Should marijuana be made more accessible to researchers and clinicians who seek to use it for treatment of conditions such as chemotherapy-related nausea?

The question was the source of passionate debate at the Interim Meeting of the AMA House of Delegates in November. A resolution brought to the house by the Medical Student Section asked the AMA to seek the reclassification of marijuana under the Controlled Substances Act from a Schedule I drug—under which it is deemed to have high abuse potential and no proven medical uses—to another schedule that would make it more available to researchers and clinicians.

The resolution was not approved; rather, it was referred to the AMA's Council on Science and Public Health (CSPH) for further study, but not before it had consumed nearly two hours in reference committee hearings and house floor debate and had elicited strident testimony from advocates both for and against rescheduling.

Compelling case reports of individuals with serious or life-threatening conditions who benefited from marijuana use clashed with concerns about potential abuse should the drug be made more easily accessible and the social issues associated with a declaration that marijuana is a safe and effective medicine. Adding to the mix of opinion was new information about the physiology of the endocannabinoid system and testimony about the advantages and disadvantages of new cannabinoid-based pharmaceutical products versus use of the crude marijuana plant.

Addiction psychiatrist John Halperin, M.D., a researcher at the McLean Hospital Biological Psychiatry Laboratory, said he cannot do research on the medical uses of marijuana.

"I would love to do research with marijuana, but I will not do it because of the current paradigm being foisted on me [requiring me] to go through unnecessary review by NIDA to request NIDA-sourced marijuana that is of substandard quality," Halperin said. "It is a setup for failed research. I would like to do research where I would have input into the design and growth of marijuana that would be useful to research.... I urge you to pass this resolution so that we can get real research going [on the medical uses of marijuana]."

George Wagoner, M.D., an obstetrician-gynecologist, emotionally testified about his wife's experience with chemotherapy-related nausea, the failure of Marinol to control the nausea (Marinol is a synthetic form of THC, the active ingredient in marijuana, and is known to sometimes cause delusions and hallucinations), and the successful use of inhaled marijuana.

"By the second inhalation, my dear wife experienced sudden and complete relief of her nausea that lasted four to six hours.... The relief was as dramatic and as complete as any I have experienced in medicine."

Melvyn Sterling, M.D., a palliative-care physician from California, echoed those remarks, saying that many end-of-life patients could benefit from the medicinal effects of marijuana and that there was a bountiful body of research on its benefits. "It's time to get our heads out of the sand," he said.

But psychiatrists and other physicians countered that the potential for abuse was significant and that the possible unintended consequences of rescheduling marijuana called for further study by the CSPH.

"I have seen many cases of exacerbations of schizophrenia and bipolar disorder brought on by marijuana use," said psychiatrist Kenneth Certa, M.D., a member of the Section Council on Psychiatry. "Another problem I can see is that the marijuana in the community is often not very pure and is frequently adulterated with PCP [phencyclidine, an hallucinogen], which can also cause problems with psychosis.

"I understand that ideally if we had medical marijuana approved, we would have a purer supply and better control, but it would also send a message to others that marijuana is OK to use," Certa said. "And what's out on the street would not be so easy to control."

Albert Osbahr, M.D., an occupational health physician and a member of the CSPH, agreed that the council needed to revisit the issue; its last report was in 1997. "There has been a lot of research done since then, and we need to update the house," he said. "I think after doing that, we can answer the question of reclassification."

Addiction psychiatrist Stuart Gitlow, M.D., also a member of the CSPH, predicted that approval of medical marijuana would result in an upsurge in addicted patients.

"We don't have any good studies to demonstrate significant value from smoked marijuana," Gitlow said. "That's not to say there is no value, but simply that such value hasn't been demonstrated to the level that we demand of prescribed medication. We have an enormous literature detailing the risks of marijuana use. Such risks are likely not going to be present in an end-of-life treatment scenario. Rather, the risks will be present to the adolescents coming into the home of this scenario and finding marijuana just as easily as they now find opioids and sedatives." ▪