Public nuisance or therapy?
(marijuana use for theraputic purposes)
by Lester Grinspoon, M.D.
*Member of the faculty of the Harvard Medical School and coauthor of Marihuana, the Forbidden Medicine (Yale University Press, Revised and Expanded Edition, 1997).
Sunday, November 1, 1998
On one side stand the millions of Californians who voted in favor of Proposition 215, the 1996 referendum that approved the possession and use of marijuana for gravely ill patients.
The majority of citizens let their consciences speak. They realized the benefits of medicinal marijuana. They had heard or knew from firsthand experience that marijuana offers relief for arthritis pain, nausea, muscle spasms and glaucoma. They saw appetites restored to AIDS and chemotherapy patients who smoked joints or nibbled on marijuana brownies. Bodies gained strength. Patients were better able to fight disease.
On the other side stand Californias politically ambitious attorney general, Dan Lungren, and his allies in Washington: Attorney General Janet Reno, drug czar Barry McCaffrey and President Bill Clinton. Presumably, these agents of the war on drugs have family members who feel no pain, whose joints function effortlessly and whose appetites are never ravaged by serious disease.
Fifty-six percent of California voters approved Proposition 215, but in San Francisco the numbers reached 78 percent. Within weeks of the vote, more than 30 cannabis clubs opened to help sick people in need of relief. One club quickly grew to include 8000 members.
Then the backlash began. Lungren convinced a state judge that cannabis clubs were a public nuisance. The war- on-drugs crowd noted that marijuana remained classified by the federal government as a Schedule I drug, meaning it could not be prescribed because it had no known medical uses. (Cocaine and morphine are Schedule II drugs, and thus can be prescribed by a doctor.) Lungren glowed when the courts ruled that, despite the referendum, cannabis clubs violated state laws against the possession and sale of cannabis. One judge interpreted Proposition 215 as allowing individuals to grow marijuana only for personal medical useno clubs allowed.
California legislators implored Washington to recognize the voice of the people. In a letter to Clinton, nearly two dozen lawmakers pleaded:
"This issue wont go away so long as human beings believe they have the right to attend to their own illnesses, as their doctors recommend, rather than as government dictates." Californians have rebuffed the feds before: When evidence showed that intravenous-drug users were spreading HIV by sharing needles, San Francisco was the first city to supply them with clean syringes through an exchange program.
Californians invited lawmakers in Washington, D.C. to fly west and formulate a safe and affordable system for the delivery of medicinal marijuana, but the feds declined. As Lungren harassed and eventually closed the most visible cannabis clubs, advocates spoke of reinventing them. They thought Lungren was riled by the public nature of the clubsperhaps the answer might lie in rerouting medicinal marijuana through the traditional medical hierarchy. Maybe doctors in white coats would be more acceptable to the feds than were proprietors in tie-dye and denim.
Disagreements within the medicinal marijuana movement on the value of the clubs resulted in two distribution models after the passage of Proposition 215. One model is based on the conventional delivery system for medicine: A patient visits a buyers club (read: pharmacy), where he or she presents a note from a physician, certifying that the patient has a condition for which the physician recommends cannabis (read: prescription). The proprietor of the club (read: pharmacist) fills the prescription and the patient leaves to use the medicine, presumably at home.
This model preserves the medical professions authority to decide who shall use a medicine and for how long. The pharmacy provides a sourcein this case a nonprofit onefor the medicine. If the doctor and the pharmacist behave ethically, only those who have a medical need for marijuana can receive it. In turn, patients now have a reliable source for the drug, relieving them of the stress of buying it on the street or secretly growing their own.
The Oakland Cannabis Buyers Cooperative is one of a number of clubs that conform to this model. Patients enter the cooperative with documentation from their physicians, purchase the marijuana and leave. The staid setup of the club and the attitudes of the proprietors make it clear that the patient is no more expected to use his medicine there than he would be at a conventional pharmacy. Some clubs, such as the Los Angeles Cannabis Resource Center in West Hollywood, have a policy of allowing emergency medical smoking; this takes place in a smoking room, and the sharing of joints is not allowed. The Santa Clara County Medical Cannabis Center, which recently shut its doors under pressure from local authorities, did not allow smoking anywhere on the premises, including in the parking lot; if a patient violated this rule, his or her membership was revoked.
The second distribution model resembles a social club more than it does a pharmacy. The dispensing area is plastered with menus offering types, grades and prices. Large rooms are filled with brightly colored posters, lounge chairs and sofas, tables, magazines and newspapers. While some people remain only long enough to buy their medicine, most stay to smoke and talk. There are animated conversations, laughter, music and the pervasive, pungent odor of reefer.
The atmosphere is informal, welcoming and warm, providing support for patients who may be socially isolated and have little opportunity to share concerns and feelings about their illnesses. This type of club is a blend of Amsterdam-style coffeehouse, American bar and support group. The model was epitomized by the San Francisco Cannabis Cultivators Club, which was shut down by sheriffs deputies following local and federal court rulings.
Until some kind of legal accommodation makes it possible for patients to receive marijuana without violating the law, buyers clubs are the best approach to the problem. Yet the government, including the White House, the Drug Enforcement Administration and law enforcement at all levels, remains opposed to the idea. While the feds are retreating somewhat from their position that marijuana has no therapeutic value, they are still working diligently to close cannabis clubs. Many if not most advocates who recognize the importance of buyers clubs believe that the model exemplified by the Oakland, Santa Clara and Los Angeles clubs is preferable to that represented in San Francisco. The former are more businesslike, conform more closely with the pharmacy model and at least appear to be more vigilant about checking the documentation of people who present themselves as patients. The San Francisco club, largely because of the on-site cannabis smoking and its relaxed atmosphere, appeared to be more casual in its commitment to confirming medical need, which made even the supporters of buyers clubs a little nervous.
Yet the importance of the social aspect of buyers clubs cannot be underestimated. It is becoming increasingly clear that emotional supportcontacts with and help from friends, family, co-workers and othersplays a salutary role in battling many illnesses. This kind of support improves the quality of life, and there is growing evidence that it may even prolong life. In one study, socially isolated women were found to be five times more likely to die from ovarian and related cancers than women with networks of friends and families. In another study, women with breast cancer were found to be 50 percent less like-ly to die in the first few months after surgery if they had confidants. In a four-year study of 133 breast cancer patients, married women had a longer average survival time.
Researchers have consistently found that support groups are effective for patients with a variety of cancers. Participants become less anxious and depressed, make better use of their time and are more likely to return to work than patients who are given only standard care, regardless of whether they have serious psychiatric symptoms. There is evidence that even brief supportive therapy can have benefits that last for months. Some researchers have made the controversial claim that mere participation in support groups can keep cancer patients alive.
The San Francisco buyers club functioned very much as an informal support group. It was not designed by psychiatrists and social scientists to provide supportive group therapy, but theres reason to believe it did. One of the properties of marijuana may have contributed to its effectiveness: When people use cannabis, they tend to be more sociable and find it easier to share difficult thoughts and feelings. If there is even a kernel of truth to the idea that talking about the stress, setbacks and triumphs in the battle against an illness can help a patient cope and recover, it is clear that the San Francisco model provides the best environment for the dispensing of medicinal marijuana.
Unfortunately, we live in a culture that considers such a facility a public nuisance and criminalizes a compassionate form of caring out of loyalty to a symbolic war on drugs.
The contentious legal battle continues. This past summer Oakland designated the employees of the local cannabis club as officers of the city. This inspired political move uses a section of the Federal Controlled Substances Act and grants buyers for the cannabis cooperative the same protection as undercover narcs (who buy and sell drugs as part of investigations) have from possible prosecution. The club remains open in defiance of a federal judges order to close.
Dr. Grinspoon is seeking contributors to a book in progress, "The Uses of Marijuana." Contact the author at http://www.marijuana-uses.com or by writing to him at Harvard Medical School, 74 Fenwood Road, Boston, Massachusetts 02115.