AMNews: editorial, April 7, 1997

American Medical Association News Editorial for April 7, 1997

Reefer candidness

Now that it's OK to talk about medical marijuana, let's see if there's anything to say

Why not pot?

It's a question from patients that physicians were justifiably jittery about answering for awhile, in light of some intimidating official rhetoric. After voters in California and Arizona approved marijuana for medical use, physicians were told -- by the formidable trio of U.S. drug czar Barry McCaffrey, Attorney General Janet Reno and Health and Human Services Secretary Donna Shalala, PhD -- that recommending marijuana to patients carried the risk of prosecution, cancellation of prescribing privileges and exclusion from Medicare or Medicaid participation.

It was an unfortunate misstep from an administration that has shown commendable leadership against managed care attempts to keep physicians from speaking freely with patients. Fortunately, in this instance, the administration recognized its mistake.

The Justice Dept. and HHS recently produced a clarification stating that physicians have a the right to discuss marijuana use as they would any other treatment option. The AMA played a significant role in bringing to the administration the medical profession's perspective on the importance of open communication between doctor and patient.

Now the only talking that physicians apparently cannot do about marijuana is a recommendation that can be used by a marijuana outlet -- a so-called cannabis buyers club -- to fill an order for a patient. That constraint keeps physicians from being complicit in a federal crime, the delivery of marijuana. (Since marijuana is a DEA Schedule I substance, no written prescription was ever truly legitimate, regardless of the wording of state laws.)

So ends the easy part of this muddle over medical marijuana. What patients and physicians deserve now is some much-needed clinical research that will decide the issue of whether medical marijuana is even worth talking about. The AMA, which opposes general legalization of marijuana, has for years called for such scientific study.

Certainly medical marijuana has a loyal following of patients. As the ballot measures indicate, it has also captured the imagination of the public at large. Unfortunately, unproven therapies often do.

But it is not only the desperate and the curious who are involved. Some physicians, drawing on their experience and sense of compassion, are in good conscience advising some of their patients to use cannabis. A 1990 poll of oncologists found that more than 40% had recommended smoking marijuana to patients to overcome nausea following chemotherapy. Some physicians who treat AIDS patients advise them to smoke marijuana as an appetite-increasing therapy against wasting associated with the disease. In neither of these cases is marijuana a medical breakthrough, but proponents say that it can greatly increase the quality of life for these patients.

All this suggests that the current curiosity over medical marijuana will not fade away, regardless of how much the administration may hope it might. The longer it goes on, the more likely we are to see quasilegal referendums and state laws -- already eight states allow medical use of marijuana -- increasing the politicization of an issue more properly left to science.

Drug czar McCaffrey has pledged nearly $1 million for an 18-month study of the current literature on marijuana by the National Academy of Science's Institute of Medicine. It is a start, but well-designed clinical tests -- now lacking in the literature -- are what's needed.

Given the nuances particular to marijuana, that will take some doing. As the Federation of American Scientists points out in its own plea to President Clinton in favor of testing, marijuana "would fair poorly under the current drug research and approval regimen."

Marijuana doesn't fit neatly into traditional protocols because the dosage is inexact, the quality and strength of marijuana varies, and each puff contains more than 400 chemicals, not just a single active agent to be isolated. (The fact that patients can dose themselves as needed may be a significant factor in marijuana's apparent effectiveness.) Since there is no patent potential, no drug company will be willing to underwrite the research. Clearly, government funding is essential.

The sooner researchers start on this course the better. The question "Why not pot?" is not only one for physicians. It's increasingly asked of the government and must be answered to the satisfaction of patients, doctors and the general public. If the answer is to be believed, it must be based in science.

Contents Copyright 1997 American Medical Association. All rights Reserved.

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