Journal Of The American
Medical Association Reviews Marihuana, The Forbidden Medicine
March 29, 1998(Ed. note: For some time I have
been wanting to find the time to do a review of this book that would do it justice. I want
to say more than "Buy it; read it; buy more copies; give them away."
But for now that will have to do. This is a very important book. The JAMA’s review
makes that clear. The JAMA even mentions the arrest statistics! However, the review does
not make clear the degree to which the government has gone and continues to go to suppress
medical marijuana.
Instead, it complains that the book does not make adequate policy recommendations for
the distribution of medical marijuana. The real problem is that neither the government nor
the medical profession has proven that they can be trusted to deal honestly with this
subject.)
Journal of the American Medical Association (JAMA. 1998;279:963-964)
Books, Journals, New Media
March 25,1998
JAMA-letters@ama-assn.org
Editors note: Before writing to JAMA please review the requirements at:
http://www.ama-assn.org/public/journals/jama/letters.htm
MARIHUANA: THE FORBIDDEN MEDICINE, by Lester Grinspoon and James B. Bakalar, revised
ed, 296 pp, $35, ISBN 0-300-07085-3, paper, $16, ISBN 0-300-07086-1, New Haven, Conn, Yale
University Press, 1997.
The first edition of Marihuana: The Forbidden Medicine was published in 1993 and
reviewed in JAMA.[1] In it, Grinspoon and Bakalar (from Harvard Medical and Law Schools,
respectively) presented numerous case reports of symptomatic relief from marijuana in a
wide variety of physical and psychological disorders. The patients were those who had been
treated less than adequately by more traditional methods and who did not necessarily
belong to a drug-abusing subculture.
In the intervening 4 years, much has happened in the "medical marijuana"
field. Voters in California and Arizona passed initiatives legalizing medical marijuana
and protecting physicians who recommend it. New clinical research using marijuana in
wasting syndrome of the acquired immunodeficiency syndrome (AIDS) is poised to begin.
Research into the pharmacology of the endogenous marijuana-like substances, the
anandamides, is progressing at a rapid pace. On the other hand,
there were 600,000 marijuana-related arrests in the United States in 1995. The time feels
like a watershed for attitudes and policy regarding marijuana; something has to change.
The ideal book entering the contemporary medical marijuana debate ought to address at
least three major issues: efficacy, safety, and policy. This revised
and expanded edition of Marihuana: The Forbidden Medicine is even more thorough in
documenting cases of self-reported efficacy than the original edition. It more than
adequately covers safety issues. However, as in the first edition, the book fails to
consider practical policy or implementation issues in a serious manner.
Grinspoon and Bakalar present over 30 new case reports suggesting beneficial effects of
marijuana. The conditions found in "Common Medical Uses" include cancer
chemotherapy-induced nausea and vomiting, glaucoma, and mood disorders. Examples of
"Less Common Medical Uses" are asthma, posttraumatic stress disorder, and Crohn
disease.
The anecdotal nature of these self reports is acknowledged as the
unfortunate state of the art. Furthermore, it is unlikely that the typical drug trials
using single, pure, synthetic compounds, required by the Food and Drug Administration for
a New Drug Application (NDA), will occur with marijuana because of its chemical
complexity. The whole plant contains numerous biologically active components. An
assessment of their therapeutic effects, singly and in various combinations, is probably,
for all intents and purposes, not practical.
However, it may be less than prudent to conclude that "no double-blind studies are
needed to prove marihuana’s efficacy." Rather, these
reports ought to stimulate clinical investigators to begin such studies of the whole
plant, using marijuana of standardized chemical composition, such as that being grown by
the National Institute on Drug Abuse. While the AIDS wasting syndrome protocol has
been subject to frustrating regulatory inconsistencies,[2] its recent approval should now
serve as a model for future projects.
SeeThe Scientist Magazine Does A Reverent Interview with the Head of
NIDA
Grinspoon and Bakalar’s summary of the safety and toxicology
data is clinically and logically unassailable. Undoubtedly there are batches of
mold-contaminated marijuana; coordination and motor reflexes are impaired during acute
intoxication; chronic use of marijuana subtly affects cognitive function and produces
upper respiratory problems. However, for the amount being smoked, it is reassuring that no
deaths directly resulting from marijuana overdose have been reported, nor have there been
documented cases of lung cancer even in heavy chronic smokers. For a more
thoroughly referenced and argued, albeit rhetorically tinged, discussion of these issues,
Zimmer and Morgan’s Marijuana Myths, Marijuana
Facts -- "Extraordinarily Well-Researched And Passionately Argued"
(reviewed in JAMA, February 25, 1998) is also worth reading.
The most enlarged chapter in this revised edition, "The Once and Future
Medicine," expands upon the authors’ social and political analysis of what
prevents regulatory acceptance of marijuana as medicine. The analysis is cogent as far as
it goes, eg, "saving face" by the government; vested
interests keeping marijuana illegal; and the antiestablishment stigma associated with
marijuana use. However, these issues seem less proximate and convincing than those
raised by these authors in a previous book.[3] These include moral and ethical issues that
reflect deep-seated psychological fears of losing control, both individually and as a
society, and the role of pleasure in our culture.
Any current book proposing widespread availability of medical marijuana is that much
more valuable if it proposes models for a dispensing infrastructure that take into account
diversion, quality control, training and certification of those who prescribe it, extant
scheduling laws, and accessibility. The first edition of this book waited until its final
paragraph before proposing a liquor-store model for sales of marijuana to individuals of
legal age. Regrettably, this second edition makes the same suggestion at the same point in
the book.
The authors do discuss why current models are unlikely to work:
the "compassionate use permit" (of which there are now only eight in the United
States); the over-the-counter pharmacist model (which is mentioned but not described); the
drug company-NDA model; reducing marijuana from schedule I to II and having doctors
prescribe it; and underground "buyers’ clubs." However, other possibilities
come to mind. One is the creation of specially licensed and certified clinics, like those
dispensing methadone for treatment of opiate dependence, but with a much broader
distribution base.
It is difficult to see how the growing tide of acceptance of medical marijuana might
be stemmed much longer by accusations of "covert legalization tactics."
Grinspoon and Bakalar deserve credit for unstintingly keeping the issue alive in the face
of the medical profession’s general reluctance to consider such a thorny issue.
See "High On A
Lie"-- The Reader’s Digest Attacks The Medical Marijuana Movement; Yes,
Someone Is Lying
However, they need to keep pace with their own success. While Marihuana: The Forbidden
Medicine remains the definitive collection of case reports of therapeutic effects of
marijuana, we must look elsewhere for models to put into practice what they so
convincingly argue must happen.
Rick J. Strassman, MD University of British Columbia Victoria
References
1. Strassman RJ. Review: Grinspoon L, Bakalar JB. Marihuana, The Forbidden Medicine
(New Haven, Conn Yale University Press; 1993). JAMA . 1993;270:2878-2879.
2. Kassirer JP. Federal foolishness and marijuana. N Engl J Med.
1997;336:366-367.
3. Bakalar JB, Grinspoon L. Drug Control in a Free Society. New York, NY:
Cambridge University Press; 1984.
© 1995-1998 American Medical Association.
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