SOURCE: Medical Tribune News Service

The Medicolegal Muddle of Medicinal Marijuana
BY NICHOLAS K. ZITTELL

Dec. 30, 1996, was a day that may not necessarily live in infamy,
but certainly one that lives on in the minds and hearts of the legislators,
lawenforcement officials, physicians and patients who are at painful
odds over the value of medicinal marijuana.

In a press conference that became the flash point over the national
media dialogue over proposition 215, the government 'drug czar' Gen.
Barry McCaffrey, reaffirmed Drug Enforcement Administration policy
to revoke the registration of any physician who ``prescribes''
marijuana to any patient.

At the time, the American Medical Association exhorted on the
administration directive, advising doctors to stick to ``effective, legal
medications available to compassionately treat disease and relieve
pain.''

The protagonists in this debate sit in two distinct camps: one says that
marijuana is a cheap and effective treatment for HIV/AIDSrelated
loss of appetite, glaucoma and for the nausea and vomiting that
accompany chemotherapy and opioid narcotics for pain; while the
other insists that it's an illicit compound that, if made available for
medicinal purposes, will lead to the slippery slope of heavier drug use.

Amid the posturing between the clinical utilitarians and the 'reefer
madness' patrol, we have lost sight of the fact that there are effective
medications for nausea and vomiting on the market, and that many
doctors who treat AIDS and cancer patients are unaware of these
agents, which include ondansetron (marketed as Zofran by Glaxo) and
dronabinol (sold as Marinol by Roxane). The latter contains a
synthetic form of the active ingredient in marijuana called
tetrahydrocannabinol.

A California internist, who professed to having the largest medical
practice in the United States devoted to HIV treatment and research,
stopped by the offices of Medical Tribune recently to decry the lack
of awareness of dronabinol among doctors and to sing the praises of
the drug.

Dronabinol is generally welltolerated by patients, can be dosed to
individual needs (apparently in some patients, one capsule can make
patients too stoned to eat, or they just fall asleep) and the
manufacturer has helped to establish a program to cover the costs for
uninsured and indigent AIDS patients.

Others are less sanguine about dronabinol. As one Florida internist put
it: ``My HIV/AIDS and cancer patients are underwhelmed and
unimpressed...with its marginal effects...and outrageous price (about
$10 a day).'' The camps remain firmly entrenched.

Some doctors who have to constantly look over their shoulder when
prescribing opioid narcotics also would be fearful of recommending
another drug like dronabinol. (The same DEA that threatens sanctions
against physicians who prescribe marijuana also plays watchful big
brother for those doctors who write too many morphine
prescriptions.)

While I support the renewed focus on a drug that is a welcome
addition to the AIDS armamentarium, let's not forget that many of
these patients are taking up to 10 drugs a day (protease inhibitors,
antifungals, antibacterials, etc.), and one more bigticket item can
strain if not break the back of an AIDS patient's healthcare plan.

A study released in July by the National Alliance of State and
Territorial AIDS Directors and the AIDS Treatment Data Network
uncovered evidence that up to 22 states have imposed emergency
restrictions on the number of people enrolled in their AIDSdrug
assistance programs.

Concerns over fears about potential habituation and the moral
denigration of our nation's youth cloud the fact that marijuana, in
therapeutic doses, is less toxic than many chemotherapeutic agents.

It's also cheap.

Marijuana may very well be a treatment of last resort for cancer and
AIDS patients with unremitting loss of appetite and nausea; but it is
important to have such drugs in our pharmacopeia.

Nicholas K. Zittell is editor in chief of the Medical Tribune, based in
New York.