Reporting on marijuana medicine

In 1997, the director of the White House Office of National Drug Control Policy (ONDCP), General Barry McCaffrey, wanted to solve a big public relations problem.
Even t2hough McCaffrey, several former presidents, and a flock of anti-marijuana pundits lobbied against medical marijuana ballot initiatives in California and Arizona, voters legalized medical marijuana in 1996.

McCaffrey told voters they were stupid, that marijuana was not medicine, that the federal government would continue to prosecute marijuana crimes, and that he would take action against any doctor who discussed medical pot with patients.

The General, who resigned from his ONDCP post in January, 2001, began a massive, taxpayer-funded, and probably illegal effort to defeat medical marijuana legislation in other states. Despite his efforts, seven other states have legalized medical marijuana.

Studying studies

In 1997, McCaffrey hoped to derail med-pot momentum by commissioning a report from the Institute of Medicine (IOM).

The IOM is an offshoot of an 1863 congressional charter establishing the National Academy of Sciences, which chartered the IOM as an independent scientific advisory entity in 1970.

According to IOM neuroscientist Janet Joy, ONDCP paid IOM $896,000 to create an unbiased scientific committee that would study medical marijuana and produce a comprehensive report on its dangers and medical uses.

Joy was study director for the report, titled Marijuana and Medicine ? Assessing the Science Base, which was released in 1999.

Publicly, medical cannabis advocates praised the report, noting that it didn’t endorse the claim that marijuana use leads to use of “harder” drugs, that it downplayed marijuana’s “addiction” and harmful side-effects potential, and that it acknowledged marijuana’s medical efficacy.

Privately, med-pot advocates criticized the report. They objected to the committee’s bedrock reliance on Westernized medical and scientific standards. They argued that the report focused too narrowly on unproven harms. They said the committee erred by refusing to give greater weight to “anecdotal” evidence ? reports from users who claimed that marijuana helped them medically. Some scientists said they’d offered pro-marijuana research to the IOM committee, but that the committee had deliberately failed to consider data favorable to marijuana.

ONDCP publicly criticized the report; McCaffrey dismissed it and contradicted it. He continued to assert that marijuana causes use of harder drugs, that marijuana was severely addictive, and that marijuana has no medical usefulness.

Joy defended the 1999 report, saying it reflected the most rigorous academic standards.

“We evaluated 2000 studies,” she said. “We didn’t miss any substantive peer-reviewed work. We’re not part of the government ? we’re independent. ONDCP came to us with a politically charged study. We agreed to do the study, and then we told them to go away and let us do it. We told them nothing else until we went public. They can say, ‘Hey, this isn’t what we hoped for,’ but we said, ‘Well, that’s what the committee found.’ The people we selected for our committee were unbiased scientists who were not affiliated with anti or pro groups. The ’99 report has stood the test of time.”

Follow-up book

The 1999 report is now augmented by a new IOM publication. Titled Marijuana as Medicine ? The Science Beyond the Controversy, the new book seeks to explain and expand the 1999 report.
Joy says the first IOM marijuana book was primarily for “policymakers and scientists.”

“The follow-up book is written for the general public who have heard that marijuana can help you, to tell them what science says,” Joy reported. “It also discusses marijuana’s legal status. Most people believe that once a state medical cannabis law has been passed that it’s then ok to get marijuana, that it’s legal. Unfortunately, it’s nowhere near that simple because state laws are in conflict with federal laws, and because state governments take time to put implementation policies into effect.”

The new book was updated to also include news about medical marijuana clubs, and about med-pot clinical trials that are ongoing or planned in England and Canada, as well as a completed San Francisco HIV/pot study conducted by Dr Donald Abrams.

Addiction contradiction

Joy makes no apologies for the IOM’s “Western medicine, scientific approach” to marijuana, but she freely acknowledges that marijuana research and debate are clouded by politics, inadequate or ambiguous research results, and the complexities of marijuana’s botanical, chemical, pharmacological, and physiological actions in humans.

“The IOM is firmly in the camp of evidence-based medicine that measures how widely a substance affects people, does it harm people, can study results be replicated,” she said. “The caveat is that we are all different. For some people the regular medications don’t work, so maybe those people should be allowed to branch out and look at unproven medicines.”

The most interesting and useful aspects of both IOM books deal with marijuana’s medical utility, as well as its potential to harm users.

Joy says that people who “branch out” to medical marijuana should be aware that “marijuana is a powerful drug that affects the body and mind in a variety of ways; it is not a completely benign substance.”

At the top of the list for marijuana’s supposed negative effects are addiction, abuse, cognitive impairment, and respiratory damage, Joy says.

“Marijuana can be addictive, but the medical definition of addiction is a lot more mild than the general public realizes,” she reports. “People envision addiction as those horrible sweating, writhing withdrawals from heroin, but addiction in our terminology has a far lower threshold than that. Marijuana does qualify as an addictive substance, but the report notes that we have a lot of addictive substances in our medical choices. We manage that, and marijuana’s addictiveness can also be managed.”

Marijuana addiction, abuse or dependence are diagnosed when users need bigger and bigger doses to get high, when their drug use interferes with health or important life activities and goals, when they try to quit using marijuana and find that it’s hard to do so, and when users who quit experience a characteristic withdrawal syndrome that includes insomnia, irritability, nausea or cramps.

Joy notes that marijuana’s harmful effects, withdrawal symptoms and addiction potential are milder than all other commonly abused drugs; she adds that the IOM rejects drug warrior assertions that all use of marijuana is abuse.

“You can’t kill yourself with a single dose of marijuana, which you can do with alcohol, sleeping pills, or other substances,” Joy said. “I’ve heard people say that the withdrawal effects of quitting caffeine are more severe than for quitting marijuana. Maybe five percent of the people who try marijuana will become dependent on it.”

Who’s most at risk for having problems with marijuana?

Joy’s book says that men are nearly twice as likely as women to become dependent on “illicit” drugs, and that white Americans are twice as likely as black Americans to become drug dependent. People between the ages of 25 and 44 are at least three times as likely to abuse drugs as those aged 45 or older. Adolescents are more likely to abuse drugs than are adults; people with psychiatric disorders, especially schizophrenics, are another group at high risk for drug abuse. People with heart problems also need to be careful ? marijuana can cause heart rate increases.

Studies with twins indicate that people “inherit the tendency to enjoy marijuana’s effects? [and]may be genetically predisposed to becoming regular users,” the book says.

Who’s impaired?

Joy’s book alleges that marijuana causes short-term memory loss, impairs coordination and attention, and can create severe, unpleasant reactions, especially in novice users.

The book further states that medical marijuana’s usefulness is unproven for many conditions, and that smoked marijuana is an unacceptable delivery system that can cause respiratory harm.

Joy acknowledged that evidence used to back up these assertions is often contradictory and incomplete, and that other statured scientists differ with the IOM in their interpretations of studies and about marijuana’s potential for harm.

For example, a new book by Oxford University pharmacologist Leslie Iversen, The Science of Marijuana, examines marijuana’s harmfulness and medical efficacy, but sounds a more positive tone than the IOM reports, which imply that many medical marijuana patients wrongly believe that pot is the best medicine available to them.

“When we look at marijuana’s effect on glaucoma, for example, we find a number of problems,” Joy says. “It’s true that THC can lower intraocular pressure (IOP), and that standard treatments for glaucoma lower IOP, but nobody has actually shown that high IOP causes glaucoma ? it’s a symptom. Medical marijuana glaucoma patients like [federal med-pot recipient]Elvy Musikka are correct in stating that early glaucoma drugs didn’t work well and had nasty side-effects, but there are other drugs available now that don’t have those effects and that work for longer time periods. Using marijuana to lower IOP, you have to dose yourself about every five hours. If the goal is to fight glaucoma, marijuana simply isn’t the best drug available.”

Joy acknowledged that medical marijuana patients criticized the IOM for allegedly “devaluing” the validity of their marijuana experiences.

“It’s a difficult situation, and I have to emphasize that we think there’s a big difference between medical use and recreational use,” Joy explained. “The problem is that marijuana doesn’t work the same way for everybody. It has different effects in different people, and a lot of people find the side effects of marijuana intolerable. Some patients get very nervous and paranoid when they smoke marijuana. Others find that the euphoria that marijuana produces makes them uncomfortable. Some patients report unpleasant emotional effects. That’s why we can’t state that marijuana helps glaucoma based just on Elvy’s testimony. At best, these anecdotal reports show you a vision of what might be possible. It gives you an insight into what kinds of medicines might be developed from marijuana’s constituents.”

Joy says that critics should note that the IOM research committee took public testimony from citizens.

“We included patients’ reports in the IOM study,” Joy explained, “even though this created harsh criticism, mainly from people who oppose marijuana, that such inclusion was unscientific. One reason that we did this was to put a human face on the report. We wanted to show that medical marijuana users aren’t a bunch of crazy drug addicts or recreational smokers, or old leftover hippies who are absolute proponents of all uses of marijuana. Many of these patients are real people with ordinary lives who have terribly frustrating medical problems. They believe marijuana helps them, and in some cases, science backs them up.”

Cannabis confusion

It’s debatable whether cannabis causes mental confusion for users, but the cannabis debate certainly causes confusion.

Janet Joy is a joy to talk to, one of few statured “straight” scientists willing to speak candidly for publication in a “pro-marijuana” magazine. Joy is not rigidly opposed to cannabis users or uses; she says she is excited about future cannabis research.

On the other hand, the IOM pot studies have limitations that derive from the paradigms governing the organization’s charter and the field of health care science.

Perhaps the most influential of these paradigms is “scientism,” the unwavering belief that scientific methods are reliable, unbiased, and ultimately revelatory. In the med-pot controversy, the scientism paradigm dictates that scientific research alone should decide whether a medicine is sufficiently safe and effective for patient use.

American-style drug approval regimes assert that science-based pharmaceutical investigations subject medicines to intense scrutiny and approval regimens, thus ensuring that people can safely use “approved” drugs as directed with no fear of harmful side-effects. Yet, many drugs approved by America’s Food and Drug Administration (FDA) have later been found to be harmful and even fatal, even when used as directed.

Marijuana is safer than most drugs it competes with, but Joy’s book repeatedly expressed worry that marijuana might have hidden harmful effects that are not yet apparent.
Such fears dwell within the ideology of government-doctor-pharmaceutical company drug control hierarchies, as does the belief that external authorities ? bureaucrats, politicians, scientists, doctors, regulators ? get to decide which medicines people are allowed to use.

Plant drugs remain criminalized; money-motivated people are granted permission to create synthetics to replace natural medicines that have wrongly been deemed dangerous.
Both IOM books admit that cannabis produces medical benefits and that research might reveal even more medical uses. Even so, the last paragraph in Marijuana as Medicine concludes that scientists will eventually learn to manipulate the body’s internal cannabinoid systems using substances other than marijuana.

After marijuana has yielded up its secrets and been replaced by “superior” drugs, the book gloomily asserts, “…the medical use of marijuana should fade as a topic of heated debate to a footnote in the history of medicine.”

Perhaps medical marijuana advocates can best hope that Joy’s spirit of compassion regarding marijuana’s legal status will influence policymakers at ONDCP, DEA and other drug war agencies.

“The marijuana debate is polarized, and that isn’t good for science, recreational users or patients,” Joy said. “America is a country that doesn’t like gray areas, but marijuana is a complicated issue. You can’t say it’s all bad or all good. We have so many medications like that; most of our effective medications have a downside. The thing I find most troubling is the current approach, which takes people with health problems, or substance abuse problems, and makes criminals out of them. That’s not good medicine.”

? Marijuana and medicine, and Marijuana as medicine, are both available to be read online at