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T
he advanced stages of many illnesses and their
treatments are often accompanied by intractable nausea,
vomiting, or pain. Thousands of patients with cancer, AIDS,
and other diseases report they have obtained striking
relief from these devastating symptoms by smoking
marijuana.[
1]
The alleviation of distress can be so striking that some
patients and their families have been willing to risk a
jail term to obtain or grow the marijuana.
Despite the desperation of these patients, within weeks
after voters in Arizona and California approved
propositions allowing physicians in their states to
prescribe marijuana for medical indications, federal
officials, including the President, the secretary of Health
and Human Services, and the attorney general sprang into
action. At a news conference, Secretary Donna E. Shalala
gave an organ recital of the parts of the body that she
asserted could be harmed by marijuana and warned of the
evils of its spreading use. Attorney General Janet Reno
announced that physicians in any state who prescribed the
drug could lose the privilege of writing prescriptions, be
excluded from Medicare and Medicaid reimbursement, and even
be prosecuted for a federal crime. General Barry R.
McCaffrey, director of the Office of National Drug Control
Policy, reiterated his agency's position that marijuana is
a dangerous drug and implied that voters in Arizona and
California had been duped into voting for these
propositions. He indicated that it is always possible to
study the effects of any drug, including marijuana, but
that the use of marijuana by seriously ill patients would
require, at the least, scientifically valid research.
I believe that a federal policy that prohibits
physicians from alleviating suffering by prescribing
marijuana for seriously ill patients is misguided,
heavy-handed, and inhumane. Marijuana may have long-term
adverse effects and its use may presage serious addictions,
but neither long-term side effects nor addiction is a
relevant issue in such patients. It is also hypocritical to
forbid physicians to prescribe marijuana while permitting
them to use morphine and meperidine to relieve extreme
dyspnea and pain. With both these drugs the difference
between the dose that relieves symptoms and the dose that
hastens death is very narrow; by contrast, there is no risk
of death from smoking marijuana. To demand evidence of
therapeutic efficacy is equally hypocritical. The noxious
sensations that patients experience are extremely difficult
to quantity in controlled experiments. What really counts
for a therapy with this kind of safety margin is whether a
seriously ill patient feels relief as a result of the
intervention, not whether a controlled trial "proves" its
efficacy.
Paradoxically, dronabinol, a drug that contains one of
the active ingredients in marijuana
(tetra-hydrocannabinol), has been available by prescription
for more than a decade. But it is difficult to titrate the
therapeutic dose of this drug, and it is not widely
prescribed. By contrast, smoking marijuana produces a rapid
increase in the blood level of the active ingredients and
is thus more likely to be therapeutic. Needless to say, new
drugs such as those that inhibit the nausea associated with
chemotherapy may well be more beneficial than smoking
marijuana, but their comparative efficacy has never been
studied.
Whatever their reasons, federal officials are out of
step with the public. Dozens of states have passed laws
that ease restrictions on the prescribing of marijuana by
physicians, and polls consistently show that the public
favors the use of marijuana for such purposes.[
1]
Federal authorities should rescind their prohibition of the
medicinal use of marijuana for seriously ill patients and
allow physicians to decide which patients to treat. The
government should change marijuana's status from that of a
Schedule 1 drug (considered to be potentially addictive and
with no current medical use) to that of a Schedule 2 drug
(potentially addictive but with some accept ed medical use)
and regulate it accordingly. To ensure its proper
distribution and use, the government could declare itself
the only agency sanctioned to provide the marijuana. I
believe that such a change in policy would have no adverse
effects. The argument that it would be a signal to the
young that "marijuana is OK" is, I believe, specious.
This proposal is not new. In 1986, after years of legal
wrangling, the Drug Enforcement Administration (DEA) held
extensive hearings on the transfer of marijuana to Schedule
2. In 1988, the DEA's own administrative-law judge
concluded, "It would be unreasonable, arbitrary, and
capricious for DEA to continue to stand between those
sufferers and the benefits of this substance in light of
the evidence in this record."[
1]
Nonetheless, the DEA overruled the judge's order to
transfer marijuana to Schedule 2, and in 1992 it issued a
final rejection of all requests for reclassification.[
2]
Some physicians will have the courage to challenge the
continued proscription of marijuana for the sick.
Eventually, their actions will force the courts to
adjudicate between the rights of those at death's door and
the absolute power of bureaucrats whose decisions are based
more on reflexive ideology and political correctness than
on compassion.
References
1. Young FL.
Opinion and recommended ruling,
marijuana rescheduling petition. Department of Justice,
Drug Enforcement Administration. Docket 86-22. Washington,
D.C.: Drug Enforcement Administration, September 6,
1988.
2. Department of Justice, Drug
Enforcement Administration, Marijuana scheduling petition:
denial of petition: remand. (Docket No. 86-22.) Fed Regist
1992;57(59):10489-508. Copyright 1997, Massachusetts
Medical Society.
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