|MARIJUANA'S therapeutic uses are well documented in the modern scientific
literature. Using either smoked marijuana or oral preparations of
delta-9-THC (marijuana's main active ingredient), researchers have conducted
controlled studies. These studies demonstrate marijuana's usefulness in
reducing nausea and vomiting, stimulating appetite, promoting weight gain,
and diminishing intraocular pressure from glaucoma. There is also evidence
that smoked marijuana and/or THC reduce muscle spasticity from spinal cored
injuries and multiple sclerosis, and diminish tremors in multiple sclerosis
patients. Other therapeutic uses for marijuana have not been widely
However, patients and physicians have reported that smoked
marijuana provides relief from migraine headaches, depression, seizures,
insomnia, and chronic pain. Delta-9-THC is probably responsible for most of
marijuana's therapeutic effects, but one of marijuana's other cannabinoid
constituents--cannabidiol--appears to be useful as an anticonvulsant. Other
cannabinoids may yet prove to have medicinal value.
In the United States, using marijuana for medical purposes is illegal
because federal law includes marijuana in Schedule I, a category for drugs
deemed unsafe, highly subject to abuse, and possessing no medicinal value.
Nonetheless, since the 1970s, thirty-five state legislatures have passed
laws supporting marijuana's use as a medicine. In 1996, voters in
California and Arizona approved ballot initiatives to remove state criminal
penalties for possessing marijuana for medicinal use. However, federal law
prevents states from making marijuana supplies legally available. Eight
people receive marijuana through a federal "compassionate use" program which
stopped admitting new patients in 1992 after the number of applications,
mostly from AIDS patients, increased dramatically. Thousands of Americans
use marijuana as a medicine illegally, putting themselves at risk of arrest
and prosecution. Undoubtedly, others who might benefit from marijuana are
deterred by its illegality.
Since 1986. synthetic THC (Marinol) has been available as a Schedule II
drug, which allows physicians to prescribe it under highly regulated
conditions. Marinol is labeled officially as an anti-nauseate and an
appetite stimulant, but doctors can and do prescribe it for other
conditions, such as depression and muscle spasticity. This oral preparation
of THC, dissolved in sesame oil, works for some patients. However, many
patients find that smoked marijuana is more effective. For people suffering
from nausea and committing, who are unable to swallow and hold down a pill,
smoking marijuana is often the only reliable way to deliver THC.
nauseated patients, smoking marijuana has the additional advantage of
delivering THC quickly, providing relief in a few minutes, compared to an
hour or more when THC is swallowed.
Smoking marijuana not only delivers THC to the bloodstream more quickly than
swallowing Marinol, but smoking delivers most of the THC inhaled. When
Marinol is swallowed, it must move from the stomach to the small intestine
before being absorbed into the bloodstream. After absorption, orally
consumed THC passes immediately through the liver, where a significant
proportion is bio transformed into other chemicals.
Due to metabolism by the
liver, 90 percent or more of swallowed THC never reaches sites of activity
in the body. Two hours after swallowing ten to fifteen milligrams of
Marinol, 84 of subjects in a recent study had not measurable THC in their
blood. After six hours, 57 percent still had none. By contrast, two to
five milligrams of THC consumed through smoking reliably produces blood
concentrations above the effective level within a few minutes.
When THC is swallowed, the effects vary considerably, both from one person
to another and in the same person form one episode of use to another. And
because the onset of effect is an hour or more, patients using Marinol have
difficulty achieving just the effective dose. When THC is swallowed, the
effects last longer--up to six hours, compared to one or two hours when
marijuana is smoked. In other words, smoking marijuana is a more fexible
route of administration than swallowing. Smoking allows patients to adjust
their dose to coincide with the rise and fall of symptoms. For people
suffering from nausea and vomiting from AIDS or cancer chemotherapy, smoked
marijuana provides rapid relief with lower overall doses of THC.
Another problem with swallowed THC is that the psychoactive side effects may
be more intense than those that occur from smoking. When the liver
bio transforms THC, one of the metabolites it produces a 11-hydroxy-THC, a
compound of equal or greater psycho activity. Some 11-hydroxy-THC is
produced when marijuana is smoked, but its concentration seldom reaches
psychoactive levels. With oral ingestion, patients experience psychoactive
effects from THC *and* 11-hydroxy-THC, increasing the likelihood of adverse
psychological reactions (see chapter 10). There is also some evidence that
one of marijuana's other cannabinoids--cannabidiol--modulates the
psychoactive properties of marijuana. In a study of elderly patients, the
large dose of oral THC needed to reduce nausea and vomiting produced severe
psychoactive effects, reducing its utility as a medicine.
Given these problems, it is not surprising that physicians prescribe Marinol
rarely. In one study, researchers asked oncologists (cancer specialists) to
rank the effectiveness of available medications for the treatment nausea and
vomiting from cancer chemotherapy. They ranked THC (in natural or synthetic
form) as ninth, accounting for only 2 percent of antiemetic prescriptions.
In another study, 49 percent of oncologists said they had prescribed
Marinol, but only 5 percent had prescribed it more than ten times. A 1990
survey asked oncologists to compare the effectiveness of Marinol and smoked
Only 28 percent felt familiar enough with both drugs to answer
the question. Of these, only 13 percent though Marinol was better; 43
percent believed the two forms of THC were equally effective, and 44 parents
believed smoked marijuana was better. Four hundred and thirty0two
oncologists (44 percent of those who returned the questionnaire) said they
had recommended smoked marijuana to at least one of their cancer patients.
In a 1994 survey, 12 percent of oncologists said they might prescribe it if
it were legal.
Smoking is a highly unusual way to administer a drug. Many drugs could be
smoked, but there is no good reason to-do so because oral preparations
produce adequate blood concentrations. With THC this is not the case.
Inhaling is a better route of administration that swallowing. Inhaling is
about equal in efficiency to intravenous injection, and considerably more
Other than its illegality, the primary drawback of smoking marijuana is that
it deposits irritants in the lungs. With prolonged high doe use, this could
cause pulmonary problems (see chapter 15). However, with short-term use,
there is little risk of lung damage. For terminally ill patients, the
potential harm of smoking is of little consequence. Other THC delivery
systems--for example, suppositories and aerosol sprays--have not been proven
effective, but should be studied further. Given currently available
options, smoking marijuana is the most efficient and effective way to
deliver THC. It is also potentially the cheapest. A patient taking twenty
milligrams of Marinol per day would spend $600 or more per month for
medication. With the "black market tax" on marijuana removed, plant
preparations could be delivered to patients at a fraction of the cost of
In the 1970s, the federal government funded research into marijuana's
therapeutic uses and provided marijuana supplies to qualified researchers.
It also established the "compassionate use" program, through which patients,
on a case-by-case basis, could obtain marijuana from the government's
marijuana farm in Mississippi. In its 1976 *Marijuana and Health* reports
to Congress, the National Institute on Drug Abuse (NIDA) recommended further
exploration of marijuana's medicinal uses. NIDA's next two reports, in 1977
and 1980, reiterated this position.
Ronald Reagan's election as president in 1980 brought a renewed war on
marijuana and an end to the federal government's support for medical
marijuana. NIDA's 1982 *Marijuana and Health* report to Congress reversed
its earlier position. It warned that "the negative health effects of
marijuana" diminished its therapeutic potential, and suggested that"synthetic analogs of marijuana derivatives" should be pursued instead.
Opposition to medical marijuana continues under the Bush administration. In
1989 the head of the Drug Enforcement Administration (DEA), John Lawn,
denied a petition by the National Organization for the Reform of Marijuana
Laws (NORML) to reclassify marijuana as a Schedule II drug. This change
would have allowed physicians to prescribe marijuana under the strict
regulations that now apply to amphetamine, morphine, and cocaine. Lawn
denied the petition despite a recommendation for rescheduling by the DEA's
own administrative law judge, Francis L. Young. After reviewing the
evidence, Judge Young concluded not only that marijuana's medical utility
had been adequately demonstrated, but that marijuana had been shown to be
"one of the safest therapeutically active substances known to man." The
U.S. Court of Appeals upheld the legal authority of the DEA administrator to
ignore Judge Young's decision. Today, marijuana remains in Schedule I, a
category for drugs deemed unsafe, highly subject to abuse, and possessing no
In 1992, the Bush administration shut down the compassionate use program and
the Clinton administration, after some wavering decided against reinstating
it. The DEA continues to oppose any legal change that would make marijuana
available as a medicine and even opposes further research on the topic.
There have been no government-funded studies of marijuana's medical utility
in more than a decade. When California AIDS researcher Dr. Donal Abrams
proposed to compare the effectiveness of Marinol to smoke marijuana in the
treatment of AIDS-related wasting syndrome, NIDA denied him access to
marijuana supplies--despite the fact that his study had recieved prior
approval from the Food and Drug Administration (FDA). In 1996, the Clinton
administration opposed voter initiatives in California and Arizona to
legalize marijuana for medical use. After both initiatives passed, federal
officials threatened to criminally prosecute physicians or revoke their
licenses to prescribe controlled substances--simply for recommending smoked
marijuana to their patients.
A number of anti-drug organizations argued against legalizing the medical
use of marijuana, claiming that any change in the law would send the "wrong
message" to teenagers about marijuana's dangers. Most formal associations
of physicians have not taken an official position on medical marijuana.
However, the federal government's strict prohibitionist position is opposed
by the American Public Health Association, the Federation of American
Scientists, the Physicians Association for AIDS Care, the Lymphoma Foundation
of America, and former U.S. Surgeon General Joycelyn Elders, as well as
national associations of prosecutors and criminal defense attorneys. The *New
England Journal of Medicine *has taken a stand in support of allowing
marijuana's use as medicine, and the *Journal of the American Medical
Association *published an invited editorial with the same message.
editorial boards of numerous newspapers have urged the Clinton
Administration to loosed current restriction--a view that recent opinion
polls show is supported by a majority of Americans.
In defiance of existing law, people across the country use marijuana for
medical purposes. Some do so with the knowledge and approcal of their
physicians. Because the practice is illegal, mroe patients use marijuana
medicinally without medical supervision. Marijuana's illegality means tha
patients cannot be sure of obtaining standardized products taht are free of
funal spores--a critical problem for AIDS patients who have suppressed
immune systems (see chapter 14). In some cities, "cannabis buyer's clubs"
have formed to supply uncontaminated products to patients. However, in most
parts of the country patients must rely on criminal markets that deliver
marijuana of unknown potency and purity. Reclassifying marijuana as a
Schedule II drug and creating a legal system for its distribution would
guarantee that all patients have access to pure, standardized marijuana.
For new drug approval, the FDA requires "substantial evidence" of efficacy,
based on "adequate and well-controlled clinical investigations", plus
evidence of the drug's limited toxicity when used in therapeutic doses.
Smoked marijuana meets this standard. Based on a review of twenty-five
years of research, pharmacologist Roger Pert we concluded that "there is no
evidence to suggest that psychotropic cannabinoids (or cannabis) are
particularly unsafe or that their adverse effects are any more severe or
unacceptable than those of many drugs now used clinically.
In an important sense, the FDA's prior approval of oral THC *is* evidence of
marijuana's effectiveness in treating nausea, vomiting, and AIDS-related
wasting. The few studies that have directly compared the two forms of THC
delivery show smoke marijuana to be more effective than oral
administration. In any case, the question is not whether marijuana is *
better* than existing medication. For many medical conditions, there are
numerous medications available, some which work better in some patients and
some hcih work better in others. Having the maximum number of effective
medications available allows physicians to deliver the best possible medical
care to individual patients.
Politics, not medical science, has stood in the way of marijuana's approval
as a legal medication. In a 1982 letter to the *Journal of the American
Medical Association,*Congressman Newt Gingrich wrote that the "outdated
federal prohibition" of medical marijuana was "corrupting the intent of
state laws and depriving thousands of glaucoma and cancer patients of the
medical care promised them by their state legislatures." According to
Gingrich, "the hysteria . . . over marijuana's social abuse" and
"bureaucratic interference" by the federal government had prevented "a
factual [and] balanced assessment of marijuana's use as a mendicant."
Fifteen years later, that observation is still accurate.
|MARIJUANA IS HIGHLY ADDICTIVE. Long-term marijuana users experience
physical dependence and withdrawal, and often need professional drug
treatment to break their marijuana habits.
"There is a demand for marijuana-specific treatment that is currently
unmet. Marijuana dependence is a challenge that does not pale in comparison
to other dependencies, as many people think."
"Marijuana can put a serious chokehold on long-term users who try to quit."
"Studies show that after abruptly stopping marijuana use, the long-term
heavy pot user may develop signs and symptoms of withdrawal."
"In 1993, over 100,000 people entering drug treatment programs reported
marijuana as their primary drug of abuse, showing they need help to stop."
|MOST PEOPLE WHO SMOKE MARIJUANA SMOKE IT OCCASIONALLY.
A small minority of Americans--less than 1 percent--smoke marijuana on a daily or near daily
basis. An even small minority develop dependence on marijuana.
who smoke marijua heavily and frequently stop without difficulty.
seek help from drug treatment professionals.
Marijuana does not cause
If people experience withdrawal symptoms at all, they
are remarkably mild.