GRASSROOTS MEDICINE

David M. Fine

For several decades, researchers have sought to determine whether marijuana
has legitimate medical uses, and narcotics control agencies have
discouraged them from finding out. Now a new round of federally funded
research may provide some answers—or will it? The latest skirmish between
scientists and police comes on the heels of two popular referenda, in
California and Arizona, legalizing the medical use of marijuana. But since
it remains a federal crime to grow, sell, or prescribe cannabis, the
referenda have created only a legal morass. see related resources below

Barry McCaffrey, director of the White House Office of National Drug
Control Policy, derided the propositions as "hoax referendums," and
insisted that voters had been "duped" by deceitful ad campaigns whose real
intent was to legalize drugs. Attorney General Janet Reno announced that
prescribing or recommending marijuana was still a violation of federal law,
and that any doctors who did so could be prosecuted and lose their license
to prescribe all drugs regulated by the Drug Enforcement Administration
(DEA).

However, the medical use of marijuana has been gaining respectability.
Several states have research programs of their own and some governors,
including Republican William Weld of Massachusetts, openly endorse medical
legalization. The editor of the prestigious New England Journal of
Medicine, Jerome Kassirer, lambasted the Clinton administration in an
editorial entitled "Federal Foolishness and Marijuana" that received
national attention. "To prohibit physicians from alleviating suffering by
prescribing marijuana for seriously ill patients," Kassirer wrote, "is
misguided, heavyhanded, and inhumane."

In January, Director McCaffrey, finding himself kneedeep in a debate in
which he was little qualified to participate, tried to defuse criticism
with an announcement that the Institute of Medicine (IOM) would be given $1
million to conduct an 18month review of the current literature on
marijuana. Later that month Harold Varmus, director of the National
Institutes of Health (NIH), announced that the NIH would convene a workshop
on the medical utility of marijuana. "We have no rationale for not looking
into it," Dr. Varmus said in a phone intervwas l

But the IOM conducted a similar study back in 1982 and issued a report
entitled "Marijuana and Health," concluding that "Marijuana and its
derivatives or analogues might be useful in the treatment of glaucoma, of
nausea and vomiting brought on by cancer chemotherapy, and of asthma. . ."
A review of the existing literature, as Kassirer pointed out, will likely
be inconclusive because no definitive study has been done. The new IOM
review, Kassirer said in an interview, "was a political maneuver designed
to move the debate off center stage—it probably could be done in 18 days."

In February, the NIH held its workshop, organized by the National Institute
on Drug Abuse (NIDA), and workshop participants initially promised to
submit their recommendations for further research to Varmus by the end of
March. But as this article goes to press in midJune, three months have
passed and the recommendations have yet to be submitted.

Ever since the 1930s and the era of "Reefer Madness," when marijuana
acquired both a countercultural stigma and allure, the federal government
has resisted attempts to legalize marijuana for medical purposes—both by
inhibiting research and by restricting access to the drug. The government
has been fearful of sending the message that if marijuana is medically
useful, it also can be used safely as a recreational drug. The scientific
issue is unresolved, but nonetheless closed.

The medical marijuana movement emerged with the rise of recreational
marijuana use in the 1960s. Marijuana had long been known to promote
appetite, and a few studies in the first half of the twentieth century
showed that it aided in alleviating nausea. Many chemotherapy patients
found that smoking marijuana not only relieved their nausea and vomiting
better than any of the legally available medications, but also enhanced
appetite and relieved anxiety. For many, the relief from smoking pot was so
strikingly better than from the use of Compazine, ththe rise of
recreational marijuana use in the 1960s. Marijuana had long been known to
promote appetite, and

In a 1980 congressional hearing titled "Health Consequences of Marijuana
Abuse: Recent Findings and the Therapeutic Uses of Marijuana and the Use of
Heroin to Reduce Pain," two prominent oncologists—Steven Sallan, then
clinical director of pediatric oncology at the Sidney Farber Cancer
Institute, and Solomon Garb, president of the medical staff at the AMC
Cancer Research Center in Lakewood, Colorado—and others attested to the
medical utility of both smokable marijuana and its primary active
ingredient, delta9THC. They also testified to the difficulties in
obtaining the drugs to conduct research: While anyone could buy marijuana
on the street on any given day, Garb had to wait seven months for his
research supply and knew others who had waited up to two years.

However, marijuana remained a Schedule I drug—a substance with potential
for abuse and no medical uses. Despite a number of petitions to move
marijuana to Schedule II, the DEA refused even to hold a public hearing on
the issue. So while the federal government resisted, states took the
initiative. By the late 1980s, 34 states had passed some form of medical
marijuana legislation. Several states organized marijuana research programs
so they could legitimately obtain synthetic THC—and in a few cases,
marijuana—from the federal government, for suffering patients. Results from
studies, though not rigorously scientific, conducted in New Mexico,
Tennessee, New York, and elsewhere, found that smokable marijuana and THC
outperformed the best available prescription drugs, reporting success rates
close to 90 percent; anecdotal evidence suggested that smoked marijuana was
more effective than Marinol, the synthetic THC pill.

Finally, in 1985 the coalition of doctors, patients, and marijuana
activists persuaded the Department of Health and Human Services to move
Marinol to Schedule II, making it legally available by prescription to
patients. Soon after, the DEA announced that public hearings on the
rescheduling of marijuana itself would finally be held. Those hearings
lasted two years and culminated in the recommendation of DEA Administrative
Law Judge Francis L. Young in 1988, who wrote that it is unrealistic and
unreasonable to require unanimity of opinion on the question confronting
us. For the reasons there indicated, acceptance [of marijuana having a
medical use] by a significant minority of doctors is all that can
reasonably be required. This record makes it abundantly clear that such
acceptance exists in the United States. . . . One must reasonably conclude
that there is accepted safety for use of marijuana under medical
supervision.

But the DEA administrator did not act on this recommendation and marijuana
remained in Schedule I.

The prolegalization National Organization for the Reform of Marijuana Laws
(NORML) petitioned the DEA to reschedule marijuana for review again in
1992. Denying this petition, DEA Administrator Robert Bonner wrote in the
Federal Register, "Our nation's top cancer experts reject marijuana for
medical use." To support his claim, he cited the testimony of David S.
Ettinger, a professor of medicine at Johns Hopkins University School of
Medicine and "nationally respected cancer expert," who said: "There is no
indication that marijuana is effective in treating nausea and vomiting
resulting from radiation treatment or other causes. No legitimate studies
have been conducted which make such conclusions."

Bonner thus concluded, "Not one nationally recognized cancer expert could
be found to testify on marijuana's behalf." But in a recent phone
interview, Ettinger said he had changed his position. He now believes that
in cases of intractable nausea "smoking marijuana is reasonable" and that
there are "patients for whom therapies don't work and in that situation
anything is worth trying." He also said a study should be conducted
comparing the efficacy of smoked marijuana to Marinol.

>From the late 1980s up to the present, the federal government has appeared
content to close the book on the medical marijuana question, inhibiting any
attempts at further research of its medical utility, and limiting research
to marijuana's negative effects. In 1994 Dr. Donald Abrams, a California
AIDS specialist, submitted a research proposal to compare smokable
marijuana and Marinol because, he said, "we have 1,100 AIDS patients in the
Bay Area using marijuana [on their own]." Abrams's draft proposal did not
pass peer review, but the FDA helped Abrams develop a revised proposal,
which was approved by several California research committees and submitted
in August 1994. After a delay of nine months, Abrams received a letter from
Dr. Alan Leshner, director of the NIDA, turning down the proposal and
leaving no room for further negotiation over revisions. "As an AIDS
investigator who has worked closely with the National Institutes of Health
and the U.S. Food and Drug Administration for the past 14 years of this
epidemic, I must tell you that dealing with your institute has been the
worst experience of my career!" Abrams replied.

Polls show broad support for medicalization. An ABC/Discovery Channel
nationwide poll conducted in May found that 69 percent of respondents
favored permitting doctors to prescribe marijuana. Now, after several years
of relative quiet, states and local organizations are again pursuing the
issue of medical marijuana. The California Medical Association recently
backed a bill in May that would provide $6 million for researching the
medical benefits of marijuana, and Americans for Medical Rights is gearing
up to get medical marijuana ballots placed in a half dozen states for 1998.
In addition to the California and Arizona referenda, the state governments
of Massachusetts and Washington are creating programs to distribute
marijuana to qualifying patients, though of course these programs are
contingent on federal approval. In a sense, these could be test cases,
signaling whether federal health officials will keep an open mind about the
potential medical benefits of cannabis.

RAISING THE HURDLE

In the past, the DEA argued that marijuana had no accepted medical use. Now
the government has altered that argument subtly, raising the hurdle for a
revision in its policy. Director McCaffrey, in testimony December 2, 1996,
before the Senate Judiciary Committee, stated, "There is no scientifically
sound evidence that smoked marijuana is medically superior to currently
available therapies [emphasis added]."

There are, in fact, some new antinausea treatments that may provide relief
comparable or superior to marijuana. For example, new antiemetic drugs
such as Ondansetron and Kytril (trade names), are administered to patients
intravenously, and work well. But they are difficult to administer and are
astronomically expensive. In tablet form, for outpatient chemotherapy,
Kytril retails for around $86 for a daily twomilligram dose. Legal
marijuana would cost just a few cents a dose. Moreover, it is not FDA
policy to disallow one treatment simply because another, more expensive or
elaborate one is available. Dr. Robert Temple, associate director for
medical policy in the Center for Drug Evaluation and Research at the FDA,
who also attended the NIH workshop, told the New York Times, "FDA approval
does not require that any [new] drug be better than, or even as good as, an
existing drug." Such an action would be equivalent to the FDA denying
approval to, say, Pepcid, because Tagamet is a sufficient acidblocking drug.

Other Schedule I drugs have been rescheduled because they provided
relatively minor increased flexibility or improvement in treatment. LAAM
(Lalphaacetylmethodol), a drug now used with or in place of methadone to
treat heroin addicts, was recently moved from Schedule I to II because it
can be taken every other day compared to the required daily prescription of
methadone. This allows recovering addicts to use the day in the middle for
counseling.

Many AIDS patients suffer from AIDS wasting syndrome, during which they are
so sick they cannot eat. Chemotherapy and radiationtreatment patients
often suffer from extreme nausea and vomiting. All of these patients might
be candidates for marijuana therapy, to promote appetite and relieve nausea
and vomiting. Many patients smoke marijuana that they obtain illegally
because they can control the dosage: The palliative effects occur about 45
minutes faster and the psychoactive effects go away more quickly than when
the patients take Marinol. Ironically, the government approved Marinol in
part because it seemed less "recreational" than smoked marijuana. But
clinically, the psychoactive effects of Marinol characteristically last
nearly eight hours, while those of a comparable dose of smoked marijuana
generally last between two and four.

Moreover, for patients suffering from extreme nausea and vomiting, the
Marinol pill is not practical because they may not be able to retain it. In
the 1980 congressional hearing on marijuana, Dr. Steven Sallan testified to
the benefits of smoking as a venue for ingesting antinausea medication:
There is no question in my mind that the oral route for an antiemetic, a
pill, is the absolute worst route for the patient who has a lot of
anticipatory nausea and vomiting. . . . The smoke route is in some ways
ideal. Certainly when we want a drug to be absolutely sure, general
anesthesia, we put it on the face, they breathe it across their lungs, it's
in their bloodstream immediately.

Dr. Lester Grinspoon, author of Marihuana: The Forbidden Medicine, says it
may be possible to inhale only the therapeutically effective chemicals of
marijuana and leave the tar and carcinogens behind. He attests that
marijuana can be heated to a certain point at which the cannabinoids (the
pharmacologically effective chemicals) are released, but the plant will not
actually burn. "In the future, [patients] will be inhaling the vapors of
marijuana," Grinspoon said, if the government allows the technology to be
developed. In an April interview in the online magazine Salon, Dr. William
Beaver, professor of pharmacology at Georgetown and chair of the NIH
workshop, mentioned the possibility of developing such a delivery system.
Currently, however, paraphernalia laws forbid the production or the sale of
marijuana vaporizers.

A TROJAN HORSE FOR LEGALIZATION?

Is medical marijuana just a stalking horse? It's true that prolegalization
organizations such as NORML play an active role in the med ical marijuana
movement. Philanthropist George Soros and his Drug Policy Foundation,
advocates of general decriminalization, have financially backed medical
marijuana initiatives. A February 17 article in the New Republic, "The
Return of Pot" by Hanna Rosin, also characterized the raison d'être of the
medical marijuana movement as general legalization. "The truth about the
marijuana movement is . . . blindingly obvious after a day in [Dennis]
Peron's club. The movement is . . primarily about legalization," Rosin
wrote. While the movement "may feature billboards of the infirm . . . in
the offices of its activists you are more likely to find a different
poster, a stoner classic: The Declaration of Independence and the
Constitution Were Written on Hemp Paper."

The reality is that the medical legalization coalition includes potheads,
scientists, oncologists, patients, and social reformers. Bill Zimmerman,
who coordinated California's prolegalization Proposition 215, says, "Some
people supporting medical marijuana initiatives are without question using
it as an attempt to legalize marijuana. Other people are supporting
marijuana policy changes out of a genuine concern for patients. It's a free
country." And while Rosin paints a pretty bleak picture of the California
marijuana scene—scrawny pot junkies with grimy teeth using excuses of
migraine headaches to legitimately obtain their fix—she leaves out
biographies of activists like conservative notable William F. Buckley, Jr.,
who found marijuana's medical illegality absurd when his sister preferred
it to standard drugs in alleviating the negative affects of her
chemotherapy. Ironically, it is marijuana's medical illegality that
perpetuates the very cannabis clubs Rosin finds contemptible. Such clubs
would largely disappear if marijuana were available by prescription.

One curious footnote to this controversy is that the federal government is
currently dispensing smokable marijuana—to eight individuals. The Food and
Drug Administration began the Single Patient Investigational New Drug
Program (commonly know as compassionate IND) in the mid1970s.
Settldispensing smokable marijuanaRandall v. U.S., the federal government
determined it would provide Robert Randall, who suffered from glaucoma,
smokable marijuana legally. Fourteen people in all were admitted to the
compassionate IND program before its suspension in 1990 and its closure in
1992. The FDA ended the program due to a deluge of applications—again, the
government was worried about the public perception of liberally dispensing
the drug. Nonetheless, eight people, beneficiaries of a grandfather clause,
continue to receive federal marijuana to this day.

The strongest argument against prescribed marijuana remains the concern
that it would remove whatever stigma marijuana retains and thus proliferate
recreational usage. Joseph Califano, president of the National Center on
Addiction and Substance Abuse (CASA), wrote in a Washington Post oped
attacking medical legalization: Our children are at stake here. . . . A
state has an enormous interest in protecting children from proposals likely
to make drugs such as marijuana, heroin and LSD more acceptable and
accessible. But would making marijuana prescribable do either? The list of
dangerous and addictive drugs currently prescribable by physicians is
enormous and all of them are tightly controlled by the DEA. Although
opiates have been abused for centuries, drugs such as codeine, morphine,
and dilaudid are carefully regulated, widely prescribed, and relieve the
suffering of millions. The use of cocaine has declined drastically from 5.7
million people in 1985 to 1.4 million in 1994, and the drug is a
prescribable Schedule II controlled substance.

At the 1980 congressional hearing, North Carolina Congressman Stephen Neal,
the chairman of the task force, responded to similar fears expressed by the
NIDA spokesperson in the following testimony: I have two teenage children.
. . . They are at the prime age for exposure to these drugs. . . . It seems
to me, watching them and watching what our government has done over the
years, that we have spread a good deal of misinformation . . . and that
people, and young people in particular respond very positively to accurate
information. . . . I really think that my own kids can understand the
difference between a use of a drug for a particular illness and its
recreational use. . . . It just doesn't seem reasonable to me we would have
to sacrifice the potential for some good use of these drugs . . . it
doesn't seem consistent. Not only that, but I think kids will see right
through it.

However, for President Clinton and many other elected officials, the
question is not so simple.

Having spent decades branding marijuana a killer weed, the government is
caught in its own rhetoric. This administration, like previous ones, is
fearful that if it softens on the issue of the medical use of marijuana, it
risks being labeled soft on drugs. When President Clinton began cutting the
drug war budget during his first term, he was soon confronted with harsh
criticism from the right—William Bennett wrote in a 1995 congressional
testimony, "The Clinton Administration suffers from moral torpor on this
issue"—and with claims of increased marijuana use among teens. These
factors led Clinton to announce the largest drug war budget ever for 1996.
Again in 1997, the United States has appropriated $16 billion for the drug
war budget.

It remains to be seen whether the federal government will have the courage
to allow scientists to resolve the issue of marijuana's medical use in the
face of pot's longstanding cultural stigma. But the government will not
depress recreational marijuana use or make progress in the war on hard
drugs by denouncing referenda, threatening prosecution of doctors, and
blocking legitimate medical research. It will onscientists to resolve the
issue of marijuana's medical use in the face of pot'

Related Resources For information about medical uses of marijuana,
including clinical studies, reform efforts, and related links, go to
http://www.marijuanaasmedicine.org/

Copyright © 1997 by The American Prospect, Inc.