THE FORBIDDEN MEDICINE:
a doctor challenges the feds.
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).
Saturday, August 1, 1998
In my book Marihuana Reconsidered I recounted the history of medical cannabis. But it was not until 1972, a year after the hooks publication, that what had been an issue of public policy became a personal one. Early that spring I fell into conversation at a dinner party with Dr. Emil Frei, who had recently arrived from Texas to serve as head of cancer research at Bostons Childrens Hospital. Dr. Frei told me about an 18-year-old Houston man who had become increasing-ly reluctant to undergo chemotherapy for his leukemia because the nausea and vomiting were unbearable H is doctors and family were having trouble persuading him to take the drug he needed to survive. One day the patients attitude changed, and he no longer feared ehemotherapy. It turned out he was preventing nausea by taking a few puffs of marijuana 20 minutes before each session. On the way home my wife, Betsy. suggested some-thing that had occurred to both of us: Marijuana might be what our son Danny needed.
Danny was diagnosed with acute lymphocytic leukemia in July 1967, when he was en. For the first few years he willingly accepted his treatment at Childrens Hospital and even the occasional need for hospitalization. In 1971 he started taking the first of the chemotherapy drugs that cause severe nausea and vomiting. In his case the standard treatments were ineffective. He started to vomit shortly after his chemotherapy sessions and continued retching for as long as eight hours. He would vomit in the car as w e drove home and then lie in bed with his face over a bucket on the floor. Still, I dismissed the idea of using marijuana to ease his discomfort. It was against the law and might embarrass the hospital staff that had been so devoted to Dannys care. At that point. I had been exposed to the medical benefits of marijuana on-ly through text and testimony. Had I known how dramatically it would affect my son I would never have objected.
The next chemotherapy session was two weeks after the conversation at the dinner party. When I arrived at the hospital, Betsy and Danny were already there, and I shall never for get my surprise. They were relaxed instead of anxious, and they seemed almost to be playing a joke on me. On their way to the clinic they had stopped near Wellesley High School and spoken with one of Dan friends. After recovering from his shock at their request, the friend ran off and reappeared a few minutes later with a small amount of marijuana. Danny and Betsy smoked it in the hospital parking lot before entering the clinic. I was relieved and then de-lighted as I observed how comfort-able Danny was. He didnt protest as he was given the treatment, and he felt no nausea afterward. On the way hack we stopped to buy him a submarine sandwich.
The next day I called Dr. Norman Jaffe, the physician in charge of Dan-nys care, to explain what had happened. I said hat although I didnt want to embarrass him or Iris staff had witnessed the effect of the drug and could not stand in the was of further marijuana use. Dr. Jaffe suggested Danny smoke in his presence in the treatment room, next time Again Danny became completely relaxed arid again he asked for a submarine sandwich afterward. During the remaining year of his life he used marijuana before each treatment, and I cannot overstate how much it his dying and gave comfort to the whole family. As Danny put it, "Pot turns bad things into good." Sometimes I wondered whether he ever asked himself why his father an authority on medicinal marijuana, had not suggested this possibility earlier.
How did marijuana become the forbidden medicine? In the 19th century, physicians knew more about marijuana than contemporary doctors do. Between 1840 and 1900, medical journals published more than 100 papers on therapeutic use of Indian hemp. It was recommended as an appetite stimulant, muscle relaxant, analgesic sedative and anticonvulsant, and as a treatment for opium, and diction and migraines. As it was chiefly administered orally in an alcohol solution, the potency varied and the response was often unreliable. Shortly after the turn of the century, synthetic alternatives became available for insomnia and moderate pain. In the U.S., what remained of marijuanas legitimate medical use was effectively eliminated by the Marijuana Tax Act of 1937 which was ostensibly designed to prevent non-medical use. The law made cannabis so difficult to obtain that it was removed from standard pharmaceutical references. In 1970, as I was completing Marihuana Reconsidered, a new federal law classified marijuana as a Schedule I drug. which means the government believes it has a high potential for abuse, has no accepted medical use and is unsafe even under medical supervision.
That didnt stop sick people from experimenting. Letters about marijuanas medical uses began to appear in PLAYBOY and other publications in the early Seventies. People who had learned that marijuana could relieve asthma, nausea, muscle spasms and pain shared their knowledge. Thirty-five states passed legislation that would have permitted the medical use of cannabis but for the federal law. The most effective spur to the movement came from the AIDS epidemic. People with AIDS learned that the drug could restore their appetites and prevent what is known as the AIDS wasting syndrome.
In 1972 the National Organization for the Reform of Marijuana Laws entered a petition to move marijuana out of Schedule I so that it could become a prescription drug. It wasnt until 1986 that the Drug Enforcement Administration agreed to the public hearings required by law. After two years of testimony, the DEAs administrative law judge, Francis L. Young, declared that marijuana fulfilled the requirement for transfer to Schedule II. He described it as "one of the safest therapeutically active sub-stances known to man." His decision was overruled by the DEA.
The Schedule I classification persistspolitically entrenched but medically absurd, legally questionable and morally wrong. After Dannys death, I began to think about how many other people like him might enjoy similar physical and emotional relief from marijuana. Maybe this medicine had advantages over conventional drugs in more than one way. In the years since, I have been able to pursue this question.
One patient, whom I will call John, was a 65-year-old retired college professor from New York City. He said he had been depressed for 20 years and had been in psychotherapy all that time. He had been treated with electroconvulsive therapy and given prescriptions for one antidepressant drug after another, always without success. John consulted me because of my writings on marijuana. He had been hospitalized several times, and on one of those occasions a marijuana cigarette given to him by a fellow patient produced "the first authentic depression-free moment of my life." But marijuana was difficult to obtain, and he was worried about going to jail. I recommended and his doctor prescribed Marinol (a synthetic version of delta-9-tetrahydro-cannabinol, the main active substance in cannabis). Marinol has been avail-able in oral form for limited purposes as a Schedule II drug since 1985. Al-though patients and physicians agree it is generally less effective, with more uncomfortable side effects, than smoked marijuana, it is the only legal alternative. It works fairly well for some patientsincluding, fortunately, John. He is still taking Marinol, and his depression has not recurred.
From this and other experiences in the past 30 years, I have become convinced that marijuana is a strikingly versatile medicine for treating nausea and vomiting caused by cancer chemotherapy, weight-loss syndrome of AIDS, glaucoma, epilepsy, muscle spasms, chronic pain, depression and other mood disorders.
Marijuana is also remarkably safe, with fewer serious side effects than most prescription medicines. Since it has little effect on the physiological functions needed to sustain life, there have been no cases of death or serious injury from an overdose. If you know anything about medicines, you will know how extraordinary that is. A re- cent study estimated that adverse reactions to prescription drugs kill more than 100,000 patients a year.
Some people find cannabis useful for relieving the pains of osteoarthritis. The standard treatments are aspirin and other nonsteroidal anti-inflammatory drugs, which cause more than 7600 deaths and 70,000 hospitalizations each year from gastrointestinal complications (mainly stomach bleeding). Another standard treatment is acetaminophen, which is one of the most common causes of terminal kidney failure. If some people with arthritis find marijuana to be as effective as these drugs, they should be allowed to use it.
A familiar objection to marijuana as medicine is that the evidence is anecdotal-that supporters count apparent successes and ignore failures. It is true that no efficacy studies have been done, chiefly because legal, bureaucratic and financial obstacles have been put in the way of such testing. Yet so much research has been done on marijuana in unsuccessful efforts to demonstrate its health hazards and addictive potential that we know more about it than we do about most prescription drugs.
Besides, anecdotal evidence is the source of much of our knowledge of drugs. Controlled experiments were not needed to recognize the therapeutic potential of barbiturates, aspirin, insulin, penicillin or lithium. Anecdotal evidence would be a serious problem only if cannabis were a dangerous drug. Even if just a few patients can get relief from cannabis, it should be made available. The risks are so small. For example, many people with multiple sclerosis find cannabis reduces muscle spasms and pain. The standard treatments include baclofen, dantrolene and high doses of diazepamall potential-ly dangerous or addictive drugs. If cannabis were not prohibited, it would cost less than most conventional medications. The price would be $20 to $30 an ounce, or about 30 cents per cigarette. One cigarette usually relieves the nausea and vomiting produced by chemotherapy. A standard dose of ondansetron (Zofran), the best legally available treatment, costs the patient $30 to $40.
The many thousands of Americans who use marijuana as a medicine are, legally, criminals. Sick people have to weigh the benefits against the risks of financial ruin, loss of a career or forfeiture of an automobile or home. A few have been given absurdly long prison sentences.
One case I am familiar with involves Harvey Ginsburg, a professor of psychology at Southwest Texas State University. He suffers from glaucoma, and since 1986 had been taking marijuana to treat the illness. He also has taken prescription medicines, which his ophthalmologist says are insufficient to prevent progression of the disease. After he began using marijuana, his eye-sight stopped deteriorating and his intra-ocular pressure improved. On June 24, 1994 he and his wife, Diana, were arrested for felony possessionsix plants (weighing two ounces each) and eight ounces of marijuana brownies. An acquaintance of his son, responding to a flier that offered "a profitable, ex-citing, guilt-free way to earn money," had placed a call to police for a $1000 reward.
While Ginsburg prepared to present a defense of medical necessity, a lien was filed against his property and his assets were frozen to enforce payment of the Texas Controlled Substances tax. In July 1995 the district attorney decided to dismiss all charges for the sake of judicial expedience. A week later the lo-cal police chief wrote an angry letter to the town newspaper ex-pressing his displeasure. The head of the narcotics division then contacted the superintendent of the school system where Diana worked as a special education counselor. The superintendent threatened to fire her and have her teaching license revoked on the grounds that she had violated the districts zero-tolerance policy by living with an accused marijuana user. Eventually Diana decided to resign, though she later received a settlement.
Another case I have learned of involves Russ Hokanson, a 54-year-old
paraplegic who lives on a farm in New Hampshire. He has been using
cannabis as an analgesic for 30 years, because he found that marijuana
relieved his chronic pain, stimulated his appetite and reduced
depression and anxiety. He found it even helped him restore bladder control and achieve a normal erection. He decided to start growing his own medicine. As a result, he was arrested and the state of New Hampshire attempted to seize his house and land.
Pharmaceutical companies will not pursue the research needed to test marijuanas therapeutic potential be-cause they cannot patent an ancient plant medicine. The federal government, the other major source of funding for medical research, also has blocked the way. In 1994 an investigator at the University of California at San Francisco sought approval for a privately funded study comparing smoked marijuana with oral synthetic THC in the treatment of AIDS wasting syndrome. Although this project was approved by the FDA and several institutional review boards and advisory committees, the National Institute on Drug Abuse and the Drug Enforcement Administration prevented the investigator from receiving the marijuana he needed. Maybe the passage of the California initiative legalizing medicinal marijuana will persuade federal authorities to relent. The Institute of Medicine, a branch of the National Academy of Sciences, is now conduct-ing a review of marijuanas medical us-es. But a research program designed to study dinical applications of this drug will take years, and other ways must be found in the meantime to accommodate the needs of a rapidly increasing number of patients.
When medical use of marijuana in the U.S. was effectively outlawed in 1937, the American Medical Association, to its credit, opposed the ban. Since then, physicians have been both victims and agents in the spread of misinformation. Ignorance, lack of interest and government obfuscation continue to limit our chances to recognize marijuanas medical potential.
In 1990, only 43 percent of those who responded to an American Society of Clinical Oncology survey said that available legal anti-emetic drugs (including oral synthetic THC) provided adequate relief for all or most of their cancer patients. Forty-four percent had recommended the use of marijuana to at least one patient, and half would legal. On average, they considered smoked marijuana more effective than oral synthetic THC and about as safe.
When doctors confront the needs of their patients, they recognize the foolishness of these laws. But most, so far, are either afraid to do more or unable to provide further help because they know too little. To prescribe a medicine responsibly, a physician must balance risks and benefits. In most cases a doctor re-lies on the knowledge that the FDA has already analyzed a drug. A physician who recommends marijuana does not have that assurance.
Im confident, because I know the balance of risk and benefit is powerfully weighted by marijuanas time-tested safety. If I didnt recommend it when it is clearly in a patients best interests, I would be compromising my physicians oath. After 30 years of study, I know more about this substanceand about what is best for my patientsthan any government official or public relations person for the Partnership for a Drug-Free America does.
I will continue to recommend marijuana when it appears to be the most effective and least toxic choice. But under the present laws, neither I nor my patients will be able to avoid anxiety. I could lose my license to practice medicine and my patients could be arrested and have their property confiscated. This makes me uncomfortable-but not nearly so uncomfortable as I feel when I consider that if I avoid recommending marijuana, I may repeat the mistake I made by not encouraging my son to use it earlier in the course of his illness.