Chapter 5
The Debate over Medical Marijuana

The mere mention of the phrase medical marijuana is enough to get at least two groups of people agitated. There are those who believe marijuana should be accessible to patients whose doctors have recommended cannabis to improve their medical condition. These people are angry that the federal government and many states continue to insist that marijuana does not have legitimate medical value. On the other hand, opponents of medical marijuana fear that the issue is just the first step toward legalizing cannabis (and maybe other outlawed drugs).

Between 1996 and 2001, several developments occurred that have repeatedly brought the medical cannabis debate to the attention of the American public. First, beginning in 1996, voters in many states passed laws permitting access to marijuana for patients who have a doctor's statement verifying medical need. Second, places where people with doctors' statements could purchase the drug legally, called medical marijuana buyers' clubs, began to appear in the states where the new laws had been passed, creating the controversial situation of public marijuana sales. Third, in 1997 Barry McCaffrey, the federal government's highest drug law enforcement official, ordered an analysis of all the research ever done on marijuana. The analysis was conducted by a team of top scientists, took two years to complete, and resulted in a report that said cannabis does indeed have medical value, is not a gateway drug, and, while not harmless, is less harmful than alcohol and tobacco. Finally, one of the medical marijuana buyers' clubs fought the federal government's prohibition of their operation all the way to the U.S. Supreme Court and lost.

The Medical Uses of Cannabis

For a long time patients, doctors, and scientists have attributed a variety of therapeutic functions to marijuana and other THC-containing preparations. One of the most remarkable things about cannabis, say medical marijuana advocates, is that it can alleviate a wide spectrum of symptoms at one time with minimal side effects. Most notably, cannabis has been credited with reducing nausea and pain while improving appetite and a variety of movement problems.

Treating all of these symptoms at once without toxic side effects has made marijuana the treatment of choice for many HIV/AIDS and cancer patients as well as people suffering from a number of other diseases. Many HIV/AIDS patients claim marijuana gives them relief from pain, nausea, and wasting disease (loss of body mass). And thousands of cancer patients have claimed that marijuana is the best way to alleviate the loss of appetite, nausea, and vomiting that often accompany chemotherapy, which is used to treat many kinds of cancer.

Patients are not the only ones claiming marijuana has medicinal value, however. Recent research has found that some of the cannabinoids in marijuana have the capability to help protect nerves from further damage following trauma and neurological disease. And scientists contend that there is considerable evidence that using marijuana can also improve the limitations in joint movement and muscle function associated with multiple sclerosis and spinal cord injury.

Despite these claims, opponents often assert that the medical marijuana movement is nothing more than the first step toward legalization of all drugs. They also contend that even when marijuana does have some medical value, there are other drugs—legal drugs—that do the job better.

Both sides in the medical marijuana argument do agree, however, that there are some concerns to using marijuana as a medicine. First is the method of ingestion: inhaling smoke from burning plant material has definite health hazards. Second, the therapeutic values of cannabis, including pain relief, control of nausea, and appetite stimulation, can all be achieved by other drugs that are legal. Third, the euphoric effect of marijuana is an undesirable side effect for many patients.

As in most aspects of the marijuana debate, this agreement quickly turns into disagreement. Doctors and their patients who use marijuana say that the three concerns should actually be viewed as advantages. First, inhalation allows very accurate control of the dosage by the patient: smoking gives the therapeutic effect within seconds; the effects would not be felt for thirty minutes or more if the drug were taken orally (as a pill, for example), which increases the chances of under- or overdosing. Second, marijuana is the only known drug that produces multiple desired effects in a single drug, thus eliminating the need for patients to take a variety of drugs that also have a variety of side effects. Third, the euphoric effect of cannabis can reduce anxiety and calm patients.

In the medical marijuana debate, such totally opposite views are typical. Often what one side sees as a problem the other sees as an advantage. Perhaps the only clear fact about medical cannabis is that marijuana is still illegal at the federal level. Given that, the Institute of Medicine (IOM) set about to determine the truths about medical marijuana.

Investigating the Medical Value of Marijuana

In 1997 the director of the White House Office of National Drug Control Policy (ONDCP), General Barry McCaffrey, faced a big public relations problem. Even though McCaffrey, several former presidents, and many others lobbied against medical marijuana initiatives in California and Arizona, the citizens of those states voted to legalize medical marijuana. McCaffrey stuck to his conviction that marijuana was not medicine and vowed that the federal government would prosecute patients and doctors who broke federal marijuana laws.

In response to the new laws, McCaffrey began an effort to defeat medical marijuana legislation in other states. Despite his efforts, seven other states went ahead and legalized medical marijuana. In looking for a way to slow the building momentum of the medical marijuana movement, McCaffrey commissioned a report from the IOM, which he felt sure would support his position.

The U.S. National Academy of Sciences, the federal sponsor of much of the scientific research that occurs in the United States, created the IOM in 1970 to provide politically independent scientific advice to the government. McCaffrey's ONDCP paid the IOM $896,000 to create a committee of unbiased scientists to evaluate all the research on marijuana and produce a comprehensive report on its dangers and medical value. The committee released the study, titled Marijuana and Medicine: Assessing the Science Base, in 1999.

McCaffrey must have been shocked after reading the report. The IOM study, the most comprehensive government study of marijuana to date, took an opposing view of almost every one of McCaffrey's own beliefs about the drug. The study reported, for example, that the committee found no proof that marijuana use leads to use of harder drugs. It declared marijuana's addictiveness to be much less than legal drugs like alcohol and tobacco and of little consequence. It found that almost every harmful side effect that had ever been attributed to marijuana had no basis in scientific fact, and it acknowledged that marijuana did, in fact, have legitimate medical value.

Disappointed, McCaffrey and the ONDCP chose to ignore the IOM's conclusions and publicly criticized and contradicted the report. Until he resigned in 2001, McCaffrey continued to insist that marijuana leads to the use of harder drugs, is extremely addictive, and has no medical usefulness.

Among those criticized by McCaffrey was neurobiologist Janet Joy, the scientist heading the IOM committee. She publicly expressed embarrassment at McCaffrey's public attack on the report and defended it, saying the IOM report reflected the most rigorous academic standards. She told reporters that the committee's scientists and physicians, among the best in the country, had thoroughly analyzed more than two thousand scientific studies on marijuana over a two-year period. She also stated that the IOM report was based solely on medical evidence that measured the ways people are affected by cannabis, evidence that has been duplicated and confirmed numerous times by other researchers.

Most Americans agreed with Joy and the conclusions of the IOM report. In a nationwide Gallup poll conducted in 1999 after the report was published, 73 percent favored making marijuana legal for doctors to prescribe to suffering patients.

The Institute of Medicine Report

The 1999 IOM report was what scientists call a meta-analysis, meaning experts study all the research on a particular issue (medical marijuana in this case) to determine the facts and make conclusions. The IOM meta-analysis targeted very specific issues, including what medical conditions have been successfully treated by marijuana, what advantages marijuana has over legal medicines, how dangerous marijuana's side effects are, and if allowing the use of marijuana for medical purposes would promote nonmedical uses of the drug.

After studying the research on these issues, the IOM committee came to some conclusions. First, they said that marijuana was helpful, particularly for AIDS and cancer patients. The introduction to the IOM report states:

There are some limited circumstances in which we recommend smoking marijuana for medical uses. . . . The accumulated data indicate a potential thera peutic value for cannabinoid drugs, particularly for symptoms such as pain relief, control of nausea and vomiting, and appetite stimulation. . . . For patients such as those with AIDS or who are undergoing chemotherapy and who suffer simultaneously from severe pain, nausea, and appetite loss, cannabinoid drugs might offer broad-spectrum relief not found in any other single medication.²²

That last point illustrates one of medical marijuana's chief advantages over other drugs used to treat AIDS and cancer patients. Instead of taking a number of different drugs, most with significant side effects, a patient can decrease a variety of symptoms with just marijuana, which has relatively minor side effects. The IOM report confirmed that there is no single drug currently available that can do the several things that marijuana does.

Addressing the possibility of a patient becoming addicted to marijuana, the IOM report found that according to all evidence, dependence among marijuana users is rare. Further, the researchers said the dependence and withdrawal symptoms associated with smoked marijuana are "mild and subtle compared with the profound physical syndrome of alcohol or heroin withdrawal."²³

The IOM report also found no evidence that marijuana is a gateway drug likely to lead to using other drugs. And the report responded to the concern that allowing the medical use of marijuana might increase its use among the general population, in particular, among young people, stating, "No evidence suggests that the use of opiates or cocaine for medical purposes has increased the perception that their illicit use is safe or acceptable. . . . [T]here is little evidence that decriminalization of marijuana use necessarily leads to a substantial increase in marijuana use."²⁴ Finally, the IOM report explained that the danger of marijuana's side effects is actually less than the medically accepted levels of side effects associated with many legal drugs.

The one harmful aspect of using marijuana for medical purposes, said the IOM report, is the fact that currently the most effective way to take the drug is by smoking it, which may lead to lung and respiratory problems. The report added, however, that the respiratory cancers found in many chronic tobacco smokers have not been found in people who smoke marijuana daily (if they do not use tobacco). And although the researchers expressed a desire for an effective alternate means of delivering marijuana to patients, the report determined that currently existing alternatives (including Marinol, a pill of synthetic THC available by prescription since the 1980s) are not nearly as effective as the smoked form.

The IOM report concluded by stating that marijuana offers substantial therapeutic advantages. Nevertheless, the IOM committee felt that more research is needed to confirm the scope of the drug's usefulness and its side effects and to discover alternative delivery methods that are as effective as but less harmful than smoking.

Medical Marijuana Research

Research into medical applications of marijuana is made all the more difficult by the fact that all forms of cannabis remain in the schedule 1 category, which makes it almost impossible for scientists to obtain marijuana of consistent potency needed for studies. Often current marijuana laws make it very difficult for scientists at universities and pharmaceutical companies to get permission to do cannabis research at all. And if they succeed in getting permission to do cannabis research, it is very difficult for them to obtain the drug legally. Furthermore, confiscated marijuana that researchers obtain from law enforcement sources (a common source of marijuana used in cannabis research programs) varies greatly in potency and is sometimes tainted by other drugs, pesticides, and other impurities. Nevertheless, scientists have continued to do what research they can.

One important discovery took place during the 1990s when scientists found naturally occurring cannabinoid molecules in mammals, including humans, and cannabinoid receptors in the brain and the body. Researchers identified about half a dozen of these cannabinoids in the human body, which made them want to look more closely at the hundreds of cannabinoids found in marijuana. Scientists want to learn more about why the body has these natural relatives of the cannabinoids in marijuana. Further, pharmaceutical companies want to know if the cannabinoids in marijuana can help the body's own cannabinoids for some therapeutic purposes. Recent research has found, for instance, evidence that some cannabinoids, both the body's own and those found in marijuana, can control some movement disorders, such as Parkinson's disease and Tourette's syndrome, and researchers have also found indications that cannabinoids can play a role in controlling some forms of high blood pressure.

Marijuana for Brain Cancer?

Malignant glioma is a fairly common, especially aggressive, and often fatal form of brain cancer. Existing treatments for this disease have a low success rate, but recent research on rats indicates that cannabinoids from marijuana may be able to stop the disease in humans. In the research, which was performed in Spain and reported in the March 2000 issue of the scientific journal Nature Medicine, malignant brain tumors either disappeared or were reduced in two-thirds of cancerous rats injected with cannabinoids. The cannabinoid treatments caused no damage to healthy cells.

The lead researcher on the project—Manuel Guzman, Ph. D., a professor of biochemistry in Madrid (Spain)—is concerned that the debate over medical marijuana use will hinder future testing of this treatment in humans. In Liza Jane Maltin's February 2000 online article "Marijuana's Active Ingredient Targets Deadly Brain Cancer," Guzman is quoted as saying, "If these compounds were present in pine leaves or lettuce, then most likely things would be different. But they are present in marijuana, so it's controversial, which is nonsense. Hospitalized patients are given morphine and other drugs, but for some reason, it's considered immoral to give them cannabis."

Daniele Piomelli, Ph. D., a professor of pharmacology at the University of California, Irvine, agrees, saying in an editorial that accompanied the journal article, "Placing restrictions on clinical use and testing of marijuana-based therapies is not only silly, it can be criminal. When patients are dying, there should be no consideration to such matters. . . . I believe it would be ethically acceptable to offer [cannabinoids] to patients, especially in light of the fact that the toxicity is likely to be very, very small."

Cannabinoid research is also looking at the problems associated with medical marijuana use. One involves separating the medical aspects of cannabis from the aspects that make a patient high; the euphoric effect that so many recreational marijuana users seek is viewed as an adverse side effect in medical applications. Another major challenge for medical marijuana research is finding ways of administering the active ingredients (THC and other cannabinoids) without requiring the patient to smoke it. Besides introducing its own health problems, smoking is an issue in medical marijuana because many patients do not smoke or are so sick they cannot tolerate smoking. Thus, some pharmaceutical companies are developing alternative ways to administer THC. These include an aerosol inhaler much like those used to dispense asthma medication, an under-the-tongue spray, and a transdermal skin patch containing the medication in a small bandage that allows the drug to be absorbed through the skin.

Doctors and Medical Marijuana

As the research continues, the doctors who would be affected by legalizing medical marijuana remain almost evenly divided on the topic. In April 2001, in response to a question about whether doctors should be able to prescribe marijuana legally as a medical treatment, 36 percent of the physicians surveyed thought they should, 38 percent thought they should not, and 26 percent were neutral.

In some cases the specialty of the doctor affected the position. For instance, the survey found that obstetricians, gynecologists, and internists were more likely to support medical marijuana than other specialists. The survey team speculated that because doctors in those two specialties are more likely to see cancer patients, they may be more aware of marijuana's potential for managing pain and the side effects of chemotherapy and therefore more receptive to using marijuana for medical therapy.

Whether they support medical marijuana use or not, many doctors resent the intrusion of nonmedically trained politicians and law enforcement officials into the debate on medical marijuana. One of the most outspoken critics of the government's medical marijuana policy is Lester Grinspoon, M.D., an associate clinical professor of medicine at Harvard Medical School who has written two books on the medicinal use of marijuana and served as an official at NORML. After his son died from leukemia (a cancer of the blood system), Dr. Grinspoon became an avid medical marijuana activist, often recommending marijuana to his cancer and AIDS patients. Speaking about his firsthand experience with the medical use of marijuana, Grinspoon said:

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I had a son with leukemia, and I saw with my own eyes how helpful cannabis was in dealing with the nausea that he had with chemotherapy. The memory of him eating a submarine sandwich after chemotherapy—and keeping it down—is one I will never forget. . . . I know better than any federal official what's best for my patients and whether marijuana can help them. I'm not going to be told by those [federal officials] how to practice medicine.²⁵

State and Federal Governments Disagree

Despite claims like Grinspoon's, the federal government decided to challenge the Oakland Cannabis Buyers' Cooperative, a large, highly visible nonprofit organization that provided medical marijuana to patients in northern California and was and still is legal under state law. In May 2001 the U.S. Supreme Court unanimously ruled in this case that since marijuana is classified as a schedule 1 drug (no medical value, high potential for abuse), it has no legal medical use and the Oakland Cannabis Buyers' Cooperative could not continue providing marijuana to patients. This was seen as a major defeat for those who want access to the drug to relieve the symptoms of HIV/AIDS, cancer, and other diseases.

The Oakland Cannabis Buyers' Cooperative

When California voters passed Proposition 215, the law officially known as the Compassionate Use Act of 1996, people with a doctor-certified need for medical marijuana were elated. But since it was still illegal to sell marijuana in the state, patients were faced with the problem of how to obtain the drug legally. The need was filled by a new phenomenon, medical cannabis buyers' clubs and cooperatives.

As suppliers of marijuana to medically approved buyers, these organizations were protected from prosecution by state law. The only problem was that their actions were still against federal laws. Eventually one of the first buyers' clubs, the Oakland Cannabis Buyers' Cooperative (OCBC), became the subject of a federal lawsuit, a case that went all the way to the U.S. Supreme Court. Following the Court's mid-2001 decision against them, however, the OCBC was no longer able to dispense marijuana to its members.

The mission statement of OCBC, as stated on the Oakland Cannabis Buyers' Cooperative website, www.rxcbc.org, says:

The goal of the Oakland Cannabis Buyers' Cooperative (OCBC) is to provide seriously ill patients with a safe and reliable source of medical cannabis information and patient support. Our cooperative is open to all patients with a verifiable letter of recommendation for medical cannabis, used to alleviate or terminate the effects of their illnesses.

Federal statutes currently prohibit the use of cannabis as medicine. However, scientific evidence, including anecdotal evidence, documents the relief that cannabis provides to many seriously ill patients. The cooperative is dedicated to reducing the harm these patients encounter due to the prohibition of cannabis.

Following the Supreme Court decision, Republican Congressman Bob Barr said:

The unanimous vote in this case reflects the overwhelming evidence that marijuana has been appropriately and lawfully declared to be a dangerous, mind-altering substance that should not be legalized for whatever contrived reason. The true aim of those who support the so-called medical marijuana movement has been . . . the legalization of all drugs. Terminally ill patients have been used as pawns in a cynical political game designed to weaken society's opposition to drug abuse.²⁶

The federal government's position, though, did not significantly affect the beliefs of state legislators, who are often more supportive of medical marijuana. In fact, within weeks of the U.S. Supreme Court's ruling, Colorado's legislature passed a new state constitutional amendment protecting medical marijuana users from state criminal penalties; the amendment followed eight other states that had, beginning with California in 1996, passed similar legislation. The new Colorado law, which allows legally registered patients to possess up to two ounces of marijuana and/or six marijuana plants, directly opposes the Supreme Court's ruling that people or organizations that grow or distribute marijuana may not use medical necessity as a defense from federal prosecution. Defiant in the face of the Supreme Court decision, Colorado's attorney general Ken Salazar announced that the Supreme Court's ruling did not invalidate Colorado's state law or prevent the medical use of marijuana in the state. California's attorney general Bill Lockyer agreed, saying, "It's unfortunate that the Supreme Court was unable to respect California's historic role as a . . . leader in the effort to help sick and dying residents who have no hope for relief other than through medical marijuana."²⁷

Most legal experts feel that the Supreme Court decision does not prevent patients in states with medical marijuana laws from growing their own marijuana at home. But not all patients are able to do that, and they no longer have a source in the buyers' clubs. Since almost all arrests for use and possession of marijuana are done by state and local officials, the federal government is expected to confine enforcement efforts to shutting down medical marijuana distribution centers like the Oakland Cannabis Buyers' Cooperative, which triggered the Supreme Court case.

Although the immediate effect of the Supreme Court ruling was to stop the distribution of marijuana to patients in those states with medical marijuana laws, it may ultimately have another effect. Essentially the Supreme Court ruling said that as long as marijuana is classified as a schedule 1 drug, the only way to get it approved at the federal level for medical use would be for Congress to pass a new law reclassifying cannabis as a schedule 2 drug (limited medical value, high potential for abuse) or even schedule 3 (high medical value, high potential for abuse). As a result, following the Supreme Court decision, Democratic Congressman Barney Frank reintroduced legislation allowing certain patients to use marijuana for medical purposes and doctors to prescribe or recommend marijuana where permitted under state law. If that or similar legislation eventually passes, marijuana will be reclassified, paving the way for legalizing medical marijuana at the federal level.

Judges and Medical Marijuana

The justices of the Supreme Court notwithstanding, however, there is a growing trend among American judges to accept that medical use of marijuana has a place in American society. Most surprising among the many judges who have made public statements in favor of medical marijuana is Francis L. Young, a DEA administrative law judge. In 1988 Judge Young presided over a hearing in which several groups petitioned the DEA to have marijuana reclassified as a schedule 2 drug so it could be prescribed for medical needs. After considering all the testimony and exhibits, Judge Young wrote a report for the DEA stating that the court "accepted as fact" the medical value of cannabis. He listed numerous examples from individual doctors, hospitals, and patients demonstrating the medical uses of cannabis. Young concluded by saying that cannabis is "far safer than many foods we commonly consume . . . and in its natural form it is one of the safest therapeutically active substances known to man. By any measure of rational analysis marijuana can be safely used within a supervised routine of medical care."²⁸

Young is not the only judge who thinks this. In doing research for his 2001 book on the failure of the war on drugs, California Superior Court Judge James P. Gray found many other judges willing to declare their support for medical marijuana. He himself is a staunch supporter of allowing medical uses of marijuana, and in a 2001 interview Judge Gray said:

I have never used marijuana, or any of these other drugs either . . . and I have never smoked cigarettes. I believe marijuana is a carcinogenic [cancer causing], and does have other adverse effects upon the user. However, it is hard for me to be unduly hard upon marijuana users since I do drink alcohol, and believe that alcohol is potentially far more harmful to the user than marijuana, and the actions of people who have used alcohol are potentially far more harmful to other people.²⁹

Despite such strong opinions by well-respected judges, the DEA has refused, without giving a reason, to reclassify cannabis. Immediately after Judge Young's report was made public, editorials began appearing in newspapers asking why the DEA was so intent on keeping marijuana illegal in the face of so much evidence that the drug's illegality was by far the biggest, most expensive, and most unsuccessful part of the war on drugs. Judge Gray offers an explanation in his book when he points out that since marijuana users make up the vast majority of all drug users, without them the "enemy" in the drug war would instantly shrink to a fraction of its current size. Then the numbers of drug users, contends Gray, would be too small to justify the tens of billions of dollars consumed by the DEA. Of course, he claims, the DEA needs to keep marijuana illegal. The DEA, however, continues to insist simply that marijuana is a dangerous drug.

In 2001 Canada passed a new law allowing patients access to medical marijuana. This new legislation, the first federal-level medical marijuana law in the world, also provides for a company to legally grow and distribute cannabis to approved patients. With medical marijuana now legal in Canada, pressure to change the cannabis laws is even greater in the United States. Nevertheless, medical marijuana, like everything else about the drug, remains a controversial topic in American politics.