by Peter Webster
In mid-March of this year, the $ 900,000 report of the U.S. Institute of Medicine on the question of medical marijuana was finally published, having been commissioned by the U.S. Drug Czar and the Office of National Drug Control Policy in August 1997. Prohibitionists were perhaps hoping that the review of evidence for the efficacy of marijuana for certain medicinal uses would find that there was little if any justification for using the drug. Unfortunately for the ideologues, the study found that marijuana is indeed eminently useful for at least some conditions, thus refuting definitively the Drug Czar’s not completely jocular condemnation of the herb as "Cheech and Chong Medicine."
The IOM report went on to recommend further extensive research on the medical use of cannabis, research which, according to some top scientists, has been actively thwarted by the U.S. government for decades. And predictably, the report parroted the widely held view expressed by ideologues and scientists alike, that it was simply unthinkable that smoking should be considered a viable, safe and effective route for the administration of a therapeutic drug. "Marijuana’s future as a medicine does not involve smoking," insisted Dr. Stanley Watson, a neuroscientist and substance-abuse researcher from the University of Michigan and co-author of the report. Ideologues routinely confuse themselves with their own convictions, even when the facts are imposing, but scientists should be ashamed for jumping on the anti-smoke bandwagon without a moment of reflection.
True, in the modern pharmacopoeia, there are no medicinal substances delivered by smoking, and arguably such a route of administration might be avoided. But with marijuana, the nature and effects of the drug make its smoking far more effective and acceptable for patients than oral preparations, for problems of solubility make absorption by the oral route far too dependent on the presence of fats. Indeed, for the minority of medical users who are averse to smoking, marijuana may be prepared into "brownies" or other fatty pastries, and as a starting point in the recipe, the cannabis is usually heated in butter or other oil to dissolve and disperse the active cannabinoids in the plant material. Absorption in the gut is then far more reliable and predictable, if still unduly delayed. In addition, all medical marijuana users stress the importance of self-titration of the drug, and insist that smoking is by far the best existing route for implementing this technique. Oral ingestion results in little ability to control the onset of effect or the size of dose. Presumably, similar and additional concerns would make an injected cannabis preparation both impractical and unacceptable to the great majority of patients.
The argument that smoking is an inappropriate drug delivery method because no other drugs are administered that way is logically weak, at least insofar as uniqueness of method is concerned. Before the hypodermic syringe was invented no drugs were administered by injection, but with the advent of the method there was no great movement by government and medical authorities denouncing injection merely on the basis of novelty, since the delivery method was found to be effective.
Ah! But smoking is dangerous say the ideologues, as do many scientists as well. This argument is also a fallacy. Certainly I do not propose that smoking is harmless when indulged in to excess, or when the smoked substance contains outright poisons and highly addictive neurotoxins, bio-accumulated radioactive isotopes, and harmful chemical additives, as do at least some cigarettes. And surely, marijuana when burned produces carbon monoxide and a few more or less carcinogenic combustion products as do cigarettes.
But it would not be stretching credulity to argue that mankind has developed a fairly robust resistance to breathing smoke for at least part of the day, having lived for 99% of his time on earth in dwellings with open hearths. In these dwellings even the pregnant and the newborn would breathe all sorts of combustion products. Natural selection must certainly have acted to produce some immunity to smoke inhalation, or it would now be impossible to live in many of our major cities. The comparison of the daily use of a few puffs of medical marijuana and living in New York or Los Angeles must surely reveal the latter the more dangerous for the respiratory passages. Why should living in polluted air seem an acceptable risk while light to moderate medical marijuana smoking be denounced as unconscionable?
Extending the argument into sacred pharmacological territory, it cannot be ignored thatall medical preparations have side-effects. Even an aspirin has dangerous and common, occasionally fatal side-effects, and in the case of aspirin as for smoked marijuana and many other drugs, *it is the route of administration which leads to the harmful side effects*! The oral method of aspirin use leads to possibly severe and not uncommon gastro-intestinal consequences having nothing to do with the purpose of the drug nor its targeted site in the body. The smoked method of using medical marijuana may lead to some as yet unproved harm to the respiratory passages. There is simply no practical, logical, or medical argument which can justify risking stomach lesions taking aspirin for its neurological effects while denouncing as prohibitive the risk of possible lung damage smoking medical marijuana for effective therapeutic purposes. We use warning labels on the product’s package to alert the physician and user of possible side-effects, not logical fallacy disguised as medical truth, as is now being done for marijuana.
To proceed yet further with standard pharmacological tenets, no medicine, even a totally purified single chemical entity, affects all persons the same or to an equal degree, nor will it work equally at all times for the same person. Sometimes an aspirin works fine, sometimes even several doses fail to deliver any relief whatsoever. The idea that a single purified substance is the summum bonum in pharmacology is contradicted both by this non-specificity argument and the fact that custom mixtures of drugs sometimes prove the best for certain individual cases. Objecting to the proven efficacy of marijuana use on the basis that the drug contains a complex and varying mixture of substances might be a valid complaint if the pharmaceutical houses had already produced condition-specific cannabinoid preparations for given uses, therapeutically equal to whole smoked cannabis. The only pharmaceutical preparation that science has brought us so far is Marinol, consisting of only one active ingredient dissolved in sesame oil to be taken orally, a preparation which very few patients or physicians find of any use whatsoever. It is probable that the chemistry and pharmacology of cannabis is so complex that it will require decades of research to produce medicines tailor-made for conditions which are suitable for treatment right now with various strains of whole cannabis, and we can imagine that the price tag of those future researched-for-decades preparations will result in easily- and cheaply-grown whole cannabis still being the intelligent choice for many. With respect to cannabis at least, much of the pharmacological argument against ‘herbal medicine’ is a symptom of the dollar-signs-in-the-eyes syndrome.
There is a further possible factor complicating the argument against smoked cannabis: burning the substance in a certain way may actually produce altered cannabinoids which are therapeutically useful. It is known, for example, that cannabinoids in fresh green cannabis are to some degree carboxylated and largely inactive, and that smoking (or heating in butter as mentioned above) de-carboxylates and thus activates the drug. The hypothesis that smoking itself makes cannabis more therapeutically active cannot be ruled out but must be thoroughly tested. Thus medicinal cannabis preparations taken with inhalers or vaporizers mentioned in the IOM document may still not completely reproduce the effect of smoked whole cannabis. Let research on vaporizers and inhalers begin in earnest (and here the IOM report notes that such delivery methods might not be perfected for many years). But for the time being, and as has been noted by many, asking patients in need to wait years for a substitute for what they already have that works, or go to prison for insisting, is a bit extreme! The argument that whole cannabis supplies unknown and uncertain doses of active products is flawed in another respect, and here it is the smoked delivery method itself which supplies the rebuttal. As noted above, medical marijuana users insist on the importance of self-titration for administering the drug, so as to obtain the desired level of relief of symptoms while avoiding taking a dose which produces excess psychological effects or renders them temporarily overwhelmed, a frequent complaint with the oral preparation Marinol. The onset of action of the drug when smoked is particularly rapid, so that no matter what the strength of the whole cannabis, nor its particular blend of active and inert ingredients, a smoker may arrive at his required dose within a few minutes solely on the basis of perceived desired effect. Thus may he also select among varieties of whole cannabis for the best perceived remedy for his particular condition. And if there are inert and ineffective substances in the collection of "400 chemicals in marijuana," so what? Read the label of any medical preparation and see: "active ingredients," and then "inert ingredients." The onus is on science and industry to improve therapy, (need I say it?) even at the sacrifice of profits and prestige, and not to attempt to remove currently effective if imperfect therapy from the scene (and what therapy has been proved perfect?). Current arguments against smoked cannabis are morality dressed up as science, and (to quote the Drug Czar) "a cruel hoax."