Pubdate: Thur, 07 Jan 1999
Source: Arizona Republic (AZ)
Contact:  http://www.azcentral.com/news/
Forum: http://www.azcentral.com/pni-bin/WebX?azc
Copyright: 1999, The Arizona Republic.

THE STRAIGHT DOPE- DON'T EXPECT YOUR PHYSICIAN TO SAY 'SMOKE TWO JOINTS,
AND CALL ME IN THE MORNING'

In October 1995, Josh Burner was reeling from nausea triggered by massive
doses of radiation to treat the cancer eating away at his jaw, tongue and
soft palate.

No medications could abate his queasiness. He was too sick to eat.

One afternoon, he got a call from some Navajos he had met while working
undercover as a private investigator. They invited him to meet them at a
park in Tempe. They had heard about his troubles.

At a secluded spot in the park, the men gave Burner a hand-carved pipe
depicting four spirits and filled with marijuana. For a half-hour, they
smoked. First, Burner felt a sense of well-being. Then, his nausea
disappeared.

"It was very cool," he says.

He went into a nearby Mexican restaurant and ordered a pint of refried beans
and a pint of salsa, mixed them together, and gulped it down. He topped that
off with a milkshake from Dairy Queen.

"I hadn't eaten in three days," he says, "and I haven't thrown up since."

During last fall's campaign to legalize marijuana for medical use in such
illnesses as cancer and AIDS, Burner became the poster boy for legalization,
starring in pro-pot TV ads. He continues to smoke, eat and drink marijuana
to keep his nausea and cancer pain at bay.

It works, he says, and he wants the illegal weed to be available to other
suffering patients.

Whether that happens remains to be seen. Although Arizona voters in November
approved the medical use of marijuana for the second time in two years,
doctors fear their privileges to prescribe medication will be revoked if
they promote pot, thanks to the shadow of the federal Drug Enforcement
Administration.

The DEA is not amused by states' efforts to look the other way when sick
people do dope, and it has rejected smoking crude marijuana as medicine.

For their part, Arizona law-enforcement officials have generally turned a
blind eye to such patients, especially if they carry documented permission
from their doctors - a quasi "prescription."

Much of the time, politics and the fears of those who oppose any easing of
drug laws cloud the real issue: Is marijuana a legitimate weapon in the
arsenal against debilitating side effects of cancer treatment and in the
battle against other diseases?

In the 1920s, marijuana cigarettes were sold legally in drug stores as a
treatment for such ailments as asthma, migraine headaches and to ease the
pain of childbirth. During Prohibition, it was smoked recreationally to ease
the hunger pangs for outlawed liquor.

Today, marijuana is generally illegal in America, except in some cases where
it can be used medicinally, with opponents of liberalized drug laws branding
it as the gateway drug to harder substances such as cocaine and heroin.

However, some doctors and patients despair that not enough legal medications
exist to ease suffering. Why not allow one more?

Prescription drugs for nausea and vomiting, the major side effects of
radiation treatment, include Compazine, Phenergan, Tigan and Zofran.

The arsenal also includes marinol, the extract in pill form from
tetrahydrocannabinol, or THC, the active ingredient in marijuana.

Only marijuana - smoked or incorporated into foods and beverages - delivers
a "high" along with relief of symptoms, as does marinol. The exhilarating
effects of marinol, in fact, appear to last longer than the effects of
marijuana itself.

For patients depressed by their illness, this can mean a welcome emotional
lift.

"When you have a patient dying of cancer or AIDS, there's a lot going on
besides nausea," says Dr. Jeffrey Singer, a Phoenix surgeon who deals with
cancer patients and favors the medical use of marijuana. "Its tranquilizing
effects are one of the beneficial aspects."

And patients, devastated by their disease, are not primarily in search of
euphoria or the novelty of being allowed to smoke joints, Singer says.

"When a person's dying, they don't worry about being cool."

Marijuana also has a reputation for stimulating the appetite, a benefit for
patients wasting away from cancer or AIDS.

Burner, who says he now smokes a couple of joints a day - more when he's not
feeling up to snuff - dropped to 141 pounds from 193 before he discovered
the appetite-enhancing effects of marijuana. Now, consuming pot in
cigarettes and such foods as milkshakes, meatloaf, cookies and macaroni and
cheese, the former high-school athlete and Vietnam War veteran weighs in at
183.

The munchies, he says, saved him.

In addition to alleviating the effects of cancer and AIDS treatment,
marijuana has been used to relieve muscle spasms and spasticity in spinal
cord patients and those suffering such collagen-vascular diseases as lupus.
It may ease phantom limb pain after amputation.

How does it work?

Volker Sonntag, a neurosurgeon with the Barrow Neurological Institute in
Phoenix, says the mechanisms by which marijuana affects the brain are still
unclear.

Scientists believe the brain houses two receptors for the active substances,
called cannabinoids, present in marijuana. These are called CB1 and CB2.
They might work like a key in a lock, Sonntag says.

Marijuana also seems to work as an analgesic.

>From a neurological perspective, it's not certain whether pot is harmful,
Sonntag says. Long-term use does appear to impair cognitive function,
although the effects are difficult to quantify and vary between individuals.

Sonntag says patients report that smoking marijuana is "a pleasant way of
dealing with the pain" and that it seems to have few side effects.

If the drug were legal, Sonntag would not hesitate to prescribe it. He said
he believes many other doctors feel the same way.

Until it is legalized, he will not discuss it with patients because he fears
"I would be in trouble."

Although the extraction of THC, or marinol, from the marijuana plant is seen
as the proper and legal way to derive THC's benefits, Jeffrey Singer says it
might not be that easy. About 400 compounds have been identified in pot that
might work in concert to deliver the desired effects. THC alone may not do
the trick.

Because marinol comes in pill form, it loses its effectiveness for the
nauseated patient who can't keep anything down. Medication that is vomited
is useless.

Marinol also suffers from inconsistent delivery, sometimes coming on too
strong and sometimes failing to be properly absorbed, leaving the patient
under-medicated, says Dr. Paul Consroe, a professor of pharmacology and
toxicology at the University of Arizona's University Medical Center.

Smoking a joint, he says, is gentler, and it is easier for the patient to
control the dosage.

"You can take just as much as you need," he says.

THC also is more quickly absorbed when it is smoked, he says. The lungs have
a rich supply of blood vessels to deliver the drug into the body.

In the 1980s, six state health agencies conducted studies on the therapeutic
use of marijuana under research protocols endorsed by the U.S. Food and Drug
Administration. Scientists tested whether the drug could be an effective
anti-emetic (vomit preventer) for cancer patients. The consensus was that it
was effective.

California: More than 74 percent of subjects reported that marijuana was
more successful in relieving their nausea and vomiting than other drugs
tried previously.

Georgia: THC pills and smoked marijuana were found to provide anti-emetic
relief for patients who had not responded to other medications, with a
success rate of 73.1 percent.

Michigan: Of patients who received marijuana, 71.1 percent reported results
ranging from no emesis at all to moderate nausea and increased appetite.
About 90 percent chose to continue using marijuana as an anti-nausea
therapy.

New Mexico: More than 90 percent of patients who smoked marijuana and had
failed at least three other anti-emetics reported "significant or total
relief from nausea and vomiting" with no adverse side effects.

New York: Three hospitals involved in the research reported that patients
who claimed significant benefits of marijuana therapy reported success rates
of 89.7, 92.9 and 100 percent at the respective locations.

Tennessee: Patients who had failed on other therapies, including THC pills,
found an overall success rate of 90.4 percent when marijuana was smoked.

Given such numbers, marijuana would seem to be a wonder drug.

However, there is another side to the pot issue.

Dr. Philip Kanof, medical director of the substance-abuse program at the
Veterans Affairs Hospital in Tucson and an associate professor of
pharmacology at the College of Medicine at the University of Arizona, is an
outspoken opponent of the medical use of marijuana.

"Why do people consider this medically necessary?" he asks, dismayed that a
substance he believes leads to use of harder drugs could be on the threshold
of acceptance by the medical community.

He dismisses its role as another weapon against nausea and vomiting,
insisting that legal drugs do the trick when prescribed properly.

"In 1998, it is no longer a clinical problem," Kanof says. "People are not
suffering anymore."

When relief fails, he blames "physicians (who) don't know how to use these
medications effectively."

Patients can use legal drugs "without getting stoned out of their minds," he
says.

Jeffrey Singer argues that "we (physicians) prescribe these drugs according
to FDA prescription levels" and even sometimes exceed those levels in an
attempt to offer relief to patients.

Existing legal medications, and even marijuana, do not work for everybody,
he says. He points out that pharmaceutical companies, in that same belief,
continue to develop new anti-emetics.

Kanof insists that tolerating pot for medical use sends the wrong message,
allowing it to escape the rigorous scrutiny applied to prescription drugs.

Smoking an unrefined plant product means inhaling an indeterminate dosage.
The product might not be pure. There is no quality control.

However, until marijuana can be obtained easily and is legalized at least
for research, correct dosage cannot be assured and purity can not be
achieved, Kanof concedes.

"It's a Catch-22 situation," he says.

Although few side effects from smoking marijuana have been reported, and
fatal overdoses appear unlikely, the experience is not universally
pleasurable, Kanof says.

Pot smoke is acrid and must be inhaled deeply to be effective. Some people
experience paranoia and panic attacks.

"There is a lot of individual response to different drugs," Kanof says.

Patients who seek out marijuana through nefarious means put themselves in a
financial bind - pot is not cheap - and often put their lives at risk as
well, considering the undesirables with whom they must deal. According to
the DEA, pot currently sells for $70 to $120 an ounce, which makes about 30
joints, depending on its quality.

Although the term "prescription" is used, such a document simply alerts
police that marijuana possession is intended only for medical use. It
doesn't mean patients are standing in line at the pharmacy, funded by
insurance.

Burns, who is on public assistance, says pot is easy to obtain but is almost
beyond his reach financially.

As an addiction psychiatrist with a doctorate in pharmacology, Kanof says he
has seen the dangers of what seems to be an innocent recreation. He insists
smoking marijuana does lead to more ominous drug use, especially among young
people.

"This drug has an abuse potential," he says. "We know marijuana is a gateway
drug among adolescents who go on to use harder drugs. It is a key drug to
understanding the pathways to addiction . . . It is a pivotal drug in drug-
addiction careers."

Many habitual users are so drawn to the drug they spend their days smoking
instead of making productive use of their lives, he says.

Kanof does concede that marijuana can be an effective tool in relieving the
wasting syndrome that plagues AIDS patients. Prescription drugs exist, but
they are much more expensive than pot. Although all work to some extent,
Kanof says, "none are terrific."

In relieving nausea and vomiting, he counts about 10 agents that work to
some degree. The right drug, he says, can eliminate 90 percent of nausea.

Sometime this year, Kanof says, the National Academy of Sciences' Institute
of Medicine is expected to issue a report on its review of the therapeutic
use of marijuana.

He does not expect much fanfare.

"I think it's going to be a punt," he says. "More research is needed."

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