiting:

The majority of reports, the panel concluded, showed that oral THC helped
control nausea and vomiting.

In one 1988 trial, 78 percent of patients who failed with other drugs rated
smoked marijuana effective.

The panel said inhaled marijuana's potential in this area "merits testing"
in further studies.

- -- Appetite stimulation and "wasting" syndrome:

The panel concluded there is a "strong relationship" between smoking
marijuana and appetite, though research didn't prove this was a long-term
effect.

Weight gain in perilously thin AIDS patients with "wasting" syndrome has
been anecdotally associated with oral THC, but there haven't been studies.

Marinol was most providers' second choice after another drug; a study now
under way at the National Cancer Institute is comparing the two.

- -- Pain relief:

The NIH panel, which didn't consider some recent significant research,
concluded it "highly likely" that smoked marijuana helps some kinds of pain.

In one study of THC's effects on cancer patients, pain-relief effects of
THC and codeine were similar and significant.

Smoked marijuana likely allows a more precise dose than oral THC, the panel
noted, but a dose big enough to relieve pain might also cause unwanted side
effects.

- -- Spasms and neurological effects:

There is good evidence, from clinical trials and anecdote, that marijuana
can help control convulsions or spasms, and may have potential in
conditions such as epilepsy, multiple sclerosis and spinal-cord injury, the
panel said.

- -- Glaucoma:

Animal studies are conflicting, and effects on human glaucoma have "never
been investigated by modern means," the panel noted.

While there are other good treatments available, marijuana might help
patients who have an incomplete response, the panel said.

Intriguing findings

In addition, recent research on THC has produced intriguing findings not
addressed by the panel.

- -- Brain injury and stroke:

Most amusing to some marijuana activists, recent research suggests that
smoking pot may actually protect brain cells from damage.

Scientists at the NIH found that two of marijuana's cannabinoids appear to
protect brain cells when neurons are deprived of oxygen, as occurs during a
stroke.

Like most research on marijuana or its components, this wasn't done on
human patients, but in a test tube. But researchers have long noted the
presence of receptors for cannabinoids in the human brain.

- -- Marijuana, morphine and pain:

Ian Meng's recent study at UC-San Francisco showed that marijuana and
morphine, in rats' brains, act on the same neuron circuits.

Using a chemical mimic of THC, Meng found that both THC and morphine turn
off pain messages.

Meng, a post-doctoral student in the department of neurology, says previous
research pointed in the same direction. "I don't think there's much doubt
now."

Of course, the big question is always whether animal studies can be
extrapolated to effects on humans.

As the debate nears Election Day here and in several other states, more
parties have joined the fray.

The war on drugs notwithstanding, a number of groups have called for
research on marijuana as medicine, including the conservative American
Medical Association.

Federal policies that prohibit prescribing marijuana, editorialized The New
England Journal of Medicine, are "misguided, heavy-handed and inhumane."

Morgan, the pharmacology professor, predicts a new day dawning for marijuana.

The proof, he claims, is in the profits: Pharmaceutical companies are
already scrambling to develop nasal sprays, lozenges, vaporizers,
suppositories and skin patches to deliver marijuana's active ingredients to
a patient, sans smoke.

Checked-by: Mike Gogulski