Smokin Moose
Fallen Cannabis Warrior & Ex Moderator
POLICY SPOTLIGHT
REEFER MADNESS: THE ILLOGICAL POLITICS OF MEDICAL MARIJUANA
Mary Lynn Mathre
"If you want to make enemies, try to change something."
WOODROW WILSON
THE PROBLEM
It's a drug with an image problem–a drug that has been shown to help certain patients, but its use is forbidden by federal law. Most of us know it as dope, pot, reefer, grass, weed, or ganja. But in its clinical form, medical cannabis is a valuable therapeutic aid. Scientific evidence demonstrates the value of cannabis in certain clinical conditions. However, the Drug Enforcement Administration (the federal agency responsible for placing drugs in categories on the Controlled Substances Schedule) has refused to move cannabis to a less restrictive schedule, while allowing a synthetic form of the primary psychoactive substance (THC) in cannabis to be placed in a less restrictive level of the Controlled Substances. Cannabis (marijuana) and natural THC (the primary psychoactive substance in cannabis) remains in Schedule I, while dronabi-nol (Marinol), the synthetic form of THC, was originally placed in Schedule II but has since been reassigned to Schedule III (less control and more available) due to its safety and lack of diversion. In 1999, at the request of the White House, the Institute of Medicine completed its 18-month study on therapeutic cannabis (Joy, Watson, & Benson, 1999). The study team found that cannabis is not highly addictive, is not a gateway drug, and has therapeutic value; the team recommended that until pharmaceutical grade products become available, cancer and AIDS patients should be allowed to smoke the crude plant material. They also recommended that physicians should be able to conduct "n-of-1" studies on their patients whom they believe could benefit from cannabis and that research should be conducted on alternative delivery systems. This report has more or less been ignored by the federal government, but research is going forward on the therapeutic use of cannabis in the United States and other countries. Despite the barriers and seeming social bias against cannabis, 11 states have passed laws permitting the medical use of the drug. However, in June 2005, the U.S. Supreme Court ruled that federal authorities have the power to prosecute individuals for possession and use of medical marijuana even in the states that permit it (Tierney, 2005). How did this once-legal drug become socially shunned, the problem child of the pharmaceutical industry, and a political hot potato? The saga of cannabis in the U.S. health system is a story of the clash of politics, opinions, fear, emotions, and science.
ONCE UPON A TIME, CANNABIS WAS LEGAL
Before the U.S. Congress passed the Marihuana Tax Act of 1937, cannabis was a medicine commonly used by physicians for a variety of ailments. Originally, Cannabis saliva and Cannabis indica plant material were imported to this country for use in medical products. As time went on, Cannabis americana was grown in the United States to provide access to fresh plant material to avoid the degradation that occurred when it was brought overseas on slow-moving ships. Cannabis tinctures, elixirs, salves, and even smokeable products were available. It was listed in the U.S. Pharmacopoeia until 1940.
Cannabis
A plant genus that is unique in the plant kingdom in that it contains a group of chemicals known as cannabinoids.
Cannabis indica
A species of the cannabis plant that has short, broad leaflets.
Cannabis sativa
A species of the cannabis plant that has long, narrow leaflets.
Cesamet
Synthetic derivative of THC available in Europe;
manufactured by Eli Lilly.
Marijuana/marihuana
The Mexican name for cannabis, used by the U.S. federal government in their efforts to prohibit the use of the cannabis plant.
Marinol
A registered trademark of Unimed Pharmaceuticals. It is the commercial name for dronabinol (the synthetic form of delta-9-tetrahydrocannabinol) in sesame oil and encapsulated in soft gelatin capsules. When first on the market, it was a Schedule II medication for use in the treatment of nausea and vomiting caused by chemotherapy, as well as appetite loss caused by AIDS.
Sativex
A cannabis extract oro-mucosal spray developed by GW Pharmaceuticals in Great Britain and first on the market in Canada in 2005 for use by patients with multiple sclerosis.
THC
A-9-tetrahydrocannabinol, the primary psychoactive ingredient in cannabis/marijuana; one of 60 cannabinoids.
HOW AND WHY DID THE PROHIBITION BEGIN?
"Prohibition" (the alcohol prohibition in the United States in the 1930s) ended in failure, but the staff of The Bureau of Narcotics and Dangerous Drugs and its leader, Harry Anslinger, needed to find something for the department to do or it would be dissolved. Anslinger targeted a drug used by "negro" jazz musicians in the American South and Mexicans in the Southwest. The drug was cannabis, but was called "reefer" by the African American population and "marijuana" (alternately spelled "marihuana") by the Hispanic population.
THE DESCENT INTO "REEFER MADNESS"
In 1936, the film Reefer Madness was released (a reefer being a marijuana cigarette). The film's plot involves tragic events that ensue when high school students are lured by drug pushers into using marijuana. Death, suicide, and a descent into madness are the results (Wikipedia, 2005). A "Reefer Madness" mentality was adopted by some government agencies, individuals, and media moguls like William Randolph Hearst. Few people realized at the time, that this dangerous "new" drug was the same thing as the cannabis medicine that many physicians routinely prescribed.
MY INTRODUCTION TO THE PROBLEM OF MEDICAL CANNABIS USE
In the early 1980s, I was working in a small hospital in Washington state, when the director of nursing approached me with a problem. A cancer patient was going to be admitted who had experimental "marijuana" pills from the University of Washington She asked what should we do? I suggested we loock it up in the narcotics cabinet and dispense it as prescribed. No problems were encountered, and I began learning about Marinol, the synthetic "marijuana" pill. About the same time, I came across a flyer about an organization called the Alliance for Cannabis Therapeutics (ACT). It was started by a glaucoma patient, Robert Randall, and his wife. In 1976, Randall had gained legal access to feder- ally grown marijuana under the Compassionate Investigational New Drug (IND) program following a series of court battles because no other medicine could control his intraocular pressure. He formed ACT, a nonprofit organization, to let others know about the therapeutic benefits of cannabis and how patients could get a legal, federally approved supply of it. I was drawn to the issue. After moving to Ohio to complete graduate school at Case Western Reserve University in 1983, I conducted a survey on marijuana disclosure to health care professionals using the membership of NORML as my survey population (Mathre, 1985). The thrust of the survey was to determine if health care professionals asked patients about the use of cannabis and whether the survey subjects would disclose their use patterns. I received some surprising responses that led me to consider the therapeutic potential of cannabis. In a final question that asked the subjects to identify their concerns regarding the use of cannabis from a list of health problems, numerous respondents noted in the "other" option that they used it as medicine for stress, migraines, spasticity, pain, and other ailments Mathre, 1988).
AN OPPORTUNITY FOR EDUCATION
I accepted the position of director of the National Organization for the Reform of Marijuana Laws' (NORML) Council on Marijuana and Health. By 1990, there were five patients who had legal access to marijuana through the Compassionate IND program. I was serving on the planning committee for the annual NORML conference and suggested that we have all five patients present their cases in a panel presentation. The patients were eager to tell their stories and were excited to meet others in their situation. Their presentation was aired on C-SPAN and garnered national attention. Taking advantage of the opportunity, we had each patient interviewed and videotaped by a volunteer professional videographer.Over the next two years, excerpts from the interviews were used to create an 18-minute video, Marijuana as Medicine (Byrne & Mathre, 1992),designed to be a teaching aid. Following the airing of the patients' panel, the U.S. Food and Drug Administration (PDA) received many requests for IND access to marijuana, especially from HIV/AIDS patients.
The Secretary of Health and Human Services, Dr. Louis Sullivan, responded by shutting down the IND access to marijuana in 1992. At that time, 15 patients were receiving marijuana, over 30 patients had been approved and were waiting for their medication to be delivered, and hundreds of applications were waiting for review (Randall & O'Leary, 1998). Only the 15 current patients would be allowed to continue in the program, closing the door to all others. Also during that time frame, one of the legal patient's supply of marijuana was cut off. Corinne Millet, a widow and glaucoma patient, sought help from her congressman to regain her supply of medicine, but during the six weeks she spent without her medication, she lost 80% of her peripheral vision (Byrne & Mathre, 1992). These events made me feel it was important to end the prohibition on the use of cannabis in the United States. My perspective was that there was no justifiable reason for the marijuana prohibition.
It has therapeutic value, it is safe, and patients benefit from it. Patients who might benefit from it have no knowledge of its value, health care professionals are not trained to use it, and patients are harmed by the legal consequences for their use of it. I saw this as a problem that required patient advocacy and that had ethical implications, and I believed it to be a professional responsibility to try to end the cannabis prohibition and make this medicine legally available to patients.
The more I learned, the more determined I became. I embarked on a more than 20-year fight, met countless barriers, and often felt like David taking on the Goliath of the federal government. Colleagues have questioned me over the years why I'm still trying to change the laws, and my answer is always the same:
Patients still do not have access to a safe and legal supply of this medicine.
BARRIERS AND STRATEGIES
Over the years, I've encountered many barriers and I've tried various strategies; often the same strategies have been used under different circumstances. Barriers that I've encountered include misinformation presented as facts, censorship of information, intimidation, laws and regulations that prevent research, an image based on racism and ideology rather than science and reality, and pharmaceutical pressure to prevent potential competition. I've used strategies like finding a strong mentor, building a support system, mobilizing grassroots support, changing the image of the problem, partnering with patients, building a coalition, starting a nonprofit organization, providing continuing accredited education for health care professionals about cannabis, using the Internet effectively, playing by the government's rules, teaching others, conducting research, disseminating research findings, and educating the public through publications, the press, and the media.
HIDING THE TRUTH
In the years following the Marihuana Tax Act of 1937, cannabis was removed from the U.S. Pharmacopoeia, it was no longer included in medical school curricula, and health care professionals learned about marijuana only in the context of substance abuse. The Controlled Substances Act of 1970 further condemned the drug when officials wrongly, in my opinion, placed marijuana in Schedule I of the Controlled Substances Schedule,
the category of drugs that are highly addictive, not safe for medical use, and have no therapeutic value (Box 22-4). By the 1960s and 1970s, the average American had little knowledge of cannabis but had been taught about the dangers of marijuana. The legal consequences for possession of marijuana became so severe (up to a life sentence for a single "joint") that people who used it medicinally kept their use a secret. Thus, the unmotivated, "stoned" teenager became the public image of a marijuana user (think Scan Penn in the film Fast Times at Ridgemont High).
FINDING THE TRUTH
I knew cannabis had therapeutic value after searching for and reviewing historical records that included national studies and patient studies conducted in the late 1970s and early 1980s. For studies conducted before the Marihuana Tax Act of 1937, I had to search using the terms "cannabis" and "hemp." I initially depended on others in the field to gain access to rare copies of studies that validated the medicinal efficacy of cannabis. I found that some published reports had negative results, but on close review the studies were either flawed or not accurately reported.
A POWERFUL MENTOR
I was lucky to meet an influential nursing leader. Melanie Dreher, PhD, RN, FAAN, who at the time was Dean of the University of Florida School of Nursing in Miami. Her doctorate was in anthropology, and her current research was on "ganja" (marijuana) use by pregnant women in Jamaica and fetal outcome (Dreher, 1997; Dreher, Nugent, & Hudgins. 1994). She taught me a great deal and validated my understanding of the benefits of cannabis.
GAINING SUPPORT
Initially, I began collecting signatures on a petition to demand that cannabis be removed from Schedule I of the Controlled Substances to make it available for patient use. Many people agreed with the idea but were afraid to put their names on a public document Although, together with others, I collected tens of thousands of signatures, it soon became apparent that this approach was not cost- or time-effective. By getting the first five legal patients together, I had helped them develop a lasting bond, and they in turn trusted me. This bond empowered them to speak out about the injustice of the prohibition of cannabis use. The video, Marijuana as Medicine (Byrne & Mathre, 1992), has served as a powerful teaching tool for use with other health care professionals, the public, and legislators. I began to approach nursing organizations to show them the video. Following the video presentation, I urged them to pass a resolution that I had drafted in support of cannabis. My initial success began with resolutions passed by the Virginia Nurses Society on Addictions (1993), the Virginia Nurses Association (1994), and the National Nurses Society on Addictions (1995). During these presentations, the proper name for the plant, cannabis, was used in an attempt to change the negative image of marijuana. By getting professional organizations to formally support patient access to therapeutic cannabis, individual members had a stronger voice on the issue.
Schedule of Controlled Substances in the United States
SCHEDULE I DRUGS
a. The drug or other substance has a high potential for abuse,
b. The drug or other substance has no currently accepted medical use in treatment in the United States,
c. There is a lack of accepted safety for use of the drug or other substance under medical supervision.
Schedule I drugs include marijuana, heroin (Diacetylmorphine), ecstasy (MDMA), psilocybin,
GHB (Gamma-hydroxybutyrate), LSD, mescaline, and peyote.
SCHEDULE II DRUGS
a. The drug or other substance has a high potential for abuse,
b. The drug or other substance has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions.
c. Abuse of the drug or other substances may lead to severe psychological or physical dependence. Schedule II drugs are only available by prescription, and distribution is carefully controlled and monitored by the DEA.
Schedule II drugs include cocaine, methylphenidate (Ritalin), most pure opioid agonists, meperidine, fentanyl, opium, oxycodone, morphine, short-acting barbiturates such as secobarbital, methamphetamine, and PCP.
SCHEDULE III DRUGS
a. The drug or other substance has a potential for abuse less than the drugs or other substances in Schedules I and II
b. The drug or other substance has a currently accepted medical use in treatment in the United States.
c. Abuse of the drug or other substance may lead to moderate or low physical dependence or
high psychological dependence.
Schedule III drugs are available only by prescription, though control of wholesale distribution is
somewhat less stringent than Schedule II drugs.
Schedule III drugs include Marinol, anabolic steroids, intermediate-acting barbiturates such as
talbutal, preparations that combine codeine or hydrocodone with aspirin or acetaminophen, ketamine, and Paregoric.
SCHEDULE IV DRUGS
a. The drug or other substance has a low potential for abuse relative to the drugs or other substances in Schedule III.
b. The drug or other substance has a currently accepted medical use in treatment in the United States,
c. Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence
relative to the drugs or other substances in Schedule III. Schedule IV control measures are similar to Schedule III;
drugs on this schedule include benzodiazepines, such as alprazolam (Xanax), chlordiazepoxide (librium),
and diazepam (Valium); long-acting barbiturates, such as phenobarbital; and some partial agonist opioid analgesics,
such as propoxyphene (Darvon) and pentazocine (Talwin).
SCHEDULE V DRUGS
a. The drug or other substance has a low potential for abuse relative to the drugs or other substances in
Schedule IV.
b. The drug or other substance has a currently accepted medical use in treatment in the United States,
c. Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule IV.
Schedule V drugs are sometimes available without a prescription; drugs on this schedule include cough suppressants containing small amounts of codeine and preparations containing small amounts of opium, used to treat diarrhea.
top
21 U.S. Code §812(b) specifies a classification system for drugs in the United States based on the purpose,
safety, and effectiveness of the drug.
~ Title 21 United States Code (USC) Controlled Substances Act. Retrieved September 5, 2005, from deadiversion.com: The Leading Government Site on the Net
PATIENTS OUT OF TIME
In 1995, following the deaths of a young AIDS couple who were in the IND program, my husband and I felt the need to take this issue more seriously. With the help of several legal patients and other health care professionals, we founded a national nonprofit organization, Patients Out of Time. We kept our mission simple: to educate the public and health care professionals about the therapeutic use of cannabis. Initially, we focused on getting more professional organizations to issue resolutions in support of patient access to cannabis. Next on our list was the American Public Health Association (APHA). I drafted and submitted a proposed resolution to the APHA, and it was passed at their annual meeting in California in 1995. I sent out copies of the Virginia Nurses Association's resolution and a letter to the leadership of all the state nurses associations. Colorado, Mississippi, and New York were among a few states that took action. The California Nurses Association had already passed a resolution in 1994. We posted a list of these organizations on our Website (medical marijuana. patient advocacy for cannabis as medicine, clinical conference), which we continually update as more organizations join the list. We verify accuracy before placing any organization on our list. In 2002,1 received a call from a New York nurse who was drafting a resolution on therapeutic cannabis to present at the American Nurses Association (ANA) 2003 House of Delegates meeting. I assisted in developing its content and went to the convention to speak on behalf of the resolution. It easily passed. I believe the ANA resolution most clearly encompasses the issues of concern regarding the marijuana prohibition. In 2005,1 was appointed to the National Organization for Women's (NOW) newly created Women and Drug Policy ad hoc Committee; among other issues, I will advocate for the organization to pass a resolution supporting therapeutic cannabis.
CHALLENGES IN DISSEMINATING INFORMATION ABOUT CANNABIS
In 1993,1 sent a manuscript on the ethical and legal dilemmas for nurses related to therapeutic cannabis to the American Journal of Nursing (AJN) to try to increase professional awareness on this issue. I received a rejection letter from the editor of AJN that said it wasn't appropriate. I called Mary Mallison, the editor-in-chief, and after a discussion she suggested I submit a second article on cannabis dosing. On receipt of that manuscript, I received a letter from the editorial director, Martin DiCarlantonio, which stated: "We'd like to accept your manuscript and run it as soon as marijuana is moved to Schedule II category (if that day ever comes)." In 1995, I was asked by Mary Gorman, RN, to write a manuscript for AJN's Substance Abuse column on the medical use of marijuana. I prepared it and submitted it with the projected publication date for the fall of 1996. Again, it was considered too controversial and remained in their files for more than a year until a change in editorial staff occurred. It was published in November 1997 (Mathre, 1997b). In the May 1998 issue, several positive letters to the editor were printed. I was told that no negative letters to the editor had been received.
In 1999, I decided to submit another article to AJN after reading an editorial by Dr. Diana Mason,A/N's new editor-in-chief, in which she urged nurses to work to influence health policy. This manuscript was published in 2001 (Mathre, 2001), and again, only positive letters to the editor were received. In 2004, I was asked to submit a manuscript to Nursing 2004 on therapeutic cannabis. It was accepted for publication, but in 2005 I received a letter stating it would not be published because they could not get anyone to submit an opposing view.
BIRTH OF A BOOK AND DEATH OF A JOURNAL
In 1995,1 began work on a cannabis book and began finding experts on various topics who were willing to contribute a chapter. Cannabis in Medical Practice was published in 1997 by McFarland, containing the work of 17 contributing authors (Mathre, 1997a). The book received great reviews. Although it wasn't a big seller, Dr. Geoffrey Guy, a physician and drug researcher from Great Britain, read my book which, per his acknowledgment, motivated him to start a pharmaceutical company to develop cannabis-based pharmaceuticals (GW Pharmaceutical). In large part because of my book, I was invited to serve on the editorial board of a new quarterly journal, The Journal of Cannabis Therapeutics, which premiered in 2001, published by Haworth Press. Unfortunately, due to the continued illegal status of cannabis, :his journal was not picked up by many university libraries or individual subscriptions, and the publication ceased by 2004. I served as coeditor along with Ethan Russo, MD, and Melanie Dreher, RN, PhD, FAAN, on Women and Cannabis: Medicine, science and Sociology (Russo et al, 2002), which A as published as a monograph in 2002.
RAISING AWARENESS AT PROFESSIONAL CONFERENCES
In 1995, I went to the continuing education department at the University of Virginia Health System and asked if they would host a national conference n cannabis therapeutics. My formal written proposal went to the top of the administration. Here it was immediately rejected. I countered with a request to limit it to a statewide nursing conference on the topic, since the 1994 Virginia Nurses association resolution called for the "education of Virginia Nurses on evidence-based use of cannabis." I was then informed by the director of the Continuing Education department that they wouldn't support such a conference because "it still had the same political issues." In 1996, my proposal for the 100th Anniversary Convention of the ANA to present Therapeutic Cannabis & the Law: Ethical Dilemma for Nurses was accepted, and in 2002 I presented "Evidence Based Support for Cannabis Therapeutics" as part of the NOLF Lecture series at the ANA convention in Philadelphia.
THE FIRST NATIONAL CLINICAL CONFERENCE ON CANNABIS THERAPEUTICS
In 1999, Dr. Dreher, who was now the Dean of the College of Nursing at the University of Iowa (and also on the Board of Directors for Patients Out of Time), was able to gain local support to hold a national conference at the University of Iowa. Patients Out of Time managed the agenda and faculty. In 2000, Patients Out of Time held The First National Clinical Conference on Cannabis Therapeutics with the University of Iowa's Colleges of Nursing and Medicine as cosponsors. We had an international conference faculty that included researchers, clinical experts, patients, and patients' care providers, and the conference was teleconferenced to seven other sites. One of them (second conference) was in Oregon sponsored by the Oregon Public Health Department, since their new law allowed patient use of cannabis under a physician's recommendation that was regulated by the Health Department. The Oregon Public Health Department broadcast the conference throughout its system, which led them to co-sponsor the second conference in Oregon with the Oregon Nurses Association in 2002. Since the first conference, we continue to hold biannual conferences. The audience feedback has been very positive, and the faculty has been very impressed with our "nursing" approach for the conference content.
At the third conference in 2004, which was cosponsored by the University of Virginia Schools of Medicine, Nursing, and Law (persistence pays off), we applied for and received grant funding to provide scholarships to legislators and health care professionals in leadership positions to attend the conference. Some of these scholarships were nurses representing various state nurses associations. These nurses took this information back to their leadership and had articles published in their state newsletters; subsequently, the nurses from Illinois and Connecticut were able to get resolutions passed by their state associations, and the nurse representing the Virginia nurses convinced the association to reaffirm their support of the issue with the passage of a second resolution supporting therapeutic cannabis. Laurie Badzek, the director of the ANA's Center for Ethics and Human Rights was also one of the scholarship recipients and informed me that she hopes to attend our fourth conference so that she can keep the ANA up to date on the issue. Our fourth conference was in April of 2006 in Santa Barbara, California and focused on getting funding for more such scholarships. We have DVD's of all the conference proceedings available on our Website, but we also hope to broadcast the next conference live on the Internet to increase the viewing audience.
THE NEED FOR EVIDENCE
In 2001, Patients Out of Time received grant funding from John Gilmore, Preston Parish, the Zimmer Family Foundation, and the Multidisciplinary Association for Psychedelic Studies to conduct an in-depth review of the chronic effects of cannabis on four of the surviving legal medical marijuana patients. These patients offered a unique opportunity for study because they had been receiving and using a known quality and quantity of cannabis provided by the federal government. The study was led by Ethan Russo, a pediatric neurologist and expert in cannabis therapeutics, and conducted in Missoula, Montana (Russo et al., 2002).
TAKING ON THE U.S. DRUG ENFORCEMENT ADMINISTRATION
Attempts have been made to change the federal prohibition of cannabis and all have failed. Even the state initiatives that have been passed to allow patients to use cannabis medicinally under the recommendation of a physician have been thwarted by the federal government's prohibition. In November 2002, Jon Gettman, PhD, submitted a Petition to Reschedule Cannabis to the U.S. Drug Enforcement Administration (DEA) on behalf of a coalition of cannabis patients. Patients Out of Time is a leading member of that coalition and serves as the lead voice (DrugScience.org, 2005). According to the rules and regulations of the Controlled Substances Act, a drug in its natural form cannot be at a more restricted schedule than its active constituent (DrugScience.org, 2005). Synthetic THC (Marinol) was placed in Schedule II in 1980 and was approved for use as an anti-emetic and appetite stimulant. By 1989, due to a lack of diversion and its record of safety, it was moved to the less restrictive Schedule III. Following this, whole cannabis extracts should also be at a Schedule III or less restrictive category. The DEA accepted the rescheduling petition as a legitimate request and, according to protocol, passed it on to the Department of Health and Human Services (DHHS) for their review in 2004. Per protocol, they may take up to three years to review all of the new research that is available.
PROGRESS
The public's awareness and acceptance of therapeutic cannabis has increased over the years to 70% to 80% approval per public opinion polls (Medical Marijuana ProCon.org, 2005; NORML, 2005). Despite the federal prohibition, there are now 10 states that have passed voter initiatives for patient use of therapeutic cannabis and two states that have passed similar laws through legislative action. The recent discoveries of endogenous cannabinoids and cannabinoid receptors have spawned more research. Pharmaceutical companies are now conducting research into cannabis-based products. In 2005, an oro-mucosal cannabis extract spray, Sativex, developed by GW Pharmaceuticals in Great Britain was approved as medicine in Canada and approved for clinical trials to begin in the United States in 2006 for use with terminal cancer patients.
LOOKING INTO THE CRYSTAL BALL
International acceptance of cannabis-based medicines may help influence the United States to end its prohibition of medical cannabis. The body of science contained in the petition to reschedule cannabis hopefully will convince the DHHS about the efficacy of cannabis and get them to make a recommendation to place cannabis in Schedule III or a lower level of control. I believe that once health care professionals are familiar with this medication, it will be considered as the "drug of choice" in symptom management, because of its wide margin of safety, rather than the "last resort." Hopefully, medical cannabis will soon be on the market in the United States, and nurses are urged to increase their knowledge about how it may help their patients.
Key Points
* Perseverance and coalition-building are essential elements in the process of changing a policy based on ideology rather than logic or science.
* Based on the evidence-based research that supports cannabis efficacy, nurses should advocate for patients to have the option of using cannabis pharmaceutical products.
* Always consider the source of your information.
Web Resources
Alliance for Cannabis Therapeutics - Marijuana medical use
International Association for Cannabis as Medicine (IACM) . vww.cannabis-med.org
International Cannabinoid Research Society (ICRS) ICRS - The International Cannabinoid Research Society
National Organization for Reform of Marijuana Laws Marijuana Law Reform - NORML
Patients Out of Time medical marijuana. patient advocacy for cannabis as medicine, clinical conference -our Home Page
U.S. Drug Enforcement Administration, Office of Diversion Control DEA Diversion Control Program - Controlled Substance Schedules
REFERENCES
Byrne, A., & Mathre, M. L. (1992). Marijuana as medicine (video). Available here.
Dreher, M. (1997). Cannabis and pregnancy. In
M. L. Mathre, Cannabis in medical practice: Cannabis in Medical Practice | Patients Out of Time
A legal, historical and pharmacological overview of the therapeutic use of marijuana. Jefferson, NC: McFarland.
Dreher, M. C., Nugent, K., & Hudgins, R. (1994).
Prenatal marijuana exposure and neonatal outcomes in Jamaica: An ethnographic study.
Pediatrics, 93, 254-260. DrugScience.org. (2005). Retrieved March 1, 2006, from Marijuana Research: Science, Law, Medical Marijuana, Rescheduling Petition.
Joy, J. E., Watson, S. A., & Benson, J. A., Jr. (1999). Marijuana and medicine: Assessing the science base.
Washington, DC: Institute of Medicine, National Academy Press.
Mathre, M. L. (1985). Disclosure of marijuana use to health care professionals.
Unpublished master's thesis, Case Western Reserve University, Cleveland, Ohio.
Mathre, M. L. (1988). A survey on disclosure of marijuana use to health care professionals.
Journal of Psychoactive Drugs, 20(1), 117-120.
Mathre, M. L. (1996, June 17). Therapeutic cannabis and the law: Ethical dilemma for nurses.
Presentation at the 100th Anniversary Convention of the American Nurses Association in Washington, DC.
Mathre, M. L. (Ed.). (1997a). Cannabis in medical practice:
A legal, historical and pharmacological overview of the therapeutic use of marijuana. Jefferson, NC: McFarland.
Mathre, M. L. (1997b). Medicinal use of marijuana. American journal of Nursing, 97(11), 23.
Mathre, M. L. (2001). Therapeutic cannabis: A patient advocacy issue. American Journal of Nursing, 101(4), 61-68.
Mathre, M. L. (2002, July 2). Evidence-based support for cannabis therapeutics.
Part of the III NOLF Lecture Series at the American Nurses Association's
2002 Biennial Convention and Exposition in Philadelphia.
Medical Marijuana ProCon.org. (2005). Voting/polling on medical marijuana: 2000 to present.
Retrieved October 1, 2005. from Voting/Polling on Medical Marijuana - 2000-Present
National Organization for the Reform of Marijuana Laws (NORML). (2005).
Favorable medical marijuana polls. Retrieved October 1, 2005, from Marijuana Law Reform - NORML.
Randall R. C., & O'Leary A. M. (1998). Marijuana fcc: The patient's fight for medicinal pot.
New York: Thunder's Mouth Press.
Russo, E., Dreher, M., & Mathre, M. L. (Eds.). (2003).
Women and cannabis: Medicine, science, and sociology. Binghamton, NY: Haworth Integrative Healing Press.
Russo, E., Mathre, M. L., Byrne, A., Velin, R., Bach, P., Sanchez-Ramos, J., et al. (2002).
Chronic cannabis use in the compassionate investigational new drug program:
An examination of the benefits and adverse effects of legal clinical cannabis.
The Journal of Cannabis Therapeutics, 2(1), 3-57.
Tierney, J. (2005, August 27). Marijuana pipe dreams.
New York Times. Retrieved March 1, 2006, from MapInc
Wikipedia. (2005). Reefer madness. Retrieved September 1,2005, from
BOX 22-4 Schedule of Controlled Substances in the United States
Patients Out of Time is the premier organization representing medical cannabis patients,
researchers, caregivers, and drug policy reformers.
REEFER MADNESS: THE ILLOGICAL POLITICS OF MEDICAL MARIJUANA
Mary Lynn Mathre
"If you want to make enemies, try to change something."
WOODROW WILSON
THE PROBLEM
It's a drug with an image problem–a drug that has been shown to help certain patients, but its use is forbidden by federal law. Most of us know it as dope, pot, reefer, grass, weed, or ganja. But in its clinical form, medical cannabis is a valuable therapeutic aid. Scientific evidence demonstrates the value of cannabis in certain clinical conditions. However, the Drug Enforcement Administration (the federal agency responsible for placing drugs in categories on the Controlled Substances Schedule) has refused to move cannabis to a less restrictive schedule, while allowing a synthetic form of the primary psychoactive substance (THC) in cannabis to be placed in a less restrictive level of the Controlled Substances. Cannabis (marijuana) and natural THC (the primary psychoactive substance in cannabis) remains in Schedule I, while dronabi-nol (Marinol), the synthetic form of THC, was originally placed in Schedule II but has since been reassigned to Schedule III (less control and more available) due to its safety and lack of diversion. In 1999, at the request of the White House, the Institute of Medicine completed its 18-month study on therapeutic cannabis (Joy, Watson, & Benson, 1999). The study team found that cannabis is not highly addictive, is not a gateway drug, and has therapeutic value; the team recommended that until pharmaceutical grade products become available, cancer and AIDS patients should be allowed to smoke the crude plant material. They also recommended that physicians should be able to conduct "n-of-1" studies on their patients whom they believe could benefit from cannabis and that research should be conducted on alternative delivery systems. This report has more or less been ignored by the federal government, but research is going forward on the therapeutic use of cannabis in the United States and other countries. Despite the barriers and seeming social bias against cannabis, 11 states have passed laws permitting the medical use of the drug. However, in June 2005, the U.S. Supreme Court ruled that federal authorities have the power to prosecute individuals for possession and use of medical marijuana even in the states that permit it (Tierney, 2005). How did this once-legal drug become socially shunned, the problem child of the pharmaceutical industry, and a political hot potato? The saga of cannabis in the U.S. health system is a story of the clash of politics, opinions, fear, emotions, and science.
ONCE UPON A TIME, CANNABIS WAS LEGAL
Before the U.S. Congress passed the Marihuana Tax Act of 1937, cannabis was a medicine commonly used by physicians for a variety of ailments. Originally, Cannabis saliva and Cannabis indica plant material were imported to this country for use in medical products. As time went on, Cannabis americana was grown in the United States to provide access to fresh plant material to avoid the degradation that occurred when it was brought overseas on slow-moving ships. Cannabis tinctures, elixirs, salves, and even smokeable products were available. It was listed in the U.S. Pharmacopoeia until 1940.
Cannabis
A plant genus that is unique in the plant kingdom in that it contains a group of chemicals known as cannabinoids.
Cannabis indica
A species of the cannabis plant that has short, broad leaflets.
Cannabis sativa
A species of the cannabis plant that has long, narrow leaflets.
Cesamet
Synthetic derivative of THC available in Europe;
manufactured by Eli Lilly.
Marijuana/marihuana
The Mexican name for cannabis, used by the U.S. federal government in their efforts to prohibit the use of the cannabis plant.
Marinol
A registered trademark of Unimed Pharmaceuticals. It is the commercial name for dronabinol (the synthetic form of delta-9-tetrahydrocannabinol) in sesame oil and encapsulated in soft gelatin capsules. When first on the market, it was a Schedule II medication for use in the treatment of nausea and vomiting caused by chemotherapy, as well as appetite loss caused by AIDS.
Sativex
A cannabis extract oro-mucosal spray developed by GW Pharmaceuticals in Great Britain and first on the market in Canada in 2005 for use by patients with multiple sclerosis.
THC
A-9-tetrahydrocannabinol, the primary psychoactive ingredient in cannabis/marijuana; one of 60 cannabinoids.
HOW AND WHY DID THE PROHIBITION BEGIN?
"Prohibition" (the alcohol prohibition in the United States in the 1930s) ended in failure, but the staff of The Bureau of Narcotics and Dangerous Drugs and its leader, Harry Anslinger, needed to find something for the department to do or it would be dissolved. Anslinger targeted a drug used by "negro" jazz musicians in the American South and Mexicans in the Southwest. The drug was cannabis, but was called "reefer" by the African American population and "marijuana" (alternately spelled "marihuana") by the Hispanic population.
THE DESCENT INTO "REEFER MADNESS"
In 1936, the film Reefer Madness was released (a reefer being a marijuana cigarette). The film's plot involves tragic events that ensue when high school students are lured by drug pushers into using marijuana. Death, suicide, and a descent into madness are the results (Wikipedia, 2005). A "Reefer Madness" mentality was adopted by some government agencies, individuals, and media moguls like William Randolph Hearst. Few people realized at the time, that this dangerous "new" drug was the same thing as the cannabis medicine that many physicians routinely prescribed.
MY INTRODUCTION TO THE PROBLEM OF MEDICAL CANNABIS USE
In the early 1980s, I was working in a small hospital in Washington state, when the director of nursing approached me with a problem. A cancer patient was going to be admitted who had experimental "marijuana" pills from the University of Washington She asked what should we do? I suggested we loock it up in the narcotics cabinet and dispense it as prescribed. No problems were encountered, and I began learning about Marinol, the synthetic "marijuana" pill. About the same time, I came across a flyer about an organization called the Alliance for Cannabis Therapeutics (ACT). It was started by a glaucoma patient, Robert Randall, and his wife. In 1976, Randall had gained legal access to feder- ally grown marijuana under the Compassionate Investigational New Drug (IND) program following a series of court battles because no other medicine could control his intraocular pressure. He formed ACT, a nonprofit organization, to let others know about the therapeutic benefits of cannabis and how patients could get a legal, federally approved supply of it. I was drawn to the issue. After moving to Ohio to complete graduate school at Case Western Reserve University in 1983, I conducted a survey on marijuana disclosure to health care professionals using the membership of NORML as my survey population (Mathre, 1985). The thrust of the survey was to determine if health care professionals asked patients about the use of cannabis and whether the survey subjects would disclose their use patterns. I received some surprising responses that led me to consider the therapeutic potential of cannabis. In a final question that asked the subjects to identify their concerns regarding the use of cannabis from a list of health problems, numerous respondents noted in the "other" option that they used it as medicine for stress, migraines, spasticity, pain, and other ailments Mathre, 1988).
AN OPPORTUNITY FOR EDUCATION
I accepted the position of director of the National Organization for the Reform of Marijuana Laws' (NORML) Council on Marijuana and Health. By 1990, there were five patients who had legal access to marijuana through the Compassionate IND program. I was serving on the planning committee for the annual NORML conference and suggested that we have all five patients present their cases in a panel presentation. The patients were eager to tell their stories and were excited to meet others in their situation. Their presentation was aired on C-SPAN and garnered national attention. Taking advantage of the opportunity, we had each patient interviewed and videotaped by a volunteer professional videographer.Over the next two years, excerpts from the interviews were used to create an 18-minute video, Marijuana as Medicine (Byrne & Mathre, 1992),designed to be a teaching aid. Following the airing of the patients' panel, the U.S. Food and Drug Administration (PDA) received many requests for IND access to marijuana, especially from HIV/AIDS patients.
The Secretary of Health and Human Services, Dr. Louis Sullivan, responded by shutting down the IND access to marijuana in 1992. At that time, 15 patients were receiving marijuana, over 30 patients had been approved and were waiting for their medication to be delivered, and hundreds of applications were waiting for review (Randall & O'Leary, 1998). Only the 15 current patients would be allowed to continue in the program, closing the door to all others. Also during that time frame, one of the legal patient's supply of marijuana was cut off. Corinne Millet, a widow and glaucoma patient, sought help from her congressman to regain her supply of medicine, but during the six weeks she spent without her medication, she lost 80% of her peripheral vision (Byrne & Mathre, 1992). These events made me feel it was important to end the prohibition on the use of cannabis in the United States. My perspective was that there was no justifiable reason for the marijuana prohibition.
It has therapeutic value, it is safe, and patients benefit from it. Patients who might benefit from it have no knowledge of its value, health care professionals are not trained to use it, and patients are harmed by the legal consequences for their use of it. I saw this as a problem that required patient advocacy and that had ethical implications, and I believed it to be a professional responsibility to try to end the cannabis prohibition and make this medicine legally available to patients.
The more I learned, the more determined I became. I embarked on a more than 20-year fight, met countless barriers, and often felt like David taking on the Goliath of the federal government. Colleagues have questioned me over the years why I'm still trying to change the laws, and my answer is always the same:
Patients still do not have access to a safe and legal supply of this medicine.
BARRIERS AND STRATEGIES
Over the years, I've encountered many barriers and I've tried various strategies; often the same strategies have been used under different circumstances. Barriers that I've encountered include misinformation presented as facts, censorship of information, intimidation, laws and regulations that prevent research, an image based on racism and ideology rather than science and reality, and pharmaceutical pressure to prevent potential competition. I've used strategies like finding a strong mentor, building a support system, mobilizing grassroots support, changing the image of the problem, partnering with patients, building a coalition, starting a nonprofit organization, providing continuing accredited education for health care professionals about cannabis, using the Internet effectively, playing by the government's rules, teaching others, conducting research, disseminating research findings, and educating the public through publications, the press, and the media.
HIDING THE TRUTH
In the years following the Marihuana Tax Act of 1937, cannabis was removed from the U.S. Pharmacopoeia, it was no longer included in medical school curricula, and health care professionals learned about marijuana only in the context of substance abuse. The Controlled Substances Act of 1970 further condemned the drug when officials wrongly, in my opinion, placed marijuana in Schedule I of the Controlled Substances Schedule,
the category of drugs that are highly addictive, not safe for medical use, and have no therapeutic value (Box 22-4). By the 1960s and 1970s, the average American had little knowledge of cannabis but had been taught about the dangers of marijuana. The legal consequences for possession of marijuana became so severe (up to a life sentence for a single "joint") that people who used it medicinally kept their use a secret. Thus, the unmotivated, "stoned" teenager became the public image of a marijuana user (think Scan Penn in the film Fast Times at Ridgemont High).
FINDING THE TRUTH
I knew cannabis had therapeutic value after searching for and reviewing historical records that included national studies and patient studies conducted in the late 1970s and early 1980s. For studies conducted before the Marihuana Tax Act of 1937, I had to search using the terms "cannabis" and "hemp." I initially depended on others in the field to gain access to rare copies of studies that validated the medicinal efficacy of cannabis. I found that some published reports had negative results, but on close review the studies were either flawed or not accurately reported.
A POWERFUL MENTOR
I was lucky to meet an influential nursing leader. Melanie Dreher, PhD, RN, FAAN, who at the time was Dean of the University of Florida School of Nursing in Miami. Her doctorate was in anthropology, and her current research was on "ganja" (marijuana) use by pregnant women in Jamaica and fetal outcome (Dreher, 1997; Dreher, Nugent, & Hudgins. 1994). She taught me a great deal and validated my understanding of the benefits of cannabis.
GAINING SUPPORT
Initially, I began collecting signatures on a petition to demand that cannabis be removed from Schedule I of the Controlled Substances to make it available for patient use. Many people agreed with the idea but were afraid to put their names on a public document Although, together with others, I collected tens of thousands of signatures, it soon became apparent that this approach was not cost- or time-effective. By getting the first five legal patients together, I had helped them develop a lasting bond, and they in turn trusted me. This bond empowered them to speak out about the injustice of the prohibition of cannabis use. The video, Marijuana as Medicine (Byrne & Mathre, 1992), has served as a powerful teaching tool for use with other health care professionals, the public, and legislators. I began to approach nursing organizations to show them the video. Following the video presentation, I urged them to pass a resolution that I had drafted in support of cannabis. My initial success began with resolutions passed by the Virginia Nurses Society on Addictions (1993), the Virginia Nurses Association (1994), and the National Nurses Society on Addictions (1995). During these presentations, the proper name for the plant, cannabis, was used in an attempt to change the negative image of marijuana. By getting professional organizations to formally support patient access to therapeutic cannabis, individual members had a stronger voice on the issue.
Schedule of Controlled Substances in the United States
SCHEDULE I DRUGS
a. The drug or other substance has a high potential for abuse,
b. The drug or other substance has no currently accepted medical use in treatment in the United States,
c. There is a lack of accepted safety for use of the drug or other substance under medical supervision.
Schedule I drugs include marijuana, heroin (Diacetylmorphine), ecstasy (MDMA), psilocybin,
GHB (Gamma-hydroxybutyrate), LSD, mescaline, and peyote.
SCHEDULE II DRUGS
a. The drug or other substance has a high potential for abuse,
b. The drug or other substance has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions.
c. Abuse of the drug or other substances may lead to severe psychological or physical dependence. Schedule II drugs are only available by prescription, and distribution is carefully controlled and monitored by the DEA.
Schedule II drugs include cocaine, methylphenidate (Ritalin), most pure opioid agonists, meperidine, fentanyl, opium, oxycodone, morphine, short-acting barbiturates such as secobarbital, methamphetamine, and PCP.
SCHEDULE III DRUGS
a. The drug or other substance has a potential for abuse less than the drugs or other substances in Schedules I and II
b. The drug or other substance has a currently accepted medical use in treatment in the United States.
c. Abuse of the drug or other substance may lead to moderate or low physical dependence or
high psychological dependence.
Schedule III drugs are available only by prescription, though control of wholesale distribution is
somewhat less stringent than Schedule II drugs.
Schedule III drugs include Marinol, anabolic steroids, intermediate-acting barbiturates such as
talbutal, preparations that combine codeine or hydrocodone with aspirin or acetaminophen, ketamine, and Paregoric.
SCHEDULE IV DRUGS
a. The drug or other substance has a low potential for abuse relative to the drugs or other substances in Schedule III.
b. The drug or other substance has a currently accepted medical use in treatment in the United States,
c. Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence
relative to the drugs or other substances in Schedule III. Schedule IV control measures are similar to Schedule III;
drugs on this schedule include benzodiazepines, such as alprazolam (Xanax), chlordiazepoxide (librium),
and diazepam (Valium); long-acting barbiturates, such as phenobarbital; and some partial agonist opioid analgesics,
such as propoxyphene (Darvon) and pentazocine (Talwin).
SCHEDULE V DRUGS
a. The drug or other substance has a low potential for abuse relative to the drugs or other substances in
Schedule IV.
b. The drug or other substance has a currently accepted medical use in treatment in the United States,
c. Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule IV.
Schedule V drugs are sometimes available without a prescription; drugs on this schedule include cough suppressants containing small amounts of codeine and preparations containing small amounts of opium, used to treat diarrhea.
top
21 U.S. Code §812(b) specifies a classification system for drugs in the United States based on the purpose,
safety, and effectiveness of the drug.
~ Title 21 United States Code (USC) Controlled Substances Act. Retrieved September 5, 2005, from deadiversion.com: The Leading Government Site on the Net
PATIENTS OUT OF TIME
In 1995, following the deaths of a young AIDS couple who were in the IND program, my husband and I felt the need to take this issue more seriously. With the help of several legal patients and other health care professionals, we founded a national nonprofit organization, Patients Out of Time. We kept our mission simple: to educate the public and health care professionals about the therapeutic use of cannabis. Initially, we focused on getting more professional organizations to issue resolutions in support of patient access to cannabis. Next on our list was the American Public Health Association (APHA). I drafted and submitted a proposed resolution to the APHA, and it was passed at their annual meeting in California in 1995. I sent out copies of the Virginia Nurses Association's resolution and a letter to the leadership of all the state nurses associations. Colorado, Mississippi, and New York were among a few states that took action. The California Nurses Association had already passed a resolution in 1994. We posted a list of these organizations on our Website (medical marijuana. patient advocacy for cannabis as medicine, clinical conference), which we continually update as more organizations join the list. We verify accuracy before placing any organization on our list. In 2002,1 received a call from a New York nurse who was drafting a resolution on therapeutic cannabis to present at the American Nurses Association (ANA) 2003 House of Delegates meeting. I assisted in developing its content and went to the convention to speak on behalf of the resolution. It easily passed. I believe the ANA resolution most clearly encompasses the issues of concern regarding the marijuana prohibition. In 2005,1 was appointed to the National Organization for Women's (NOW) newly created Women and Drug Policy ad hoc Committee; among other issues, I will advocate for the organization to pass a resolution supporting therapeutic cannabis.
CHALLENGES IN DISSEMINATING INFORMATION ABOUT CANNABIS
In 1993,1 sent a manuscript on the ethical and legal dilemmas for nurses related to therapeutic cannabis to the American Journal of Nursing (AJN) to try to increase professional awareness on this issue. I received a rejection letter from the editor of AJN that said it wasn't appropriate. I called Mary Mallison, the editor-in-chief, and after a discussion she suggested I submit a second article on cannabis dosing. On receipt of that manuscript, I received a letter from the editorial director, Martin DiCarlantonio, which stated: "We'd like to accept your manuscript and run it as soon as marijuana is moved to Schedule II category (if that day ever comes)." In 1995, I was asked by Mary Gorman, RN, to write a manuscript for AJN's Substance Abuse column on the medical use of marijuana. I prepared it and submitted it with the projected publication date for the fall of 1996. Again, it was considered too controversial and remained in their files for more than a year until a change in editorial staff occurred. It was published in November 1997 (Mathre, 1997b). In the May 1998 issue, several positive letters to the editor were printed. I was told that no negative letters to the editor had been received.
In 1999, I decided to submit another article to AJN after reading an editorial by Dr. Diana Mason,A/N's new editor-in-chief, in which she urged nurses to work to influence health policy. This manuscript was published in 2001 (Mathre, 2001), and again, only positive letters to the editor were received. In 2004, I was asked to submit a manuscript to Nursing 2004 on therapeutic cannabis. It was accepted for publication, but in 2005 I received a letter stating it would not be published because they could not get anyone to submit an opposing view.
BIRTH OF A BOOK AND DEATH OF A JOURNAL
In 1995,1 began work on a cannabis book and began finding experts on various topics who were willing to contribute a chapter. Cannabis in Medical Practice was published in 1997 by McFarland, containing the work of 17 contributing authors (Mathre, 1997a). The book received great reviews. Although it wasn't a big seller, Dr. Geoffrey Guy, a physician and drug researcher from Great Britain, read my book which, per his acknowledgment, motivated him to start a pharmaceutical company to develop cannabis-based pharmaceuticals (GW Pharmaceutical). In large part because of my book, I was invited to serve on the editorial board of a new quarterly journal, The Journal of Cannabis Therapeutics, which premiered in 2001, published by Haworth Press. Unfortunately, due to the continued illegal status of cannabis, :his journal was not picked up by many university libraries or individual subscriptions, and the publication ceased by 2004. I served as coeditor along with Ethan Russo, MD, and Melanie Dreher, RN, PhD, FAAN, on Women and Cannabis: Medicine, science and Sociology (Russo et al, 2002), which A as published as a monograph in 2002.
RAISING AWARENESS AT PROFESSIONAL CONFERENCES
In 1995, I went to the continuing education department at the University of Virginia Health System and asked if they would host a national conference n cannabis therapeutics. My formal written proposal went to the top of the administration. Here it was immediately rejected. I countered with a request to limit it to a statewide nursing conference on the topic, since the 1994 Virginia Nurses association resolution called for the "education of Virginia Nurses on evidence-based use of cannabis." I was then informed by the director of the Continuing Education department that they wouldn't support such a conference because "it still had the same political issues." In 1996, my proposal for the 100th Anniversary Convention of the ANA to present Therapeutic Cannabis & the Law: Ethical Dilemma for Nurses was accepted, and in 2002 I presented "Evidence Based Support for Cannabis Therapeutics" as part of the NOLF Lecture series at the ANA convention in Philadelphia.
THE FIRST NATIONAL CLINICAL CONFERENCE ON CANNABIS THERAPEUTICS
In 1999, Dr. Dreher, who was now the Dean of the College of Nursing at the University of Iowa (and also on the Board of Directors for Patients Out of Time), was able to gain local support to hold a national conference at the University of Iowa. Patients Out of Time managed the agenda and faculty. In 2000, Patients Out of Time held The First National Clinical Conference on Cannabis Therapeutics with the University of Iowa's Colleges of Nursing and Medicine as cosponsors. We had an international conference faculty that included researchers, clinical experts, patients, and patients' care providers, and the conference was teleconferenced to seven other sites. One of them (second conference) was in Oregon sponsored by the Oregon Public Health Department, since their new law allowed patient use of cannabis under a physician's recommendation that was regulated by the Health Department. The Oregon Public Health Department broadcast the conference throughout its system, which led them to co-sponsor the second conference in Oregon with the Oregon Nurses Association in 2002. Since the first conference, we continue to hold biannual conferences. The audience feedback has been very positive, and the faculty has been very impressed with our "nursing" approach for the conference content.
At the third conference in 2004, which was cosponsored by the University of Virginia Schools of Medicine, Nursing, and Law (persistence pays off), we applied for and received grant funding to provide scholarships to legislators and health care professionals in leadership positions to attend the conference. Some of these scholarships were nurses representing various state nurses associations. These nurses took this information back to their leadership and had articles published in their state newsletters; subsequently, the nurses from Illinois and Connecticut were able to get resolutions passed by their state associations, and the nurse representing the Virginia nurses convinced the association to reaffirm their support of the issue with the passage of a second resolution supporting therapeutic cannabis. Laurie Badzek, the director of the ANA's Center for Ethics and Human Rights was also one of the scholarship recipients and informed me that she hopes to attend our fourth conference so that she can keep the ANA up to date on the issue. Our fourth conference was in April of 2006 in Santa Barbara, California and focused on getting funding for more such scholarships. We have DVD's of all the conference proceedings available on our Website, but we also hope to broadcast the next conference live on the Internet to increase the viewing audience.
THE NEED FOR EVIDENCE
In 2001, Patients Out of Time received grant funding from John Gilmore, Preston Parish, the Zimmer Family Foundation, and the Multidisciplinary Association for Psychedelic Studies to conduct an in-depth review of the chronic effects of cannabis on four of the surviving legal medical marijuana patients. These patients offered a unique opportunity for study because they had been receiving and using a known quality and quantity of cannabis provided by the federal government. The study was led by Ethan Russo, a pediatric neurologist and expert in cannabis therapeutics, and conducted in Missoula, Montana (Russo et al., 2002).
TAKING ON THE U.S. DRUG ENFORCEMENT ADMINISTRATION
Attempts have been made to change the federal prohibition of cannabis and all have failed. Even the state initiatives that have been passed to allow patients to use cannabis medicinally under the recommendation of a physician have been thwarted by the federal government's prohibition. In November 2002, Jon Gettman, PhD, submitted a Petition to Reschedule Cannabis to the U.S. Drug Enforcement Administration (DEA) on behalf of a coalition of cannabis patients. Patients Out of Time is a leading member of that coalition and serves as the lead voice (DrugScience.org, 2005). According to the rules and regulations of the Controlled Substances Act, a drug in its natural form cannot be at a more restricted schedule than its active constituent (DrugScience.org, 2005). Synthetic THC (Marinol) was placed in Schedule II in 1980 and was approved for use as an anti-emetic and appetite stimulant. By 1989, due to a lack of diversion and its record of safety, it was moved to the less restrictive Schedule III. Following this, whole cannabis extracts should also be at a Schedule III or less restrictive category. The DEA accepted the rescheduling petition as a legitimate request and, according to protocol, passed it on to the Department of Health and Human Services (DHHS) for their review in 2004. Per protocol, they may take up to three years to review all of the new research that is available.
PROGRESS
The public's awareness and acceptance of therapeutic cannabis has increased over the years to 70% to 80% approval per public opinion polls (Medical Marijuana ProCon.org, 2005; NORML, 2005). Despite the federal prohibition, there are now 10 states that have passed voter initiatives for patient use of therapeutic cannabis and two states that have passed similar laws through legislative action. The recent discoveries of endogenous cannabinoids and cannabinoid receptors have spawned more research. Pharmaceutical companies are now conducting research into cannabis-based products. In 2005, an oro-mucosal cannabis extract spray, Sativex, developed by GW Pharmaceuticals in Great Britain was approved as medicine in Canada and approved for clinical trials to begin in the United States in 2006 for use with terminal cancer patients.
LOOKING INTO THE CRYSTAL BALL
International acceptance of cannabis-based medicines may help influence the United States to end its prohibition of medical cannabis. The body of science contained in the petition to reschedule cannabis hopefully will convince the DHHS about the efficacy of cannabis and get them to make a recommendation to place cannabis in Schedule III or a lower level of control. I believe that once health care professionals are familiar with this medication, it will be considered as the "drug of choice" in symptom management, because of its wide margin of safety, rather than the "last resort." Hopefully, medical cannabis will soon be on the market in the United States, and nurses are urged to increase their knowledge about how it may help their patients.
Key Points
* Perseverance and coalition-building are essential elements in the process of changing a policy based on ideology rather than logic or science.
* Based on the evidence-based research that supports cannabis efficacy, nurses should advocate for patients to have the option of using cannabis pharmaceutical products.
* Always consider the source of your information.
Web Resources
Alliance for Cannabis Therapeutics - Marijuana medical use
International Association for Cannabis as Medicine (IACM) . vww.cannabis-med.org
International Cannabinoid Research Society (ICRS) ICRS - The International Cannabinoid Research Society
National Organization for Reform of Marijuana Laws Marijuana Law Reform - NORML
Patients Out of Time medical marijuana. patient advocacy for cannabis as medicine, clinical conference -our Home Page
U.S. Drug Enforcement Administration, Office of Diversion Control DEA Diversion Control Program - Controlled Substance Schedules
REFERENCES
Byrne, A., & Mathre, M. L. (1992). Marijuana as medicine (video). Available here.
Dreher, M. (1997). Cannabis and pregnancy. In
M. L. Mathre, Cannabis in medical practice: Cannabis in Medical Practice | Patients Out of Time
A legal, historical and pharmacological overview of the therapeutic use of marijuana. Jefferson, NC: McFarland.
Dreher, M. C., Nugent, K., & Hudgins, R. (1994).
Prenatal marijuana exposure and neonatal outcomes in Jamaica: An ethnographic study.
Pediatrics, 93, 254-260. DrugScience.org. (2005). Retrieved March 1, 2006, from Marijuana Research: Science, Law, Medical Marijuana, Rescheduling Petition.
Joy, J. E., Watson, S. A., & Benson, J. A., Jr. (1999). Marijuana and medicine: Assessing the science base.
Washington, DC: Institute of Medicine, National Academy Press.
Mathre, M. L. (1985). Disclosure of marijuana use to health care professionals.
Unpublished master's thesis, Case Western Reserve University, Cleveland, Ohio.
Mathre, M. L. (1988). A survey on disclosure of marijuana use to health care professionals.
Journal of Psychoactive Drugs, 20(1), 117-120.
Mathre, M. L. (1996, June 17). Therapeutic cannabis and the law: Ethical dilemma for nurses.
Presentation at the 100th Anniversary Convention of the American Nurses Association in Washington, DC.
Mathre, M. L. (Ed.). (1997a). Cannabis in medical practice:
A legal, historical and pharmacological overview of the therapeutic use of marijuana. Jefferson, NC: McFarland.
Mathre, M. L. (1997b). Medicinal use of marijuana. American journal of Nursing, 97(11), 23.
Mathre, M. L. (2001). Therapeutic cannabis: A patient advocacy issue. American Journal of Nursing, 101(4), 61-68.
Mathre, M. L. (2002, July 2). Evidence-based support for cannabis therapeutics.
Part of the III NOLF Lecture Series at the American Nurses Association's
2002 Biennial Convention and Exposition in Philadelphia.
Medical Marijuana ProCon.org. (2005). Voting/polling on medical marijuana: 2000 to present.
Retrieved October 1, 2005. from Voting/Polling on Medical Marijuana - 2000-Present
National Organization for the Reform of Marijuana Laws (NORML). (2005).
Favorable medical marijuana polls. Retrieved October 1, 2005, from Marijuana Law Reform - NORML.
Randall R. C., & O'Leary A. M. (1998). Marijuana fcc: The patient's fight for medicinal pot.
New York: Thunder's Mouth Press.
Russo, E., Dreher, M., & Mathre, M. L. (Eds.). (2003).
Women and cannabis: Medicine, science, and sociology. Binghamton, NY: Haworth Integrative Healing Press.
Russo, E., Mathre, M. L., Byrne, A., Velin, R., Bach, P., Sanchez-Ramos, J., et al. (2002).
Chronic cannabis use in the compassionate investigational new drug program:
An examination of the benefits and adverse effects of legal clinical cannabis.
The Journal of Cannabis Therapeutics, 2(1), 3-57.
Tierney, J. (2005, August 27). Marijuana pipe dreams.
New York Times. Retrieved March 1, 2006, from MapInc
Wikipedia. (2005). Reefer madness. Retrieved September 1,2005, from
BOX 22-4 Schedule of Controlled Substances in the United States
Patients Out of Time is the premier organization representing medical cannabis patients,
researchers, caregivers, and drug policy reformers.
