Pubdate: Tue, 27 Apr 1999 Source: Washington Post (DC) Page: A17 Copyright: 1999 The Washington Post Company Address: 1150 15th Street Northwest, Washington, DC 20071 Feedback: http://washingtonpost.com/wp-srv/edit/letters/letterform.htm Website: http://www.washingtonpost.com/ Author: Robert L. DuPont Note: The writer was director of the National Institute on Drug Abuse from 1973 to 1978. He is now a clinical professor of psychiatry at Georgetown Medical School. MEDICINE -- NOT POT Last month the Institute of Medicine released a report in response to the two-year-long wave of ballot initiatives supporting medical marijuana. It assessed the scientific base of the claim that suffering terminally ill people are unnecessarily deprived of a useful treatment by drug laws that criminalize smoking. There has never been controversy about the use of purified chemicals in smoke to treat any illness, as witnessed by the availability of synthetic tetrahydrocabinol (THC) since 1985. The only dispute between the drug-law hawks and doves is the place of smoked marijuana in medical treatment. The institute's report, balanced and firmly rooted in three decades of scientific research, reached this conclusion: "Although smoke delivers THC and other cannabinoids to the body, it also delivers harmful substances, including most of those found in tobacco smoke. In addition, plants contain a variable mixture of biologically active compounds and cannot be expected to provide a precisely defined drug effect. For those reasons, the report concludes that the future of cannabinoid drugs lies not in smoked marijuana but in chemically defined drugs that act on the cannabinoid systems that are a natural component of human physiology. Until such drugs can be developed and made available for medical use, the report recommends interim solutions." Here are the details of its interim solution: "Short-term use of smoked marijuana (not more than 6 months) for patients with debilitating symptoms (such as intractable pain or vomiting) must meet the following conditions: "failure of all approved medications to provide relief has been documented; "the symptoms can reasonably be expected to be relieved by rapid-onset cannabinoid drugs; "such treatment is administered under medical supervision in a manner that allows for assessment of treatment effectiveness; "and involves an oversight strategy comparable to an institutional review board process that could provide guidance within 24 hours of submission by a physician to provide marijuana to a patient for a specified use." The best hope for a resolution of this medical conflict would be for the National Institute on Drug Abuse (NIDA) to fashion definitive clinical trials of smoked marijuana vs. other standard treatments for the indications the Institute of Medicine identified (anxiety reduction, appetite stimulation, nausea reduction and pain relief). This was how a similar call for legal heroin for terminal cancer pain was disposed of a decade ago. A controlled trial conducted at Sloan-Kettering, (funded by NIDA), showed that heroin offered no advantages compared with standard pain treatments. If new trials were to show superiority for smoked marijuana, and if there was no way to identify and deliver purified chemicals with less toxicity than smoke, then I would have no objection to a carefully monitored, medically supervised use of smoked marijuana in settings that discouraged diversion. There is no controversy in the United States today about the medical use of opiates (including those derived from natural opium, as is heroin) or cocaine. The concern now is that smoked marijuana has not been shown to be superior to other treatments for any illness. Most supporters of medical marijuana do not understand three facts that were made clear in the Institute of Medicine's report: (1) "The effects of cannabinoids on the symptoms studied are generally modest, and in most cases, there are more effective medications." In other words, do not look for anything dramatic from this class of chemicals. This may explain why marijuana's chemicals have produced little enthusiasm from pharmaceutical companies. (2) Modern medicine does not burn leaves and ask sick patients to inhale the smoke. It identifies individual chemicals and delivers them in purified, often synthetic, form to treat specific illnesses. (3) Marijuana smoke is not only unstable but toxic, like tobacco smoke. These characteristics make smoked marijuana unsuitable as a medicine. Clinical trials will take several years, and they are expensive. The most regrettable aspect of this process is that scarce medical research money will be wasted on tests of the chemicals in smoke that have little medical value. Nevertheless, the political momentum created by the marijuana advocates has made it essential that these clinical trials go forward to demonstrate to a skeptical public how smoked marijuana stacks up against standard treatments. I hope that the people who now are advocating a science-based approach to this politicized problem, including the Institute of Medicine, understand that these efforts, even if completely successful, will have little impact on the pro-marijuana forces, whose only interest is free access to the drug. They do not want clinical trials, and they do not want purified or synthetic cannabinoids. They want smoked dope. The writer was director of the National Institute on Drug Abuse from 1973 to 1978. He is now a clinical professor of psychiatry at Georgetown Medical School. - --- MAP posted-by: Jo-D