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Federal Foolishness and Marijuana

The advanced stages of many illnesses and their treatment's are often accompanied by
intractable nausea, vomiting, or pain. Thousands of patients with cancer, AIDS, and
other diseases report they have obtained striking relief from these devastating symptoms
by smoking marijuana. [1] The alleviation of distress can be so striking that some patients
and their families have been willing to risk a jail term to obtain or grow the marijuana.

Despite the desperation of these patients, within weeks after voters in Arizona and
California approved propositions allowing physicians in their states to prescribe
marijuana for medical indications, federal officials, including the President, the secretary
of Health and Human Services, and the attorney general sprang into action. At a news
conference, Secretary Donna E. Shalala gave an organ recital of the parts of the body that
she asserted could be harmed by marijuana and warned of die evils of its spreading use.
Attorney General Janet Reno announced that physicians in any state who prescribed the
drug could lose the privilege of writing prescriptions, be excluded from Medicare and
Medicaid reimbursement and even be prosecuted for a federal crime. General Barry R.
McCaffrey, director of the office of National Drug Control Policy, reiterated his agency's
position that marijuana is a dangerous drug and implied that voters in Arizona and
California had been duped into voting for these propositions. He indicated that it is
always possible to study the effects of any drug, including marijuana, but that the use of
marijuana by seriously ill patients would require, at the least, scientifically valid research.

I believe that a federal policy that prohibits physicians from alleviating suffering by
prescribing marijuana for seriously 11 patients is misguided, heavy-handed, and
inhumane. Marijuana may have long-term adverse effects and its use may presage
serious addictions, but neither long-term side effects nor addiction is a relevant issue in
such patients. It is also hypocritical to forbid physicians to prescribe marijuana while
permitting them to use morphine and meperidine to relieve extreme dyspnea and pain.
With both these drugs the difference between the dose that relieves symptoms and the
dose that hastens death is very narrow; by contrast, there is no risk of death from smoking
marijuana. To demand evidence of therapeutic efficacy is equally hypocritical. The
noxious sensations that patients experience are extremely difficult to quantity in
controlled experiments. What really counts for a 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.

Paradoxically, dronabinol, a drug that contains one of the active ingredients in marijuana
(tetrahydrocannabinol), has been available by prescription for more than a decade. But it
is difficult to titrate the therapeutic dose of this drug, and it is not widely prescribed. By
contrast, smoking marijuana produces a rapid increase in the blood level of the active
ingredients and is thus more likely to be therapeutic. Needless to say, new drugs such as
those that inhibit the nausea associated with chemotherapy may well be more beneficial
than smoking marijuana, but their comparative efficacy has never been studied.

Whatever their reasons, federal officials are out of step with the public. Dozens of states
have passed laws that ease restrictions on the prescribing of marijuana by physicians, and
polls consistently show that the public favors the use of marijuana for such purposes.[l]
Federal authorities should rescind their prohibition of the medicinal use of marijuana for
seriously 81 patients and allow physicians to decide which patients to treat. The
government should change marijuana's status from that of a Schedule 1 drug (considered
to be potentially addictive and with no current medical use) to that of a Schedule 2 drug
(potentially addictive but with some accepted medical use) and regulate it accordingly.
To ensure its proper distribution and use, the government could declare itself the only
agency sanctioned to provide the marijuana. I believe that such a change in policy would
have no adverse effects. The argument that it would be a signal to the young that
"marijuana is OK" is, I believe, specious.

This proposal is not new. In 1986, after years of legal wrangling, the Drug Enforcement
Administration (DEA) held extensive hearings on the transfer of marijuana to Schedule 2.
In 1988, die DEA's own administrative-law judge concluded, "It would be unreasonable,
arbitrary, and capricious for DEA to continue to stand between those sufferers and the
benefits of this substance in light of the evidence in this record." [1] Nonetheless the
DEA overruled the judge's order to transfer marijuana to Schedule 2, and in 1992 it
issued a final rejection of all requests for reclassification.[2] Some physicians will have
the courage to challenge the continued proscription of marijuana for the sick. Eventually,
their actions win force the courts to adjudicate between the rights of those at death's door
and the absolute power of bureaucrats whose decisions are based more on reflexive
ideology and political correctness than on compassion.

JEROME P. KASSIRER, M.D.

References

1. Young FL. Opinion and recommended ruling, marijuana rescheduling petition.
Department of Justice, Drug Enforcement Administration. Docket 86-22. Washington,
Drug Enforcement .Administration, September 6. 1988.

2. Department of Justice, Drug Enforcement Administration, Marijuana scheduling
petition: denial of petition: remand. (Docket No. 86-22.) Fed Regist
1992;57(59):1 0489-508. Copyright 1997, Massachusetts Medical Society.