Before the passage of the Marijuana Tax Act of 1937, which effectively prohibited the sale of marijuana, more than twenty pharmaceuticals were on the market with marijuana as an ingredient (Medical Marijuana Briefing Paper—2005, Washington, DC: Marijuana Policy Project, http://www.mpp.org/pdf/mmjbrief.pdf). In the 1970s marijuana's medicinal properties were rediscovered by recreational users. In the November 1996 elections, California and Arizona voters approved referenda legalizing the possession of marijuana and other drugs for medical purposes. California Proposition 215, enacted as The Compassionate Use Act of 1996, permitted patients and primary caregivers to possess and/or cultivate marijuana without fear of prosecution under state laws. The act permitted physicians to recommend (not to prescribe) the use of marijuana as a treatment for cancer, AIDS, anorexia, chronic pain, glaucoma, arthritis, migraine headaches, "or any other illness for which marijuana provides relief." More than half (56%) of California voters supported Proposition 215.
In neighboring Arizona, 65% of the voters supported Proposition 200, enacted as the Drug Medicalization, Prevention, and Control Act. It provided that, in the case of medical necessity, marijuana and other drugs (including heroin and LSD) could be used in medical treatment. Two doctors would have to prescribe the use of these drugs. The law also called for probation and treatment rather than incarceration for first- and second-time non-violent drug offenders. The Arizona legislature amended the measure, saying that voters had committed a grave error, and sent it back to the voters. In 1998 Proposition 200 again passed, this time with a 57% majority.
The Justice Department brought suit in 1998 against the Oakland Cannabis Buyers' Club, which supplied marijuana for medical purposes. The government argued that the club's activities, even if legal under California law, violated federal law, specifically the Controlled Substances Act. The case reached the Supreme Court in 2001. The Court ruled in favor of the federal government and struck down state laws legalizing the use of marijuana for purposes of medical necessity, arguing that the intention of Congress in classifying marijuana as a Schedule I substance was unambiguously clear. Schedule I drugs have, by definition, "no currently accepted medical use in treatment in the United States," have "a high potential for abuse," and have "a lack of accepted safety for use under medical supervision." (United States v. Oakland Cannabis Buyers' Cooperative et al., 532 U.S. 483, decided May 14, 2001.)
The high court's actions are not the final word on medical uses of marijuana, especially because the Court's ruling was narrowly cast around the classification of marijuana as a Schedule I drug. Future amendments of the Controlled Substances Act could well remove marijuana from Schedule I and place it on Schedule II with morphine, cocaine, and methamphetamine. Schedule II states that "the drug or other substance [on the schedule] has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions."
The U.S. Supreme Court issued another relevant ruling in June of 2005, overturning a 2003 federal appeals court decision that shielded California's Compassionate Use Act, the medical marijuana initiative adopted by California voters nine years earlier. The Supreme Court's ruling in this case reaffirmed the ability of Congress to prohibit and prosecute for the possession and use of marijuana even in states (eleven as of the decision) that allow it under state law. As with the earlier Supreme Court decisions, this ruling was not the final word on medical marijuana. Other challenges to the application of federal drug laws may still be issued.
The medicinal value of THC (tetrahydrocannibinol), the active ingredient in marijuana, has long been known to the medical community. The drug has been shown to alleviate the nausea and vomiting caused by chemotherapy used to treat many forms of cancer. Marijuana has also been found useful in alleviating pressure on the eye in glaucoma patients. The drug has also been found effective in helping to fight the physical wasting that usually accompanies AIDS. AIDS patients lose their appetites and can slowly waste away because they do not eat. Marijuana has been found effective in restoring the appetites of some AIDS patients. Many of the newer AIDS remedies must be taken on a full stomach. Other studies, in contrast, have found that marijuana suppresses the immune system and contains a number of lung-damaging chemicals.
NIDA GREW IT.
During the 1970s and 1980s the National Institute of Drug Abuse grew marijuana in Mississippi to supply the drug to experimental research programs in six states. Such action is expressly permitted under the Controlled Substances Act. In 1986 the Reagan administration, feeling increasingly uncomfortable with this program and concerned that the growing AIDS epidemic might lead to increased demand for the medical legalization of marijuana, accelerated the approval of Marinol, a drug containing a synthetic form of THC. The state experimental programs were closed.
Opponents of the medical legalization of marijuana often point to Marinol as a superior alternative.
However, many patients do not respond to Marinol; the determination of the right dose is variable from patient to patient. Nonresponding patients claim that smoking marijuana allows them to control the dosage they get. Marijuana has been used, illegally, of course, by an unknown number of cancer and AIDS patients on the recommendation of doctors.
NEW ENGLAND JOURNAL OF MEDICINE.
In 1997 the highly respected New England Journal of Medicine came out in favor of legalizing marijuana for medical use. Jerome P. Kassirer, the journal's editor, published an editorial entitled "Federal Foolishness and Marijuana" in which he wrote: "I believe that a federal policy that prohibits physicians from alleviating suffering by prescribing marijuana is misguided, heavy-handed and inhumane" (vol. 336, January 30, 1997). Dr. Kassirer acknowledged that marijuana use could cause long-term adverse effects and could even lead to serious addiction, but he felt that these risks were irrelevant when the drug was used to combat uncontrollable nausea and pain in patients critically ill with cancer, AIDS, and other serious diseases.
The editorial mentioned that dronabinol (the generic name of Marinol) contains THC, but this legal drug is not widely prescribed because its therapeutic dosing is difficult to determine. "By contrast," wrote Kassirer, "smoking marijuana produces a rapid increase in the blood level of the active ingredients and is thus more likely to be therapeutic." He makes the point that doctors can prescribe morphine and other very strong drugs that can cause death, but with marijuana there is no immediate risk of death.
THE INSTITUTE OF MEDICINE STUDY.
With the California and Arizona medical legalization propositions as background, General Barry McCaffrey, the Clinton administration's drug czar, asked the Institute of Medicine (IOM), a private organization that advises the government on medical matters, to review the scientific evidence on marijuana in order to assess the potential health benefits and risks of marijuana and its constituent cannabinoids. The review began in August 1997 and culminated in March 1999 with a report entitled Marijuana and Medicine: Assessing the Science Base (Janet E. Joy, Stanley J. Watson, Jr., and John A. Benson, Jr., eds., Washington, DC: National Academy Press, 1999).
Cannabinoids, a group of compounds found in marijuana, contain THC, the primary psychoactive ingredient in marijuana. The IOM report drew the following general conclusions regarding cannabinoids:
Cannabinoids likely have a natural role in pain modulation, control of movement, and memory.
The natural role of cannabinoids in immune systems is likely multifaceted and remains unclear.
The brain develops tolerance to cannabinoids.
Animal research demonstrates the potential for dependence, but this potential is observed under a narrower range of conditions than with benzodiazepines, opiates, cocaine, or nicotine.
Withdrawal symptoms can be observed in animals but appear mild compared with those of opiates or benzodiazepines such as diazepam (Valium).
The IOM report concluded that "the future of cannabinoid drugs lies not in smoked marijuana, but in chemically defined drugs that act on the cannabinoid systems that are a natural component of human physiology. Until such drugs can be developed and made available for medical use, the report recommends interim solutions."
John Benson and Stanley Watson, the report's principal investigators, determined that marijuana's effects are limited to symptom relief and that, for most symptoms, more effective drugs already exist. However, for patients who do not respond well to standard medications, cannabinoids seem to hold potential for treating pain, chemotherapy-induced nausea and vomiting, and the poor appetite and wasting caused by AIDS and advanced cancer.
The report noted that medical use of marijuana is not without risk. The primary negative effect is diminished control over movement (psychomotor performance). In some cases users may experience unpleasant emotional states or feelings. In addition, the usefulness of medical marijuana is limited by the harmful effects of smoking, which can increase a person's risk of cancer, lung damage, and problems (such as low birth weight) with pregnancies. Therefore, the report concluded, smoking marijuana should be recommended only for terminally ill patients or those with debilitating symptoms who do not respond to approved medications.
The report recommended that patients with no alternative to smoking marijuana be allowed to use it on a short-term, experimental basis. Both physical and psychological effects should be closely monitored and documented under medical supervision. Clinical trials of marijuana should be carried out parallel with the development of new delivery systems, such as inhalers, that are safe, fast-acting, and reliable but that do not involve inhaling harmful smoke. Cannabinoid compounds that are produced under controlled laboratory conditions are preferable to plant products because they deliver a consistent dose.
Data collected in the review did not support the contention that marijuana should be used to treat glaucoma. Though smoked marijuana can reduce some of the eye pressure related to glaucoma, it provides only
short-term relief that does not outweigh the hazards associated with long-term use of the drug. Also, with the exception of painful muscle spasms in multiple sclerosis, there is little evidence of marijuana's potential for treating migraines or movement disorders like Parkinson's disease or Huntington's disease.
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