Pubdate: Mon, 06 Sep 1999 Source: Bangor Daily News (ME) Copyright: 1999, Bangor Daily News Inc. Contact: http://www.bangornews.com/ Author: Wyatt Olson, NEWS Staff DOCTORS UNLIKELY TO BACK POT VOTE While it seems unlikely the Maine Medical Association will support a fall referendum intended to legalize marijuana for medical purposes, the medical field is by no means of one mind on the value and safety of the drug. Some doctors consider marijuana a traditional medicine that has been swept aside and vilified unjustly. Others see it as a mind-altering drug that has no medical benefits that cannot be found in tested and approved prescription drugs. In late August the Maine Medical Association's public health committee unanimously recommended that the MMA's House of Delegates publicly oppose the referendum, which would allow patients suffering from persistent nausea and vomiting, glaucoma, seizures and other symptoms to possess and use limited amounts of marijuana. The MMA will hold its annual meeting in Bar Harbor next week, with the House of Delegates, the governing body for the MMA's 1,680 physicians, expected to debate the marijuana resolution Sept. 16. The MMA could choose to remain neutral on the subject, which some medical associations have done in other states debating legalized medical marijuana. About 2,500 doctors have active practices in Maine. "From a public health standpoint, it doesn't make sense to legalize the use of this substance,'' said Dr. John Garofalo, a family practitioner in Augusta who chairs the MMA's public health committee. "Granted, it's supposed to be under certain limited circumstances, but the problem we're worried about is diversion and misuse of those exemptions.'' Marijuana is a "gateway'' drug that leads users to stronger and more harmful illicit drugs, say Garofalo and others, and the scientific basis for using the drug is too tentative to outweigh the risks. But medical marijuana proponents challenge those assumptions, pointing to a report released in March by the National Academy of Sciences' Institute of Medicine that concluded short-term use of marijuana is appropriate for certain debilitating symptoms - provided they meet certain conditions - and that there is no evidence to suggest medical availability of marijuana would increase drug abuse. The report, which was requested by the White House Office of National Drug Control Policy in 1997, was intended to review the scientific evidence to assess the potential health benefits and risks of marijuana. According to Craig Brown, campaign manager for Mainers for Medical Rights, which has been the spearhead group behind the referendum, medical marijuana advocates look at the report as a long-awaited stamp of government approval for the legitimacy of the alternative treatment. "Marijuana is not just a medicine, but the best medicine in some cases,'' Brown said. Indeed, an analysis published in the Journal of the American Pharmaceutical Association in March 1998 concluded, "As a medical drug, marijuana should be available for patients who do not adequately respond to currently available therapies.'' If Maine voters approve the referendum, the state would join Alaska, Arizona, California, Oregon and Washington, all of which legalized medical marijuana by referendum. Nevada voters approved a constitutional amendment for medical marijuana in 1998, but must approve it again in 2000 for it to go into effect. If passed, Maine patients would not be subject to criminal prosecution provided they have the consent of a doctor and are suffering from persistent nausea, vomiting or severe loss of appetite as a result of AIDS or chemotherapy; glaucoma; severe seizures; or persistent muscle spasms associated with debilitating diseases such as multiple sclerosis. Patients could possess no more than 10 ounces of marijuana at any one time and could have six marijuana plants, with no more than three being mature enough to produce a usable drug. Legalized medical marijuana would leave doctors in an awkward position, said Gordon Smith, executive director of the Maine Medical Association. Though doctors wouldn't actually be writing prescriptions, they would need to make medical assessments for a drug that has not been approved by the U.S. Food and Drug Administration. Unlike with approved prescription drugs, there are no set dosages for marijuana, which is smoked or ingested. Dr. Rob Killian, 38, a physician in Seattle and author of Washington's medical marijuana law which has been in effect about eight months, said that it has improved doctor-patient dialogue about treatment options. "The main thing we did in approving it here is just protect a practice that's been ongoing for quite a while,'' he said. Killian ran a hospice for two years and at times when terminal patients were suffering with nausea or vomiting, no conventional drug worked. When family or friends helped a patient get and use marijuana as an alternative, Killian would have to turn his back and "disappear in that process.'' "What happens today is that I don't have to feel like I'm abandoning the patient,'' he said. "They still have to go out and get it somewhere, but now it can all be aboveboard. There's no shame. You don't feel like you have to whisper or talk about secrets. "I don't know of any physician who uses marijuana as a first-line treatment. Usually it comes after other normally prescribed drugs have been used and failed to work,'' he said. Killian now runs a private practice and specializes in treating HIV-positive and AIDS patients, who sometimes experience "wasting syndrome'' in which their weight declines and they have no appetite. In Killian's experience, one of marijuana's most legitimate and efficacious uses is slowing or reversing wasting. The Institute of Medicine report notes that "anecdotes abound'' that smoked marijuana is useful in treating HIV-associated weight loss, but there have been no controlled studies published on the subject. There is, in fact, a dearth of controlled studies on the efficacy of marijuana in treating various diseases and conditions. If there is one theme struck in the institute's report, it is its call for clinical trials of marijuana. In 1997 the American Medical Association's Council on Scientific Affairs made similar recommendations. But federal laws severely restrict access to marijuana, even for scientific study. According to Dr. Lester Grinspoon, a professor in the department of psychiatry at Harvard Medical School and an unabashed advocate of medical marijuana, what was known then as Cannabis indica was used regularly as an appetite stimulant, muscle relaxant, analgesic and anticonvulsant in the 1800s and early 1900s. Its use declined the first part of this century largely because synthetic alternatives became available, such as aspirin and barbiturates. "In the United States, the final blow was struck by the Marihuana Tax Act of 1937,'' Grinspoon wrote in a commentary published in the Journal of the American Medical Association in 1995. "Designed to prevent nonmedical use, this law made cannabis so difficult to obtain for medical purposes that it was removed from the pharmacopeia.'' Under the federal Controlled Substances Act of 1970 marijuana was confined to Schedule I, which lists drugs that have a high potential for abuse, lack an accepted medical use and are unsafe for use under medical supervision. Other Schedule I drugs are heroin and LSD. Ballot initiatives in California and Arizona in 1996 for approval of medicinal marijuana sparked a national debate over its federal designation. In December 1996, Barry McCaffrey, director of the Office of National Drug Control Policy, announced that any doctors who tried to make use of the new law could lose their federal Drug Enforcement Administration licenses for prescribing controlled substances, lose Medicare and Medicaid reimbursement and be subject to criminal prosecution. Several California doctors and patients filed a class action suit based on First Amendment grounds seeking a permanent injunction against federal regulations that punish doctors for talking to patients about medical marijuana. A federal judge granted a temporary injunction allowing California doctors to recommend marijuana without fear of prosecution, which will remain in place until the lawsuit is settled. Some doctors argue that debating the issue of medical marijuana is pointless, given that its primary psychoactive substance, delta-9-tetrahdrocannabinol, or THC for short, is now available in synthetic form and can be prescribed by doctors. "We have the active ingredient available in Maine - in a form that's available to everyone,'' said Dr. Ronald Blum, president of the Maine Academy of Family Physicians and a member of the MMA's public health committee. "Why not use that instead of legalizing what is basically a street drug?'' Proponents of medical marijuana chafe under the argument that marijuana is a street drug that leads to stronger, more dangerous drugs. "It's a fallacy,'' said Killian, again referring to the Institute of Medicine report that concluded: "In the sense that marijuana use typically precedes rather than follows initiation into the use of other illicit drugs, it is indeed a gateway drug. However, it does not appear to be a gateway drug to the extent that it is the cause or even that it is the most significant predictor of serious drug abuse; that is, care must be taken not to attribute cause to association.'' Although doctors have not been formally polled on the subject, Garofalo and Blum say they have heard few Maine doctors express support for passage of the referendum. And ultimately, doctors will have little say in the matter as Maine residents make their choice in November. - --- MAP posted-by: manemez j lovitto