Correspondence

Medicinal Marijuana?

N Engl J Med 1997; 336:1184-1187April 17, 1997

Article

To the Editor:

With respect to your editorial on the medicinal use of marijuana (Jan. 30 issue),1 I made it a priority, as the first director of the National Institute on Drug Abuse (1973 to 1978), to investigate the health effects of smoking marijuana and to report on them regularly to the Congress and the public. Particular chemical constituents of smoked marijuana may have medical benefits, but it is unthinkable that in the closing decade of the 20th century, American medicine would return to prescribing smoked leaves for any condition. The history of the past hundred years in medicine has been to identify chemicals that offer benefits for specific problems and then to make those chemicals available in stable, known doses. The proper mechanism for sorting out claims of safety and efficacy was established by the Pure Food and Drug Act in 1906. . . .

Robert L. DuPont, M.D.
Institute for Behavior and Health, Rockville, MD 20852

1 References

1. 1

   Kassirer JP. Federal foolishness and marijuana. N Engl J Med 1997;336:366-367
   Full Text | Web of Science | Medline

To the Editor:

. . . The image of smoking marijuana, even for “medicinal” purposes, is inextricably linked to images of illicit drug use in our culture and could send the powerful message to adolescents that marijuana use is OK. Although many adolescents who experiment with marijuana will later stop using illicit drugs,1 a substantial minority will use this drug as a gateway to more serious forms of addiction.2

Data are not yet available on how the passage of the medical-legalization propositions in California and Arizona have influenced adolescents' perceptions of the harmfulness of marijuana or the likelihood that they will experiment with this drug. In the interim, the debate over medical legalization must consider not only the potential benefit to patients who may obtain relief from their symptoms but also the potential harm to the public at large, including the devastation of the lives of adolescents whose experimentation progresses to serious forms of drug abuse. Should the welfare of the many be compromised in an effort to meet the needs of the very few?

Philip D. Kanof, M.D., Ph.D.
University of Arizona College of Medicine, Tucson, AZ 85724

2 References

1. 1

   Kandel DB, Raveis VH. Cessation of illicit drug use in young adulthood. Arch Gen Psychiatry 1989;46:109-116
   Web of Science | Medline

2. 2

   Dupre D, Miller NS, Gold MS, et al. Initiation and progression of alcohol, marijuana and cocaine use among adolescent users. Am J Addict 1995;4:43-48
   Web of Science

To the Editor:

You are to be congratulated on your thoughtful editorial on marijuana. Your review of the available scientific evidence is straight to the point; there are no data to support the current proscription of medical marijuana use. Still, I do not foresee a reversal by the attorney general or the secretary of health and human services any time soon. I base this prediction on my belief that emotion and symbolism govern the debate over marijuana, not science.

Drug abuse is an enormous problem in our country. As the parent of two teenagers, I worry about the messages society is sending them. Certainly, I am worried about “street drugs,” but I am equally worried about tobacco, alcohol, and a cornucopia of prescription and nonprescription medications that seem to promise a discomfort-free life through pharmaceuticals.

I am not particularly worried about marijuana. In 1995, the American Medical News reported that almost 70 million Americans older than 12 years had tried marijuana at least once.1 Not all these 70 million lives were ruined. Although I hope my children will not try marijuana, I believe they are likely to lead normal lives even if they do experiment with it.

With all the other drug problems in our society, I am frankly dumbfounded as to why marijuana has become such an important symbol in our national psyche, but it has.

William A. Hensel, M.D.
Moses Cone Health System, Greensboro, NC 27401

1 References

1. 1

   Hearn W. Considering cannabis: does marijuana have medicinal value? Recent developments are reigniting a longstanding debate. American Medical News. October 2, 1995:19, 21-3.
   

To the Editor:

In the 16th century, Juan de Cardenas, a Spanish physician, wrote, “To seek to tell the virtues and greatness of this holy herb, the ailments which can be cured by it, and have been, the evils from which it has saved thousands would be to go on to infinity . . . this precious herb [tobacco] is so general a human need not only for the sick but for the healthy.” 1 Just as this 16th-century physician cited anecdotal evidence in support of his statement about tobacco, in your editorial, “Federal Foolishness and Marijuana,” you advocate the use of marijuana on the basis of anecdotes and the testimony of “thousands of patients.” One might reflect on the medical foolishness that might be seen in the future by those looking back at this episode in our history.

Laurence Domino, M.D.
St. Lawrence Hospital, Lansing, MI 48915

1 References

1. 1

   Goodman J. Tobacco in history: the cultures of dependence. New York: Routledge, 1993:44.
   

To the Editor:

It is very disturbing to realize that Giovanni Polli (1812 to 1880), the father of laboratory medicine in Italy, was more compassionate 130 years ago than many government authorities today. In 1861 he reported that he had treated a patient with rabies, who eventually died, with “haschisch” and that it provided excellent palliation. He advocated its use in terminally ill patients,1 saying, “Very often most therapy, or even the entire therapy, is no more than palliative; therefore, the physician who finds a convenient and effective palliative treatment is lucky. . . . It is obvious that haschisch, which we tried, can always be called on for help as the most benign and sure sedative when there is no hope of a definitive cure.”

Romolo M. Dorizzi, M.D.
Azienda Ospedaliera di Verona, 37124 Verona, Italy

1 References

1. 1

   Polli G. Risultato di un eseprimento terapeutico dell'haschisch. Ann Univers Med 1861;155:632-637
   

To the Editor:

. . . It would be incorrect to transfer Schedule 1 agents to Schedule 2, permitting physicians to prescribe them. Physicians would be pressed into a state of continual vigilance with respect to the drug culture. Despite their best efforts, a substantial diversion of medically prescribed agents to the general population for personal use and sale would be unpreventable. A demand for such diversion within families would arise uncontrollably. The corruption of physicians, already a problem, would inevitably increase. The adverse medical and behavioral effects of marijuana as a schedule I agent would create social problems, as well as major problems, hitherto unstudied, in patient care. Medicolegal complications for families, physicians, and the institutions that employ physicians would multiply, and the costs of care would escalate.

Arthur Taub, M.D., Ph.D.
Yale University School of Medicine, New Haven, CT 06519

To the Editor:

. . . Should hospitals waive their no-smoking rules for patients smoking marijuana cigarettes, while cracking down on those who smoke tobacco products?

Marshall E. Deutsch, Ph.D.
41 Concord Rd., Sudbury, MA 01776-2328

To the Editor:

In your fine editorial, you did not point out an ironic contradiction in federal policy. In December the Health Care Financing Administration issued a directive that Medicare beneficiaries in health maintenance organizations (HMOs) are entitled to information from physicians on all options for medically necessary treatments. HMOs are forbidden to “gag” doctors. Yet the attorney general has threatened sanctions and criminal prosecution for a doctor who prescribes marijuana.

David Grant, M.D.
602 West French Pl., San Antonio, TX 78212

To the Editor:

. . . The recent legislation in California and Arizona is sloppy, irresponsible lawmaking. In California, marijuana can now be recommended for anyone, of any age, for any ailment. In Arizona, all Schedule 1 drugs can be prescribed, without provisions governing quality, dosage control, supervision, or compliance. These drugs are still produced by an unregulated, criminal black market.

James E. Copple, M.Div.
Community Anti-Drug Coalitions of America, Alexandria, VA 22306

To the Editor:

Your judgment that proscribing the use of marijuana is hypocritical, given the acceptance of narcotic analgesics for the relief of pain, does not withstand scrutiny. The latter are reproducibly effective for their primary use, to provide analgesia. Their pharmacologic and pharmacodynamic characteristics have been well studied, as have their toxicity and relative merits. I see no reason why marijuana should be exempt from such considerations. The hypocrisy, in my opinion, is in those who dismiss demonstrably effective therapies for nausea, glaucoma, headaches, fatigue, or depression, while neglecting to admit that the preference for marijuana rests on its principal effect, euphoria. . . .

John A. Tilelli, M.D.
Arnold Palmer Hospital for Children and Women, Orlando, FL 32806

To the Editor:

As a person with AIDS who has to use medicinal marijuana in my fight to stay alive, I thank you for your support. I do not drink, nor do I use drugs, and I would not use marijuana if I did not have to. There is little hope for me after 16 years of infection with the human immunodeficiency virus (HIV). The medicinal use of marijuana is one of the only things that makes me feel generally better, and it helps me eat.

Gary Allen Johnson
San Francisco, CA 94123-1861

To the Editor:

I was the care giver for a dear friend who died of AIDS. In his final months, he asked me to obtain marijuana for his nausea. The marijuana eased his suffering.

But this issue goes beyond marijuana. As my friend's care giver, I had to struggle with his doctor over pain control. My friend was in constant, severe pain, and it was a never-ending battle to convince the doctor to prescribe Demerol (meperidine). There was always much ado over the triplicate forms and the suspicions of government drug regulators. Everyone knew the end was near. Still, I had to battle for every drop of meperidine. The war on drugs has become the war on patients.

Richard Mays, M.A.
P.O. Box 2764, Guerneville, CA 95446

To the Editor:

You point to largely experiential evidence of the medicinal benefits of marijuana and the apparent absence of serious short-term toxicity. However, a note of caution is warranted. Although it is true that smoking marijuana carries no immediate risk of death, there may be serious adverse effects in the very patients for whom medicinal marijuana is most commonly considered (i.e., those whose immune defenses are already compromised by AIDS or cancer plus chemotherapy). For example, in patients with AIDS, marijuana use has been associated with the development of both fungal and bacterial pneumonias.1,2 Moreover, among HIV-positive persons, marijuana use has been shown to be a risk factor for rapid progression from HIV infection to AIDS and the acquisition of opportunistic infections or Kaposi's sarcoma, or both.3

Cellular studies and studies in animals lend support to these potential health consequences of marijuana. For example, delta-9-tetrahydrocannabinol has been shown to have immunosuppressive effects on macrophages, natural killer cells, and T cells, as well as on the response of mice to opportunistic infection.4 In our own studies,5 (and unpublished data) we recovered alveolar macrophages from the lungs of habitual marijuana smokers and found a significant reduction in their ability to kill fungi, bacteria, and tumor cells, as well as a deficiency in their ability to produce protective inflammatory cytokines, such as tumor necrosis factor α.

Donald P. Tashkin, M.D.
Michael D. Roth, M.D.
Steven M. Dubinett, M.D.
UCLA School of Medicine, Los Angeles, CA 90095-1690

5 References

1. 1

   Denning DW, Follansbee SE, Scolaro M, Norris S, Edelstein H, Stevens DA. Pulmonary aspergillosis in the acquired immunodeficiency syndrome. N Engl J Med 1991;324:654-662
   Full Text | Web of Science | Medline

2. 2

   Caiaffa WT, Vlahov D, Graham NM, et al. Drug smoking, Pneumocystis carinii pneumonia, and immunosuppression increase risk of bacterial pneumonia in human immunodeficiency virus-seropositive injection drug users. Am J Respir Crit Care Med 1994;150:1493-1498
   Web of Science | Medline

3. 3

   Tindall B, Cooper DA, Donovan B, et al. The Sydney AIDS Project: development of acquired immunodeficiency syndrome in a group of HIV seropositive homosexual men. Aust N Z J Med 1988;18:8-15
   CrossRef | Medline

4. 4

   Newton CA, Klein TW, Friedman H. Secondary immunity to Legionella pneumophilia and Th1 activity are suppressed by delta-9-tetrahydrocannabinol. Inject Infect Immun 1994;62:4015-4020
   Web of Science | Medline

5. 5

   Sherman MP, Campbell LA, Gong H Jr, Roth MD, Tashkin DP. Antimicrobial and respiratory burst characteristics of pulmonary alveolar macrophages recovered from smokers of marijuana alone, smokers of tobacco alone, smokers of marijuana and tobacco, and nonsmokers. Am Rev Respir Dis 1991;144:1351-1356
   Web of Science | Medline

Author/Editor Response

Dr. Kassirer replies:

Let's set the record straight. I recommend that only desperately ill patients be allowed to use marijuana, that only physicians prescribe it, and that the government regulate it. Like some of the writers, I am opposed to the referendums in California and Arizona, and I stated publicly on several occasions that I would have voted against them. My argument for prescribing marijuana for seriously ill patients without requiring further research was based on compassion for these suffering people and on the grounds that short-term use of the agent is virtually harmless. If the only effect in these patients is to produce euphoria, so what? In fact, I did support more research on the effectiveness of marijuana in comparison with available agents, but I made two points: first, that such research is extremely difficult because the outcomes that are evaluated are entirely subjective, and second, that the government — despite nearly a century of mechanisms for assessing safety and efficacy — almost never permits clinical research on marijuana.

Reasonable people differ on the possible consequences of my proposal. I disagree that the compassionate provision of marijuana to very sick people would lead to more widespread abuse of marijuana; such abuse is a function of the availability of street drugs, not prescription drugs. There is no comparable epidemic of morphine or meperidine use. Similarly, though putting physicians in charge of prescribing marijuana would increase their burden somewhat, making decisions about who should receive which drugs (and how often) is precisely what doctors do well. It is hard to imagine why malpractice claims and costs would increase if physicians were made responsible for prescribing just one more controlled substance.

It is true that smoking is not a traditional means of delivering a medication, yet inhalers are used for many conditions, and the pulmonary route of absorption is extremely effective for many agents. I am sure that we could find some way of dealing with smoking in hospitals, maybe by allowing patients to use marijuana in other forms.

Finally, I believe that the influence of marijuana on immunity in humans requires far more confirmation. The scattered anecdotal reports of an association of marijuana with aspergillus infections in patients with HIV infection are worrisome, but an association alone does not prove causality. Aspergillus species are also found in the air, the soil, and plant matter such as tobacco. In addition, all the patients in the Journal article who were infected with aspergillus must have been severely immunosuppressed, because they had already had serious infections with other opportunistic organisms. Needless to say, claiming cause and effect in such patients is treacherous.

Jerome P. Kassirer, M.D.