Myths and Misconceptions about Drug Legalization: US Dept. of Justice

Chapter Seven: Medical Uses of Presently Illegal Drugs

DISCUSSION

I. Their Argument

Proponents of legalization suggest that even if drugs such as cocaine, marijuana, and heroin are not fully legalized, they should be made more available as forms of medical treatment. For example, legalizers suggest that heroin should be used much in the same way as is morphine presently and that marijuana should be used in treating glaucoma and the side-effects of chemotherapy.

II. Our Argument

In order to fully analyze the debate surrounding the medical uses of heroin and marijuana, each drug should be discussed in turn.

1. Heroin

Heroin is an opiate, as are drugs such as morphine. Legalizers suggest that because morphine does not always succeed in relieving the pain of, for example, cancer patients, the only logical step is to try heroin. This is factually incorrect.

In order to understand why this argument is flawed, one must know how heroin and morphine differ from one another. As Drs. Robert McCarthy and Michael Montagne explain, "Kaiko, et al. found that although heroin is more potent - and achieves peak pain control and mood elevation effects faster, both pain control and mood elevation are more prolonged with morphine. "116 That is, heroin gives you a quicker "high," but morphine provides longer-lasting effects. Furthermore, we have many other opioids available under present pharmaceutical laws. As Professor Arthur G. Lipman explains,

[s]ome advocates of heroin legalization argue that it should be available as an alternative opioid because some patients respond better to one opioid than another. That is true. However, we already have a variety of opioids commercially available in this country. If a patient does not respond to morphine as expected, it would be more logical to use a chemically different opioid (e.g., hydromorphone, methadone) than a morphine product [such as heroin]. Therefore, the argument for heroin is not logical. 117

Not only is Professor Lipman's argument medically sound, but it makes common sense. Heroin and morphine have similar chemical structures. If morphine does not work for a given patient, it makes more sense to try an opioid with a different chemical construct than to give them a drug very similar to the one that is not working.

These two facts----that heroin does not produce as constant and prolonged a treatment as does morphine, and that many other opioids presently exist that can do the job better than heroin in the event that morphine does not work - help to explain why the vast majority of medical society members do not favor the use of heroin as a form of therapeutic treatment. The British doctors who initially suggested the viability of therapeutic heroin treatment long ago reversed their position.118 And although Maurice Bectel, President of the American Pharmaceutical Association, admits that problems do exist in the treatment of cancer pain, these problems stem largely from the fact that "physicians fail to prescribe proper dosages of existing medications, not because of the lack of availability of heroin."119 Indeed, as Professor Lipman correctly notes, "[i]f the energy devoted to legalizing heroin were redirected toward better use of available opioids, patients would benefit.120

But not only is allowing the therapeutic use of heroin unnecessary, it also could create other problems. For example, increased medical use of heroin increases the risk of "diversion"-- that the patients would sell their heroin on the black market.121 Also, if pharmacies routinely stocked a supply of heroin, it would increase the risk of burglaries. This fact gives one special concern when one notes that fully 50% of burglaries against pharmacies are committed with the intention of stealing controlled substances.122

In short, Lipman concludes that "[m]isinformation about heroin has clouded the issue, but there is

valid, published scientific evidence that unequivocally refutes the argument that heroin should be legalized."123

116 Robert L. McCarthy and Michael Montagne, "The argument for therapeutic use of heroin in pain management," American Journal of Hospital Pharmacists, May 1993.

117 Arthur G. Lipman, "The argument against therapeutic use of heroin in pain management,"

American Journal of Hospital Pharmacists, May 1993.

118 Id.

119 Robert L. McCarthy and Michael Montagne, "The argument for therapeutic use of heroin in pain management," American Journal of Hospital Pharmacists, May 1993.

120 Arthur G. Lipman, "The argument against therapeutic use of heroin in pain management," American Journal of Hospital Pharmacists, May 1993.

121 Id.

122 Id.

123 Id.

2. Marijuana

a. Treatment for glaucoma

Glaucoma is a disease in which the fluid pressure within the eyeball (known as the intraocular pressure) increases and thereby damages the optic nerve, potentially causing blindness. Legalizers advance the claim that marijuana can decrease the intraocular pressure and thereby prevent blindness. Let's look at this claim.

First, the studies that the legalizers cite for support of their propositions assume the use of THC itself rather than marijuana.125 Thus while one may claim that THC decreases intraocular pressure, it is not technically correct to claim that marijuana does as well.

Second, even if marijuana does decrease intraocular pressure, it does so only at high dosages - in order to get the benefits, you have to stay stoned all day. Doctor Keith Green suggests that in order to decrease intraocular pressure, one would have to smoke the equivalent of six joints a day.126 Michael Van Buskirk, Director of Glaucoma Services and Chairman of the Department of Ophthalmology at Devers Eye Institute agrees, stating that "[a]lcohol also produces a profound reduction in . . . intraocular pressure. 'Me recommendation to use marijuana is exactly analogous to the recommendation to ingest alcohol and maintain a state of drunkenness to treat glaucoma."127

Third, even if marijuana successfully combats one symptom of glaucoma - intraocular pressure - it does so at the expense of exacerbating another symptom. For while marijuana may decrease intraocular pressure, it also decreases blood pressure (and thus blood flow) to the eye. Carl Kupfer, director of the National Eye Institute, explains:

For the optic nerve to be properly nourished, there, must be an adequate amount of blood flowing to that nerve at all times, so that if we have a drug that both lowers intraocular pressure as well as blood pressure, we may be interfering with the supply of blood to the optic nerve, and therefore even though the pressure in the eye may decrease, such a patient will not be protected against losing visual function from the glaucoma process.128

Thus, marijuana at best alleviates one problem of glaucoma while increasing the risk of another. And in order to even accomplish this ambivalent goal, one must stay stoned the entire day. It is no surprise, then, that experts such as Doctor Green conclude that "marijuana. . . has little potential future as a glaucoma medication."129

b. Treatment for chemotherapy

Proponents also suggest that marijuana is useful to combat the side-effects of chemotherapy such as nausea and vomiting. To support their position, they cite a study conducted by Mark Kleiman which found that 40% of cancer specialists had recommended marijuana to relieve chemotherapy nausea. 130

First, the Kleiman study is flawed statistically and methodologically. 57% of the doctors that Kleiman sent questionnaires to did not even bother to return them. Also, Kleiman does not document the number of questionnaires that were returned unanswered. Further, Kleiman does not document the number of questionnaires that expressed no opinion as to the therapeutic use of marijuana. Once all of these factors are considered, Kleiman's "40%" acceptance rate would be no more than 15%, and, according to Dr. Richard Schwartz, Clinical Professor of Pediatrics at Georgetown University School of Medicine, is "probably much less."131

Second, the nation's top cancer experts reject marijuana for chemotherapy treatment. As David Ettinger, professor of oncology at the Johns Hopkins University School of Medicine notes, "There is no indication that marijuana is effective in treating nausea and vomiting resulting from radiation treatment or other causes. No legitimate studies have been conducted which make such conclusions."132 Doctor John Laszlo, Vice President of Research for the American Cancer Society agrees that there is insufficient evidence to suggest that marijuana is a useful chemotherapy treatment.133

Third, the National Cancer Institute itself notes that "other antiemetic agents such as ondansetron, metoclopramine, droperidol, etc. have been shown to be more useful than marijuana-related compounds as first line therapy."134

Thus, while there is no evidence to prove marijuana's use in chemotherapy, there are numerous alternative drugs that obviate the need to even pursue research on the subject.

c. Treatment for AIDS

Proponents of legalized drugs next suggest that marijuana is useful in treating AIDS both because it relieves pain and because it stimulates appetite. Unfortunately, marijuana would actually exacerbate the health risks associated with AIDS. First, studies conducted at the Virginia Medical College suggest that the THC in marijuana damages the immune system, making the patient more susceptible to colds, viruses, and influenza while at the same time increasing the severity of any illnesses that the patient has.135 Clearly, the last thing that a patient with AIDS needs is to have his or her immune system weakened. Second, the marijuana smoke itself is damaging to the AIDS patients. As Dr. Sonia Buist, Professor of Medicine at Oregon Health Sciences University explains, "I cannot support the use of marijuana to treat patients with this condition [AIDS]. Furthermore, I would maintain that its use is contraindicated because marijuana smoke is extremely irritating to the airways and may add additional pulmonary problems in these very susceptible individuals."136

d. Treatment for multiple sclerosis

Proponents of legalization finally argue that marijuana is useful to stop the spasms caused by multiple sclerosis. Experts on MS absolutely reject this proposition. In fact, the scientific opinion may be summed up by Dr. Donald Silberberg, Chair of the Department of Neurology at the University of Pennsylvania School of Medicine and Chief of the Neurology Service at the Hospital of Pennsylvania, when he states that

I have not found any legitimate medical or scientific works which show that marijuana... is medically effective in treating multiple sclerosis or spasticity.... The long-term treatment of the symptoms of multiple sclerosis through the use of marijuana could be devastating. . . . The use of (marijuana), especially for long-term treatment ... would be worse than the original disease itself."

Having proved that marijuana is not effective in the treatment of glaucoma, the treatment of chemotherapy side-effects, the treatment of AIDS, or the treatment of MS, we should discuss the evidence that suggests that marijuana is harmful to one's health. Recall the material presented in Chapter One [Addiction Rates] that suggested that marijuana caused numerous health problems. Let us expand upon the inquiry. First, Swedish researchers found that people who smoked pot fifty or more times were six times as likely to develop schizophrenia. The study specifically found that marijuana increased the incidence of schizophrenia not only in those patients who were predisposed to the illness, but also in those who were not.138 Second, physicians in 1986 began reporting cases of lung, head, neck, tongue, and respiratory tract cancer in patients aged 17 to 39.139 Third, maternal use of marijuana increases the risk of childhood leukemia by 1,000%.140 Fourth, marijuana exposure produces abnormalities similar to the Fetal Alcohol Syndrome but at five times the rate of alcohol. 141

Thus, not only is marijuana not a good medical treatment, but it also causes schizophrenia, cancer, leukemia, and childhood abnormalities. Consequently, it is unsurprising to learn that "marijuana has been rejected as medicine by the American Medical Association, the National Multiple Sclerosis Society, the American Glaucoma Society, the American Academy of Ophthalmology and the American Cancer Society. Not one American health association accepts marijuana as medicine."142

124 Purnell and Gregg (1975); Perez-Reyes et al. (1976); Merritt et al. (1980); Green and Roth (1982); Jay and Green (1983).

125 Marijuana Scheduling Petition; Denial of Petition; Remand; 21 CFR Part 1308 [Docket No. 86-22), 1986.

126 Id.

127 Sandra Bennett, "Therapeutic Marijuana: Fact or Fiction," Drug Awareness Information Newsletter, July 1992.

128 Cannabis and Society, Chpt. 5, p. 453 (citing Carl Kupfer).

129 Marijuana Scheduling Petition; Denial of Petition; Remand; 21 CFR Part 1308 (Docket No. 86-22], 1986.

130 "Study. 40% of doctors favor some use of pot," Press & Sun-Bulletin, May 1, 1991.

131 Sandra S. Bennett, "Therapeutic Marijuana: Fact or Fiction," Drug Awareness Information

Newsletter, July 1992.

l32 Marijuana Scheduling Petition; Denial of Petition; Remand; 21 CFR Part 1308 [Docket No. 86-22], 1986.

133 Id.

134 Janet D. Lapey, "Marijuana As Medicine Refuted by NIH Scientists," Drug Watch, August 1992.

135 Guy A. Cabral, "Marijuana and Virus Infections," Southeast Regional Center for Drug-Free Schools and Communities Newsletter. See also Guy A. Cabral, "Marijuana Decreases Macrophage Antiviral and Antitumor Activities," Advances in the Biosciences Vol. 80, 1991.

136 Sandra S. Bennett, "Therapeutic Marijuana: Fact or Fiction," Drug Watch, July 1992.

137 Marijuana Scheduling Petition- Denial of Petition; Remand; 21 CFR Part 1308 [Docket

No. 86-22],1986.

138 Marsha Keith Schuchard, "Marijuana: An Environmental Pollutant," Publication of the

National Parent's Resource Institute for Drug Education.

139 Id.

140 Id.

141 Id.

142 Marijuana Scheduling Petition; Denial of Petition; Remand; 21 CFR Part 1308 [Docket No.

86-22], 1986.

Chapter Seven Summary Sheet: Medical Uses of Presently Illegal Drugs

If they say...

We should allow for therapeutic use of heroin.

Then you say...

Morphine provides longer-lasting, more consistent pain relief than does heroin. [Robert L. McCarthy and Michael Montagne, "The argument for therapeutic use of heroin in pain management," American Journal of Hospital Pharmacists, May 1993].

If morphine does not work for a given patient, you should not use- heroin, which is chemically very similar to morphine, but instead should use a different opioid such as methadone. [Arthur G. Lipman, "The argument against therapeutic use of heroin in pain management," American Journal of Hospital Pharmacists, May 1993].

The British doctors who initially advocated the therapeutic use of heroin long ago reversed their position. [Lipman, citation above].

The American Pharmaceutical Association admits that there are problems in pain management, but that they are due to the tendency of doctors to fail to prescribe sufficient dosages of presently available opioids, not because of the unavailability of heroin. [Lipman, citation above].

Allowing the therapeutic use of heroin increases the risk of diversion-i.e. that patients will sell their drugs on the black market rather than using it themselves. (Lipman, citation above],

Allowing pharmacies to stock heroin likely would 'increase the risk of robbery, especially when one considers that 50% of all pharmacy burglaries are committed to steal controlled substances. [Lipman, citation above].

If they say...

Marijuana should be used to treat glaucoma.

Then you say...

The studies which assert that marijuana helps to decrease intraocular pressure were conducted with THC, not with marijuana per se. [Marijuana Scheduling Petition; Denial of Petition; Remand; 21 CFR Part 1308 (Docket No. 86-22), 1986].

In order to see a significant decrease in intraocular pressure, you would have to smoke so much marijuana that you would be stoned all day. [Scheduling Petition, citation above].

In fact, alcohol also decreases intraocular pressure. But as with marijuana, you would have to consume so much that you would be drunk all day. [Sandra S. Bennett, "Therapeutic Marijuana: Fact or Fiction," Drug Watch, July 1992].

Although marijuana may reduce one symptom of glaucoma (intraocular pressure), it also exacerbates another problem. Specifically, marijuana decreases blood pressure and hence. blood supply to the optic nerve- Because the optic nerve no longer receives an adequate blood supply, it can be just as damaging to eyesight as the high intraocular pressure itself. [Bennett, citation above (citing Michael Van Buskirk, Director of Glaucoma Services and Chair of the Department of Ophthalmology at

Devers Eye Institute)].

According to Doctor Keith Green, who serves or has served on the boards of eight prestigious eye journals, "Marijuana ... has little potential future as a glaucoma medication." [Marijuana Scheduling Petition; Denial of Petition; Remand; 21 CFR Part 1308 (Docket No. 86-22), 1986].

If they say...

Marijuana should be used for therapeutic treatment of the side- effects of chemotherapy such as nausea and vomiting.

Then you say...

The study that the legalizers will probably cite-the one conducted by Mark Kleiman, which says that 40% of doctors questioned supported the therapeutic use of marijuana for cancer patients--is methodologically flawed. Specifically, its return rate (number of questionnaires returned), was only 42%, which raises

the strong potential of response bias. Also, Kleiman did not inform the reader how many of the people who did return the questionnaire did in fact answer the questions. As one expert in bio-statistics concluded, "The report seems simple and careless. - This is mere propaganda, and will be seen as such by the informed reader." [Robert E. Peterson, "Student Exercise for Marijuana Activist Group Given National Media Attention to Influence Court Case," Drug Prevention Newsletter, June 1991).

As David Ettinger, professor of oncology at the Johns Hopkins University School of Medicine notes, "There is no indication that Marijuana is effective in treating nausea and vomiting resulting from radiation treatment or other causes." [Marijuana Scheduling Petition; Denial, of Petition; Remand; 21 CFR Part 1308 (Docket No. 86-22), 1986].

The National Cancer Institute concluded that other drugs such as ondansetron, metoclopramine, droperidol, etc. are more useful for treating chemotherapy than is marijuana. [Janet Lapey, "Marijuana As Medicine Refuted by NIH Scientists," Drug Watch, August 1992].

If they say...

Marijuana is a useful treatment for AIDS patients.

Then you say...

Studies show that marijuana actually damages one's immune system and makes one more susceptible to colds, viruses, and influenza. [Guy A. Cabral, Marijuana and Virus Infections, Southeast Regional Center for Drug-Free Schools and Communities Newsletter].

Marijuana actually increases the health risk to AIDS patients because the smoke causes pulmonary problems. [Sandra S. Bennett, "Therapeutic Marijuana: Fact or Fiction, "Drug Watch, July 1992].

If they say...

Marijuana is a useful treatment for MS(multiple sclerosis patients).

Then you say...

According to Doctor Donald H. Silberberg, Chair of the Department of Neurology at the University of Pennsylvania, there is no evidence that marijuana helps MS, and, in fact, it likely

would be very harmful to the patient. [Marijuana Scheduling Petition; Denial of Petition; Remand; 21 CFR Part 1308 (Docket No. 86-22), 1986].

If they say...

Marijuana on the whole is a good medicine.

Then you say...

According to Swedish researchers, use of marijuana increases the incidence of schizophrenia six-fold for long-term users. [Marsha Keith Schuchard, "Marijuana: An Environmental Pollutant" Publication of the National Parent's Resource Institute for Drug Education, Inc.].

Use of marijuana increases the threat of lung cancer, throat cancer, tongue cancer, and head cancer. [Schuchard, citation above].

Use of marijuana by pregnant mothers increases the risk that their child will develop leukemia by 1000%. [Schuchard, citation above].

Use of marijuana increases the risk of abnormalities similar to those caused by Fetal Alcohol Syndrome by 500%. [Schuchard, citation above].

(See also Chapter One, Addiction Rates).

If they say...

The medical community condones the therapeutic use of marijuana.

Then you say...

Marijuana as medicine has been rejected by Medical Association, the National Multiple Sclerosis Society, the American Glaucoma Society, the American Academy of Ophthalmology, and the American Cancer Society. Not one American health association accepts marijuana as medicine. [Marijuana Scheduling Petition; Denial of Petition; Remand, 21 CFR Part 1308 (Docket No. 86-22), 1986].