ONE DRUG, TWO TAKES

Some scientists and patients scoff at a recent FDA announcement that
smoking marijuana has no medical benefits.

As assistant district attorney in San Francisco, Keith Vines
prosecuted one of the largest illicit drug busts the city had ever
seen. Then he came down with AIDS wasting syndrome and lost 60 pounds
over three years.

To stimulate his appetite, he started taking marinol, an FDA-approved
drug containing THC, one of the active ingredients in marijuana. He
says he couldn't control the dose of the drug, which must be
swallowed. "I would be out of it for four or five hours," he says.

And so, instead of continuing with marinol, he started smoking
medical marijuana, keeping his head clear by puffing only as much as
he needed to get hungry. He gained back all his weight, he says.

Like many in his condition, Vines flatly disagrees with an April 20
announcement by the Food and Drug Administration and several other
federal agencies that smoking marijuana confers no medical benefits.

So do physicians who write prescriptions for medical marijuana.
(Doctors can't prescribe the plant.) They say the government hasn't
done its homework - and cite a 1999 report by the Institute of
Medicine, a prestigious organization that advises the government,
that found otherwise.

That 1999 report concluded that smoked marijuana could stimulate
appetite in some patients with AIDS wasting disease; lessen nausea
and vomiting caused by chemotherapy for cancer; and alleviate pain.

"I'm disappointed that they haven't really read the research or
spoken with people in the field," says Los Angeles internist Dr. Eve
H. Elting, who recommends medical marijuana to treat patients with
chronic pain due to cancer and injuries; nausea and vomiting caused
by chemotherapy; and migraines.

"The FDA statement directly opposes what the [Institute of Medicine]
said," says Dr. Jean Talleyrand of Ukiah, who also recommends medical
marijuana. "My first question is, how did they come to that conclusion?"

Some scientists involved in crafting the 1999 report were more circumspect.

"I thought there was pretty good agreement among the panel that THC
has good benefit, and it's in marijuana," says Billy R. Martin, a
professor of pharmacology and toxicology at Virginia Commonwealth University.

But, he adds, "when you turn to the FDA, they require well-controlled
studies showing efficacy."

Martin says in many ways the tussle between federal agencies such as
the FDA and medical marijuana proponents boils down to politics - on
both sides.

"I'm sad, but I don't think science is a factor," he says.

Dr. Howard Fields, a professor of neurology and psychology at UC San
Francisco and another panel member, agrees. "There is so much
distortion of the research on both ends of the spectrum," he says.

FDA's Statement

According to FDA spokeswoman Kathleen Quinn, the agency's decision to
issue a statement about marijuana was prompted by inquiries from
individuals and members of Congress who were curious about "recent
reports [that] have suggested that smoked marijuana may offer pain
relief for [some] conditions," she wrote in an e-mail.

The FDA, she added, drew upon "the latest formal scientific
evaluation of the government" of marijuana - a 2001 Drug Enforcement
Agency report.

Some doctors and scientists say they trust science over drug laws.
Scientists outside of law enforcement crafted the Institute of
Medicine report. To write it, Martin, Fields and nine other clinical
and basic researchers perused hundreds of studies on marijuana,
consulted biomedical and social researchers in the field, held
workshops with medical marijuana patients, and visited HIV/AIDS clinics.

The result was neither a blanket endorsement nor an utter dismissal
of medical marijuana use - but something in-between.

Some of the studies, the scientists found, lend support for Vines'
experience with marinol and marijuana. Marinol pills release their
contents slowly, taking 2.5 hours to maximize their levels in blood.
Smoking delivers the chemicals in 2.5 minutes.

In addition, studies show that the chemicals delivered to the body
differ, depending on whether marijuana's active compounds travel
through the stomach (as they do when swallowed) or the liver (as they
do when smoked).

"There's less of a psychoactive chemical when you inhale it," says
Dr. Donald I. Abrams, a professor of hematology and oncology at UC
San Francisco, who was not a member of the panel.

The report also points out that some chemotherapy patients would not
be able to keep down pills long enough for the drugs to take effect.

"No doubt about it. Marijuana smoke is a great way to deliver drugs,"
says Martin.

The scientists also looked at few studies that tested the ability of
THC-related compounds to quell chronic pain due to cancer or nerve damage.

For example, in one 1975 study, researchers gave either placebos or
THC pills in a range of doses to 10 cancer pain patients averaging 51
years of age. They found that higher doses quelled the pain significantly.

Glaucoma patients have long valued marijuana's medicinal properties
of reducing internal pressure of the eye. Such pressure can
eventually cause blindness.

But Martin says the panel didn't recommend marijuana for glaucoma
because the connection between eye pressure and nerve damage is not
clear, and studies hadn't addressed whether marijuana is safe for the
optic nerve.

Although eight studies which gauged eye measurements in people taking
marijuana or THC support the idea that marijuana can reduce eyeball
pressure, clinical studies are only now underway to test the effects
of the drug more closely.

For nausea, the panel examined about a dozen studies that looked at
THC or marijuana's ability to quell nausea during chemotherapy. For
example, in one study, 56 cancer patients who did not respond to
other anti-nausea and vomiting drugs were given marijuana. More than
one-third rated the plant as moderately or highly effective.

The report pointed out, however, that these studies weren't well
controlled - and controls, Martin says, are especially important in
studying smoked marijuana. "There are a fair number of learned
behaviors with marijuana - such as expecting to feel good," he says.

The report also stated that the benefits of smoking the plant must be
weighed against the potential harm in the smoke. Marijuana smoke
contains some of the same hazardous chemicals found in cigarette smoke.

Scientists say that there is no conclusive evidence that smoking
marijuana causes cancer in people. Still, because of the potential
carcinogenicity, the American Cancer Society does not advocate the
use of inhaled marijuana or the legalization of marijuana, while
agreeing that THC and cannabinoids in marijuana will help alleviate
some symptoms, says ACS spokesman David Sampson.

Nonsmoking Options

There could be ways to mitigate that risk. Both the Institute of
Medicine report and the Drug Enforcement Agency report used by the
FDA recommended that alternatives to smoking marijuana cigarettes be developed.

They cited vaporizers, available to medical marijuana users these
days, that "toast" marijuana rather than burn it.

This lets the volatile THC and other active compounds escape the
plant for inhalation, leaving behind some of the toxic chemicals,
such as benzene and toluene. The appliances, however, can cost 20
times that of a conventional marijuana pipe.

In the midst of the impassioned debate, a lot of people overlook the
fact that THC (although not marijuana's other active ingredients) is
available in pill form, Fields says. The pain relief offered by
marinol is comparable to that of aspirin, he says, "so why would
anyone want to use cannabis?"

Fields does think that there are some people who could benefit from
smoking marijuana. And Vines, for whom marinol did not work, says the
government could erase many of the problems associated with medical
marijuana use by altering its legal status so the drug can be
obtained - but by prescription only.

"You can't help but scratch your head and wonder what the government
is doing," he says.