Lester Grinspoon, MD

12/07/2000 Boston Globe Op/Ed

High-ranking government officials in the United States have referred to the concept of medical marijuana as a hoax, a subterfuge by which proponents of a more liberal policy toward this drug will succeed in undoing the long-standing, harsh prohibition. Ignorant of the role cannabis played in Western medicine from mid 19th into the early 20th century, they and their many supporters view the notion that cannabis has medicinal properties as a new intrusion into allopathic medicine.  The parochialism of this view is highlighted by ethno-historical studies which document not only how ancient is the use of this substance as a medicine, but as well, the multiplicity of cultures that have used it in so many different ways for the treatment of a large variety of human ailments and discomforts. Its use as a medicine is so widespread and reports of its toxicity so rare, the contemporary judgment of Western medicine seems deviant. One might ask why the government of the United States, the leading oppositional force, clings so tenaciously to this insular and harmful policy?  The answer, of course, is the fear that as people gain more experience with cannabis as a medicine they will discover for themselves that its toxicity has been greatly exaggerated, its usefulness undervalued, and that it can be used for purposes the government disapproves of.  Having made these discoveries, they will be less supportive of the present prohibition and its enormous costs, among which is the annual arrest of 700,000 people in the United States alone.

With the publication of its report in March 1999, the Institute of Medicine of the National Academy of Sciences grudgingly acknowledged that cannabis has some medical utility but averred that because smoking it was too dangerous to their health, patients would have to await the development of pharmaceutical products which would eliminate this hazard. While the report greatly exaggerates the danger of smoking cannabis, it fails to provide a discussion of vaporization, a technique that allows patients who wish to avoid the smoke to inhale the cannabinoids largely free of particulate matter.  Another reason the authorities would have patients wait for the "pharmaceuticalization" of marijuana is to allow for the development of cannabinoid analogs that will be free of any psychoactive effects.  This goal is based on the assumption that the psychoactive effects are both unhealthy and bad for the patient in the vague way in which the "high" is thought by the prohibitionists to be deleterious.  It is an assumption that is not supported by the mountain of anecdotal evidence that supports marijuana's usefulness as a medicine.  While there are some patients who do not like the psychoactive effects, they are relatively rare; the vast majority, patients suffering from serious illnesses, finds that smoking cannabis not only relieves a particular symptom, but also makes them "feel better".  Helping patients, particularly those with chronic diseases, to feel better is an important goal of the humane practice of medicine.  And there is a growing understanding in medicine that patients who feel better do better.

The resistance of government authorities to allowing the availability of cannabis as a medicine is generally supported by the Western medical establishment.  This has not always been so.  Physicians in the United States were enthusiastic about the medicinal uses of cannabis from the middle of the nineteenth century until the passage of the first of the Draconian legislation aimed at marijuana in 1937 (the Marihuana Tax Act).  Under pressure from the Federal Bureau of Narcotics, the predecessor organization to the present Drug Enforcement Administration (DEA), the Journal of the American Medical Association published in 1945 a vehemently anti-marijuana editorial, which signaled a sea change in the attitude of doctors toward this drug.  They became both victims and agents of the marijuana disinformation campaign launched by Harry Anslinger, the first Chief of the Federal Bureau of Narcotics.  Many physicians today still suffer from both this legacy and fear of the DEA, so much so that they are afraid to prescribe Marinol (a legally available synthetic THC, both more expensive and less effective than marijuana). 

Today, the medical establishment takes the position that there is no scientific evidence  demonstrating that cannabis has medical usefulness.  This stance is based on the fact that there is a paucity of double-blind controlled studies of the clinical usefulness of marijuana.  This scarcity is likely to persist for some considerable time. The costs of such studies are generally underwritten by pharmaceutical firms who stand to gain much if they can demonstrate a therapeutic usefulness in, and win Food and Drug Administration (FDA) approval of, a drug whose patent they hold.  Because this naturally occurring herb can not be patented, these firms will not invest the more than $200 million needed to do the studies required for official approval of a pharmaceutical.  Consequently, the medical utility of marijuana will continue to rest on anecdotal evidence of which a great deal has accumulated here in the West and all around the world. 

It would not be the first medicine to be admitted to the pharmacopoeia on the strength of anecdotal evidence.  Anecdotal evidence commands much less attention then it once did, yet it is the source of much of our knowledge of synthetic medicines as well as plant derivatives.  Controlled experiments were not needed to recognize the therapeutic potential of chloral hydrate, barbiturates, aspirin, curare, insulin, or penicillin.  It is unlikely that marijuana should or will ever be developed as an officially recognized medicine via the FDA approval process, which is ultimately a risk/benefit analysis.  Thousands of years of widespread use have demonstrated its medical value; the extensive multi-million dollar government-supported effort (through the National Institute of Drug Abuse) of the last three decades to establish a sufficient level of toxicity to support the harsh prohibition has instead provided a record of safety that is more compelling than that of most approved medicines.  The modern FDA protocol is not necessary to establish a risk-benefit estimate for a drug with such a history.  To impose this protocol on cannabis would be like making the same demand of aspirin, which was accepted as a medicine more than sixty years before the advent of the double-blind controlled study.  Many years of experience have shown us that aspirin has many uses and limited toxicity, yet today it could not be marshaled through the FDA approval process.  The patent has long since expired, and with it the incentive to underwrite the enormous cost of this modern seal of approval. Cannabis too is unpatentable, so the only source of funding for a "start-from-scratch" approval would be the government, which is, to put it mildly, unlikely to be helpful.  Other reasons for doubting that marijuana would ever be officially approved are today's anti-smoking climate and, most important, the widespread use of cannabis for purposes disapproved of by the US government.  As a result, we are going to have two distribution systems for medical cannabis. One will be the conventional model of pharmacy-filled prescriptions for FDA-approved medicines derived from cannabis as isolated or synthetic cannabinoids and cannabinoid analogs.  The other will have more in common with some of the means of distribution and use of alternative and herbal medicines.  The only difference, an enormous one, will be the continued illegality of whole smoked or ingested cannabis.  In any case, increasing medical use by either distribution pathway will inevitably make growing numbers of people familiar with cannabis and its derivatives.  As they learn that its harmfulness has been greatly exaggerated and its usefulness underestimated, the pressure will increase for drastic change in the way we as a society deal with this drug.

  Dr. Lester Grinspoon, professor emeritus at Harvard Medical School, is the author of "Marihuana Reconsidered" and, with James B. Bakalar, "Marihuana, the Forbidden Medicine."