April 16, 1999

By Richard Karel

More than two years after skeptical federal drug control policy director Barry McCaffrey requested an objective report on marijuana's medical potential, a prestigious scientific body has issued a qualified endorsement of marijuana as medicine.

The report from the Institute of Medicine (IOM), a branch of the National Academy of Sciences (NAS), created headlines nationwide. The IOM qualified its endorsement by noting that inhaling smoke is potentially harmful and by urging, as an alternative, development of a bronchial inhaler.

The IOM also suggested that the future lies not in the use of whole marijuana, but rather in the development of therapeutic compounds based on cannabinoids, the active compounds in marijuana.

While the IOM was specifically prohibited from commenting on legal issues, it suggested that a program of compassionate provision of marijuana could be implemented until an inhalation device was developed. Such a program was killed in March 1992 by then Health and Human Services Secretary Louis Sullivan, M.D. At the time 13 patients were legally receiving government-grown marijuana. Only eight of those patients survive today, and they are the only people legally using marijuana in the U.S.

Researchers at Virginia Commonwealth University (VCU) in Richmond have successfully tested a THC inhaler on mice, but no human trials have been conducted, according to Billy Martin, Ph.D., the Louis and Ruth Harris Professor of Pharmacology and Toxicology at VCU and one of the 11 experts who produced the IOM report.

The IOM report strongly endorsed clinical trials. "Patients who are prescribed marijuana should be enrolled in short-term clinical trials" with oversight from an institutional review board or similar entity, said co-principal investigator John Benson Jr., dean and professor of medicine emeritus at the Oregon Health Sciences University School of Medicine in Portland. Such trials should involve "only those patients most likely to benefit," such as people with "debilitating symptoms that do not respond to approved medications" or the terminally ill, Benson said.

So far, there is little indication the report will spur a change in federal marijuana policy.

Donald Vereen Jr., M.D., is the deputy director of the Office of National Drug control Policy (ONDCP) and a corresponding member of the APA Council on Addiction Psychiatry. He told Psychiatric News that individual physicians and patients have no authority to make medical policy and suggested that there has been little legitimate research on marijuana because organized medicine, including APA and the AMA, expressed little interest until the recent controversy. Vereen branded as "irresponsible" physicians who recommend marijuana to sick patients, and he endorsed the continuing arrest of marijuana users, whether sick or well.

"What the report does in general terms is that it makes it clear that this is a medical research issue," he commented. "Individuals and individual doctors don't make medical policy and that's what this is-it's a medical policy issue, it's not just a drug control issue."

Physicians who recommend marijuana to their patients "are also recommending that their patients break the law, too, and I would argue that's irresponsible."

A person who says that he or she is using marijuana for medical reasons is no more entitled to leniency than would be someone who said he or she was using cocaine for its antidepressant effects, said Vereen. "If you claim to be using cocaine to treat depression, you are going to get arrested just as fast," he commented. "It doesn't matter what the excuse is, because you are practicing medicine without a license."

"I think APA should support the [IOM's] recommendations for continued research and clinical trials on a research basis," Richard Suchinsky, M.D., vice chair of APA's Council on Addiction Psychiatry, told Psychiatric News. "The recommendation for short-term use of smoked marijuana under strict conditions for patients with debilitating symptoms merits consideration" with attention given to defining "strict conditions" and "short-term use," he added.

The issue has generated interest within APA, which approved a policy guideline on medical marijuana in December 1997.