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MARIJUANA, THE AIDS WASTING SYNDROME,
AND THE U.S. GOVERNMENT
To
the Editor: Evidence of the therapeutic value and limited toxicity of marijuana
in the treatment of various symptoms and syndromes is rapidly accumulating. Patients
with glaucoma, migraine, epilepsy, multiple sclerosis paraplegia, quadriplegia, the AIDS
wasting syndrome, or nausea and vomiting due to chemotherapy for cancer have risked severe
penalties to acquire cannabis, because they find it more useful than legally available
medicines.1,2 The U.S. government has consistently refused to permit prescription sales
of marijuana, insisting that the evidence of its safety and efficacy is inadequate.
In response to a lawsuit brought by advocates
of the medical use of marijuana, an administrative law judge with the Drug Enforcement
Administration (DEA) recommended in 1988 that the federal legal classification of
marijuana be changed so that physicians can prescribe it.3 The DEA did not implement the
recommendation. In 1992, Richard Bonner, then DEA administrator, offered this
suggestion: "Those who insist that marihuana has medical uses would serve society
better by promoting or sponsoring more legitimate scientific research, rather than
throwing their time, money, and rhetoric into lobbying, public relations campaigns, and
perennial litigation."4
Encouraged by this declaration, Donald Abrams,
of the University of California, San Francisco, sought permission to conduct a privately
financed pilot study comparing three potencies of inhaled marijuana (high, medium, and
low) with oral delta-9-tetrahydrocannabinol (dronabinol) capsules, which are available by
prescription in the United States, for the treatment of weight loss associated with the
AIDS wasting syndrome. Dr. Abrams's protocol (Investigational New Drug No. 43,542)
was designed in consultation with the Food and Drug Administration (FDA) and approved by
the FDA, the University of California, San Francisco, institutional review board, the
California Research Advisory Panel, and the scientific advisory committee of the San
Francisco Community Consortium.
Unfortunately, the U.S. government will not
allow Dr. Abrams to obtain a legal supply of marijuana. The DEA refused to permit
him to import marijuana from Hortapharm, a company licensed by the government of the
Netherlands to cultivate cannabis for botanical and pharmaceutical research. The
National Institute on Drug Abuse (NIDA), which controls the domestic supply of marijuana
for clinical research, rejected Dr. Abrams's request in April 1995. The letter of
rejection, from NIDA director Alan I. Leshner, was sent nine months after Dr. Abrams had
submitted his request.
Given the limited sources of support for
research on marijuana (pharmaceutical companies, for example, are not interested in
supporting such research), the U.S. government by now should have taken note of the
increasingly persuasive therapeutic claims and sponsored its own clinical trials through
the National Institutes of Health. Instead, as Dr. Bonner's remark and the handling
of Dr. Abrams's protocol indicate, the government has responded by urging others to
investigate the medical potential of marijuana and then creating obstacles that make the
research impossible to pursue.
Boston, MA 02115 |
LESTER GRINSPOON, M.D. |
Cambridge, MA 02138 |
RICK DOBLIN |
Editor's note: Drs. Leshner and Abrams
were offered the opportunity to respond. Dr. Leshner declined to do so. Dr.
Abrams's reply follows.
To the
Editor: The San Francisco Community Consortium is an association of providers of care
for patients infected with the human immunodeficiency virus (HIV) in the San Francisco Bay
area. The consortium conducts community-based clinical trials of therapies of
potential benefit to our patients. Inhaled marijuana is being used increasingly by
people with HIV infection, especially for its purported benefit as an anti-emetic agent
and an appetite stimulant in those with the AIDS wasting syndrome. Up to 2000 people
infected with HIV are reported to be obtaining marijuana at a cannabis buyer's club in our
area. The California State Assembly has recently endorsed legislation to make
medicinal marijuana available to patients with life-threatening illnesses.
In an effort to determine whether inhaled
marijuana is truly of any potential benefit and, more important, to evaluate its safety in
people with AIDS, the Community Consortium designed a pilot study. We thought it
would be appropriate to conduct a small study of the overall feasibility of investigating
inhaled marijuana use by such patients, before embarking on a full-scale trial of its
efficacy. The pilot-drug-evaluation staff at the FDA provided valuable comments on
the design of the protocol. Pulmonary-function tests, lymphocyte-sub-group analyses,
and measurements of viral burden by the branched-DNA technique were to be performed
serially for safety. Body composition was to be measured by state-of-the-art
techniques to assess potential trends in the amelioration of wasting.
The FDA and the institutional review board
supported the study. Unfortunately, the DEA and the NIDA opposed it. Most
disturbing was the absence of a response from either agency for an unacceptably long
period, followed by the NIDA's outright rejection of the proposal without any opportunity
for dialogue or compromise. Such behavior is offensive not only to the investigators
but to the patients for whom we seek to find safe and effective treatments.
San Francisco, CA 94143 |
DONALD I. ABRAMS, M.D. |
New England Journal of Medicine
Sept. 7, 1995
Vol. 333 No. 10 pp. 670-671