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State of Iowa
Board of Pharmacy Examiners
1209 East Court Avenue, Executive Hills West, Des Moines, Iowa 50319-0187
Telephone: (515) 281-5944 Facsimile: (515) 281-4609

BOARD MEMBERS   BOARD MEMBERS
MARIAN L. ROBERTS
Laurens

  MATTHEW C. OSTERHAUS
Maquoketa

PHYLLIS A. MILLER
Leon

PHYLLIS A. OLSON, Urbandale
Chairperson

ARLAN D. "JACK" VAN NORMAN
Swea City

MARY PAT MITCHELL
Council Bluffs
LLOYD K. JESSEN, R.Ph., J.D.
West Des Moines
Executive Secretary/Director

MELVIN L. GRUNDLEGER
Clive
March 10, 1995

Senator Elaine Szymoniak
The Iowa Senate
Statehouse
L O C A L

Dear Senator Szymoniak:

I am again writing in response to your letter dated February 23, 1995,
concerning the medicinal use of marijuana.  Board members and staff have
conducted an extensive review of the medical literature pertaining to
medical marijuana, including American, British, and Australian sources.
Our search included all of the references listed at the end of this
letter.  The Board believes that the pertinent medical literature
supports its opposition to marijuana for therapeutic purposes and offers
the following information for your review:

1.     "...[T]he essence of arguments on both sides revolves around how
much research is enough...despite published studies, very little still is
known about the extent of marijuana's physiological and psychoactive
effects."1

2.     Janet D. Lapey, M.D., the executive director of Concerned Citizens
for Drug Prevention, Inc., is one of medicinal marijuana's most vocal
opponents.  Dr. Lapey has stated that "crude marijuana contains some 400
chemicals, many unidentified, that, when smoked, combust into more than
2,000 chemicals, including carcinogens and toxins such as benzene and
toluene.1  Cannabis has also been described by C. H. Ashton as "a prime
example of a pharmacologically 'dirty' drug.  It contains many active
substances with multiple effects and several (unknown) mechanisms of
action."21

Senator Elaine Szymoniak            Page 2                 March 10, 1995

3.     Dr. Lapey has also stated that the National Institutes of Health
reports that "new drugs, including the serotonin receptor antagonist
ondansetron hydrochloride (Zofran...), surpass THC's therapeutic value in
calming cancer patients' chemotherapy-induced nausea.  For HIV wasting
syndrome, she points to the availability of dronabinol, noting the
potential dangers of immunocompromised patients smoking a carcinogen-
containing substance."1

4.     Christine Hartel, Ph.D., the associate director for neuroscience
in the Division of Clinical Research at the National Institute on Drug
Abuse (NIDA), reinforces Dr. Lapey's remarks.  Dr. Hartel has stated
"that after 20 years of research that produced synthetic THC in
dronabinol capsules, 'the doctors and researchers at the NIH do not see
[inhaled] marijuana as having much promise'."1

5.     One recent article published In The Western Journal of Medicine
has stated the following: "Marijuana smoke contains carcinogens and more
tar than tobacco smoke, and the psychoactive effects of marijuana
ingestion have been implicated as a risk factor for injuries...daily
marijuana smoking appears to be associated with respiratory conditions
even among persons who never smoked tobacco."2  The study also found
"increased risks of injury-related and other (nonrespiratory, noninjury)
outpatient visits among marijuana smokers, suggesting that marijuana use
may have many adverse health effects" (emphasis added).2  The authors
concluded that "[D]aily marijuana smoking, even in the absence of
tobacco, appeared to be associated with an elevated risk of health care
use for various health problems."2

6.     Donald P. Tashkin, M.D., a professor of medicine at the University
of California School of Medicine in Los Angeles, has stated that
"[s]everal lines of evidence suggest that marijuana smoking is also
associated with an increased risk for the development of respiratory
tract malignancy."3

7.     Although the use of cannabis for medical purposes has been
legalized in Canberra, Australia, it remains highly controversial.  The
Australian federal health minister, the Australian Medical Association,
and the Australian federal police are all pressuring lawmakers to repeal
the new law.  The Australian Federal Attorney General has called on the
members who passed the law to "move quickly to repeal the amendments and
repair the damage done to the territory's reputation for responsible law
making."4

8.     Richard H. Schwartz, M.D., of the Fairfax Hospital for Children in
Falls Church, Virginia, has stated that "support of the use of marijuana
for medical purposes is  scientifically unfounded.  There is no evidence
that marijuana is superior to ondansetron (Zofran), dexamethasone, or
synthetic tetrahydrocannabinol (Marinol) as an antiemetic in patients
undergoing chemotherapy.  Nor is there scientific evidence to support the
use of marijuana for AIDS-associated anorexia, depression, epilepsy,
narrow-angle glaucoma, or spasticity associated with multiple sclerosis.
As a crude drug, moreover, marijuana has been shown to produce
undesirable mental changes, disturbances in coordination, giddiness, and
hypotension in at least 25 percent of novice users..."6

Senator Elaine Szymoniak            Page 3                 March 10, 1995

9.     Doris H. Milman, M.D., of the Children's Medical Center of
Brooklyn (New York) has stated that "[m]arijuana cannot be characterized
as 'a remarkably safe substance.'  Its  active ingredient,
tetrahydrocannabinol, may have some therapeutic value as an antiemetic
but has not been generally accepted thus far, because there are other,
more useful, such drugs and because its other applications are far from
established."6

10.    An Australian article published in 1992 concluded that "the
results of standard in-vitro and in-vivo toxicological tests performed in
the 1970s on animal preparations to which marijuana extracts were
administered have proved to be good predictors of the long-term
pathophysiological manifestations observed 20 years later in chronic
marijuana smokers.  These manifestations also confirm anecdotal accounts
reported throughout history of the damaging effects of cannabis."7

11.    Amanda Caswell, another Australian author, has warned that
"smoking is not an ideal method of drug delivery and chronic marijuana
smoking has been associated with bronchitis and asthma."8

12.    Several authorities have criticized the survey of oncologists
conducted by Richard E. Doblin and Mark A. R. Kleiman.  In their survey,
Doblin and Kleiman stated the  following: "Of the respondents who
expressed an opinion, a majority (54%) thought marijuana should be
available by prescription."12  In response, Richard H. Schwartz, M.D.,
has stated the following: "I calculate that this 'majority' can be no
more than 15% to 20% of the original sample and is probably much less."9
Sandra S. Bennett of the Oregon Federation of Parents for Drug Free Youth
stated the following in a letter to the editors of the Annals of Internal
Medicine: "
     I want...to point out that, although the authors [Doblin and
Kleiman] stated their association with the John F. Kennedy School of
Government of Harvard University, they failed to mention that Mr. Doblin
is the founder and president of the Multidisciplinary Association for
Psychedelic Studies (MAPS), referred to as the 'People's Psychedelic
Pharmaceutical Company' in their newsletter head.  The organization has
advocated research on humans with the street drug Ecstasy and the gradual
medicalization and legalization of psychedelics.
     In MAPS newsletters dated Summer 1990 and August 1991, Doblin
outlines a plan to use different forums, including Annals and the press,
to lend credibility to the campaign to legalize marijuana use and to
bolster a suit against the Drug Enforcement Administration.  I believe
that the authors' bias and hidden agenda should be made known to your
readers.9

13.    Stuart M. Levitz, M.D., of the Boston University School of
Medicine, has warned that "[p]atients should be aware that this practice
[of smoking marijuana] may involve unforeseen risks.  Studies have shown
that most illegally obtained marijuana is contaminated with Aspergillus
species...Aspergillus spores easily pass through

Senator Elaine Szymoniak            Page 4                 March 10, 1995

contaminated marijuana that is smoked...in immunocompromised patients,
invasive pulmonary aspergillosis may ensue.11

14.    Rayford Kytle, the spokesperson for the United States Public
Health Service, reports that scientists at the National Institutes of
Health (NIH) have concluded that existing medical evidence does not
support continuation of the policy that has allowed a small number of
cancer, glaucoma, and AIDS patients to smoke marijuana legally.  "NIH
scientists believe that there are better and safer treatments than smoked
marijuana for controlling chemotherapy-induced nausea, relieving eye
pressure caused by Glaucoma, and stimulating the appetites of patients
with HIV-wasting syndrome," Kytle has said.10

15.    J. Thomas Ungerleider, M.D., of the UCLA Center for the Health
Sciences, Department of Psychiatry, has stated the following:
     A special problem that arises when cannabis or THC is researched is
the positive and negative bias about the drug that the subject or patient
brings to the study.  Since it is believed that marijuana effects are
readily identified, then even in a blind study certain patients might
detect it, attribute magical powers to the drug, and overreport its
beneficial impact.  In the large cancer chemotherapy study recently
completed at UCLA, it was found that 75% of the patients were unable to
distinguish when they received THC and when they received Compazine.
     One thing is clear:  Marijuana is neither the wonder drug that some
people have assumed it is, nor the embodiment of evil that others assume.
If it finally gains some position in the medical armamentarium, it will
likely be a modest one, providing symptomatic rather than curative
relief.14

16.    The possible adverse effects of cannabis on health include the
following: impaired immunity; chromosomal damage; psychopathology
(including acute panic reaction, toxic delerium, acute paranoid states,
psychoses, flashbacks, violence, amotivational syndrome, residual
psychomotor impairment, and brain damage); tolerance and dependence, lung
problems; cardiovascular problems; eye problems; and effects on driving
an automobile.15

17.    Harry S. Greenberg, M.D., and others recently studied the effects
of smoking  marijuana on patients with multiple sclerosis.  "The
hypothesis of this study was that marijuana smoking would relieve the
spasticity of patients with multiple sclerosis (MS) sufficiently to allow
better postural control and thus produce a therapeutic
benefit...Marijuana smoking worsened the dynamic posturography of both
the patients and the control subjects.  Therefore the hypothesis that
initiated this research was not confirmed" (emphasis added).16

18.    According to a study on the management of cancer pain in adults
published in the American Journal of Hospital Pharmacy in 1994,
cannabinoids are not recommended for the treatment of cancer pain due to
adverse effects such as dysphoria, drowsiness, hypotension, and
bradycardia.17

Senator Elaine Szymoniak            Page 5                 March 10, 1995

19.    "Despite initial hopes...the therapeutic use of cannabinoids
remains limited."21

20.    Robert E. Peterson, director of Michigan's Office of Drug Control
Policy, has stated that "there's no...support from the medical community
when it comes to lifting the medicinal marijuana ban."1  He and other
opponents also say that medicalized marijuana is a smoke screen.  "The
only reason we're having the medical debate is because [advocates] want
it legalized for recreational use."1

21.    Lester Grinspoon, M.D., a leading advocate of marijuana's
medicinal value, admits  that a meaningful marijuana compassionate use
program would require "an army of bureaucrats..."1

In summary, the Board wishes to emphasize the following:

         The survey of oncologists conducted by Richard E. Doblin and
Mark A. R. Kleiman in 1990 has been questioned and criticized by medical
practitioners and others.  The findings of the survey may in inaccurate
and flawed.  As a result, we do not believe that the survey should be
relied upon.

         In regard to research, good data is lacking to prove the
therapeutic effectiveness of smoking marijuana.  While the Board does not
oppose research, we believe that it will be difficult for any researcher
to obtain unbiased data.

         Chemotherapy-induced nausea and vomiting is a very weak excuse
for justifying marijuana use.  New drugs, such as ondansetron
hydrochloride (Zofran), work very well to control nausea and vomiting in
cancer patients.

         Allowing AIDS or cancer patients who are already
immunocompromised to inhale marijuana smoke only exposes them to
additional health risks (bacterial infection, lung cancer, etc.).

         The purity and consistency of the marijuana product is a
significant factor.  The dose of active ingredient administered from
inhalation by smoking cannot be controlled.

         The offices of the Iowa Board of Pharmacy Examiners are
clerical offices.  The Board has no resources or laboratory facilities
available to it which would allow bench research or scientific
extrapolation of marijuana products to test for purity or quality.  The
statement in your letter of February 23, 1995, that "any marijuana
received [by the board]...shall be made free of impurities and analyzed
for potency by the board" is not possible due to the limitations of the
Board's current facilities and level of funding.

Senator Elaine Szymoniak            Page 6                 March 10, 1995

     Thank you for understanding the cautious attitude of the Board in
regard to this issue.  When regulating the practice of pharmacy, the
Board always strives to take whatever action is necessary to adequately
promote, preserve, and protect the public health, safety, and welfare.

Sincerely yours,


Lloyd K. Jessen
Executive Secretary/Director
IOWA BOARD OF PHARMACY EXAMINERS


cc:    Mark Schoeberl
       Legislative Liaison
       Iowa Department of Public Health

Senator Elaine Szymoniak            Page 7                 March 10, 1995

References

1.    Voelker, Rebecca, "Medical Marijuana: A Trial of Science and
Politics," Journal of the American Medical Association, June 1, 1994,
Volume 271, No. 21, pp. 1645 to 1648.

2.    Polen, Michael R., et. al., "Health Care Use by Frequent Marijuana
Smokers Who Do Not Smoke Tobacco," The Western Journal of Medicine, June
1993, Volume 158, No. 6, pp. 596 to 600.

3.    Tashkin, Donald P. M.D., "Is Frequent Marijuana Smoking Harmful to
Health?" The Western Journal of Medicine, June 1993, Volume 158, No. 6,
pp. 635 to 637.

4.    Zinn, Christopher, "Canberra legalises cannabis for patients in
trials," British Medical Journal, December 10, 1994, Volume 309, p. 1532.

5.    Tonks, Alison, "British patients demand to use cannabis," British
Medical Journal, December 10, 1994, Volume 309, pp. 1532 to 1533.

6.    "Correspondence," The New England Journal of Medicine, July 14,
1994, Volume 331, No. 2, pp. 126 to 129.

7.    Nahas, Gabriel, and Latour, Colette, "The human toxicity of
marijuana," The Medical Journal of Australia, April 6, 1992, Volume 156,
pp. 495 to 497.

8.    Caswell, Amanda, "Marijuana as medicine," The Medical Journal of
Australia, April 6, 1992, Volume 156, Issue 7, pp. 497 to 498.

9.    "Correspondence" (letter from Richard H. Schwartz, M.D., and letter
from Sandra S. Bennett), Annals of Internal Medicine, August 1, 1992,
Volume 117, No. 3, pp. 268 to 269.

10.   Bowersox, John, "PHS Cancels Availability of Medicinal Marijuana,"
Journal of the National Cancer Institute, April 1, 1992, Volume 84, No.
7, pp. 475 to 476.

11.   "Correspondence" (letter from Stuart M. Levitz, M.D.), Annals of
Internal Medicine, October 1, 1991, Volume 115, No. 7, pp. 578 to 579.

12.   Doblin, Richard E. and Kleiman, Mark A.R., "Marijuana as Antiemetic
Medicine: A Survey of Oncologists' Experiences and Attitudes," Journal of
Clinical Oncology, July 1991, Volume 9, No. 7, pp. 1314 to 1319.

13.   Busto, U., et. al., "Clinical Pharmacokinetics of Non-Opiate Abused
Drugs," Clinical Pharmacokinetics, Volume 16, Issue 1, pp. 1 to 26
(1989).

Senator Elaine Szymoniak            Page 8                 March 10, 1995

14.   Ungerleider, J. Thomas, M.D., et. al., "Therapeutic Issues of
Marijuana and THC (Tetrahydrocannabinol)," The International Journal of
the Addictions, Volume 20, Issue 5, pp. 691 to 699 (1985).

15.   Hollister, Leo E., "Health Aspects of Cannabis," Pharmacological
Reviews, Volume 38, Issue 1, pp. 1 to 20 (1986).

16.   Greenberg, Harry S., M.D., et. al., "Short-term effects of smoking
marijuana on balance in patients with multiple sclerosis and normal
volunteers," Clinical Pharmacology and Therapeutics, March 1994, Volume
55, Issue 3, pp. 324 to 328.

17.   Jacox, Ada, et. al., "Management of cancer pain: Adults," American
Journal of Hospital Pharmacy, July 1, 1994, Volume 51, Issue 13, pp. 1643
to 1656.

18.   Agurell, Stig, et. al., "Pharmacokinetics and Metabolism of
delta-1-Tetrahydrocannabinol and Other Cannabinoids with Emphasis on
Man*," Pharmacological Reviews, Volume 38, Issue 1, pp. 21 to 43 (1986).

19.   Dewey, William L., "Cannabinoid Pharmacology," Pharmacological
Reviews, Volume 38, Issue 2, pp. 151 to 178 (1986).

20.   Graves, Terri, "Ondansetron: A New Entity in Emesis Control," DICP,
The Annals of Pharmacotherapy, November 1990, Volume 24, Issue 11S, pp.
S51-S54.

21.   (Editorial) Ashton, C.H., "Cannabis: dangers and possible uses,"
British Medical Journal, January 17, 1987, Volume 294, Issue 6565, pp.
141-142.
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