Copyright The American Prospect (ISSN: 10497285)

GRASSROOTS MEDICINE
By 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 answersor 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.

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 interview.

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 stageit 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 purposesboth 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, the antinauseant of
choice, that word quickly spread among patients and doctors and then on to
legislators.

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 oncologistsSteven
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, Coloradoand 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 druga 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 THCand in a
few cases, marijuanafrom 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 these 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'
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 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 [ital]medically
superior to currently available therapies [ital] [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
medical 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'tre 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 marijuanato eight
individuals. The Food and Drug Administration began the Single Patient
Investigational New Drug Program (commonly know as compassionate IND) in
the mid 1970s. Settling out of court in the case Randall 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 applicationsagain, 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 only make it
more difficult for severely ill people to relieve their suffering.

Copyright The American Prospect