BOOK REVIEW: MARIJUANA: THE FORBIDDEN MEDICINE

Marihuana: The Forbidden Medicine, by Lester Grinspoon and James B Bakalar,
revised ed 296 pp, $35, ISBN 0-300-07085-3 paper $16. ISBN 0-300-07086-1.
New Haven, Conn. Yale University Press, 1997

The first edition of Marijuana: Forbidden Medicine was published in 1993
and reviewed in JAMA. In it, Grinspoon and Bakalar (from Harvard Medical
and Yale Law Schools, respectively) presented numerous case reports of
symptomatic relief from marijuana in a wide variety of physical and
psychological disorders. The patients were those who had been treated than
adequately by more traditional methods and who did not necessarily belong
to a drug abusing subculture.

In the intervening 4 years, much has happened in the "medical marijuana"
field. Voters in California and Arizona passed initiatives legalizing
medical marijuana and protecting physicians who recommend it. New clinical
research using marijuana in wasting syndrome of the acquired
immunodeficiency syndrome (AIDS) is poised to begin. Research into the
pharmacology of the endogenous marijuanalike substances, the anandamides,
is progressing at a rapid pace. On the other hand, there were 600 000
marijuana-related arrests in the United States in 1995. The time feels like
a watershed for attitude,, and policy regarding marijuana; something has to
change.

The ideal book entering the, contemporary medical marijuana debate ought to
address at least three major issues: efficacy, safety, and policy. This
revised and expanded edition of Marijuana:Forbidden Medicine is even
more thorough in documenting cases of self-reported efficacy than the
original edition. It more than adequatelv covers safety issues. However, as
in the first edition, the book fails to consider practical policy or
implementation issues in a serious manner.

Grinspoon and Bakalar present over 30 new case reports suggesting
beneficial effects of marijuana. The conditions found in "Common Medical
Uses" in-elude cancer chemotherapy -induced nausea and vomiting, glaucoma,
and mood disorders. Examples of "Less Common Medical Uses" are asthma,
posttraumatic stress disorder, and Crohn disease.

The anecdotal nature of these self reports is acknowledged as the
unfortunate state of the art. Furthermore, it is unlikely that the typical
drug trials using single, pure, synthetic compounds, required by v the
Food and Drug Administration for a New Drug Application (NDA), will occur
with marijuana be-cause of its chemical complexity. The whole plant
contains numerous biologicalIy active components. An assessment of their
therapeutic effects, singly and in various combinations, is probably, for
all intents and purposes, not practical.

However, it may be less than prudent to conclude that "no double-blind
studies are needed to prove marijuana's efficacy." Rather, these reports
ought to stimulate clinical investigators to begin such studies of the
whole plant, using inarijuana of standardized chemical composition, such as
that being grown by the National Institute of Drug Abuse. While the AIDS
wasting syndrome protocol has been subject to frustrating regulatory
inconsistecies2, its recent approval should now serve as a model for future
projects.

Grinspoon and Bakalar's summary of the safety and toxicology data is
clinically and logically unassailable. Undoubtedly there are batches of
mold-contaminated inarijuana; coordination and motor reflexes are impaired
during acute intoxication; chronic use of marijuana subtly affects
cognitive function and produces upper respiratory problems. However, for
the amount being smoked, it is reassuring that no deaths directly resulting
from marijuana overdose have been reported, nor have there been documented
cases of lung cancer even in chronic smokers. For a more thoroughly
referenced and argued, albeit rhetorically tinged, discussion of these
issues, Zimmer and Morgan's Marijuana Myths, Marrijuana Facts(reviewed in
JAMA, February 25,1998) is also worth reading.

The most enlarged chapter in this revised edition, "The Once and Future
Medicine," expands upon the authors' social and political analysis of what
prevents regulatory acceptance of marijuana as medicine. The analysis is
cogent as far as it goes, eg, "saving face" by the government; vested
interests keeping marijuana illegal; and the antiestablishment stigma
associated with marijuana use. However, these issues seem less proximate
and convincing than those raised by these authors in a previous book.:'
These include moral and ethical issues that reflect deep-seated
psychological fears of losing control, both individually and as a society,
and the role of pleasure in our culture.

Any current book proposing widespread availability of medical marijuana is
that much more valuable if it proposes models for a dispensing
infrastructure that take into account diversion, quality control, training
and certification of those who prescribe it, extant scheduling laws, and
accessibility. The first edition of this book waited until its final
paragraph before proposing a liquorstore model for sales of marijuana to
individuals of legal age. Regrettably, this second edition makes the same
suggestion at the same point in the book.

The authors do discuss why current models are unlikely to work: the
"compassionate use permit" (of which there are now only eight in the United
States); the over-the-counter pharmacist model (which is mentioned but not
described); the drug company-NDA model; reducing marijuana from schedule 1
to II and having doctors prescribe it; and underground "buyers'elubs."
However, other possibilities~ come to mind. One is the creation of
specially licensed and certified clinics, like those dispensing methadone
for treatment of opiate dependence, but with a much broader distribution
base.

It is difficult to see how the growing tide of acceptance of medical
marijuana might be stemmed much longer by accusations of "covert
legalization tactics." Grinspoon and Bakalar deserve credit for
unstintingly keeping the issue alive in the face of the medical
profession's general reluctance to consider such a thorny issue. However,
they need to keep pace with their own success. While Marijuana: The
Forbidden Medicine remains the definitive collection of case reports of
therapeutic effects of marijuana, we must look elsewhere for models to put
into practice what they so convincingly argue must happen.

Rick J. Strassman. MD

University of British Columbia Victoria

1. Strassman RJ. Review: Grinspoon L. Bakalar JP. Marijuana: The Forbidden
Medicine(Nem Haven,Conn Yale University Press: 1993;270:2878-2879.

2. Kassirer JP. Federal foolishness and marijuana, N Engl J Med. 1997;336,
366-367

3. BakalarJB, Grinspoon L. Drug ControI in a Free New York, NY: Cambridge
Press:1984.