Ida Pemberton marijuana illustration courtesy of the University of Colorado Museum.
Since November 1996, when voters in California overwhelmingly approved Proposition 215, the Compassionate Use Act, it has been legal under state law for any “seriously ill” Californian to obtain marijuana upon the recommendation of a physician and for patients and their caregivers to cultivate it. Last summer, I traveled to Northern California, the seedbed of the medical-marijuana movement, to hear what patients, doctors, and others were saying, and learn what it might mean for the rest of us.
The Patients: A Lesser-of-Evils Pain Reliever
In California I met scores of patients who credit marijuana with dimming their pain, quelling their nausea, firing their appetites, and quelling their seizures; I also met a handful of people who believe marijuana is keeping them alive. Keith Vines is one patient who has no doubt on that score, nor does his doctor. Vines told me his story over a 16-ounce rib-eye steak at Harris’ Restaurant in Pacific Heights. I mention the detail because Vines is an AIDS patient afflicted with wasting syndrome; for someone in his situation, polishing off a big steak (along with a Caesar salad, scalloped potatoes, sugar snap peas, and a slab of pastry) counts as an accomplishment.
Not long after arriving in San Francisco in 1983, Vines—a former U.S. Air Force captain and malpractice lawyer, a father, and, as a member of the Federal Narcotics Strike Force, a successful prosecutor of what had been San Francisco’s second-biggest drug case in that city’s history—was infected with HIV. By 1993, he had developed wasting syndrome, a little-understood metabolic change that causes patients to lose rapidly not only fat but also muscle tissue. It is often a death sentence. “In a matter of months I dropped from 195 pounds to 150,” Vines said. “You wouldn’t have recognized me; it wasn’t the death camps, quite, but close.” This was hard to believe: the man before me looked as robust and thickly muscled as a football player.
Like many AIDS patients, Vines takes ten to fifteen medications a day. Many of these medicines cause debilitating nausea and suppress appetite, yet many of these drugs must be taken on a full stomach—and missing even a single dose can be disastrous. Vines was dying a slow death by emaciation when he managed to get into an experimental trial that was treating wasting syndrome with human growth hormone, a treatment approved by the U. S. Food and Drug Administration (FDA). His doctor explained that for the new drug to have any chance of working, it was essential that Vines eat three meals a day—something he found impossible to do.
Dr. Lisa Capaldini, Vines’s primary physician, suggested he try Marinol to stimulate his appetite. Marinol is a synthetic form of THC—the principal active ingredient in marijuana. It was approved by the FDA initially as an anti-emetic for chemotherapy patients and then, in 1993, as an appetite stimulant for AIDS patients. But like many people who take it, Vines found that Marinol took a long time to kick in and that, when it did, the effects were far too powerful and long-lasting. “One capsule would make me feel stoned for hours,” he said. “Sometimes I’d be too stoned to eat, or I’d just fall asleep.”
Opponents of medical marijuana often point to Marinol as a superior alternative; indeed, it appears that the government speeded the development and approval of the drug as a way to relieve the political pressure to legalize medical marijuana, which was building in the wake of the AIDS epidemic.
But many AIDS patients find, as Vines did, that the pills don’t do the job. When it became clear Marinol wasn’t working for Vines, Dr. Capaldini mentioned to him that many of her patients were getting better results from inhaled marijuana. They found they could more easily control the dose simply by adjusting the number of puffs.
“When I looked at Keith,” Capaldini told me, “I didn’t see a district attorney. I saw a patient who was dying.”
Vines didn’t find the decision to try marijuana particularly difficult, either. “I’m hanging off a cliff, staring at death, and my doctor’s telling me this might help,” he recalled. “It’s against the law, yes, but I’m not thinking of myself as a prosecutor. I’m a man fighting for his life.”
So Keith Vines felt compelled to break the same drug laws he’d been working to uphold. San Francisco being San Francisco, everyone—including, eventually, his boss, District Attorney Terrence Hallinan—was supportive.
For Vines, the hard part was obtaining a supply of marijuana without finding his face in the paper. It’s difficult to imagine Vines, who probably would not object to my describing him as something of a square, riding up in the Jerry Garcia Memorial Elevator to the third floor of the San Francisco Buyers Club—a smoky loft done in High Crash Pad, circa 1969. This is where club patrons place their orders from the marijuana menu board (Humboldt Green: $65 an eighth; marijuana lemon squares, $5 each) and if they choose, light up and pass out. Keith Vines got his eighth to go, and went.
Marijuana had never been a part of Vines’s life until now. He began taking a puff or two from a pipe before dinner—just enough to make him hungry without getting stoned. It worked, and very quickly Vines began gaining weight. “I saw myself in the mirror literally coming back to life,” he said. “It was the growth hormone that put on the weight, but it would never have worked if the marijuana hadn’t given back my appetite.
“I understand the drug laws, I know why marijuana is illegal,” Vines went on to say. “I certainly don’t want my seventeen-year-old son smoking it—we have a serious drug problem with our youth in this country.” He pointed out that legal opiates like morphine have done nothing to undermine the war against heroin, and suggested the same would be true for medical marijuana. “They can still have their war on drugs,” he said. “Just take this out of it. This is medicine.”
If the FDA ever does approve marijuana, it will probably be as an anti-emetic and appetite stimulant for people like Keith Vines. But of course Proposition 215 opened the way not only for them but also for anyone suffering from “any other illness for which marijuana provides relief,” and a whole assortment of Californians are squeezing through that door. My notebooks are stuffed not only with the testimonies of cancer and AIDS patients who vouched for marijuana’s efficacy, but also with those of people suffering from parapelgia, multiple sclerosis, insomnia, post-traumatic stress disorder, anorexia, anxiety, psoriasis, and even drug addiction.
“I’m hanging off a cliff, staring at death, and my doctor’s telling me this might help,” Vines recalled. “It’s against the law, yes, but I’m not thinking of myself as a prosecutor. I’m a man fighting for his life.”
The Doctors: A “Don’t Chart” Philosophy
Mention “December 30, 1996” to any physician in the state of California and he or she will know precisely what you’re talking about. That was the day when General Barry McCaffrey, the Clinton Administration’s drug czar, flanked by Attorney General Janet Reno, Secretary of Health and Human Services Donna Shalala, and a DEA official stood before the television cameras to deliver an unprecedented threat to the doctors of California. According to a statement issued at the news conference, “a practitioner’s action of recommending or prescribing Schedule I controlled substances”—like marijuana—“will lead to administrative action by the Drug Enforcement Adminstration to revoke the practitioner’s registration.” Though doctors are licensed by the states, without a DEA registration they cannot prescribe medicine—cannot, in effect, practice. The new policy also threatened to criminally prosecute doctors who recommend medical marijuana, and to exclude them from Medicare and Medicaid.
McCaffrey spoke of the federal government’s special responsibility to insure the safety and effectiveness of medicine through a drug-approved process that had “prevented thalidomide and Laetrile and other nonsense substances from going in front of the American public.”
McCaffrey made much the same point when I spoke to him last July. He explained that “some very cunning people have displaced the argument for legalization—which Americans overwhelmingly reject—to one that is more acceptable.” He attributes support in California, and elsewhere, for medical marijuana to the fact that, understandably, “a lot of Americans are worried about pain management.”
McCaffrey went on to express concern about the referendum process that legalized medical marijuana. Proposition 215 “isn’t part of the medical process—there’s no physical exam, no prescription,” he says. “An aromatherapist, a ‘caregiver,’ even a patient can grow their own in their backyard. We don’t tell people to grow their own heart medicine! We don’t decide flight rules for L.A. airport by plebiscite!”
McCaffrey is worried too about the effect medical marijuana will have on marijuana use among teenagers. “As the fear of marijuana continues to go down,” he told me, “use among young people goes up.” Marijuana use among teenagers has, in fact, been rising in recent years, though it has not reached the levels (35 percent and more) seen in the 1970s. McCaffrey subscribes to the theory that marijuana is a “gateway” drug, and he cited recent studies that have found a statistical correlation between teenage marijuana use and later addiction to harder drugs. Anything that diminishes the fear of marijuana should trouble us, he argues, which is why Prop 215 sends a “terrible message” to the nation’s youth.
The loudest message of the news conference on December 30 was the one delivered to the doctors of California, who heard the Attorney General of the United States tell them that the act of recommending marijuana to a patient could cost them their livelihood. And in the short term, the threat had the intended effect: Doctors stopped writing letters of recommendation; many even stopped discussing marijuana with their patients, or returning calls from cannibis clubs seeking to confirm diagnoses. More than one doctor told me that patients had probably been better off before Proposition 215, when doctors had actually felt freer to recommend marijuana.
It is true that marijuana had been a quiet, relatively uncontroversial part of American medical practice for years before Proposition 215, though it’s hard to know exactly how commonly it was recommended. When, in the mid-80s, a DEA adminstrative law judge held hearings on rescheduling marijuana as a Schedule II drug so doctors could prescribe it, he concluded that marijuana already had an “accepted medical use,” especially among doctors treating cancer patients. (“Marijuana, in its natural form, is one of the safest therapeutically active substances known to man,” Judge Francis Young wrote in a 1988 decision that was promptly overruled by the DEA.) One Harvard Medical School survey of 2,000 oncologists conducted in 1991 found that 44 percent had recommended marijuana to their patients. I’m told it is not at all uncommon to smell marijuana smoke in the cancer wards of American hospitals.
Talking to doctors about marijuana, I heard little of the evangelical fervor I came to expect from patients. With the exception of AIDS specialists, few regarded marijuana as much more than a “second or third line treatment” for their “refractory patients”—the ones who don’t respond to conventional medicines. Many recognize the therapeutic value of THC, but are troubled by the “delivery system”—inhaled smoke that contains some 400 poorly understood compounds, several of which are carcinogens.
Dr. Debasish Tripathy, a prominent breast cancer specialist in San Francisco, told me he typically has a handful of patients for whom marijuana is the only drug that will quell the nausea induced by chemotherapy—nausea so debilitating that patients will sometimes choose to discontinue treatment rather than endure it. Tripathy regards marijuana as a treatment of last resort (though since December 1996 he has declined to recommend it even in those cases), but he also emphasizes just how important it is to have such drugs in the pharmacopoeia. “The whole notion of a ‘best medicine’ is erroneous,” Tripathy explains, because patients vary so in their response to drugs. “Indeed, the phrase ‘best medicine’ belies the concept of individualized care.”
Like many of the doctors I spoke to, Tripathy seems somewhat mystified by the government’s intransigence on the subject of marijuana, particularly in view of its comparative safety. “Marijuana is far less toxic than many of the medicines I prescribe to my cancer patients,” Tripathy points out. Doctors are accustomed to objectively weighing the benefits and risks of any treatment, and the unwillingness of the government simply to let science decide the issue of medical marijuana is incomprehensible to them. Tripathy would like to see more studies, especially trials comparing the effectiveness of Marinol and smoked marijuana in combating nausea. Dr. Donald Abrams, an AIDS researcher at the University of California, San Francisco, has been trying to organize just such a trial for four years. Though the FDA has approved his study, the DEA and the National Institute of Drug Abuse have refused to give him access to the marjuana he needs to carry it out.
For many California doctors, what the government dismisses as “anecdotal evidence” for the efficacy of marijuana is of course just an unflattering name for their own clinical experience, which has already been encouraging enough to justify the drug’s use without waiting for large clinical trials of FDA approval.
Doctors who treat AIDS are by far the ones most enthusiastic about medical marijuana. Dr. Virginia Cafaro is a physician with the Conant Medical Group, the largest AIDS practice in San Francisco. Her first encounter with medical marijuana came seven or eight years ago, when her patients began reporting that smoking pot helped relieve their nausea and stimulated their appetite. “I looked into it and found it was being used by oncologists,” she told me, “so I began recommending it for cases where nothing else was working.”
But if the lack of big clinical trials and FDA approval haven’t inhibited Dr. Cafaro from using medical marijuana in her practice, General McCaffrey’s December 30 threat certainly has. “Since the threats by federal officials,” she has written, “I have avoided directly broaching the subject of medical marijuana even with patients who could, in my judgment, obtain marked relief” from it. Other doctors have adopted a “tell, don’t chart” policy: They recommend marijuana, but don’t write the information down, either in a letter or on the patient’s chart. Some told me they now look askance at any new patient who inquires about marijuana, wondering if perhaps the patient might be an undercover DEA agent.
Michael Pollan is a contributing writer for The New York Times Magazine and an editor-at-large for Harper’s Magazine. He is author of Second Nature (Dell, 1991).
Excerpted with the author’s permission from “Living with Medical Marijuana”, The New York Times Magazine, July 20, 1997.