MEDICINAL USES OF MARIJUANA

To the Editor: Voth and Schwartz (1) sound like patriarchal moralists, not
scientists. They conveniently ignore scientific studies, patient anecdotes,
court decisions, and voters who disagree with them when discussing a
5000yearold herbal medicine. Many physicians and organizationsincluding
Dr. Kassirer, Editor of The New England Journal of Medicine (2); the
National Institutes of Health (3); the American Public Health Association;
the San Francisco Medical Society; the California Academy of Family
Physicians; Harvard professor Dr. Grinspoon; the Federation of American
Scientists; and the National Academy of Sciences (4)believe that cannabis
may be beneficial and that further research should be done. Users of
medical cannabis are not criminals. If this issue is controversial, then
suffering patients deserve the benefit of the doubt so that they can have
access to medical cannabis while more research is being done. The National
Institute on Drug Abuse has even impeded medical research on medical
cannabis (5).

Voth and Schwartz also seem to encourage the use of Marinol, an oral
product produced by a large pharmaceutical firm (Unimed, Inc., Buffalo
Grove, Illinois) and containing only the psychoactive cannabinoid
(delta5tetrahydrocannabinol) instead of the cannabis plant. Is it
possible that they have a conflict of interest? What is the International
Drug Strategy Institute? Do they directly or indirectly get any
pharmaceutical money? The Annals Editors may have been negligent by failing
to disclose to their readers information about financial incentives to
promote the agenda of the large pharmaceutical companies over the agenda of
suffering patients.

The "War on Drugs" is a political war on compassionate U.S. physicians and
their patients. The "War" spills into our examination rooms and influences
how we prescribe. Even when clinical practice guidelines on pain management
have been followed (U.S. Department of Health and Human Services
publication AHCPR0032), I have found that appropriate narcotic
prescriptions can trigger an investigation by the state Board of Medical
Examiners. Calling off the "War on Drugs" will be good for science,
physicians, and patients. Accurate (not DARE propaganda) methods for
prevention and harm reduction need to be instigated.

Voth and Schwartz do not present a compelling reason to oppose the desires
of our patients, the scientists who disagree with the authors, and the
democratic process of voter initiatives.

Richard Bayer, MD
Portland, OR 97225

References

1. Voth EA, Schwartz RH. Medicinal applications of
delta9tetrahydrocannabinol and marijuana. Ann Intern Med. 1997;126:7918.
2. Kassirer JP. Federal foolishness and marijuana [Editorial]. N Engl J
Med. 1997;336:3667.

3. Voelker R. NIH panel says more study is needed to assess marijuana's
medicinal use. JAMA. 1997;277:8678. 4. NORML Medical Marijuana Documents
ONLINE. http://www.natlnorml.org/medical/medmj.shtml. 5. MAPS Newsletter on
Marijuana and AIDS Wasting Syndrome
Study.http://www.maps.org./newsletters/v06n2/06207mmj.html.

To the Editor: Voth and Schwartz's perspective on medicinal use of
marijuana (1) is significant for several reasons. Most disturbing to me is
that it represents a departure from principle by a medical journal.

The federal government responded to "medical marijuana" by threatening
physicians. Unlike Jerome Kassirer, in his straightforward editorial
objection in The New England Journal of Medicine (2), you've chosen to
obliquely endorse marijuana prohibition by publishing a slanted review
article by two of marijuana's most infamous doctrinaire opponents.

Anyone unaware that the politics of this issue have overshadowed science
for six decades is not in touch with reality. This purported review of the
literature clearly supports continued listing of "crude" marijuana on
schedule 1, while allowing its synthetic analogue, Marinol, to be legally
prescribed on schedule 2.

This is logical sleight of hand: Schedule 1 cites three criteria: (lack of)
safety, potential for addiction, and (lack of) medical utility. Because the
two agents are nearly identical, neither efficacy nor potential for
addiction can justify their separate listing. Furthermore, because acute
toxicity of marijuana is nonexistent, the major justification for continued
listing on schedule 1 while leaving Marinol on schedule 2 would have to be
fear of chronic harm from a delivery system requiring smoking. This
argument loses all validity when used by a government that allows tobacco
use.

The selective nature of Voth and Schwartz's perspective can be inferred
from their choice of 92 references claiming to examine "relevant research
published between 1975 and 1996" but that ignores Hollister's exhaustive
1986 review article (3). The latter cited twice as many references as did
Voth and Schwartz and reached quite different conclusions. Voth and
Schwartz submitted their modern "scientific" version of a 1930s "reefer
madness" article, and you published it. For shame.

Thomas J. O'Connell, MD
Daly City, CA 94015

References

1. Voth EA, Schwartz RH. Medicinal applications of
delta9tetrahydrocannabinol and marijuana. Ann Intern Med. 1997;126:7918.
2. Kassirer JP. Federal foolishness and marijuana [Editorial]. N Engl J
Med. 1997;336:3667.

3. Hollister LE. Health aspects of cannabis. Pharmacol Rev. 1986;38:120.

To the Editor: The welldocumented review of medicinal potential of
delta9tetrahydrocannabinol and marijuana by Voth and Schwartz (1) is
timely because the wellfunded drug legalization lobby, which includes
physicians, is actively trying to duplicate the California and Arizona
marijuana initiatives in many other states. Voth and Schwartz's surveys
show that only a small percentage of oncologists would recommend marijuana
as medicine. Moreover, no evidence suggests that even this small number of
physicians have the necessary information on which to base their opinion.
The U.S. Food and Drug Administration's approval of drugs as medicine is
based on wellcontrolled scientific studies, not on surveys, polls,
anecdotes, or popular vote. Furthermore, with the current heavy advertising
of prescription drugs on television and radio and in the print media,
physicians are under unprecedented pressure to prescribe drugs that their
patients demand. Indeed, it was the multimilliondollar television blitz
fraudulently advertising marijuana as medicine that deceived the voters in
California and Arizona. It is not compassionate for physicians to recommend
an unsafe, unproven substance that may worsen their patients' condition,
especially when better, safer drugs are available.

Janet D. Lapey, MD
Concerned Citizens for Drug Safety
Hanover, MA 02339

Reference

1. Voth EA, Schwartz RH. Medicinal applications of
delta9tetrahydrocannabinol and marijuana. Ann Intern Med. 1997;126:7918.

In response: The attitudes of Drs. Bayer and O'Connell are precisely why we
undertook the project of sorting out emotion and passion from science and
fact as they relate to the use of crude marijuana as a medicine. We found
no compelling reason to abandon the Food and Drug Administration process of
proving safety and efficacy and stepping back to the days of unproven and
potentially toxic potions and tonics. That is the net effect of views
represented by Drs. Bayer and O'Connell. Unlike the anecdotal diatribes
that pervade support for the medicinal use of marijuana, our review was
extensive and covered existing science.

O'Connell's comments are consistent with those that he voices on
prolegalization or "drug policy reform" World Wide Web sites. He overlooks
the fact that crude marijuana is a toxic, impure herb containing more than
480 substances. Marinol has side effects (as does marijuana) but at least
is a single, pure substance.

Bayer mixes fact with fiction in his criticism. In fact, many of the
positions to which he refers are based on uncontrolled anecdotes, not
controlled studies. Contrary to Bayer's assertions, the National Institutes
of Health have previously stated that marijuana adds nothing to the
currently available regimens for such conditions as nausea, glaucoma, and
spasticity (Lee PR. Personal communication to Congressman Dan Hamburg).

Bayer raises questions about the International Drug Strategy Institute. We
are a group of more than 40 physicians, attorneys, and drug policy
specialists, including some of the most respected authorities on drug
policy in the world. We receive no "pharmaceutical" funding and have no
vested interest in anything except the health and wellbeing of patients.
In contrast, the medicinal marijuana movement was fathered by the National
Organization for the Reform of Marijuana Laws. The stated goal of this
organization is to use the medical marijuana issue to gain public support
and the ultimate legalization of marijuana (1). Bayer even cites the NORML
Web site as a resource. That site also outlines the medical marijuana and
hemp legislative strategy for the United States.

Dr. Lapey draws attention to the organized and wellfunded ballot
initiatives in Arizona and California, in which millions of dollars from
wealthy supporters of legalization essentially bought drug policy. Dr.
Lapey makes a calm and sane plea to base medical decisions on the Food and
Drug Administration process of proving safety and efficacysomething that
the supporters of medicinal marijuana are quick to abandon.

We continue to maintain that research should continue into alternative
delivery systems for pure delta9tetrahydrocannabinol and its analogues.
Patients should be provided with predictable, safe, and effective
medicines, not unproven herbal potions.

Eric A. Voth, MD
Richard H. Schwartz, MD
International Drug Strategy Institute
Topeka, KS 66606

Reference

1. Cowan R. Building a new NORML: strategies for the legalization of
marijuana by 1997. High Times. 1993;January:63.

Copyright © 1997 by the American College of Physicians.