Pot Shots
Governmental resistance to medical marijuana represents a triumph of ideology over science.
In August 1996, two months after Proposition 215 qualified for the California ballot, drug czar Barry McCaffrey offered his first public assessment of the medical-marijuana initiative. "There is not a shred of scientific evidence that shows that smoked marijuana is useful or needed," he said. "This is not science. This is not medicine. This is a cruel hoax that sounds more like something out of a Cheech and Chong show."
That November the initiative passed with 65 percent of the vote, and on December 30 McCaffrey appeared at a press conference with Attorney General Janet Reno and Secretary of Health and Human Services Donna Shalala. Posing as defenders of science and responsible medicine, they threatened doctors who recommended marijuana to their patients with loss of prescribing privileges, exclusion from Medicare and Medicaid, and criminal prosecution. Asked whether there is "any evidence…that marijuana is useful in a medical situation," McCaffrey replied, "No, none at all. There are hundreds of studies that indicate it isn't."
A week after that comment, McCaffrey announced that his Office of National Drug Control Policy would ask the Institute of Medicine, a branch of the National Academy of Sciences, to review the evidence of marijuana's medical utility. The government would give the IOM 18 months and $1 million to prepare its report a lot of time and money to examine evidence that McCaffrey had repeatedly insisted did not exist.
Even before he announced the research review, it was clear to anyone familiar with the subject that McCaffrey was lying or, to be charitable, that he was inexcusably ignorant about an issue concerning which he was not only pontificating but making policy. In a 1995 interview with The Journal of the International Hemp Association, the government's leading marijuana expert, Mahmoud ElSohly, said, "There is no question about the use of cannabis for certain conditions. It does have a history. It does have utility." To suggest otherwise is not science. It is not medicine. It is politics. Having portrayed marijuana as inherently evil, drug warriors like McCaffrey are afraid to admit that it might be good for anything.
As McCaffrey should have known, people have been using marijuana as a medicine for thousands of years, beginning in China, India, and the Middle East. The plant's therapeutic potential became known in Western countries during the 19th century. From 1840 to 1900, more than 100 articles on the medicinal properties of cannabis appeared in European and American medical journals, recommending it as an appetite stimulant, muscle relaxant, painkiller, sedative, and anti-convulsant.
With the popularization of aspirin and injectable opiates, the use of cannabis preparations declined. Nevertheless, when the Marihuana Tax Act, aimed at discouraging recreational use, was proposed in 1937, the American Medical Association testified against it, arguing that the law would also impede medical applications. The AMA was right. The paperwork required by the act, combined with federal anti-diversion regulations, made the medical use of marijuana extremely burdensome, and in 1941 the drug was removed from the United States Pharmacopeia and National Formulary.
As the recreational use of marijuana rose in the 1960s and '70s, so did interest in its potential as a medicine. Cancer patients undergoing chemotherapy found that marijuana relieved their nausea and enabled them to eat. Research showed that marijuana reduced the intraocular pressure that can lead to blindness in glaucoma patients. Migraine sufferers found relief from their headaches, while victims of spinal injuries, multiple sclerosis, and epilepsy reported that marijuana seemed to control their spasms.
Just when Americans were rediscovering the therapeutic properties of marijuana, Congress was making it impossible to obtain legally. The Controlled Substances Act of 1970 classified marijuana (along with heroin) as a Schedule I drug, signifying "a high potential for abuse," "no currently accepted medical use," and "a lack of accepted safety for use…under medical supervision." By contrast, both cocaine and morphine are Schedule II drugs, meaning they can be prescribed despite their potential for abuse.
In 1972 the National Organization for the Reform of Marijuana Laws petitioned the Bureau of Narcotics and Dangerous Drugs (the Drug Enforcement Administration's predecessor) to reclassify marijuana as a Schedule II substance. The ensuing legal battle dragged on for two decades. In 1988, after two years of hearings, the DEA's chief administrative law judge, Francis L. Young, concluded that backing by a "significant minority" of doctors established marijuana's "currently accepted medical use." And since "marijuana, in its natural form, is one of the safest therapeutically active substances known to man," he said, "[o]ne must reasonably conclude that there is accepted safety for use of marijuana under medical supervision." He recommended that the DEA grant NORML's petition to reschedule the drug. DEA Administrator John Lawn rejected Young's findings and, presaging McCaffrey's reaction to Prop. 215, said supporters of medical marijuana were perpetrating a "dangerous and cruel hoax."
If so, it's a hoax that has tricked a lot of respectable people. Since 1978, 34 states and the District of Columbia have adopted legislation approving the medical use of marijuana for certain conditions. Because of the federal prohibition, most of these laws had little practical effect, though research programs in seven states provided marijuana to several hundred patients in the late 1970s and early '80s. Until 1991, under its "compassionate use" program, the federal government itself accepted applications from patients seeking medical marijuana, eight of whom continue to receive legal cannabis. After it became clear that the government would be inundated with requests from AIDS patients (who, like cancer patients, had found that marijuana restored their appetites and helped maintain their weight), the Bush administration closed the program to new applicants, deciding that it sent "the wrong message."
Aside from the charge that legalizing a drug for medical purposes encourages recreational use a fear that has not stopped the government from allowing doctors to prescribe a host of abusable opioids, stimulants, and sedatives the main rap against medical marijuana is that its supporters have not satisfied the Food and Drug Administration's requirements for approving new drugs. With a 5,000-year history of use as a medicine, marijuana is hardly a "new drug," but never mind. Since the 19th century, medical journals have published hundreds of studies investigating the therapeutic potential of cannabis, including more than 65 with human subjects. The best-established uses of marijuana are for controlling nausea, stimulating appetite, and reducing intraocular pressure. Other applications are based mainly on case studies and reports by patients. Large, randomized, double-blind clinical trials the kind of studies the FDA likes to see are conspicuously lacking.
One reason is a shortage of financial support. Marijuana cannot be patented by a pharmaceutical company, and the federal government has been loath to fund research that might make the main target of its war on drugs look good. Indeed, even while saying that more evidence is needed to demonstrate marijuana's effectiveness, the government has been blocking further research. In 1994, after two years of effort, Donald Abrams, a researcher at the University of California at San Francisco, won FDA approval for a pilot study of marijuana as a treatment for AIDS wasting syndrome. But the National Institute on Drug Abuse, which manages the only legal source of research marijuana in the United States, has refused to give him any.
In a sense, marijuana's effectiveness has already been demonstrated to the FDA's satisfaction, since the agency has approved Marinol, a gelatin capsule containing synthetic THC (delta-9 tetrahydrocannabinol) in sesame oil, for treating both AIDS wasting syndrome and the side effects of chemotherapy. The research needed to gain approval for Marinol showed that marijuana's main active ingredient is effective for these purposes. Opponents of medical marijuana say Marinol is an adequate substitute, but many patients and doctors disagree. For people suffering from severe nausea, a capsule that must be swallowed has obvious drawbacks. Even if a patient can manage the capsule, smoked marijuana takes effect more quickly, the dosage is easier to control, and even at black-market prices it's less expensive than Marinol. Finally, other ingredients in marijuana may contribute to its therapeutic properties or reduce the anxiety sometimes associated with THC.
Whatever one makes of the Marinol precedent, the sort of research traditionally required by the FDA may not be appropriate for marijuana. Because of the drug's psychoactive effects, subjects could figure out pretty quickly whether they'd been given the real thing or a placebo, and experimenters would probably notice too, compromising the double-blind design. Furthermore, as New England Journal of Medicine Editor Jerome Kassirer observes, "The noxious sensations that patients experience are extremely difficult to quantify in controlled experiments. What really counts for therapy with this kind of safety margin is whether a seriously ill patient feels relief as a result of the intervention, not whether a controlled trial proves' its efficacy."
Scientists are rightly skeptical of anecdotal evidence, but the experiences of thousands of people who have independently found that marijuana relieves their symptoms should not be dismissed. A June 1996 poll conducted by the Prop. 215 campaign found that one in three California voters knew someone who had used marijuana for medical purposes. In their 1993 book Marihuana, the Forbidden Medicine, Lester Grinspoon and James Bakalar offer one account after another from patients whose symptoms subsided when they used marijuana and came back when they didn't. It seems unlikely that all of these people are simply beneficiaries of a placebo effect.
Even if marijuana fails to help other patients with similar symptoms, there is little risk involved. Although the federal government has obstructed studies of marijuana's benefits, it has enthusiastically funded research designed to prove the drug's hazards for many years, with little to show for its efforts. In his 1992 book Against Excess, UCLA drug policy scholar Mark Kleiman writes, "Aside from the almost self-evident proposition that smoking anything is probably bad for the lungs, the quarter century since large numbers of Americans began to use marijuana has produced remarkably little laboratory or epidemiological evidence of serious health damage done by the drug." So far as we know, no one has ever died of a marijuana overdose. Based on extrapolations from animal experiments, the ratio of marijuana's lethal dose to its effective dose is something like 40,000 to 1 (compared to between 10 and 20 to 1 for aspirin and between 4 and 10 to 1 for alcohol). With a safety margin like that, the most significant risk faced by patients who use marijuana is the risk of arrest.
Polls consistently find that a large majority of Americans think such patients should be able to obtain their medicine without fear of prosecution. That view is shared by many physicians. A 1990 survey of oncologists reported in the Journal of Clinical Oncology found that 44 percent had recommended marijuana to at least one patient, 48 percent said they would prescribe it if it were legal, and 54 percent thought it should be rescheduled. Since the response rate was relatively low (43 percent), these results should be interpreted with caution, but they do indicate substantial support for medical marijuana among doctors who treat cancer patients. An editorial in the January 30 New England Journal of Medicine said marijuana should be rescheduled, calling the current federal policy "misguided, heavy-handed, and inhumane." Repeal of the federal ban on medical marijuana has also been endorsed by the American Public Health Association, the Federation of American Scientists, and the Physicians Association for AIDS Care.
And by the Speaker of the House. Sort of. In a 1982 letter to The Journal of the American Medical Association, a young congressman from Georgia named Newt Gingrich boasted that he had cosponsored a bill to legalize medical marijuana. "We believe licensed physicians are competent to employ marijuana," he said, "and patients have a right to obtain marijuana legally, under medical supervision, from a regulated source." On June 3, Representative Barney Frank (D., Mass.) introduced a bill that would allow doctors to prescribe marijuana. So far Gingrich has not signed on.
