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Member
Interview
Medical Marijuana and Altered States
of Consciousness: A Conversation with
Harvard Medical School’s
Dr. Lester Grinspoon
lester grinspoon, m.d.
[email protected]
grant j. rich, editor,
Anthropology of Consciousness
[email protected]
Abstract
This is an interview with author Lester Grinspoon, M.D., whose work on psychoactive
substances over the last thirty-five years has been highly influential. His
book, Marihuana: The Forbidden Medicine (written with James B. Bakalar), is
a classic source on the medical marijuana controversy. His books Psychedelic Drugs
Reconsidered and Cocaine: A Drug and Its Social Evolution are standards in the
field. Dr. Grinspoon received his M.D. from Harvard Medical School and currently
is associate professor emeritus at Harvard Medical School. His academic work has
also reached a general audience through publications ranging from the New York
Times Book Review to Playboy. Describing him as the “complete medical scholar,”
his citation for the Lindesmith Award for Achievement in the Field of Scholarship
also notes, “Lester Grinspoon represents all those scholars who report the
results of their research truthfully, despite the political consequences of this
unwelcomed honesty.”
key words: Marijuana, Interview, Psychoactive substances, Altered states
Grant J. Rich: How did you first become interested in marijuana?
Lester Grinspoon: My interest in cannabis began to develop in 1967. As the senior
author of a book on schizophrenia, I found myself with what I estimated
would be two to three relatively free months before my co-authors would finish
their chapters. Because I had become concerned that so many young people
52 anthropology of consciousness 15.2
were using the terribly dangerous drug marijuana, I decided to use the time to
review the medical literature so that I could write a reasonably objective and scientifically
sound paper on the harmfulness of this substance. Young people were
ignoring the warnings of the government, but perhaps some would seriously
consider a well-documented review of the available data. So I began my systematic
review of the medical and scientific literature bearing on the toxicity—mental
and physical—of marijuana. It never occurred to me then that there were other
dimensions of this drug that warranted exploration.
During my initial foray into this literature I discovered, to my astonishment,
that I had to seriously question what I believed I knew about cannabis. As I
began to appreciate that what I thought I understood was largely based on
myths, old and new, I realized how little my training in science and medicine
had protected me against this misinformation. I had become not just the victim
of a disinformation campaign, but because I was a physician, one of its agents as
well. Believing that I should share my skepticism about the established understanding
of marijuana, I wrote a long paper that was published in the nowdefunct
International Journal of Psychiatry; a shorter version was published as
the lead article in the December 1969 issue of Scientific American. In these
papers I questioned whether the almost ubiquitous belief that marijuana was
an exceedingly harmful drug was supported by any substantial data to be found
in the scientific and medical literature. While there was little reaction to
the paper published in the psychiatric journal there was much interest in the
Scientific American article.
Within a week of the appearance of the article, I received a visit from the associate
director of the Harvard University Press, who suggested that I consider writing
a book on marijuana. I found the idea both attractive and daunting. The subject
was worthy of a book-length exposition, and I would have a reason to deepen
my exploration of this fascinating misunderstanding. And there was another
reason, perhaps the most compelling of all. The one aspect of my work that interested
my twelve-year-old son Danny was my study of marijuana. His illness
began in July of 1967, just about the time I decided to learn about the dangers
of marijuana. He was diagnosed with acute lymphocytic leukemia, and his prognosis
was, of course, grave. He was both excited and pleased when I told him that
I had decided to write a book on marijuana.
A few weeks later I learned that the Board of Syndics of the Harvard University
Press had rejected the book proposal as too controversial. Until that moment I was
unaware of the existence of this board, which must approve every book published
by the Press. An image of the Rembrandt painting “Syndics of the Cloth Guild”
came to mind: a group of serious-looking, long-haired men sitting around a table,
exuding caution and conservatism. I was disappointed but not surprised that they
rejected the proposal; it was the first instance of academic resistance to my work in
this area. I could have signed on immediately with a trade publisher that offered
the prospect of selling more books. But I believed that a conservative, prestigious
grinspoon on medical marijuana 53
press would lend more credibility to a book that promised to be quite controversial.
The director of the press was undaunted; he believed that he could persuade the
Syndics to reverse their decision. And so he did.
It turned out to be a much bigger project than I had anticipated. I found that
I had more than the medical and scientific literature to review. Because so much
of the misinformation and myths about this drug had their origins in the gaudy
writings of the French Romantic Literary Movement, I felt compelled to examine
the works of Theophile Gautier, Charles Baudelaire, and other members of
Le Club des Haschichins, as well as those of Bayard Taylor and Fitz Hugh Ludlow.
It was fascinating to learn that much of the mythology about cannabis that was
being promulgated by the U.S. government had its origins in these writings. It is
difficult to imagine that Harry Anslinger (our first drug czar) was directly familiar
with these 19th century authors, but clearly some of their hyperbolic descriptions
of the cannabis experience, largely products of effusive imagination under the
influence of copious amounts of hashish, are echoed almost a century later in
the “teachings” of Harry Anslinger.
In any event, the bargain I struck with Harvard University Press was that if I
gave them the manuscript by a certain date, they would have a book in my hands
by March 24, 1971. I was confident that this would make it possible for Danny to
see the book. To be able to deliver the manuscript to the Press on schedule while
I continued to pursue my responsibilities at the medical school and hospital
meant working long hours.
There were many nights when I worked into the wee hours, and my wife can
tell you I would sometimes get up at three in the morning to go to my office as
that deadline approached. The bottom line is, however, that I did finish the book
[Marihuana Reconsidered] on time. It is dedicated to him (“To Danny: Children
are the greatest high of all”) and he was just as pleased as he could be.
It was a book which at that time, June of 1971, had an impact. The New York
Times Book Review had a front page review. “The Best Dope on Pot So Far” was
the headline, and this was quite remarkable, because this was a book that said, in
effect, that we’ve all been sold a bill of goods about cannabis, that while it is not
harmless, it is far less harmful than alcohol and tobacco. The most dangerous
thing about cannabis was not to be found in any inherent psychopharmacological
property of the drug, but rather in the way we, as a society, treated people
who used or possessed it. At that time, we were arresting about 300 thousand
mostly young people on marijuana charges (a figure which has now grown to
over 700 thousand people a year). It concluded that the only sensible way to deal
with this substance was to decriminalize it and to regulate it in the same way we
do alcohol. As you can imagine, that was a very controversial position. But there
were also a lot of people (I think mostly people who had had personal experience
with cannabis) who, even then, felt that these were reasonably accurate statements;
not just the statements about the drug and its alleged harms, but about
how we should move to address this issue.
54 anthropology of consciousness 15.2
GR: Will you briefly sketch the highlights of the history of marijuana
legislation in the United States?
LG: Marijuana was known to relatively few people at the beginning of the 20th
century and they were mostly black jazz musicians; they introduced it to others
as they traveled up the Mississippi and around the country. While its use
slowly spread, there were just a handful of states that had any legislation involving
cannabis until in 1932 Harry Anslinger, an out-of-work, former prohibition
agent, was asked to head up the newly formed Federal Bureau of Narcotics. It’s
difficult to know how much of it came from real conviction that marijuana was
terribly dangerous and how much of his anti-marijuana zeal originated in the
desire to find an issue which would further the funding of his new Bureau, but
Anslinger worked vigorously to develop the marijuana scare with what he
called his “educational” program. For example, the movie Reefer Madness is
a perfect illustration of what that educational program was about. You’ve seen
it obviously.
GR: Ha. Of course.
LG: He was successful in persuading Congress which then passed the so-called
Marijuana Tax Act of 1937, the first of the draconian legislation aimed at marijuana.
How people could have believed this so naively and how this thing has
grown over the years is an absolute mystery to me. Are you familiar with Charles
MacKay’s Extraordinary Popular Delusions and the Madness of Crowds?
GR: Yeah, on human folly.
LG: Exactly, on community folly such as the tulip mania of 17th century Flanders.
I predict that sometime in the not-too-distant future, we’re going to look back on
this marijuana history, in this country particularly, and see it as MacKay would
have as an “extraordinary popular delusion” of our times. In my view, this country,
through the Federal Bureau of Narcotics, which morphed into the Federal
Bureau of Narcotics and Dangerous Drugs, and then finally into the Drug
Enforcement Administration (DEA), has tried to establish a drug hegemony.
The whole world has been involved in this delusional view of cannabis. I think
some years down the pike, we’re going to look back on this and wonder, “How in
the world could so many people have bought into this nonsense?” While Harry
Anslinger is right there at the top of the list, there are a lot of other people who
have contributed to it. What these people have written and said is simply divorced
from the reality of this substance. And now we’re in a situation where we arrest
about 700 thousand people annually in this country, most of them young people,
and 89% for mere possession. While the United States government pressure on
marijuana has been growing every year, it has in recent years been diminishing
in Australia, New Zealand, Canada, England, the Netherlands, Belgium, France,
Spain and other Western European countries. These nations are moving toward
grinspoon on medical marijuana 55
more realistic cannabis policies and in doing so they are actively opposing the
United States. The United States is now putting tremendous pressure on the
Canadians as they presently seek a way to provide it to patients who need it medically.
In fact, the marijuana prohibition hegemony is doomed largely because it
is becoming increasingly clear to people around the world that cannabis is a very
useful medicine.
GR: Can you talk about some of its medical usages?
LG: Its use as a medicine began in this country in the mid-19th century. At that
time it was virtually never used for other than medicinal purposes and it was not
smoked; it was dispensed as minims of a tincture (an alcoholic solution) of
cannabis. It was widely used as an analgesic and a soporific (a sleep-inducing
medicine). It was also used in the treatment of tetanus, neuralgia, as an analgesic
during labor, in dysmenorrhea, convulsions, the pain of rheumatism, asthma,
gonorrhea, chronic bronchitis, and to stimulate appetite. Because there were no
bioassays at that time, dosing was always uncertain; and because it was not
smoked, self-titration was impossible. If physicians of that era had known that the
dose could be titrated by having the patient smoke, I believe this would clearly
have been the preferred means of administration. As it was, dose was pretty much
hit or miss but physicians appeared not to worry about overdose because they
understood toxicity was limited. They were concerned that the effect they sought
did not come on for one and a half to two hours; again, if they had used it as a
smokable, the effects would have appeared almost immediately.
GR: What accounts for its demise as a medicine?
LG: Its demise as a medicine came about for two reasons. Two of the major indications
for 19th century physicians to use cannabis were pain and insomnia. The
only alternative analgesic at that time was morphine. Lots of people were using
laudanum, a solution of opium in alcohol, but they could get hooked on it.
Although not as powerful as opium, cannabis was frequently used as an analgesic.
And it was a good soporific or hypnotic; people could use it as we now use
sleeping pills. Then in 1898, acetylsalicylic acid (aspirin) was synthesized. And
now doctors had a shiny new white pill, useful for the treatment of mild to moderate
pain. They knew the dose and they could control it. “Take one of these
every four . . . and so forth.” That was much more appealing to doctors than
going blindly with tinctures of cannabis of uncertain potency. In 1900, the first of
the barbiturates was synthesized and soon became available in pill form. Now,
the second of the two most common uses of cannabis—to treat insomnia, was
replaced by a pill whose potency was precisely known.
So even before 1937, the year of the passage of the Marijuana Tax Act, physicians
were losing interest in cannabis because now they could prescribe these
pills. The Marijuana Tax Act excluded any intention to remove it as a medicine,
56 anthropology of consciousness 15.2
but the red tape now involved in filling out the papers for this exception was so
bothersome that most physicians just stopped prescribing cannabis, and it dropped
out of the pharmacopeia in 1941.
GR: When did you become personally interested in cannabis as a medicine?
LG:Well, I began to understand that there were people who were using it illicitly
as a medicine in the 1970s. One would occasionally come across a letter, usually
in alternative publications, in which the author claimed that marijuana was more
useful than the conventional drug he had been prescribed for the treatment of his
symptom or disorder. A lot of these letters appeared in Playboy. Such letters
would say something like, “I suffer from migraine, and I find by far the best thing
to treat it is to smoke a joint.” I began to think that these claims were consistent
with those of 19th century clinicians; maybe there is something to this. Then when
Danny became sick, something happened which was very powerful for me.
Danny was taken care of by Dr. Sydney Farber, who was the premier child
oncologist in Boston. He had also been my professor at the Harvard Medical
School. When Sydney retired, Emil Frei from Houston was selected to head up
the child oncology division. Shortly after he arrived in Boston, my wife and I
were invited by a friend in the children’s oncology department to have dinner to
meet Dr. Frei. Emil was familiar with Marihuana Reconsidered, or at least the
chapter on medicine, and he asked me, “Dr. Grinspoon, is there anything in
that 19th century literature to suggest that cannabis is a good antiemetic?” I
replied affirmatively. He said, “Well, let me tell you a story.” He went on to tell
me about a 17-year-old young man with acute lymphocytic leukemia he had
treated in Houston. The young man had arrived at the point where he said he
would not take the cancer chemotherapeutics anymore because he could not
stand the nausea and vomiting. Some of the cancer chemotherapeutics generate
extreme and prolonged nausea and vomiting. There are patients who just stop
taking them because they can’t stand it. Stephen Jay Gould, in the account he
wrote for my book, Marihuana, the Forbidden Medicine, at one point wondered
if he could go on with the treatment of his cancer. Emil described how they used
to have to really pressure this young man to get him to take it. Then one day he
came in, climbed on the table without any resistance, took the infusion, and
hopped off the table, with no nausea and no vomiting. Smiling, he waved, “See
ya,” and left the clinic. Emil and his team were mystified. Next time he came in,
he did the same thing. So Emil asked him, “How come this difference?” He said,
“You really want to know? I smoke a little bit of grass 20 minutes before I come in
here.” They were incredulous that he would do such a thing or that it had anything
to do with this. Nonetheless, the young man continued his treatments without
further difficulties with nausea and vomiting. Then Doctor Frei asked me,
“Do you think there’s anything to it?” I replied, “Because it’s such an effective
anti-nauseant, I believe it.”
grinspoon on medical marijuana 57
Driving home from dinner that night, my wife said, “Given what Dr. Frei
said, and what you said, shouldn’t we try to get some marijuana for Danny?” I
said, “No, no, that’s against the law, and furthermore I don’t want to do anything
that would embarrass the people at Children’s Hospital who are doing
such a wonderful job taking care of Danny.” My office is a block from Children’s
Hospital. When Betsy and Danny would drive in for his treatment, I’d
walk over and meet them. Generally, when I walked in, his face radiated anxiety;
he feared and hated this more than anything in the world, and the anxiety was
reflected in his face, and before long mirrored in Betsy’s and mine. On this
occasion when I joined them in the treatment room before he was to get the
infusion they appeared, much to my surprise, to be having a good time as though
they were playing a joke on me. I asked, “What in the world is going on?”
Finally they told me what had happened. That morning on their way to the hospital
Betsy had driven to the Wellesley High School parking lot before school,
found Danny’s friend Mark, and asked him if he could get her a small amount
of marijuana. Mark, once he recovered from his absolute disbelief, ran off to
return a few minutes later with a small amount of grass. When they arrived at
the hospital parking lot Danny smoked some of the marijuana. Previously, he
would begin to feel the intense nausea right then and there, and then vomit and
dry-heave for about eight hours. We used to put a bucket on a towel by his bed;
needless to say, it was heart-breaking to see what he went through. This time he
jumped off the table and he said, “Hey Mom, can we stop for a sub sandwich
on the way home?” He loved sub sandwiches. Furthermore, instead of taking to
his bed for the rest of the day, he went back to school. I called Norman Jaffe,
who was the doctor directly in charge of Danny and told him what had happened.
I also told him that there was no way in which I was going to get in the
way of Danny’s doing this again. He said, “No, you have him smoke in the treatment
room. I want to see this for myself.” I said, “What about the nurses?” He
replied, “Don’t worry. I’ll take care of them.” So several weeks later when he
had his next treatment, Danny smoked a few puffs 15–20 minutes before treatment.
The same thing happened. Norman was amazed. So we made an appointment
with Emil Frei, and Norman and I went up to his office a week later and told
him about this. He said, “That confirms the impression I had in Houston, as
you know.” So he organized a study, but NIDA [National Institute on Drug
Abuse] wouldn’t let them do it with children, and the cannabis had to be in the
form of THC capsules. Nevertheless, the study was completed and the paper
published in the New England Journal of Medicine in 1975. It was the first study
published on the remarkable antiemetic effect of cannabis. This experience
had a powerful impact on me because I began to wonder, “If this works this well
on Danny, are there other children and their families who are needlessly suffering
in this way? How many other children and adults might profit from this?
Shouldn’t they know about this?”
58 anthropology of consciousness 15.2
GR: Tell us about some of the conditions for which marijuana has been useful.
You mentioned leukemia.
LG: Leukemia is one of many cancers. Anyone with cancer who requires treatment
with one of the cancer chemotherapeutics that leads to the severe nausea
and vomiting might benefit from cannabis. While there are very good conventional
drugs, like ondansetron, for example, it doesn’t work as well for some people
as does cannabis. Furthermore ondansetron is very expensive. Ondansetron costs
about $25 to $40 per five-milligram pill, and depending on how severe the nausea
is, a patient may require between one and four pills. If the patient cannot
swallow the pills, an intravenous infusion will be required and that may cost
about $800. Most patients will get the same relief from smoking a quarter to a
third of a joint, which if it weren’t for what I call the prohibition tariff, would cost
just about $5 per joint. This kind of economy would be realized in many medical
situations where cannabis is as or more effective than the conventional medicines;
it could be considerably less expensive. In the case of the nausea and
vomiting of cancer chemotherapy, one can’t say it works for everyone but it is the
best treatment for many if not most. The reputation of cannabis as an antinauseant
has traveled around the cancer grapevine and many facing this treatment
now ask me how they can get hold of some cannabis.
Another condition for which it is useful is glaucoma, which is caused by
increased intraocular pressure and may, if not checked, lead to blindness. In the
early seventies it was discovered that smoking cannabis reduces intraocular pressure.
However, using it for this purpose requires that the patient smoke as often
as eight to ten times a day.
It is widely used as a general analgesic, but it is particularly useful in some
chronic painful conditions, such as osteoarthritis. And, of course, many elderly
people have arthritic pain. In fact, when I was doing a book tour in Europe,
many of the people with whom I talked were elderly people who regularly used
it to treat their arthritic pain. It makes sense when you think of what these folks
have available to them by way of conventional drugs. There are opiate-derivative
medicines, but for a number of reasons it’s not a good idea for patients to take
these drugs over extended periods of time. Or they have the non-steroidal antiinflammatory
drugs, NSAIDs. Ibuprofen is a commonly used example of this
class. About four or five years ago, a paper published in the New England Journal
of Medicine addressed the serious side effects of the NSAIDs. The survey said
about 100 thousand people were hospitalized annually in this country because of
NSAID side effects, most of them gastric bleeding. Ten percent of those patients
lost their lives. That’s about ten thousand people. Compare that to cannabis. Let’s
imagine that you have a serious arthritic condition such as ankylosing spondylitis.
If you use cannabis, you may get what lots of people discover is better relief than
that from NSAIDs; it is at least as good and there is no risk that you will experience
a serious side effect. Here the risk has more to do with the law than it has to
do with any inherent toxicity of the drug.
grinspoon on medical marijuana 59
Because cannabis is such a versatile medicine, the list of symptoms and syndromes
for which patients have found it useful is quite long. The evidence presently
supporting its usefulness in most of the conditions is anecdotal, but as cannabis
becomes increasingly accepted as a medicine, the list of appropriate indications
for its use will climb to firmer ground. In the meantime, I will delineate only the
most common symptoms and syndromes for which it is presently used. They
include, in addition to the above-mentioned, epilepsy, multiple sclerosis, paraplegia
and quadriplegia, AIDS, migraine, severe pruritus, premenstrual syndrome, menstrual
cramps, labor pain, depression and other mood disorders, asthma, insomnia,
adult attention deficit disorder, systemic sclerosis, Crohn’s disease, and phantom
limb pain.
GR: I’ve heard you say marijuana is not a harmless substance, and by that
do you mean it’s not any potential medical side effects which are harmful,
but the legal and social consequences.
LG: Yes, the legal and social consequences of using cannabis today are what most
patients fear when they use this drug. However, there is one infrequent but distressing
“side effect” in that some people can become quite anxious and even
paranoid. This is a time-limited dose-related phenomenon which is best treated
through reassurance. It almost invariably occurs in people who have had little or
no experience with marijuana and do not yet know how to titrate it. When marijuana
becomes widely accepted as a medicine, physicians will not be able to recommend
or prescribe it with a simple, “Go home and take two puffs before meals.”
The doctor is going to have to help the patient to learn to use this medicine or
refer him to a clinic or “Compassion Club” where its use is taught. A patient who
is marijuana-naïve may need special attention. But in general, it is safe to say that
once cannabis regains its rightful place in the pharmacopeia, a place it lost in
1941, it will be seen as one of the least toxic substances in that whole compendium.
There has never been a case of a death from pure cannabis. Europeans smoke it
mixed with tobacco, which is to me a foolish way to use it, but if you consider just
plain cannabis, you cannot identify a documented case. It is difficult to identify
other medicines about which such a claim can be made. Nor can you find any
credible literature which makes the point that it harms any particular tissue or
organ. I think it’s safe to say that it is remarkably free of toxicity.
GR: Do you think a lot of the data that you publish in your work is based
on anecdotal case studies?
LG: It’s almost all anecdotal, but it’s curious to me how people devalue anecdotal
data. It’s almost as though nothing in medicine was believable until the
invention of the double-blind crossover study in the early sixties. That is, of course,
not true. Modern Western medicine grew up on careful clinical observations. It
was all anecdotal. I was asked to be an official reviewer for the Institute of Medicine
[1999] report, and I wrote about twenty pages of criticism, much of it directed
60 anthropology of consciousness 15.2
at its devaluation of the mountain of anecdotal evidence at its disposal. Also,
while it did grudgingly acknowledge that cannabis had medicinal utility, it grossly
exaggerated the dangers of both smoking as a means of delivery and the psychoactive
effects.
With so much anecdotal evidence and with so many people now using
cannabis as a medicine, is one to believe that all these people who risk something
legally to possess and use this drug are out of their minds? They believe that it is at
least as useful, that it is less toxic, and that it is of most importance to the many
who are medically uninsured, less expensive than the conventional medicines it
displaces. Are they all deluding themselves? In fact, I have argued that Food and
Drug Administration [FDA] approval is superfluous where cannabis as a medicine
is concerned. Drugs must undergo rigorous, expensive and time-consuming
tests before they are approved by the FDA for marketing as medicines. The purpose
is to protect the consumer by establishing safety and efficacy. Because no
drug is completely safe or always efficacious, an approved drug has presumably
satisfied a risk-benefit analysis. When physicians prescribe for individual patients
they conduct an informal analysis of a similar kind, taking into account not just
the drug’s overall safety and efficacy, but its risks and benefits for a given patient
with a given condition. The formal drug approval procedures help to provide
physicians with the information they need to make this analysis. This system is
designed to regulate the commercial distribution of drug company products and
protect the public against false or misleading claims about the efficacy and safety.
The drug is generally a single synthetic chemical that a pharmaceutical company
has acquired or developed and patented. It submits an application to the FDA
and tests it first for safety in animals and then for clinical efficacy and safety. The
company must present evidence from double-blind control studies showing that
the drug is more effective than a placebo. Case reports, expert opinion, and clinical
experience are not considered sufficient.
The standards have been tightened since the present system was established
in 1962, and few applications that were approved in the early 1960s would be
approved today on the basis of the same evidence. Certainly we need more laboratory
and clinical research to improve our understanding of medicinal
cannabis. We need to know how many patients with each symptom or syndrome
are likely to find cannabis more effective than existing drugs. We also need to
know more about its effects on the immune system in immunologically impaired
patients, its interactions with other medicines, and its possible uses for children.
But I have come to doubt whether the FDA rules should apply to cannabis.
Thousands of years of use have demonstrated its medicinal value. The government
has itself acknowledged its medical usefulness when it authorized the
Compassionate IND [Investigational New Drug] program and when it supported
the development of dronabinol [a synthetic form of THC]. And there is no question
about its safety; it is one of humanity’s oldest medicines, used for thousands
grinspoon on medical marijuana 61
of years by millions of people with very little evidence of significant toxic effects.
More is known about its adverse effects than about those of most prescription
drugs. The government of the United States has conducted through NIDA a
decades-long multi-million-dollar research program in a futile attempt to demonstrate
significant toxic effects that would justify the prohibition of cannabis as a
non-medical drug. The modern FDA protocol is not necessary to establish a riskbenefit
assessment for a drug with such a history. Should time and resources be
wasted to demonstrate for the FDA what is already so obvious?
But even if it were legally and practically possible to do the various phased
studies to win FDA approval, where would the money to finance these studies
come from? New medicines are almost invariably introduced by drug companies
that spend many millions of dollars on the development of each product.
They are willing to undertake these costs only because of the anticipated large
profits during the 20 years they own the patent. Obviously pharmaceutical companies
cannot patent marijuana. To impose this protocol on cannabis would be
like making the same demand of aspirin, which was accepted as a medicine more
than 60 years before the advent of the double-blind controlled study. Many years
of experience have shown us that aspirin has many uses and limited toxicity, yet
today it could not be marshaled through the FDA approval process. The patent
has long since expired, and with it the incentive to underwrite the substantial
cost of this modern seal of approval. Cannabis, too, as a plant is not patentable;
so the only sources of funding for a “start-from” “start-from-scratch” approval
would be non-profit organizations or the government, which is, to put it mildly,
unlikely to be helpful. Other reasons for doubting that herbal marijuana would
ever be officially approved are today’s anti-smoking climate and, most important,
the widespread use of cannabis for purposes disapproved by the government.
GR: Surely the government will have to make some accommodation
for the growing number of people who use herbal marijuana as a medicine.
How do you see that coming about?
LG: I think the government sees the solution in what I call the “pharmaceuticalization
of cannabis:” prescription of isolated individual cannabinoids, synthetic
cannabinoids, and cannabinoid analogs. While this solution was most recently
proposed in the Institute of Medicine report, it actually goes back to 1985 when
the FDA approved dronabinol (Marinol) for the treatment of the nausea and
vomiting of cancer chemotherapy. Dronabinol is a solution of synthetic tetrahydrocannabinol
in sesame oil (to prevent its being smoked). Dronabinol was developed
by Unimed Pharmaceuticals, Inc. with financial support from the U.S.
government. This was the first hint that the “pharmaceuticalization of cannabis”
would provide the government with the solution to the medical marijuana problem,
the problem of how to make the medicinal properties of cannabis available
while prohibiting its use for any other purpose. But Marinol did not displace
62 anthropology of consciousness 15.2
marijuana as “the treatment of choice;” most patients found the herb itself much
more useful than dronabinol in the treatment of the nausea and vomiting of
cancer chemotherapy. In 1992, the treatment of the AIDS wasting syndrome was
added to dronabinol’s labeled uses; again, patients reported that it was inferior to
smoked marijuana. In my own clinical experience, of those patients who have
had the opportunity to use both herbal marijuana and dronabinol, the latter is
rarely the drug of choice. In general, patients find it less effective than smoked
marijuana, it cannot be titrated because it has to be taken orally, it takes at least
an hour and a half for the therapeutic effect to manifest itself, and even with the
prohibition tariff on street marijuana, Marinol is more expensive. Thus, the first
attempt at pharmaceuticalization proved not to be the answer. In practice, for
many patients who use marijuana as a medicine the doctor-prescribed Marinol
prescription serves primarily as a cover from the threat of the growing ubiquity of
urine tests.
Even as we speak several pharmaceutical firms are developing cannabis-based
medicinals of one sort or another. The question is whether these developments
will make marijuana itself medically obsolete. Surely many of these new products
would be useful and safe enough for commercial development. It is uncertain,
however, whether pharmaceutical companies will find them worth the enormous
development costs. Some may be (for example, a cannabinoid inverse agonist
that reduces appetite might be highly lucrative), but for most specific symptoms,
analogs or combinations of analogs are unlikely to be more useful than herbal
cannabis. Nor are they likely to have a significantly wider spectrum of therapeutic
uses, since the natural product contains the compounds (and synergistic combinations
of compounds) from which they are derived.
GR: You alluded to the idea of patient self-titration with smoked marijuana.
Can you tell me what the importance of titration is and whether it can be
achieved through other means of delivery? And wouldn’t these other means
of delivering this medicine allow the patient to avoid the dangers of smoking?
LG: One of the great advantages of the administration of cannabis through the
pulmonary system is the rapidity (several minutes) with which its effects are
experienced. This in turn allows for the self-titration of dosage, the best way of
adjusting individual dosage. With other routes of delivery the response time is
longer and self-titration becomes more difficult. Thus, self-titration is not possible
with oral ingestion of cannabis whether it be in the form of herbal marijuana
cooked into brownies or a pharmaceutical company pill, because the response
time is one and a half to two hours. While the response time for sublingual or
oral mucosal administration of cannabis is shorter than it is with oral ingestion,
20 to 45 minutes, it is significantly longer than that from absorption through the
lungs and therefore is a considerably less useful route of administration for selftitration.
And today for those patients who consider the health risks of smoking
grinspoon on medical marijuana 63
marijuana much more compelling than is justified by either the medical or epidemiological
literature, there is now available a device which eliminates the smoke;
it is called a vaporizer. Nature constructed cannabis in such a way that if one
heats it to between 284–392° Fahrenheit, just below the point of combustion where
smoke is produced, the cannabinoids vaporize; the marijuana does not burn and
therefore one inhales no smoke.
GR: What about the psychoactive effect or the high? Are you concerned about
that? And is it possible to separate the high from the therapeutic effect?
LG: I am not concerned about the high. It is not harmful; in fact, for most
patients it is reflected in a slight elevation in mood. Furthermore, I am not sure
that one can separate the full therapeutic potential from the psychoactive effects.
Many patients with multiple sclerosis who use cannabis primarily for the relief of
muscle spasm or to achieve bladder control report that they feel better in general
as do other patients who use cannabis as a medicine. We are increasingly learning
in medicine that people who feel better, do better.
GR: Often substance abuse counselors report that their clients self-medicate.
The substance abuse clients may be dually diagnosed with bipolar disorder,
depression or anxiety, and they haven’t sought treatment, so they haven’t
received Prozac, or Paxil or Zanax, or one of these particular medications.
The counselors find that the clients are self-medicating on street drugs, which
work on some of the same neurotransmitter systems as marijuana. What’s
your take?
LG: You will find in the book Marijuana, the Forbidden Medicine a section on
bipolar disorder; I also wrote a paper on this topic which was published in the
Journal of Psychoactive Drugs. I have found so many people who suffer from bipolar
disorder who find that cannabis is useful. Many bipolar people find lithium,
Depakote and other conventional approaches to this disorder of no or limited
use; is it not time for psychiatry to take a look at marijuana? Eventually that is
going to happen. There is something in smoking cannabis which is clearly useful
to those patients, particularly in the hypomanic phase. Now which cannabinoid
it is, or whether it’s a synergy of a number of them, I don’t know, but there is
no doubt that many people with bipolar disorder find it useful. I may not be alive
when it happens, but eventually cannabis is going to constitute, in one form or
another, a treatment for that disorder.
GR: You appear to be doubtful that herbal marijuana will be approved
for use as a medicine anytime in the near future. How do you see the use
of marijuana as a medicine playing out?
LG: Two powerful forces are now colliding: the growing acceptance of medical
cannabis and the proscription against any use of the plant marijuana, medical
64 anthropology of consciousness 15.2
or non-medical. There are no signs that we are moving away from absolute prohibition
to a regulatory system that would allow responsible use of marijuana. As
a result, we are going to have two distribution systems for medical cannabis: the
conventional model of the pharmacy-filled prescriptions for FDA-approved
cannabinoid medicines, and a model closer to the distribution of alternative
and herbal medicines. The only difference, an enormous one, will be the continued
illegality of smoked or ingested cannabis. In any case, increasing medical
use by either distribution pathway will inevitably make growing numbers of people
familiar with cannabis and its derivatives. As they learn that its harmfulness has
been greatly exaggerated and its usefulness underestimated, the pressure will
increase for drastic change in the way we as a society deal with this drug.
GR: We’ve talked about some of the possible medical uses of marijuana.
You’ve also described a category of use for marijuana which you described as
the “enhancement uses” of marijuana. Could you describe what you mean
by that term and speak to that a little bit?
LG: That’s a big topic. You could provide the Uses of Marijuana website project
address, www.marijuana-uses.com. [Editor’s note: Dr. Grinspoon also maintains
a medical website at www.rxmarijuana.com.] Those readers who are interested
can get a pretty good idea of what I mean when I make the claim that cannabis
has the capacity to enhance many aspects of life from the enjoyment of food and
sex to the amplification of one’s creative capacities. I would suggest that they
read my essay “A Cannabis Odyssey” in which I describe my own use, and those
by Allen Ginsberg and Carl Sagan. This web site will also provide readers with
an opportunity to read accounts by a number of people they have never heard of,
people who have written essays for the website because they find that marijuana
is so useful.
select bibliography
Grinspoon, Lester
1969. Marihuana. Scientific American 221(6):17–25.
1977. Marihuana Reconsidered. Cambridge, MA: Harvard University Press.
2002. A Cannabis Odyssey. Journal of Cognitive Liberties 3(1):7–28.
Grinspoon, Lester, and James B. Bakalar
1981. Psychedelic Drugs Reconsidered. New York: Basic Books.
1985. Cocaine: A Drug and Its Social Evolution. New York: Basic Books.
1993. Marihuana: The Forbidden Medicine. New Haven: Yale University Press.
1997. What the General Will Learn. Playboy June:49–53.
1998. The Use of Cannabis as a Mood Stabilizer in Bipolar Disorder: Anecdotal
Evidence and the Need for Clinical Research. Journal of Psychoactive Drugs
30(2):171–177.
grinspoon on medical marijuana 65
Institute of Medicine
1999. Marijuana and Medicine: Assessing the Science Base. Washington, D.C.:
National Academies Press.
MacKay, Charles
1989[1841]. Extraordinary Popular Delusions and the Madness of Crowds. New York:
Barnes and Noble.
Sallan, S, N. Zinberg and E. Frei
1975. Antiemetic Effect of Delta-9-tetrahydrocannabinol in Patients Receiving
Cancer Chemotherapy. New England Journal of Medicine 293:7975–7977.
Medical Marijuana and Altered States
of Consciousness: A Conversation with
Harvard Medical School’s
Dr. Lester Grinspoon
lester grinspoon, m.d.
[email protected]
grant j. rich, editor,
Anthropology of Consciousness
[email protected]
Abstract
This is an interview with author Lester Grinspoon, M.D., whose work on psychoactive
substances over the last thirty-five years has been highly influential. His
book, Marihuana: The Forbidden Medicine (written with James B. Bakalar), is
a classic source on the medical marijuana controversy. His books Psychedelic Drugs
Reconsidered and Cocaine: A Drug and Its Social Evolution are standards in the
field. Dr. Grinspoon received his M.D. from Harvard Medical School and currently
is associate professor emeritus at Harvard Medical School. His academic work has
also reached a general audience through publications ranging from the New York
Times Book Review to Playboy. Describing him as the “complete medical scholar,”
his citation for the Lindesmith Award for Achievement in the Field of Scholarship
also notes, “Lester Grinspoon represents all those scholars who report the
results of their research truthfully, despite the political consequences of this
unwelcomed honesty.”
key words: Marijuana, Interview, Psychoactive substances, Altered states
Grant J. Rich: How did you first become interested in marijuana?
Lester Grinspoon: My interest in cannabis began to develop in 1967. As the senior
author of a book on schizophrenia, I found myself with what I estimated
would be two to three relatively free months before my co-authors would finish
their chapters. Because I had become concerned that so many young people
52 anthropology of consciousness 15.2
were using the terribly dangerous drug marijuana, I decided to use the time to
review the medical literature so that I could write a reasonably objective and scientifically
sound paper on the harmfulness of this substance. Young people were
ignoring the warnings of the government, but perhaps some would seriously
consider a well-documented review of the available data. So I began my systematic
review of the medical and scientific literature bearing on the toxicity—mental
and physical—of marijuana. It never occurred to me then that there were other
dimensions of this drug that warranted exploration.
During my initial foray into this literature I discovered, to my astonishment,
that I had to seriously question what I believed I knew about cannabis. As I
began to appreciate that what I thought I understood was largely based on
myths, old and new, I realized how little my training in science and medicine
had protected me against this misinformation. I had become not just the victim
of a disinformation campaign, but because I was a physician, one of its agents as
well. Believing that I should share my skepticism about the established understanding
of marijuana, I wrote a long paper that was published in the nowdefunct
International Journal of Psychiatry; a shorter version was published as
the lead article in the December 1969 issue of Scientific American. In these
papers I questioned whether the almost ubiquitous belief that marijuana was
an exceedingly harmful drug was supported by any substantial data to be found
in the scientific and medical literature. While there was little reaction to
the paper published in the psychiatric journal there was much interest in the
Scientific American article.
Within a week of the appearance of the article, I received a visit from the associate
director of the Harvard University Press, who suggested that I consider writing
a book on marijuana. I found the idea both attractive and daunting. The subject
was worthy of a book-length exposition, and I would have a reason to deepen
my exploration of this fascinating misunderstanding. And there was another
reason, perhaps the most compelling of all. The one aspect of my work that interested
my twelve-year-old son Danny was my study of marijuana. His illness
began in July of 1967, just about the time I decided to learn about the dangers
of marijuana. He was diagnosed with acute lymphocytic leukemia, and his prognosis
was, of course, grave. He was both excited and pleased when I told him that
I had decided to write a book on marijuana.
A few weeks later I learned that the Board of Syndics of the Harvard University
Press had rejected the book proposal as too controversial. Until that moment I was
unaware of the existence of this board, which must approve every book published
by the Press. An image of the Rembrandt painting “Syndics of the Cloth Guild”
came to mind: a group of serious-looking, long-haired men sitting around a table,
exuding caution and conservatism. I was disappointed but not surprised that they
rejected the proposal; it was the first instance of academic resistance to my work in
this area. I could have signed on immediately with a trade publisher that offered
the prospect of selling more books. But I believed that a conservative, prestigious
grinspoon on medical marijuana 53
press would lend more credibility to a book that promised to be quite controversial.
The director of the press was undaunted; he believed that he could persuade the
Syndics to reverse their decision. And so he did.
It turned out to be a much bigger project than I had anticipated. I found that
I had more than the medical and scientific literature to review. Because so much
of the misinformation and myths about this drug had their origins in the gaudy
writings of the French Romantic Literary Movement, I felt compelled to examine
the works of Theophile Gautier, Charles Baudelaire, and other members of
Le Club des Haschichins, as well as those of Bayard Taylor and Fitz Hugh Ludlow.
It was fascinating to learn that much of the mythology about cannabis that was
being promulgated by the U.S. government had its origins in these writings. It is
difficult to imagine that Harry Anslinger (our first drug czar) was directly familiar
with these 19th century authors, but clearly some of their hyperbolic descriptions
of the cannabis experience, largely products of effusive imagination under the
influence of copious amounts of hashish, are echoed almost a century later in
the “teachings” of Harry Anslinger.
In any event, the bargain I struck with Harvard University Press was that if I
gave them the manuscript by a certain date, they would have a book in my hands
by March 24, 1971. I was confident that this would make it possible for Danny to
see the book. To be able to deliver the manuscript to the Press on schedule while
I continued to pursue my responsibilities at the medical school and hospital
meant working long hours.
There were many nights when I worked into the wee hours, and my wife can
tell you I would sometimes get up at three in the morning to go to my office as
that deadline approached. The bottom line is, however, that I did finish the book
[Marihuana Reconsidered] on time. It is dedicated to him (“To Danny: Children
are the greatest high of all”) and he was just as pleased as he could be.
It was a book which at that time, June of 1971, had an impact. The New York
Times Book Review had a front page review. “The Best Dope on Pot So Far” was
the headline, and this was quite remarkable, because this was a book that said, in
effect, that we’ve all been sold a bill of goods about cannabis, that while it is not
harmless, it is far less harmful than alcohol and tobacco. The most dangerous
thing about cannabis was not to be found in any inherent psychopharmacological
property of the drug, but rather in the way we, as a society, treated people
who used or possessed it. At that time, we were arresting about 300 thousand
mostly young people on marijuana charges (a figure which has now grown to
over 700 thousand people a year). It concluded that the only sensible way to deal
with this substance was to decriminalize it and to regulate it in the same way we
do alcohol. As you can imagine, that was a very controversial position. But there
were also a lot of people (I think mostly people who had had personal experience
with cannabis) who, even then, felt that these were reasonably accurate statements;
not just the statements about the drug and its alleged harms, but about
how we should move to address this issue.
54 anthropology of consciousness 15.2
GR: Will you briefly sketch the highlights of the history of marijuana
legislation in the United States?
LG: Marijuana was known to relatively few people at the beginning of the 20th
century and they were mostly black jazz musicians; they introduced it to others
as they traveled up the Mississippi and around the country. While its use
slowly spread, there were just a handful of states that had any legislation involving
cannabis until in 1932 Harry Anslinger, an out-of-work, former prohibition
agent, was asked to head up the newly formed Federal Bureau of Narcotics. It’s
difficult to know how much of it came from real conviction that marijuana was
terribly dangerous and how much of his anti-marijuana zeal originated in the
desire to find an issue which would further the funding of his new Bureau, but
Anslinger worked vigorously to develop the marijuana scare with what he
called his “educational” program. For example, the movie Reefer Madness is
a perfect illustration of what that educational program was about. You’ve seen
it obviously.
GR: Ha. Of course.
LG: He was successful in persuading Congress which then passed the so-called
Marijuana Tax Act of 1937, the first of the draconian legislation aimed at marijuana.
How people could have believed this so naively and how this thing has
grown over the years is an absolute mystery to me. Are you familiar with Charles
MacKay’s Extraordinary Popular Delusions and the Madness of Crowds?
GR: Yeah, on human folly.
LG: Exactly, on community folly such as the tulip mania of 17th century Flanders.
I predict that sometime in the not-too-distant future, we’re going to look back on
this marijuana history, in this country particularly, and see it as MacKay would
have as an “extraordinary popular delusion” of our times. In my view, this country,
through the Federal Bureau of Narcotics, which morphed into the Federal
Bureau of Narcotics and Dangerous Drugs, and then finally into the Drug
Enforcement Administration (DEA), has tried to establish a drug hegemony.
The whole world has been involved in this delusional view of cannabis. I think
some years down the pike, we’re going to look back on this and wonder, “How in
the world could so many people have bought into this nonsense?” While Harry
Anslinger is right there at the top of the list, there are a lot of other people who
have contributed to it. What these people have written and said is simply divorced
from the reality of this substance. And now we’re in a situation where we arrest
about 700 thousand people annually in this country, most of them young people,
and 89% for mere possession. While the United States government pressure on
marijuana has been growing every year, it has in recent years been diminishing
in Australia, New Zealand, Canada, England, the Netherlands, Belgium, France,
Spain and other Western European countries. These nations are moving toward
grinspoon on medical marijuana 55
more realistic cannabis policies and in doing so they are actively opposing the
United States. The United States is now putting tremendous pressure on the
Canadians as they presently seek a way to provide it to patients who need it medically.
In fact, the marijuana prohibition hegemony is doomed largely because it
is becoming increasingly clear to people around the world that cannabis is a very
useful medicine.
GR: Can you talk about some of its medical usages?
LG: Its use as a medicine began in this country in the mid-19th century. At that
time it was virtually never used for other than medicinal purposes and it was not
smoked; it was dispensed as minims of a tincture (an alcoholic solution) of
cannabis. It was widely used as an analgesic and a soporific (a sleep-inducing
medicine). It was also used in the treatment of tetanus, neuralgia, as an analgesic
during labor, in dysmenorrhea, convulsions, the pain of rheumatism, asthma,
gonorrhea, chronic bronchitis, and to stimulate appetite. Because there were no
bioassays at that time, dosing was always uncertain; and because it was not
smoked, self-titration was impossible. If physicians of that era had known that the
dose could be titrated by having the patient smoke, I believe this would clearly
have been the preferred means of administration. As it was, dose was pretty much
hit or miss but physicians appeared not to worry about overdose because they
understood toxicity was limited. They were concerned that the effect they sought
did not come on for one and a half to two hours; again, if they had used it as a
smokable, the effects would have appeared almost immediately.
GR: What accounts for its demise as a medicine?
LG: Its demise as a medicine came about for two reasons. Two of the major indications
for 19th century physicians to use cannabis were pain and insomnia. The
only alternative analgesic at that time was morphine. Lots of people were using
laudanum, a solution of opium in alcohol, but they could get hooked on it.
Although not as powerful as opium, cannabis was frequently used as an analgesic.
And it was a good soporific or hypnotic; people could use it as we now use
sleeping pills. Then in 1898, acetylsalicylic acid (aspirin) was synthesized. And
now doctors had a shiny new white pill, useful for the treatment of mild to moderate
pain. They knew the dose and they could control it. “Take one of these
every four . . . and so forth.” That was much more appealing to doctors than
going blindly with tinctures of cannabis of uncertain potency. In 1900, the first of
the barbiturates was synthesized and soon became available in pill form. Now,
the second of the two most common uses of cannabis—to treat insomnia, was
replaced by a pill whose potency was precisely known.
So even before 1937, the year of the passage of the Marijuana Tax Act, physicians
were losing interest in cannabis because now they could prescribe these
pills. The Marijuana Tax Act excluded any intention to remove it as a medicine,
56 anthropology of consciousness 15.2
but the red tape now involved in filling out the papers for this exception was so
bothersome that most physicians just stopped prescribing cannabis, and it dropped
out of the pharmacopeia in 1941.
GR: When did you become personally interested in cannabis as a medicine?
LG:Well, I began to understand that there were people who were using it illicitly
as a medicine in the 1970s. One would occasionally come across a letter, usually
in alternative publications, in which the author claimed that marijuana was more
useful than the conventional drug he had been prescribed for the treatment of his
symptom or disorder. A lot of these letters appeared in Playboy. Such letters
would say something like, “I suffer from migraine, and I find by far the best thing
to treat it is to smoke a joint.” I began to think that these claims were consistent
with those of 19th century clinicians; maybe there is something to this. Then when
Danny became sick, something happened which was very powerful for me.
Danny was taken care of by Dr. Sydney Farber, who was the premier child
oncologist in Boston. He had also been my professor at the Harvard Medical
School. When Sydney retired, Emil Frei from Houston was selected to head up
the child oncology division. Shortly after he arrived in Boston, my wife and I
were invited by a friend in the children’s oncology department to have dinner to
meet Dr. Frei. Emil was familiar with Marihuana Reconsidered, or at least the
chapter on medicine, and he asked me, “Dr. Grinspoon, is there anything in
that 19th century literature to suggest that cannabis is a good antiemetic?” I
replied affirmatively. He said, “Well, let me tell you a story.” He went on to tell
me about a 17-year-old young man with acute lymphocytic leukemia he had
treated in Houston. The young man had arrived at the point where he said he
would not take the cancer chemotherapeutics anymore because he could not
stand the nausea and vomiting. Some of the cancer chemotherapeutics generate
extreme and prolonged nausea and vomiting. There are patients who just stop
taking them because they can’t stand it. Stephen Jay Gould, in the account he
wrote for my book, Marihuana, the Forbidden Medicine, at one point wondered
if he could go on with the treatment of his cancer. Emil described how they used
to have to really pressure this young man to get him to take it. Then one day he
came in, climbed on the table without any resistance, took the infusion, and
hopped off the table, with no nausea and no vomiting. Smiling, he waved, “See
ya,” and left the clinic. Emil and his team were mystified. Next time he came in,
he did the same thing. So Emil asked him, “How come this difference?” He said,
“You really want to know? I smoke a little bit of grass 20 minutes before I come in
here.” They were incredulous that he would do such a thing or that it had anything
to do with this. Nonetheless, the young man continued his treatments without
further difficulties with nausea and vomiting. Then Doctor Frei asked me,
“Do you think there’s anything to it?” I replied, “Because it’s such an effective
anti-nauseant, I believe it.”
grinspoon on medical marijuana 57
Driving home from dinner that night, my wife said, “Given what Dr. Frei
said, and what you said, shouldn’t we try to get some marijuana for Danny?” I
said, “No, no, that’s against the law, and furthermore I don’t want to do anything
that would embarrass the people at Children’s Hospital who are doing
such a wonderful job taking care of Danny.” My office is a block from Children’s
Hospital. When Betsy and Danny would drive in for his treatment, I’d
walk over and meet them. Generally, when I walked in, his face radiated anxiety;
he feared and hated this more than anything in the world, and the anxiety was
reflected in his face, and before long mirrored in Betsy’s and mine. On this
occasion when I joined them in the treatment room before he was to get the
infusion they appeared, much to my surprise, to be having a good time as though
they were playing a joke on me. I asked, “What in the world is going on?”
Finally they told me what had happened. That morning on their way to the hospital
Betsy had driven to the Wellesley High School parking lot before school,
found Danny’s friend Mark, and asked him if he could get her a small amount
of marijuana. Mark, once he recovered from his absolute disbelief, ran off to
return a few minutes later with a small amount of grass. When they arrived at
the hospital parking lot Danny smoked some of the marijuana. Previously, he
would begin to feel the intense nausea right then and there, and then vomit and
dry-heave for about eight hours. We used to put a bucket on a towel by his bed;
needless to say, it was heart-breaking to see what he went through. This time he
jumped off the table and he said, “Hey Mom, can we stop for a sub sandwich
on the way home?” He loved sub sandwiches. Furthermore, instead of taking to
his bed for the rest of the day, he went back to school. I called Norman Jaffe,
who was the doctor directly in charge of Danny and told him what had happened.
I also told him that there was no way in which I was going to get in the
way of Danny’s doing this again. He said, “No, you have him smoke in the treatment
room. I want to see this for myself.” I said, “What about the nurses?” He
replied, “Don’t worry. I’ll take care of them.” So several weeks later when he
had his next treatment, Danny smoked a few puffs 15–20 minutes before treatment.
The same thing happened. Norman was amazed. So we made an appointment
with Emil Frei, and Norman and I went up to his office a week later and told
him about this. He said, “That confirms the impression I had in Houston, as
you know.” So he organized a study, but NIDA [National Institute on Drug
Abuse] wouldn’t let them do it with children, and the cannabis had to be in the
form of THC capsules. Nevertheless, the study was completed and the paper
published in the New England Journal of Medicine in 1975. It was the first study
published on the remarkable antiemetic effect of cannabis. This experience
had a powerful impact on me because I began to wonder, “If this works this well
on Danny, are there other children and their families who are needlessly suffering
in this way? How many other children and adults might profit from this?
Shouldn’t they know about this?”
58 anthropology of consciousness 15.2
GR: Tell us about some of the conditions for which marijuana has been useful.
You mentioned leukemia.
LG: Leukemia is one of many cancers. Anyone with cancer who requires treatment
with one of the cancer chemotherapeutics that leads to the severe nausea
and vomiting might benefit from cannabis. While there are very good conventional
drugs, like ondansetron, for example, it doesn’t work as well for some people
as does cannabis. Furthermore ondansetron is very expensive. Ondansetron costs
about $25 to $40 per five-milligram pill, and depending on how severe the nausea
is, a patient may require between one and four pills. If the patient cannot
swallow the pills, an intravenous infusion will be required and that may cost
about $800. Most patients will get the same relief from smoking a quarter to a
third of a joint, which if it weren’t for what I call the prohibition tariff, would cost
just about $5 per joint. This kind of economy would be realized in many medical
situations where cannabis is as or more effective than the conventional medicines;
it could be considerably less expensive. In the case of the nausea and
vomiting of cancer chemotherapy, one can’t say it works for everyone but it is the
best treatment for many if not most. The reputation of cannabis as an antinauseant
has traveled around the cancer grapevine and many facing this treatment
now ask me how they can get hold of some cannabis.
Another condition for which it is useful is glaucoma, which is caused by
increased intraocular pressure and may, if not checked, lead to blindness. In the
early seventies it was discovered that smoking cannabis reduces intraocular pressure.
However, using it for this purpose requires that the patient smoke as often
as eight to ten times a day.
It is widely used as a general analgesic, but it is particularly useful in some
chronic painful conditions, such as osteoarthritis. And, of course, many elderly
people have arthritic pain. In fact, when I was doing a book tour in Europe,
many of the people with whom I talked were elderly people who regularly used
it to treat their arthritic pain. It makes sense when you think of what these folks
have available to them by way of conventional drugs. There are opiate-derivative
medicines, but for a number of reasons it’s not a good idea for patients to take
these drugs over extended periods of time. Or they have the non-steroidal antiinflammatory
drugs, NSAIDs. Ibuprofen is a commonly used example of this
class. About four or five years ago, a paper published in the New England Journal
of Medicine addressed the serious side effects of the NSAIDs. The survey said
about 100 thousand people were hospitalized annually in this country because of
NSAID side effects, most of them gastric bleeding. Ten percent of those patients
lost their lives. That’s about ten thousand people. Compare that to cannabis. Let’s
imagine that you have a serious arthritic condition such as ankylosing spondylitis.
If you use cannabis, you may get what lots of people discover is better relief than
that from NSAIDs; it is at least as good and there is no risk that you will experience
a serious side effect. Here the risk has more to do with the law than it has to
do with any inherent toxicity of the drug.
grinspoon on medical marijuana 59
Because cannabis is such a versatile medicine, the list of symptoms and syndromes
for which patients have found it useful is quite long. The evidence presently
supporting its usefulness in most of the conditions is anecdotal, but as cannabis
becomes increasingly accepted as a medicine, the list of appropriate indications
for its use will climb to firmer ground. In the meantime, I will delineate only the
most common symptoms and syndromes for which it is presently used. They
include, in addition to the above-mentioned, epilepsy, multiple sclerosis, paraplegia
and quadriplegia, AIDS, migraine, severe pruritus, premenstrual syndrome, menstrual
cramps, labor pain, depression and other mood disorders, asthma, insomnia,
adult attention deficit disorder, systemic sclerosis, Crohn’s disease, and phantom
limb pain.
GR: I’ve heard you say marijuana is not a harmless substance, and by that
do you mean it’s not any potential medical side effects which are harmful,
but the legal and social consequences.
LG: Yes, the legal and social consequences of using cannabis today are what most
patients fear when they use this drug. However, there is one infrequent but distressing
“side effect” in that some people can become quite anxious and even
paranoid. This is a time-limited dose-related phenomenon which is best treated
through reassurance. It almost invariably occurs in people who have had little or
no experience with marijuana and do not yet know how to titrate it. When marijuana
becomes widely accepted as a medicine, physicians will not be able to recommend
or prescribe it with a simple, “Go home and take two puffs before meals.”
The doctor is going to have to help the patient to learn to use this medicine or
refer him to a clinic or “Compassion Club” where its use is taught. A patient who
is marijuana-naïve may need special attention. But in general, it is safe to say that
once cannabis regains its rightful place in the pharmacopeia, a place it lost in
1941, it will be seen as one of the least toxic substances in that whole compendium.
There has never been a case of a death from pure cannabis. Europeans smoke it
mixed with tobacco, which is to me a foolish way to use it, but if you consider just
plain cannabis, you cannot identify a documented case. It is difficult to identify
other medicines about which such a claim can be made. Nor can you find any
credible literature which makes the point that it harms any particular tissue or
organ. I think it’s safe to say that it is remarkably free of toxicity.
GR: Do you think a lot of the data that you publish in your work is based
on anecdotal case studies?
LG: It’s almost all anecdotal, but it’s curious to me how people devalue anecdotal
data. It’s almost as though nothing in medicine was believable until the
invention of the double-blind crossover study in the early sixties. That is, of course,
not true. Modern Western medicine grew up on careful clinical observations. It
was all anecdotal. I was asked to be an official reviewer for the Institute of Medicine
[1999] report, and I wrote about twenty pages of criticism, much of it directed
60 anthropology of consciousness 15.2
at its devaluation of the mountain of anecdotal evidence at its disposal. Also,
while it did grudgingly acknowledge that cannabis had medicinal utility, it grossly
exaggerated the dangers of both smoking as a means of delivery and the psychoactive
effects.
With so much anecdotal evidence and with so many people now using
cannabis as a medicine, is one to believe that all these people who risk something
legally to possess and use this drug are out of their minds? They believe that it is at
least as useful, that it is less toxic, and that it is of most importance to the many
who are medically uninsured, less expensive than the conventional medicines it
displaces. Are they all deluding themselves? In fact, I have argued that Food and
Drug Administration [FDA] approval is superfluous where cannabis as a medicine
is concerned. Drugs must undergo rigorous, expensive and time-consuming
tests before they are approved by the FDA for marketing as medicines. The purpose
is to protect the consumer by establishing safety and efficacy. Because no
drug is completely safe or always efficacious, an approved drug has presumably
satisfied a risk-benefit analysis. When physicians prescribe for individual patients
they conduct an informal analysis of a similar kind, taking into account not just
the drug’s overall safety and efficacy, but its risks and benefits for a given patient
with a given condition. The formal drug approval procedures help to provide
physicians with the information they need to make this analysis. This system is
designed to regulate the commercial distribution of drug company products and
protect the public against false or misleading claims about the efficacy and safety.
The drug is generally a single synthetic chemical that a pharmaceutical company
has acquired or developed and patented. It submits an application to the FDA
and tests it first for safety in animals and then for clinical efficacy and safety. The
company must present evidence from double-blind control studies showing that
the drug is more effective than a placebo. Case reports, expert opinion, and clinical
experience are not considered sufficient.
The standards have been tightened since the present system was established
in 1962, and few applications that were approved in the early 1960s would be
approved today on the basis of the same evidence. Certainly we need more laboratory
and clinical research to improve our understanding of medicinal
cannabis. We need to know how many patients with each symptom or syndrome
are likely to find cannabis more effective than existing drugs. We also need to
know more about its effects on the immune system in immunologically impaired
patients, its interactions with other medicines, and its possible uses for children.
But I have come to doubt whether the FDA rules should apply to cannabis.
Thousands of years of use have demonstrated its medicinal value. The government
has itself acknowledged its medical usefulness when it authorized the
Compassionate IND [Investigational New Drug] program and when it supported
the development of dronabinol [a synthetic form of THC]. And there is no question
about its safety; it is one of humanity’s oldest medicines, used for thousands
grinspoon on medical marijuana 61
of years by millions of people with very little evidence of significant toxic effects.
More is known about its adverse effects than about those of most prescription
drugs. The government of the United States has conducted through NIDA a
decades-long multi-million-dollar research program in a futile attempt to demonstrate
significant toxic effects that would justify the prohibition of cannabis as a
non-medical drug. The modern FDA protocol is not necessary to establish a riskbenefit
assessment for a drug with such a history. Should time and resources be
wasted to demonstrate for the FDA what is already so obvious?
But even if it were legally and practically possible to do the various phased
studies to win FDA approval, where would the money to finance these studies
come from? New medicines are almost invariably introduced by drug companies
that spend many millions of dollars on the development of each product.
They are willing to undertake these costs only because of the anticipated large
profits during the 20 years they own the patent. Obviously pharmaceutical companies
cannot patent marijuana. To impose this protocol on cannabis would be
like making the same demand of aspirin, which was accepted as a medicine more
than 60 years before the advent of the double-blind controlled study. Many years
of experience have shown us that aspirin has many uses and limited toxicity, yet
today it could not be marshaled through the FDA approval process. The patent
has long since expired, and with it the incentive to underwrite the substantial
cost of this modern seal of approval. Cannabis, too, as a plant is not patentable;
so the only sources of funding for a “start-from” “start-from-scratch” approval
would be non-profit organizations or the government, which is, to put it mildly,
unlikely to be helpful. Other reasons for doubting that herbal marijuana would
ever be officially approved are today’s anti-smoking climate and, most important,
the widespread use of cannabis for purposes disapproved by the government.
GR: Surely the government will have to make some accommodation
for the growing number of people who use herbal marijuana as a medicine.
How do you see that coming about?
LG: I think the government sees the solution in what I call the “pharmaceuticalization
of cannabis:” prescription of isolated individual cannabinoids, synthetic
cannabinoids, and cannabinoid analogs. While this solution was most recently
proposed in the Institute of Medicine report, it actually goes back to 1985 when
the FDA approved dronabinol (Marinol) for the treatment of the nausea and
vomiting of cancer chemotherapy. Dronabinol is a solution of synthetic tetrahydrocannabinol
in sesame oil (to prevent its being smoked). Dronabinol was developed
by Unimed Pharmaceuticals, Inc. with financial support from the U.S.
government. This was the first hint that the “pharmaceuticalization of cannabis”
would provide the government with the solution to the medical marijuana problem,
the problem of how to make the medicinal properties of cannabis available
while prohibiting its use for any other purpose. But Marinol did not displace
62 anthropology of consciousness 15.2
marijuana as “the treatment of choice;” most patients found the herb itself much
more useful than dronabinol in the treatment of the nausea and vomiting of
cancer chemotherapy. In 1992, the treatment of the AIDS wasting syndrome was
added to dronabinol’s labeled uses; again, patients reported that it was inferior to
smoked marijuana. In my own clinical experience, of those patients who have
had the opportunity to use both herbal marijuana and dronabinol, the latter is
rarely the drug of choice. In general, patients find it less effective than smoked
marijuana, it cannot be titrated because it has to be taken orally, it takes at least
an hour and a half for the therapeutic effect to manifest itself, and even with the
prohibition tariff on street marijuana, Marinol is more expensive. Thus, the first
attempt at pharmaceuticalization proved not to be the answer. In practice, for
many patients who use marijuana as a medicine the doctor-prescribed Marinol
prescription serves primarily as a cover from the threat of the growing ubiquity of
urine tests.
Even as we speak several pharmaceutical firms are developing cannabis-based
medicinals of one sort or another. The question is whether these developments
will make marijuana itself medically obsolete. Surely many of these new products
would be useful and safe enough for commercial development. It is uncertain,
however, whether pharmaceutical companies will find them worth the enormous
development costs. Some may be (for example, a cannabinoid inverse agonist
that reduces appetite might be highly lucrative), but for most specific symptoms,
analogs or combinations of analogs are unlikely to be more useful than herbal
cannabis. Nor are they likely to have a significantly wider spectrum of therapeutic
uses, since the natural product contains the compounds (and synergistic combinations
of compounds) from which they are derived.
GR: You alluded to the idea of patient self-titration with smoked marijuana.
Can you tell me what the importance of titration is and whether it can be
achieved through other means of delivery? And wouldn’t these other means
of delivering this medicine allow the patient to avoid the dangers of smoking?
LG: One of the great advantages of the administration of cannabis through the
pulmonary system is the rapidity (several minutes) with which its effects are
experienced. This in turn allows for the self-titration of dosage, the best way of
adjusting individual dosage. With other routes of delivery the response time is
longer and self-titration becomes more difficult. Thus, self-titration is not possible
with oral ingestion of cannabis whether it be in the form of herbal marijuana
cooked into brownies or a pharmaceutical company pill, because the response
time is one and a half to two hours. While the response time for sublingual or
oral mucosal administration of cannabis is shorter than it is with oral ingestion,
20 to 45 minutes, it is significantly longer than that from absorption through the
lungs and therefore is a considerably less useful route of administration for selftitration.
And today for those patients who consider the health risks of smoking
grinspoon on medical marijuana 63
marijuana much more compelling than is justified by either the medical or epidemiological
literature, there is now available a device which eliminates the smoke;
it is called a vaporizer. Nature constructed cannabis in such a way that if one
heats it to between 284–392° Fahrenheit, just below the point of combustion where
smoke is produced, the cannabinoids vaporize; the marijuana does not burn and
therefore one inhales no smoke.
GR: What about the psychoactive effect or the high? Are you concerned about
that? And is it possible to separate the high from the therapeutic effect?
LG: I am not concerned about the high. It is not harmful; in fact, for most
patients it is reflected in a slight elevation in mood. Furthermore, I am not sure
that one can separate the full therapeutic potential from the psychoactive effects.
Many patients with multiple sclerosis who use cannabis primarily for the relief of
muscle spasm or to achieve bladder control report that they feel better in general
as do other patients who use cannabis as a medicine. We are increasingly learning
in medicine that people who feel better, do better.
GR: Often substance abuse counselors report that their clients self-medicate.
The substance abuse clients may be dually diagnosed with bipolar disorder,
depression or anxiety, and they haven’t sought treatment, so they haven’t
received Prozac, or Paxil or Zanax, or one of these particular medications.
The counselors find that the clients are self-medicating on street drugs, which
work on some of the same neurotransmitter systems as marijuana. What’s
your take?
LG: You will find in the book Marijuana, the Forbidden Medicine a section on
bipolar disorder; I also wrote a paper on this topic which was published in the
Journal of Psychoactive Drugs. I have found so many people who suffer from bipolar
disorder who find that cannabis is useful. Many bipolar people find lithium,
Depakote and other conventional approaches to this disorder of no or limited
use; is it not time for psychiatry to take a look at marijuana? Eventually that is
going to happen. There is something in smoking cannabis which is clearly useful
to those patients, particularly in the hypomanic phase. Now which cannabinoid
it is, or whether it’s a synergy of a number of them, I don’t know, but there is
no doubt that many people with bipolar disorder find it useful. I may not be alive
when it happens, but eventually cannabis is going to constitute, in one form or
another, a treatment for that disorder.
GR: You appear to be doubtful that herbal marijuana will be approved
for use as a medicine anytime in the near future. How do you see the use
of marijuana as a medicine playing out?
LG: Two powerful forces are now colliding: the growing acceptance of medical
cannabis and the proscription against any use of the plant marijuana, medical
64 anthropology of consciousness 15.2
or non-medical. There are no signs that we are moving away from absolute prohibition
to a regulatory system that would allow responsible use of marijuana. As
a result, we are going to have two distribution systems for medical cannabis: the
conventional model of the pharmacy-filled prescriptions for FDA-approved
cannabinoid medicines, and a model closer to the distribution of alternative
and herbal medicines. The only difference, an enormous one, will be the continued
illegality of smoked or ingested cannabis. In any case, increasing medical
use by either distribution pathway will inevitably make growing numbers of people
familiar with cannabis and its derivatives. As they learn that its harmfulness has
been greatly exaggerated and its usefulness underestimated, the pressure will
increase for drastic change in the way we as a society deal with this drug.
GR: We’ve talked about some of the possible medical uses of marijuana.
You’ve also described a category of use for marijuana which you described as
the “enhancement uses” of marijuana. Could you describe what you mean
by that term and speak to that a little bit?
LG: That’s a big topic. You could provide the Uses of Marijuana website project
address, www.marijuana-uses.com. [Editor’s note: Dr. Grinspoon also maintains
a medical website at www.rxmarijuana.com.] Those readers who are interested
can get a pretty good idea of what I mean when I make the claim that cannabis
has the capacity to enhance many aspects of life from the enjoyment of food and
sex to the amplification of one’s creative capacities. I would suggest that they
read my essay “A Cannabis Odyssey” in which I describe my own use, and those
by Allen Ginsberg and Carl Sagan. This web site will also provide readers with
an opportunity to read accounts by a number of people they have never heard of,
people who have written essays for the website because they find that marijuana
is so useful.
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