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Unlike hospice, long-term drug safety is an important issue in palliative medicine. Opioids may produce significant morbidity. Cannabis is a safer alternative with broad applicability for palliative care. Yet the Drug Enforcement Agency (DEA) classifies cannabis as Schedule I (dangerous, without medical uses). Dronabinol, a Schedule III prescription drug, is 100% tetrahydrocannabinol (THC), the most psychoactive ingredient in cannabis. Cannabis contains 20% THC or less but has other therapeutic cannabinoids, all working together to produce therapeutic effects. As palliative medicine grows, so does the need to reclassify cannabis. This article provides an evidence-based overview and comparison of cannabis and opioids. Using this foundation, an argument is made for reclassifying cannabis in the context of improving palliative care and reducing opioid-related morbidity.

Given the very limited toxicity of marijuana and the growing appreciation of its therapeutic value, it will undoubtedly find increasing application as a medicine in the coming years. But there is uncertainty about the forms in which it will be made available. Governments are hesitant to approve it because of concern about its use for nonmedical purposes and the difficulties of distributing as a medicine a substance that is already easily available. An alternative is the development of commercial cannabis pharmaceuticals that can be regulated and controlled. But pharmaceutical firms will be reluctant to invest the necessary money if they believe they cannot compete successfully with marijuana. Some of these products may have advantages over whole smoked or ingested marijuana, but most will not, and they will all be quite expensive. Ultimately, we can anticipate two medical distribution networks, a legal one for cannabinoid pharmaceuticals and an illegal one for street or homegrown marijuana.

Cannabis was first admitted to Western pharmacopoeias one and a half centuries ago. In 1839 W. B. O'Shaughnessy at the Medical College of Calcutta observed its use in the indigenous treatment of various disorders and found that tincture of hemp was an effective analgesic, anticonvulsant, and muscle relaxant.1 Publication of O'Shaughnessy's paper created a stir within a medical establishment that at that time had access to only a few effective medicines. In the next several decades, many papers on cannabis appeared in the Western medical literature. It was widely used until the first decades of the 20th century, especially as an analgesic and a hypnotic. Symptoms and conditions for which it was found helpful included tetanus, neuralgia, labor pain, dysmenorrhea, convulsions, asthma, and rheumatism.2 Administering a medicine through smoking was unheard of until the late 19th century, when pharmaceutical houses prepared coca leaf cigars and cheroots were occasionally used in lieu of cocaine? If physicians had realized that titration of the dose was easier and relief came faster when marijuana was inhaled, they might have preferred to administer it by smoking. However, in the 19th century it was prepared chiefly as a tincture (alcoholic solution), generally referred to as tincture of hemp, tincture of cannabis, or Cannabis indica. The potency and bioavailability of oral cannabis varied widely, and there were no reliable bioassay techniques. Nevertheless physicians prescribed cannabis without much concern about overdoses or side effects because they knew how safe it was. But, understandably, they considered it less reliable as an analgesic than opium and opium derivatives. Furthermore, unlike opiates, it could not be used parenterally because it was not water-soluble. Then, at the turn of the century, the first synthetic analgesics and hypnotics (aspirin and barbiturates) became available. Physicians were immediately attracted to these drugs because their potencies were fixed and they were easily dispensed as pills. Beginning in the 1920s, interest in cannabis as a recreational drug grew, along with a disinformation campaign calculated to discourage that use. In 1937 the first draconian federal legislation against marijuana, the Marijuana Tax Act, was passed. At that time the medical use of cannabis had already declined considerably; the act made prescription of marijuana so cumbersome that physicians abandoned it. Now physicians themselves became victims of the "Reefer Madness" madness. Beginning with an editorial published in the Journal of the American Medical Association in 1945, the medical establishment became one of the most effective agents of cannabis prohibition.4 The modern renaissance of medicinal cannabis began in the early 1970s, when several young patients who were being treated with the recently developed cancer chemotherapies discovered that marijuana was much more effective than conventional medicines for the relief of the intense and prolonged nausea and vomiting induced by some of these agents.5 Word spread rapidly over the cancer treatment grapevine. By mid-decade the capacity of marijuana to lower intraocular pressure had been observed, and patients suffering from glaucoma began to experiment with it.6 As the AIDS epidemic gathered momentum, many patients who suffered HIV-associated weight loss learned that marijuana was the most effective and least toxic treatment for this life-threatening symptom. These three new medical uses of cannabis have led to wider folk experimentation. The use of marijuana in the symptomatic treatment of convulsive disorders, migraine, insomnia, and dysmenorrhea has been rediscovered. We have now identified more than 30 symptoms and syndromes for which patients have found cannabis useful,7 and others will undoubtedly be discovered. Many patients regard it as more effective than conventional medicines, with fewer or less-disturbing side effects. Consider the pain of osteoarthritis, which in the 19th century was often treated with tincture of cannabis. …

(2000). Editorial: Medical Cannabis: The Patient's and the Doctor's Dilemmas. Addiction Research: Vol. 8, No. 1, pp. 1-4.

As the medical virtues of cannabis become increasingly clear, the question of how to make it available to patients becomes increasingly urgent. Conventional routes to medical legitimacy—the process by which pharmaceutical companies satisfy government requirements for a new medicine—are inappropriate because of the unique history and properties of this substance. Its full medical potential cannot be realized as long as present prohibition laws are enforced. For medical as well as other reasons, cannabis should be available to the public under restrictions similar to those governing alcohol. Although early changes in the law are unfortunately unlikely, increasing public understanding of the medical usefulness of cannabis may lead to changes in enforcement patterns that bring the 60 year reign of prohibition to a de facto conclusion.

The medical value of marijuana is becoming increasingly clear, as it proves to be a remarkably versatile, safe, and inexpensive drug. Arrangements now being proposed for making cannabis constituents medically available include quasi-legal buyers clubs, restrictive classification as a prescription drug, the isolation of individual cannabinoids, and the manufacture of synthetic analogs. Careful analysis potentially of this inexpensive drug shows that all these proposals are unworkable. Furthermore, cannabis has so many beneficial uses that the strictly medical ones should not be singled out for approval, and its medical potential cannot be fully realized as long as its use for any other purpose is prohibited. Therefore cannabis should be made available under laws similar to those now applied to alcohol.

This commentary presents the case for the legalization of marihuana for medicinal purposes. It examines the history of medical marihuana, briefly discusses its clinical uses and presents a general overview of the legal classification (scheduling) of the drug in the United States of America today.

After nearly 10 years of escalation, the government assault on illicit drugs has proved to be a costly failure. We have all been paying the price in misdirected resources, social tension, violent crime, ill health, compromised civil liberties, and international conflict. The war on drugs is, in effect if not in intention, a war on drug users. The federal budget for the control of illicit drugs has increased more than eightfold since 1981, and more than two thirds of the total is devoted to the enforcement of increasingly harsh criminal laws1. These laws needlessly make criminals of at least . . .

A “Harmfulness Tax” is proposed as an alternative to the present unsuccessful drug prohibition policy. Both legal and currently illegal drugs would be taxed in proportion to the social cost associated with their use. In a sense, drug users would be required to buy insurance against the harm their drug use might cause to society. The scheme would be implemented in stages beginning with alcohol, tobacco and marijuana. After the program had been established in this way, it would be extended to other drugs, including cocaine. This proposal accords well with experiences gained in taxing legal drugs and with the realities of current drug use in America.

The authors present case histories indicating that a number of patients find cannabis (marihuana) useful in the treatment of their bipolar disorder. Some used it to treat mania, depression, or both. They stated that it was more effective than conventional drugs, or helped relieve the side effects of those drugs. One woman found that cannabis curbed her manic rages; she and her husband have worked to make it legally available as a medicine. Others described the use of cannabis as a supplement to lithium (allowing reduced consumption) or for relief of lithium's side effects. Another case illustrates the fact that medical cannabis users are in danger of arrest, especially when children are encouraged to inform on parents by some drug prevention programs. An analogy is drawn between the status of cannabis today and that of lithium in the early 1950s, when its effect on mania had been discovered but there were no controlled studies. In the case of cannabis, the law has made such studies almost impossible, and the only available evidence is anecdotal. The potential for cannabis as a treatment for bipolar disorder unfortunately can not be fully explored in the present social circumstances.

The drug revolution that began 30 years ago has transformed psychiatry, but it has left little imprint on psychotherapeutic procedures themselves. Little attention has been given to the possibility of using drugs directly to enhance the process of psychotherapy — fortifying the therapeutic alliance and facilitating the production of memories, fantasies, and insights. A change may now be coming; for example, a psychiatrist known for his research on the therapeutic alliance has proposed that a “pharmacotherapy of interpersonal processes” might be considered both to study and to improve the alliance [1], The wait has been long partly because the research involved is complex and hard to perform. The theoretical bases for the two types of therapy are vastly different; these differences are reflected in the way experiments arc conducted and the results are evaluated. Reconciliation and unification will not be easy to achieve. One of the best ways to see why that is so is to examine the different significance assigned to placebo effects in drug experiments and psychotherapy studies.

In Reply. —As Dr Lowenthal points out, the contrast between tobacco policies and marijuana policies is instructive in more ways than one. Dr Bennetts raises the issues of social acceptability, cost, and alternatives. His fear that medical availability would lead to more nonmedical use is unwarranted. Cocaine and morphine, for example, have always been available as prescription drugs, but no one believes that availability is a significant cause of illicit use. On the issue of cost, it is important to point out that marijuana is less expensive than many of the medicines it could replace. As for the question of alternatives, of course we have no objection to advocacy for other orphan drugs and nonchemical approaches. Dr Nahas and Manger are wrong in their assertion that all the pharmacological properties of marijuana are attributable to THC. One reason most patients prefer smoked marijuana to oral dronabinol 1(p39) is the powerful

BETWEEN 1840 and 1900, European and American medical journals published more than 100 articles on the therapeutic use of the drug known then asCannabis indica(or Indian hemp) and now as marihuana. It was recommended as an appetite stimulant, muscle relaxant, analgesic, hypnotic, and anticonvulsant. As late as 1913 Sir William Osler recommended it as the most satisfactory remedy for migraine. Today the 5000-year medical history of cannabis has been almost forgotten. Its use declined in the early 20th century because the potency of preparations was variable, responses to oral ingestion were erratic, and alternatives became available—injectable opiates and, later, synthetic drugs such as aspirin and barbiturates. In the United States, the final blow was struck by the Marihuana Tax Act of 1937. Designed to prevent nonmedical use, this law made cannabis so difficult to obtain for medical purposes that it was removed from the pharmacopeia. It is now

In a recent six-month period, a state-operated community mental health center was required to gather data for nine major surveys, reviews, and budget requests. Such surveys cover much the same ground, yet without any attempt to standardize formats so that the data a center compiles for one survey can be used in the next. The surveys frequently are not designed for the programs required to complete them; they are a drain on increasingly scarce staff time and deplete staff morale. A two-part solution to the problem would involve coordiantion and control of the demands for data, perhaps through the development of a model mental health data set and format by the National Institute of Mental Health, and the development of locally based, smaller-scale information systems. The latter step would generate more complete and reliable data for local clinicians and administrators and yield a limited amount of basic information to be used by outside agencies.

Many preindustrial cultures traditionally use certain psychedelic plants to enhance a procedure that resembles psychotherapy--an idea that was also tested in Western psychiatry in the 1950s and 1960s. LSD and related drugs were used to facilitate the production of memories, fantasies and insights and to enhance the therapeutic alliance. The results were inconclusive, and research was largely abandoned after the drugs became difficult to obtain. It may now be possible to revive this research, using new drugs that do not have some of the disadvantages of the old ones. The drug now of most interest is MDMA (3,4-methylenedioxymethamphetamine) a relatively mild and short-acting substance that is said to give a heightened capacity for introspection and intimacy without the perceptual changes, emotional unpredictability, and occasional adverse reactions associated with LSD. Therapists who have used the drug claim that it can enhance the therapeutic alliance by inviting self-disclosure and promoting trust. Whether MDMA fulfills this promise or not, other drugs may eventually prove useful in psychotherapy. Research on their potential should not be curtailed because of fear that they will be subject to illicit abuse.

The authors review research on the effects of amphetamines on children, particularly hyperactive children in the classroom. They point out that there is no clear evidence these drugs should be prescribed as often as they are. The "hyperkinetic syndrome" remains vague both in its diagnosis and its etiology, and the mechanism of amphetamine action is unclear. The assumption that amphetamines have a paradoxical,calming effect on hyperactive children, unlike the stimulating effect they exert on adults, may accurately describe the apparent effects of the drugs on attention and other aspects of socially accepted classroom behavior, but it does not justify the interpretation that amphetamine effects are qualitatively different for children than for adults, without the same potential for harm. The authors conclude that the possible adverse effects of these drugs and their unknown long-term risks require that we consider the present policy of amphetamine administration in the schools.

Feedback on patterns of social interaction was given to chronic schizophrenic patients at their weekly ward community meetings for a period of four weeks. This feedback produced a significant decrement in aloneness (from an initial level of 80% to 72%) relative to the initial pre-feedback period. Isolation had returned to the initial pre-feedback level six months later at which time a replication of the feedback procedures again produced a similar aloneness decrement. No differences were observed between drug (phenothiazine) and placebo patients.

DAY care is at the present time a most interesting movement in mental health. It appears to be ever increasing in momentum both in this country and abroad, and it portends dramatic change in the traditional relations between the mental hospital, its patients and the community. Although the day-care movement is not new, its first practical application having taken place as early as 1933,1 only during the last decade and a half has it seemed to catch fire. Similarly, day care at the Massachusetts Mental Health Center is not new; a much broadened application of the concept, however, has only . . .

Summary This paper attempts to review reports on combinations of drugs and other modalities. The following tentative impressions appear warranted: 1. Combined ECT and drugs: Anti-depressants may maintain post-ECT improvement in mood, but no decided advantage obtains from its use during a course of ECT treatment. Combination of reserpine and ECT may be dangerous. Phenothiazines may have beneficial effects as a tranquilizer, but synergism with ECT remains doubtful. 2. Combined occupational therapy and drugs: Apparently drugs make it possible for many inaccessible patients to participate meaningfully in social interaction and to learn new skills. 3. Combined psychotherapy and drugs: Various drugs are alleged to hasten or facilitate individual psychotherapy; however, where anxiety is reduced it is also reported that patients stop working in psychotherapy and become complacent. Individualization and special attention to drug dosage may optimize usefulness of drugs in this context. In group therapy, tranquilizers appear to facilitate interaction and enhance the group process.

Therapists who participated in previous active drug-placebo studies of chronic and acute schizophrenics were rated on the Whitehorn-Betz A-B scale. The ratings were then related to treatment outcome. Patients who had been treated with phenothiazines and by Type A (verbal-intellectual) therapists improved more than those treated with placebo and by Type B (practical-mechanical) therapists, although the results were not statistically significant. The authors stress the importance of further research in this area.

Increased activity of cieatine phosphokinase (CPK) or aldolase, or both, was found, on a blind basis, in the serum of 25 of 39 acute schizophrenic patients at some phase of their illness. The median increase in serum enzyme activity was approximately threefold. Smaller increases in serum CPK and aldolase activity were also found in five of 22 first-degree relatives of the acute patients. In the patients, the serum enzyme activity increased briefly and returned to normal but the enzyme increases were persistent in the relatives.

Two groups of chronic schizophrenic patients were treated with intensive psychotherapy for a period of two years, starting in 1962 and 1964. Half of the patients also took phenothiazines. Control groups at a local state hospital received phenothiazines but no psychotherapy. A follow-up of the groups on three tests of adjustment, administered at the end of 1967, indicated some trends toward better adjustment by patients who had received psychotherapy but there were no statistically significant differences among the groups.

ALTHOUGH thromboembolism has frequently been attributed to abnormal blood coagulation, convincing evidence for this concept has been lacking. The disclosure of hitherto unrecognized coagulation factors and the development of methods for their assay prompted re-examination of this question. Pregnancy was selected as the initial area of study because it constitutes a common, temporary, reversible, physiologic state that is too frequently complicated by thromboembolism. This report presents data indicating that during pregnancy abnormally high levels of at least one important clotting constituent do develop, returning to normal in most cases after term. It is proposed that these changes reflect a state . . .

1. 1. Two groups of chronic schizophrenic patients had a sufficient difference in skin potential response wave form to a loud noise so that they could be rank ordered with respect to normal responses. 2. 2. The skin potential response wave form rank order correlated with the rank order as determined by two behavioral measures of the patient's clinical state. 3. 3. No specific component of the wave form correlated with the clinical state. 4. 4. The skin potential response wave form may provide a physiologic way of following a chronic schizophrenic clinical state.

THE alteration of carbohydrate metabolism in Cushing's syndrome and during ACTH (1) and cortisone (2) administration has led to the belief that, at least in some cases of diabetes mellitus, an elevated level of adrenal cortical function may be of etiologic significance. On the other hand, recent studies of the response of diabetics to stress (3) and determinations of urinary steroid excretion in diabetics (4, 5) have led some to the belief that perhaps there exists a degree of decreased adrenal cortical function. It has been demonstrated repeatedly that a variety of stress situations and the administration of ACTH and epinephrine all induce a pronounced fall in the level of circulating eosinophils, due presumably (except possibly for epinephrine) to stimulation of the adrenal cortex (6–11). This fact, together with the ease of counting eosinophils, has led to the introduction of the ACTH test (12) and the epinephrine test (13), both of which, within certain limits, are valuable tools for the estimation of...

Coca has been used in folk medicine in South America for thousands of years both as a general stimulant and for more specific medical purposes. It remains one of the most commonly used medicines in some areas of Bolivia and Peru. The medical use of coca and cocaine in the industrial world has a more dramatic and varied history. Coca extract and cocaine were introduced as pancreas for a wide variety of complaints in the late 19th century. Cocaine was the first effective local anesthetic; prescription drugs, patent medicine, and soda drinks containing it were also popular. When its dangers became apparent and substitutes became available, its medical use went into decline, especially when, in the 1930s, amphetamine began to replace it for some purposes. Today its only generally accepted medical use is as a topical anesthetic in certain kinds of minor surgery and other clinical procedures. There are, however, some recent and so far uncertain signs of reviving interest in cocaine and even coca itself for other medical purposes, in research as well as in diagnosis and treatment.

The Quarterway House was founded in December 1978 to deinstitutionalize and provide rehabilitation services to a small group of long-term, seriously ill inpatients of the Massachusetts Mental Health Center. The purposes of the residential program are to provide a less institutional therapeutic environment and to develop a psychosocial treatment program that might enable some patients to move toward more independent settings in the community. In a randomized experimental study, with center inpatients as the control group, the effectiveness of the program was assessed by multiple outcome measures before the program began and at one year. Although neither group moved rapidly to more independent community living, Quarterway House patients showed improvement in general functioning and socialization-survival skills and decreased medication and seclusion. They did not show a decline in psychotic symptoms, obstreperousness, or antisocial behavior. Over-all, the findings suggest the program may prove useful for the long-term rehabilitation of severely ill patients.

Some kinds of risk-taking in the pursuit of pleasure or the improvement of work performance are considered socially and legally acceptable. Drug use is not, except for alcohol, tobacco, and caffeine. This is certainly not because the dangers of drugs have been carefully compared with other kinds of danger, and not even because the risks of legal drug use have been carefully balanced against the benefits, or against the cost of enforcing punitive laws. Ironically, if we did those things, alcohol and tobacco might be the first drugs banned. But this kind of reckoning is regarded, in effect, as too difficult and uncertain. Instead, social and legal policy is guided by certain unconscious analogies, whereas others are ignored or rejected. The analogies we actually use are not entirely misleading, but they are partial; in this case they justify severe social disapproval and legal restraints that we would not tolerate for equivalent dangers not produced by drugs. It is useless to protest against this in the name of abstract consistency and rationality; the current drug control arrangements and their justifying analogies have the weight of all twentieth century history behind them, and they are similar everywhere in the world. They are the accepted and perhaps inevitable response, in our time, to a social need for classification and control of a complicated and ambiguous phenomenon. But at least we should allow ourselves to be more aware of what we are doing and describe it more candidly.

Twenty-seven chronically ill mental patients were followed up four years after their discharge from a state hospital to the Massachusetts Mental Health Center. In interviews with the patients and their caregivers, data were gathered on the patients' current places of residence, mental status, time spent in the hospital since discharge, levels of functioning, and quality of life. The authors found that patients tended to move from hospital to community, with rehospitalization dropping dramatically once patients were placed in the community; that the group of patients living in the community had a better average mental status; that all but two patients preferred their current living situations to life at the state hospital; and that the best predictor of community residence was age at first admission (over 20). Two policy issues are discussed: the relationship (or lack of one) between restrictiveness and type of residence, and the importance to the findings of changes in psychiatric practice over the lifetime of the sample.

Virtually all known human groups have devised and regularly used techniques for altering consciousness, among which alcohol and drugs are prominent. James B. Bakalar and Lester Grinspoon offer a provocative analysis of the philosophical and historical foundations for efforts to control these techniques in industrial societies. What are the rights of individuals to diversity and enrich their experience? What, conversely, are the obligations of governments to protect their citizens? The authors explore the relevance to drug control of traditional doctrines of political liberty. They discuss the ideas of addiction, dependence, and compulsive drug use, central in both medical and legal definitions of drug abuse. They consider the history and sociology of modern drug control, and go on to present a useful typology of the forms of drug control. After assessing each point, they examine alternative ways of looking at what is usually called the drug problem. The book will be of interest to all those concerned with drugs and social control, in a wide range of fields.