A standard tactic of opponents to medical access to marijuana has been to claim that this is something supported only by the "pro-drug" lunatic fringe and there are no respectable authorities supporting or even interested in it. However, in January Dr. Jerome Kassirer, the editor of The New England Journal of Medicine (January 30, 1997 -- Volume 336, Number 5) wrote an editorial favoring limited medical access to marijuana, saying, "Thousands of patients with cancer, AIDS, and other diseases report they have obtained striking relief from these devastating symptoms by smoking marijuana. The alleviation of distress can be so striking that some patients and their families have been willing to risk a jail term to obtain or grow the marijuana." This presented prohibitionists with a strategic problem.

At this point the editorial page editors of the Wall Street Journal once again called on Dr. Gabriel Nahas to present the prohibitionist party line. For over 25 years Nahas has been the guru of latter day reefer madness. His works have appeared frequently in the WSJ and were the source of most of the articles by the late Peggy Mann in the Readers Digest. He is also the guiding light for the prohibitionist propaganda organization, PRIDE, and is the chief "drugs policy" advisor to French President Jacques Chirac. Consequently, Nahas is someone to be taken seriously, at least for his influence.

There is, however, another reason to take Nahas seriously. The frequent publication of his writings on the editorial page of a newspaper as influential as The Wall Street Journal demonstrates a complete disregard for the need for critical thought amongst committed prohibitionists like the editorial page editors of the Journal. Consider that there has been extensive documentation available for years proving that Nahas is simply not a credible source of information regarding cannabis. This does not stop his statements being used to justify the persecution of the sick and dying in order to suppress the medical use of marijuana. That such an egregious fraud can be used for such inhumane objectives demonstrates a major failure of values and judgement at the highest levels in our society.

Below is the title and abstract of one of the most devastating documents ever to be consigned to the memory hole of drug-free America.

(For the full text: University of Sydney)
COMMENTARY

The human toxicity of marijuana: a critique of a review by Nahas and Latour BY MCDONALD J. CHRISTIE & GREGORY B. CHESHER

Department of Pharmacology, University of Sydney, New South Wales, Australia

Abstract

A review entitled "The human toxicity of marijuana" was published in 1992 in the Medical Journal of Australia. The authors claimed that the adverse effects of cannabis use have been trivialized and that the effects are much more serious than earlier reported. We have made a careful study of this review and examined the claims made. We compared the claims of the authors with the information contained in the documents they cited and found that at least 28 of the 35 citations in this article were cited inaccurately. Five of these publications were misquoted, or the findings of the study were not fully reported. Twenty-three citations contained other errors, leaving only six to eight (two citations could not be retrieved because of their obscurity) accurate citations among 35. All of these inaccuracies operate in the direction of finding an adverse effect of marijuana. [Christie M, Chesher GB The human toxicity of marijuana: a critique of a review by Nahas and Latour. Drug Alcohol Review l994:13:209-216.]

(emphasis added)

In this context it is useful to examine Nahas' critique of the NEJM editorial and compare it with what the editorial actually said. The full text of the two documents are reproduced at the end of this piece, and there are links to originals of both.

Regarding the NEJM editorial, it must be said that Kassirer took a very conservative position. He did not endorse either California Proposition 215 or Arizona Proposition 200. In fact, he has said elsewhere that he would have voted against both. Moreover, he confines his call for medical access to marijuana to include only "seriously ill patients" and even speaks of those at "death's door." Appropriately, the key points of the editorial were in the first paragraph:

The advanced stages of many illnesses and their treatments are often accompanied by intractable nausea, vomiting, or pain. Thousands of patients with cancer, AIDS, and other diseases report they have obtained striking relief from these devastating symptoms by smoking marijuana. The alleviation of distress can be so striking that some patients and their families have been willing to risk a jail term to obtain or grow the marijuana. (emphasis added.)

Typically Nahas never addresses this point, although he has repeatedly called for the imprisonment of marijuana users. Nahas' critique consists of six points.

1. It underestimates the toxic properties of marihuana smoke. This smoke contains carbon monoxide, acetaldehyde, napthalene and carcinogens. Inhalation of THC decreases lung defense mechanisms which are already compromised in AIDS patients, who are extremely vulnerable to pulmonary infections and tumours like Kaposi´s Sarcoma. Thus marihuana smoke is a questionable choice to treat the symptoms of AIDS or cancer, especially when safer and more effective medications are available.

Nahas states these points as though they are established scientific consensus, supported by the kind of science that he demands for medical access to marijuana. This is simply not the case. Beyond the fraudulent use of sources, it is obvious that our society has its standards of evidence reversed. Why is that we require rigorous proof to justify NOT arresting sick people for using medicine that they say helps them, but very low standards of evidence to justify arresting both sick and healthy people? The burden of proof should not be on individual freedom, but on state coercion.

Moreover, most of the medical marijuana users described by Kassirer would not be using very much marijuana, and in the case of the terminally ill, their use would obviously not be long-term. Of course, all of this completely ignores the fact that marijuana can be vaporized so that most of the objectionable properties of smoking can be avoided altogether.

However, consider what Kassirer actually said:

Marijuana may have long-term adverse effects and its use may presage serious addictions, but neither long-term side effects nor addiction is a relevant issue in such patients. (emphasis added) It is also hypocritical to forbid physicians to prescribe marijuana while permitting them to use morphine and meperidine to relieve extreme dyspnea and pain. With both these drugs the difference between the dose that relieves symptoms and the dose that hastens death is very narrow; by contrast, there is no risk of death from smoking marijuana.

Note that Nahas did not address Kassirer's last point about the comparison: "the difference between the dose that relieves symptoms and the dose that hastens death." Nor did Nahas even acknowledge that "there is no risk of death from smoking marijuana." In short, Nahas posits unproven long-term risks of marijuana, but ignores the immediate risk of overdosing on morphine and other legal drugs for patients who are critically ill.

A common sense observation: if marijuana were as immunosuppressive as Nahas claims and therefore contraindicated for even short term use by the critically ill, then the consequences of this toxicity should be massively evident in the actuarial data on populations of long term heavy users. There is no such evidence. For example, there is a high correlation between intravenous drug use and AIDS, but there is no such correlation with long term heavy marijuana use.

Nahas' next point borders on the bizarre:

2. It implies that marihuana smoking relieves pain. THC (or marihuana) does not interfere directly with the endorphin system. Indeed, it increases the perception of pain. Dr. Kassirer declares it "hypocritical" to forbid a physician to prescribe marihuana yet allow him to prescribe morphine for the relief of pain. If he means to imply that marihuana is analgesic, he is simply wrong. If the implication is that it is hypocritical to prescribe one dependence-producing drug and not another, Dr. Kassirer is relying on a spurious analogy that beclouds the basic pharmacological question: What is the effectiveness of the therapeutic substance prescribed by a physician?

If marijuana really did increase "the perception of pain" then there would not be much demand for it, except perhaps among the terminally masochistic. Think about this for a moment. There are large numbers of people with serious health problems using marijuana. If it actually increased the perception of pain, would they or their doctors even consider the use of marijuana? And as Nahas surely must know there are different kinds of pain, but what he says simply does not address Kassirer's point. The "hypocrisy" that Kassirer is denouncing is not about pain per se, but the types of medications that can be prescribed.

What Kassirer actually said:

It is also hypocritical to forbid physicians to prescribe marijuana while permitting them to use morphine and meperidine to relieve extreme dyspnea* and pain. (emphasis added) With both these drugs the difference between the dose that relieves symptoms and the dose that hastens death is very narrow; by contrast, there is no risk of death from smoking marijuana. To demand evidence of therapeutic efficacy is equally hypocritical. The noxious sensations that patients experience are extremely difficult to quantify in controlled experiments. What really counts for a therapy with this kind of safety margin is whether a seriously ill patient feels relief as a result of the intervention, not whether a controlled trial "proves" its efficacy. (*Dyspnea is the inability to breathe and is not "pain." RCC)

The "effectiveness of the therapeutic substance" that Nahas demands is precisely the point being made by Kassirer. Now notice that Nahas has posited that marijuana "increases the perception of pain" which is by definition "subjective" and then consider his next statement:

3. It argues that the patient's "feelings" are the determinant therapeutic criterion. Dr. Kassirer deems it "hypocritical" to demand scientific evidence of therapeutic efficacy. To determine whether marihuana use is an effective therapy, he says, one should rely "not (on) whether a controlled trial proves its efficacy" but on how patients say they feel after the intervention. (emphasis added) Marihuana smoking would therefore become a privileged therapeutic procedure, exempted from the general proof of efficacy required for all drugs, and untested in double-blind controlled placebo trials.

What Nahas is saying is that marijuana cannot be used for analgesia because it increases the perception of pain, but if the patient says that it decreases the perception of pain, this cannot be "the determinant therapeutic criterion."

Also note the call for "double-blind controlled placebo trials." At the NIH Medical Marijuana Workshop several of the doctors there, including Dr. Avram Goldstein, the noted pharmacologist, questioned the possibility of doing a double blind test of marijuana, because the patient will know whether he is smoking active marijuana. Moreover, all of them rejected as unethical the use of placebos in cases of serious pain or nausea. In short, Dr. Nahas is calling for a procedure that is unscientific, unethical and inhumane, the perfect defense for our current medical marijuana policies.

Of course, Nahas also ignores the fact that morphine has not passed the sort of tests which he would require for marijuana. Morphine, like marijuana has been used medically since long before the FDA was established. However, marijuana was excluded from the pharmacopoeia in 1941 for political reasons.

Next Nahas charges:

4. It makes implausible claims about the advantages of smoking marihuana over oral THC. "Since smoking marihuana produces a rapid increase in the blood level of active ingredients, it is more likely to be therapeutic," Dr. Kassirer claims. But based on pharmacology, the opposite should be the case: Plasma THC concentration following oral administration reaches a more sustained, steady level, lasting three to four hours, twice as long as after smoking. Such prolonged concentration should be more effective than a rapid rise and fall of THC concentration after smoking.

This does not at all address what Kassirer actually said:

Paradoxically, dronabinol, a drug that contains one of the active ingredients in marijuana (tetrahydrocannabinol), has been available by prescription for more than a decade. But it is difficult to titrate the therapeutic dose of this drug, and it is not widely prescribed. By contrast, smoking marijuana produces a rapid increase in the blood level (emphasis added) of the active ingredients and is thus more likely to be therapeutic.

Kassirer did not say that smoking would produce a more sustained level than would oral ingestion, but rather a more rapid onset. Indeed, sustained dosage was one of the things he was trying to avoid. Oral ingestion does produce a more sustained level than does smoking, but this is not desirable, because oral ingestion makes it more "difficult to titrate the therapeutic dose of this drug," (emphasis added) meaning that the patient has greater control of the dosage when smoking than when taking it orally. Moreover, when the patient is suffering, the rapidity of onset when a medication is smoked is of great value to the patient, if not to Dr. Nahas.

In his next point Nahas again completely misrepresents what Kassirer actually says and does a clever bait-and-switch:

5. It claims the efficacy of new drugs to treat nausea has not been tested. Dr. Kassirer ignores that experimental and clinical studies have clearly established the superiority of substituted benzamide and ondansetron over oral THC, though acknowledges that these drugs may be more beneficial than marihuana.

What Kassirer actually said:

Needless to say, new drugs such as those that inhibit the nausea associated with chemotherapy may well be more beneficial than smoking marijuana, but their comparative efficacy has never been studied. (emphasis added)

Kassirer did not say that the efficacy of the new anti-emetics had not been tested, but rather that their efficacy compared with smoked marijuana had not been tested. This is correct, because the government has blocked tests of marijuana as an anti-emetic after it was established in FDA approved trials that marijuana was superior to the previous generation of pharmaceutical anti-emetics. Nahas cites studies that established the superiority of the pharmaceutical anti-emetics over oral THC to refute something that Kassirer did not say.

Nahas then goes on to say:

6. It dismisses as "specious" the argument that approving marihuana for medical use would send the wrong signal to the young. Epidemiological surveys, however, indicate, that the greater the perception of harm associated with marihuana, the lower the frequency of its use among children and adolescents.

Kassirer did dismiss this view as specious, but he did not explain his basis for doing so.

The argument that it would be a signal to the young that "marijuana is OK" is, I believe, specious.

There are actually two reasons why this view may be "specious," neither of which are addressed by Nahas' reference to "epidemiological surveys."

First, the fact that something is medically useful does not necessarily imply that it is there is no "harm associated with" it. If making marijuana medically available implies that it is safe for children and adolescents, why does the same not apply to morphine, etc.?

Second, even if that were the case, should seriously ill people be required to suffer because we have so little ability to communicate with our children that we cannot teach them these very relevant distinctions between medicine for the dying and fun for the immature? In short, if marijuana has medical value it should be available to those who need it, and references to adolescent misconceptions are indeed specious, epidemiology not withstanding.

Nahas' next comment (beyond his six points) is simply an appeal to authority that is circular and ignores Kassirer's arguments and misrepresents both the law and the facts.

It condemns as "misguided, heavy handed and inhumane" the Drug Enforcement Administration's refusal to reclassify marihuana from Schedule I (addictive and illegal) to Schedule II (addictive but legal for some medical uses). Yet this refusal was based on a thorough analysis of reports from medical specialists in ophthalmology, oncology and neurology. None reported evidence that smoking marihuana was more effective than current approved remedies. The DEA´s decision was supported by both the Food and Drug Administration and the Public Health Service. A doctor prescribing marihuana to a patient may be "courageous" in Dr. Kassirer´s mind - but he is also scientifically misinformed and in violation of federal law.

First, in citing the DEA, not an unbiased authority, Nahas ignores the fact that the DEA dismissed the findings of its own administrative law judge in 1988 that marijuana should be made medically available.

Second, there are in fact "reports from medical specialists in ophthalmology, oncology and neurology" that suggest that marijuana is already being used extensively.

Third, it is not necessary that marijuana be "more effective than current remedies" in order to be approved for medical use. This is not the standard set by law. Marijuana need only be relatively safe and effective. It is generally accepted that most drugs have potential dangers and that they do not work for every patient. The fact that current pharmaceutical anti-emetics may work for most patients is of no comfort for those for whom they do not work, or for those who simply cannot afford these very expensive products.

Nahas gets even more disingenuous:

Dr. Kassirer recommends that the federal government get into the marihuana business, by "declaring itself the only agency sanctioned to provide the marihuana." Thus the government would "ensure its proper distribution and use." In effect, Dr. Kassirer is opening the door to the "controlled" legitimization of marihuana as it exists in the Netherlands - but even the Dutch have not approved marihuana for medical use!

What Kassirer actually said,

The government should change marijuana's status from that of a Schedule 1 drug (considered to be potentially addictive and with no current medical use) to that of a Schedule 2 drug (potentially addictive but with some accepted medical use) and regulate it accordingly. To ensure its proper distribution and use, the government could declare itself the only agency sanctioned to provide the marijuana.

I disagree with Kassirer's proposal that the government "declare itself the only agency sanctioned to provide the marijuana" because there is no reason to think that the government will be any better at producing marijuana than it is at producing anything else. Perhaps Dr. Kassirer thinks that all marijuana is the same, but that would be true only if it were all produced by the government. Then, it would all be mediocre. In any case, Nahas' extraneous comparison with Holland is both misleading and irrelevant.

What Kassirer is proposing has nothing in common with Dutch policy. In the Netherlands the small-scale possession, cultivation and sale of cannabis is tolerated. It is not produced by a government monopoly for medical use. How such a government monopoly on the production of medical marijuana would "open the door to controlled legitimization" is not only unclear, to say the least, but is simply irrelevant.

It is also untrue that marijuana is not medically available in the Netherlands. It is true that marijuana is not included in the state health insurance. However, Dutch doctors are free to discuss the use of cannabis with their patients. They can also write prescriptions for cannabis for their patients. The patients can then take their prescriptions to certain "coffee shops" and buy their marijuana at a substantial discount. Alternatively, they can grow their own in their own homes and be certain that they will be immune from arrest. This is far beyond what even Dr. Kassirer is recommending.

Nahas' closing comments:

Finally, Dr. Kassirer makes the obligatory appeal to "compassion" for the suffering. He considers the prohibition of marihuana smoking to infringe on the right of the patients at "death's door." In this instance, the use of marihuana can no longer be considered a therapeutic intervention but one of several procedures used to ease the ebbing of life of the terminally ill.

Dr. Nahas never acknowledges that he considers arrest one of the "several procedures used to ease the ebbing of life of the terminally ill," but that was Dr. Kassirer's essential point, and the American reality: "Some patients and their families have been willing to risk a jail term to obtain or grow the marijuana." Anyone who opposes the medical use of marijuana must state whether they favor the arrest of the sick, dying, and disabled who disregard their advice. Silence is indeed acceptance.

Note: There always has been and always will be people like Gabriel Nahas, but the editors of The Wall Street Journal and others who disseminate this venom must bear the moral responsibility for the persecution of the sick and dying. The editors of the Journal have repeatedly declined to meet with the internationally respected doctors on the NORML Board of Directors. I would urge readers to print out this report along with the Christie and Chesher study and mail a copy to the editors of the Wall Street Journal, and/or members of the Board of Directors of the Dow Jones &Company. Ironically, their address is on Liberty Street: 200 Liberty Street, New York, New York, 10281

Copyright © marijuanamagazine.com. All rights reserved.

Revised: December 02, 1998.

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See the The Wall Street Journal article: Costs keeping 'rescue' drugs from patients Health: Physicians advise chemotherapy patients to ask about treatments that may reduce suffering from side effects. By Marilyn Chase

Editor's note: There are two points of relevance to the medical marijuana issue here. First, prohibitionists claim that there are pharmaceuticals that make medical marijuana unnecessary. This article makes clear that this is simply not true. Second, even if it were true, there are large numbers of people in America, and many more in other countries, for whom this is irrelevant because they just cannot afford these very expensive pharmaceuticals. Could this be why so many cancer wards are said to reek of marijuana? Also note the ironic header: "Physicians advise chemotherapy patients to ask about treatments that may reduce suffering from side effects." Consider this in the context of the recent efforts to make it a crime for a doctor even to recommend the medical use of marijuana.

Exhibits: The two articles below are copyrighted and are reproduced here under the fair use doctrine so that readers can more easily be certain that any quotations are not misrepresented or taken out of context. Not that anyone would ever do that, eh, Dr. N?

January 30, 1997 -- Volume 336, Number 5

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Editorial: The New England Journal of Medicine (Note: The highlighted numbered hyperlinks on the editorial notes below can by be reached from the NEJM site by clicking on the link to the right.)

Federal Foolishness and Marijuana

The advanced stages of many illnesses and their treatments are often accompanied by intractable nausea, vomiting, or pain. Thousands of patients with cancer, AIDS, and other diseases report they have obtained striking relief from these devastating symptoms by smoking marijuana. (1) The alleviation of distress can be so striking that some patients and their families have been willing to risk a jail term to obtain or grow the marijuana.

Despite the desperation of these patients, within weeks after voters in Arizona and California approved propositions allowing physicians in their states to prescribe marijuana for medical indications, federal officials, including the President, the secretary of Health and Human Services, and the attorney general sprang into action. At a news conference, Secretary Donna E. Shalala gave an organ recital of the parts of the body that she asserted could be harmed by marijuana and warned of the evils of its spreading use. Attorney General Janet Reno announced that physicians in any state who prescribed the drug could lose the privilege of writing prescriptions, be excluded from Medicare and Medicaid reimbursement, and even be prosecuted for a federal crime. General Barry R. McCaffrey, director of the Office of National Drug Control Policy, reiterated his agency's position that marijuana is a dangerous drug and implied that voters in Arizona and California had been duped into voting for these propositions. He indicated that it is always possible to study the effects of any drug, including marijuana, but that the use of marijuana by seriously ill patients would require, at the least, scientifically valid research.

I believe that a federal policy that prohibits physicians from alleviating suffering by prescribing marijuana for seriously ill patients is misguided, heavy-handed, and inhumane. Marijuana may have long-term adverse effects and its use may presage serious addictions, but neither long-term side effects nor addiction is a relevant issue in such patients. It is also hypocritical to forbid physicians to prescribe marijuana while permitting them to use morphine and meperidine to relieve extreme dyspnea and pain. With both these drugs the difference between the dose that relieves symptoms and the dose that hastens death is very narrow; by contrast, there is no risk of death from smoking marijuana. To demand evidence of therapeutic efficacy is equally hypocritical. The noxious sensations that patients experience are extremely difficult to quantify in controlled experiments. What really counts for a therapy with this kind of safety margin is whether a seriously ill patient feels relief as a result of the intervention, not whether a controlled trial "proves" its efficacy.

Paradoxically, dronabinol, a drug that contains one of the active ingredients in marijuana (tetrahydrocannabinol), has been available by prescription for more than a decade. But it is difficult to titrate the therapeutic dose of this drug, and it is not widely prescribed. By contrast, smoking marijuana produces a rapid increase in the blood level of the active ingredients and is thus more likely to be therapeutic. Needless to say, new drugs such as those that inhibit the nausea associated with chemotherapy may well be more beneficial than smoking marijuana, but their comparative efficacy has never been studied.

Whatever their reasons, federal officials are out of step with the public. Dozens of states have passed laws that ease restrictions on the prescribing of marijuana by physicians, and polls consistently show that the public favors the use of marijuana for such purposes. (1) Federal authorities should rescind their prohibition of the medicinal use of marijuana for seriously ill patients and allow physicians to decide which patients to treat. The government should change marijuana's status from that of a Schedule 1 drug (considered to be potentially addictive and with no current medical use) to that of a Schedule 2 drug (potentially addictive but with some accepted medical use) and regulate it accordingly. To ensure its proper distribution and use, the government could declare itself the only agency sanctioned to provide the marijuana. I believe that such a change in policy would have no adverse effects. The argument that it would be a signal to the young that "marijuana is OK" is, I believe, specious.

This proposal is not new. In 1986, after years of legal wrangling, the Drug Enforcement Administration (DEA) held extensive hearings on the transfer of marijuana to Schedule 2. In 1988, the DEA's own administrative-law judge concluded, "It would be unreasonable, arbitrary, and capricious for DEA to continue to stand between those sufferers and the benefits of this substance in light of the evidence in this record." (1) Nonetheless, the DEA overruled the judge's order to transfer marijuana to Schedule 2, and in 1992 it issued a final rejection of all requests for reclassification. (2)

Some physicians will have the courage to challenge the continued proscription of marijuana for the sick. Eventually, their actions will force the courts to adjudicate between the rights of those at death's door and the absolute power of bureaucrats whose decisions are based more on reflexive ideology and political correctness than on compassion.

Jerome P. Kassirer, M.D.

Copyright © 1997 by the Massachusetts Medical Society

Nahas, et al. on medical marijuana (Note: the text below is identical to the column in the WSJ, but was taken from the Swedish prohibitionist site, Hassela. There are no references given for the various claims. Readers are urged to visit the Hassela site to review the prohibitionist position at its most simplistic.)

Press release March 30, 1997

THE FOOLISHNESS OF MARIHUANA SMOKING FOR MEDICINE . By Dr. Gabriel G. Nahas,

Dr. Kenneth Sutin, Dr. William M. Manger and Dr. George Hyman

The debate over using marihuana as medicine has been distorted by a basic confusion: the implicit assumption that smoking marihuana is a better therapy than the ingestion of its active therapeutic agent THC or a more effective one than approved medications. This assumption is wrong. THC (also known as Marinol) is an approved remedy that may be prescribed by physicians for nausea and AIDS wasting syndrome. It is safer than marihuana smoke.

The prestigious New England Journal of Medicine added to the confusion with its January 30 editorial, signed by Editor Jerome P. Kassirer, entitled "Federal Foolishness and marihuana." Among the editorial's errors:

• It underestimates the toxic properties of marihuana smoke. This smoke contains carbon monoxide, acetaldehyde, napthalene and carcinogens. Inhalation of THC decreases lung defense mechanisms which are already compromised in AIDS patients, who are extremely vulnerable to pulmonary infections and tumours like Kaposi´s Sarcoma. Thus marihuana smoke is a questionable choice to treat the symptoms of AIDS or cancer, especially when safer and more effective medications are available.
• It implies that marihuana smoking relieves pain. THC (or marihuana) does not interfere directly with the endorphin system. Indeed, it increases the perception of pain. Dr. Kassirer declares it "hypocritical" to forbid a physician to prescribe marihuana yet allow him to prescribe morphine for the relief of pain. If he means to imply that marihuana is analgesic, he is simply wrong. If the implication is that it is hypocritical to prescribe one dependence-producing drug and not another, Dr. Kassirer is relying on a spurious analogy that beclouds the basic pharmacological question: What is the effectiveness of the therapeutic substance prescribed by a physician?
• It argues that the patient's "feelings" are the determinant therapeutic criterion. Dr. Kassirer deems it "hypocritical" to demand scientific evidence of therapeutic efficacy. To determine whether marihuana use is an effective therapy, he says, one should rely "not (on) whether a controlled trial proves it efficacy" but on how patients say they feel after the intervention. Marihuana smoking would therefore become a privileged therapeutic procedure, exempted from the general proof of efficacy required for all drugs, and untested in double-blind controlled placebo trials.
• It makes implausible claims about the advantages of smoking marihuana over oral THC. "Since smoking marihuana produces a rapid increase in the blood level of active ingredients, it is more likely to be therapeutic," Dr. Kassirer claims. But based on pharmacology, the opposite should be the case: Plasma THC concentration following oral administration reaches a more sustained, steady level, lasting three to four hours, twice as long as after smoking. Such prolonged concentration should be more effective than a rapid rise and fall of THC concentration after smoking.
• It claims the efficacy of new drugs to treat nausea has not been tested. Dr. Kassirer ignores that experimental and clinical studies have clearly established the superiority of substituted benzamide and ondansetron over oral THC, though acknowledges that these drugs may be more beneficial than marihuana.
• It dismisses as "specious" the argument that approving marihuana for medical use would send the wrong signal to the young. Epidemiological surveys, however, indicate, that the greater the perception of harm associated with marihuana, the lower the frequency of its use among children and adolescents.
• It condemns as "misguided, heavy handed and inhumane" the Drug Enforcement Administration's refusal to reclassify marihuana from Schedule I (addictive and illegal) to Schedule II (addictive but legal for some medical uses). Yet this refusal was based on a thorough analysis of reports from medical specialists in ophthalmology, oncology and neurology. None reported evidence that smoking marihuana was more effective than current approved remedies. The DEA´s decision was supported by both the Food and Drug Administration and the Public Health Service. A doctor prescribing marihuana to a patient may be "courageous" in Dr. Kassirer´s mind - but he is also scientifically misinformed and in violation of federal law.

Dr. Kassirer recommends that the federal government get into the marihuana business, by "declaring itself the only agency sanctioned to provide the marihuana." Thus the government would "ensure its proper distribution and use." In effect, Dr. Kassirer is opening the door to the "controlled" legitimization of marihuana as it exists in the Netherlands - but even the Dutch have not approved marihuana for medical use!

Finally, Dr. Kassirer makes the obligatory appeal to "compassion" for the suffering. He considers the prohibition of marihuana smoking to infringe on the right of the patients at "death's door." In this instance, the use of marihuana can no longer be considered a therapeutic intervention but one of several procedures used to ease the ebbing of life of the terminally ill. But for this purpose doctors should prescribe antiemetic and analgesic therapies of proven efficacy, rather than marihuana smoking. This therapeutic course is not based on bureaucratic absolutism, political correctness, or reflexive ideology - but on scientific knowledge and the humane practice of medicine.

Dr. Nahas, Dr. Sutin and Dr. Manger are professors at New York University's Department of Anesthesiology and Medicine. Dr. Hyman is an Emeritus professor of medicine at Columbia University's College of Physicians and Surgeons.