LCCC The case for medical marijuana.

Pubdate: February 1998
Source: Canadian Pharmaceutical Journal, Volume 131 Number 1
Author: Steve McLaren, Staff Writer

"Basically, what I do is, I cause trouble. That's my function. If you cause enough trouble eventually you effect change."

Meet Alan Young. Last summer the Osgoode Hall law professor launched a constitutional challenge against marijuana laws on behalf of Chris Clay, owner of a London, ON, store called Hemp Nation. Clay, whose merchanise included marijuana plants, was charged with trafficking and cultivating a narcotic. While Young's client was found guilty, Ontario Court Justice John McCart was tolerant, handing Clay a relatively modest $750 fine and three years probation. In his judgement, McCart said, "as it is commonly used, occasionally, cannabis presents only minor or subtle risks to the health of the individual." This spring Young will represent Lynn Harichy, a multiple sclerosis patient charged with possession after lighting a marijuana joint in front of a London police station.

Young expects many new clients now that "buyer's clubs," supplying marijuana to anyone with a doctor's recommendation, are opening in Toronto, Oakville, Kitchener, Guelph, London and Peterborough. While stressing he's not the organizer of these groups, he is willing to defend them.

Young notes that, if he potential clients are charged, it would be for trafficking, and indictable offence tried by a jury. "Dr. Henry Morgentaler was providing abortions," he says. " Abortions were against the law. He was tried seven times. He was never convicted." Calling Morgentaler's rationale the Common Law Defence of Necessity, and assuming all marijuana sales will be for medicinal purposes, Young theorizes, "I suspect if I put enough AIDS and cancer patients into the box, there aren't going to be a whole lot of juries that are going to want to put these kids in jail."

Alan Young isn't alone in his campaign to make the deccriminalization of marijuana a health issue. In December, Ontario Justice Patrick Sheppard stayed charges of cultivation and possession against Terry Parker, a Toronto man who argued he needs the drug to combat epilepsy. Concluding Parker's rights were violated. Sheppard ordered the police to return some of Parker's confiscated marijuana plants. Sheppard wrote, "Deprivation to (Mr. Parker) arising from a blanket prohibition denying him possession of marijuana, in the circumstance of this case, does little or nothing to enhance the state's interest in better health for this individual member of the community."

The Parker case was specifically referred to in January when a Kitchener man received a light sentence for possession, partly because of his diagnosed "chromic cumulative trauma disorder " and because the Parker decision left the law in "a state of flux", according to the judge.

Some advocates of medical marijuana are taking their case straight to the government. Don Kilby, director of health services at the University of Ottawa, is applying to Health Canada's Special Access Program for permission to "prescribe" marijuana to Jean Charles Pariseau, an AIDS patient who gained 20 pounds after smoking marijuana as a last resort. Even in the law-and-order-conscious Reform party, MP Jim Hart submitted a private member's motion proposing marijuana be decriminalized "for health purposes, explicitly for the purpose of providing pain relief for the terminaly ill." All of these efforts are playing out in the backdrop of an Angus Reid poll finding 83 per cent of those surveyed support the legalization of marijuana for medical purposes.

Marijuana advocates, and even those opposed, tend to agree on one point: pharmacies should have a role in the medical marijuana issue. "We have a perfectly good delivery system now through pharmacies -- they keep good records, they relate what people are taking to the other things that they're doing and I should think that they would still fulfil a role in these cases as well," says Barry Beyerstein of the Brain Behaviour Laboratory of Simon Fraser University's department of psychology, a member of the pro-decriminalization Canadian Foundation for Drug Policy. "Pharmacists are already the custodians of society of useful substances which also have some danger," concures Robin Room, chief scientist for the Addiction Research Foundation. "It would be entirely appropriate for pharmacists to be saying, 'Look, if you're going to have medical marijuana, then it makes sense for use to be the places that you get it.'"

While Room may deem their participation appropriate, pharmacy has been quiet on the health politics of marijuana. Bothe the Canadian Pharmacists Association and the Canadian Society of Hospital Pharmacists have no position on the issue. "There's a lot that need to happen, before the pharmacist can even come into play, and that is a defined sources, a controlled sources that meets regulatory requirements," says Bill Leslie, executive director of the Canadian Society of Hospital Pharmacists. Noelle-Dominique Willems, CPhA's director of government and public affairs, agrees, adding that like euthanasia it's an issue that divides the profession. Says Willems, "If there's...a Parliamentary committee that looks into it, which may happen if practice becomes more frequent, then we would definately, at that point, at least prepare a position to talk about the role of pharmacists, as we did with euthanasia."

Others suggest a number of reasons why the profession hasn't spoken out. Harold Kalant, professor emeritus of pharmacology at the University of Toronto's faculty of medicine, says, "It would create headaches, because they would have to keep extra records in the same way they do for narcotics or for other controlled drugs. Secondly, it would increase the risk for them of break-ins to try to steal their stock. Thirdly, it may be that they just don't want to get mixed up in a messy situation." Wayne Hindmarsh, dean of the faculty of pharmacy at the University of Manitoba, and author of a guide for parents called Drugs: What Your Kids Should Know, says that security could be an issue. "You're going to bring in a differnt clientele," he says. "You know, it's not just going to be marijuana. There's going to be other types of drug users as well."

However, two of the lawyers involved think the profession is reticent for other reasons. "I think pharmacists are pawns in all this," says Young. "They're a conduit for the facilitation of medical and governmental policy, and they don't necessarily lead it." Aaron Harnett, legal counsel for Terry Parker, says there's simply no money in it for pharmacists. "Marijuana costs seven dollars an ounce to grow. It sells for $350 now, so Terry now can grow it for free -- or for seven an ounce -- and he can cut out the middle man, the end man, everyone."

But even Young and Harnett agree that pharmacists shold be involved if the marijuana is for medically-approved reasons. Says Harnett, "The 60-year-old lady with glaucoma -- she's not going to want to start growing pot plants, but if her doctor says, 'Give it a try. I may save your eyesight,' she may want a legal source, where she can be assured of its quality, and not have to get her hands dirty."

Sorting out the distribution issue is proving difficult. While Kilby is optimistic federal regulators will approve his Special Access Program request for medical marijuana, Ottawa lawyer Eugene Oscapella, part of a lobby group supporting Kilby's efforts, is more sceptical after Health Canada denied their first request. The health department concluded that neither Kilby nor the listed "manufacturer," the patient's current supplier, had the proper licences under the Controlled Drugs and Substances Act. "It's hard to tell what messages we're getting from them, quite frankly," he says. "In one sense, they're scambling to find a way out of this mess. In another, we've got a guy who's dying of AIDS and who's being forced to go to the illegal market to get a drug that's saving his life."

But Dann Michols, director general of Health Canada's Therapeutic Products Program, says many controlled substances have been approved by the government, such as heroin and morphine, and "it isn't really earth-shattering to think that perhaps marijuana as a substance might have medicinal use." While Oscapella and others argue no manufacturer will ever agree to cooperate in a marijuana application, Michols calls that "supposition," arguing it could be supplied by a university, a distributor, or even a grower.

"There are other substances that are controlled substances where suppliers have obtained the necessary licences to obtain, process and distribute the product, so it's not an insurmountable barriers if someone want to do it," he says. He adds that, if Kilby went outside the country to obtain a supplier, the government itself might end up distributing the product. "Probably we would have to set up a mechanism whereby the supplier supplied us and we provide the material to the physician here, but that too is doable," he says. "The government of the importing country would have to be involved to ensure control of distribution."

While Kilby works his way through the Special Access Program, he longs for the day when patients would simply visit a pharmacy. "I'm sitting in my office now in front of about 150 binders on drugs that are accessed through (the Special Access Program), because you have to keep records for these patients, you have to provide records back to the pharmaceutical company, you have to inform the government. There's a log of red tape to go through."

Many of the smokers battling the court system would also like to see doctors and pharmacists helping them get their supply. While Lynn Harichy would like to cultivate it herself, "If you could get it at pharmacies that would be great because it is a hassle in the winter to grow it," she says. "They let us take all these other medicines --you know, trial drugs -- and the side effects are so bad. If I don't smoke (pot), I'm going to be in pain and I just, I can't take that."

Terry Parker, whose landmark victory is being appealed by the Crown, says simply, "it's just been a real nightmare trying to get this substance recognized for preventing epilepsy." Parker says because of his illness he's become addicted to prescription drugs, and candidly describes his treatment and its effects. "My skin is white as a ghost, my teeth are grinding, my left leg and my left arm are all over the place, my body is just convulsing. A couple of joints, smoke that, within two to three minutes I've got instant relief...That's the beauty about marijuana, the absolute beauty, and no pharmacists should be shy about the subject." While Parker's case is under appeal, his lawyer says other Crown Attorneys are withdrawing similar charges as a result of the decision.

The Parker case, however, may have confused things even further, according to Kalant, who was a Crown witness in the trial. "The judge was acting essentially on compassionate grounds rather than on scientific grounds," he says. "I think the judge was perhaps acting more as a humane person than as an objective arbiter of the law. There are probably valid medical uses for cannabinoids, but smoking pot is rarely they way to do it."

That is the crux of the marijuana debate: does it have medical value? Advocates argue it's been used safely for thousands of years, and point out there is no accepted lethal dose. Supporters of California's Proposition 215, a referendum that decriminalized the use of marijuana for certain medical treatments, argued the benefits of the substance in treating cancer, anorexia, AIDS, chronic pain, spasticity, glaucoma, arthritis and migraine. They said a Harvard University survey concluded on-half of oncologists would prescribe marijuana to some of their patients if it were legal. A 1992 study from Georgetown University's School of Medicine found 170 cancer specialist ranked cannabis sixth in management of severe, post-chemotherapy nausea and vomiting.

Few argue there are no risks. In a policy paper, the Addiction Research Foundation found heavy cannabis use may have negative health consequences, including respiratory damage (when smoked), impaired coordination, altered hormone production and damage to the immune system, although, "by any accounting," the health impact of marijuana is much less than alcohol or tobacco. "There is credible anecdotal evidence that some people are helped for some conditions by medical marijuana," says the ARF's Room. "People are resistant to the idea of medication that is smoked for both good and not so rational reasons."

Opponents argue there is no convincing evidence, credible or otherwise. Raju Hajela, president of the Canadian Society of Addiction Medicine (an affiliate of the Canadian Medical Association), says marijuana is not a first-line treatment for anything, the adverse effects from smoking are the same as from tobacco, and its withdrawal symptoms are similar to those of heroin. In a Dec. 12 press release he said those arguing that marijuana is not harmful are doing it to "feed their own addiction." In an interview, he said, "The most common thing that's observed in anyone who even casually smokes marijuana is the amotivational syndrome that develops, and people lose interest in their day-to-day life situations."

Wayne Hindmarch has fought marijuana acceptance for years, and says there's no evidence the drug is better than what's already legally available. "We do know that marijuana does not have a lot of toxic principles, and we've got to be careful as to the message that we're giving to younger kids," he says. "That's certainly the thing that concerns me. If you could prove scientfically that the joint is far better than any medication that's out there for a particular problem then we would have to go with that, but that hasn't been proven, in my mind."

Marijuana critics often point to two synthetic versions of one of cannabis' active ingredients, tetrahydrocannabinol (THC): Marinol and Cesamet. Michelle Foisy, HIV primary care pharmacist at Toronto's Wellesley Health Centre, says while the drugs are marketed for cancer patients, they have been given to HIV patients for nausea and vomiting, and to help them gain weight. Patients with prior marijuana experience often appreciate the effects -- or continue smoking it themselves -- but other patients aren't as receptive. "There certainly is a high percentage of people who say, 'Forget i. I don't want to feel high. I have to concentrate on my job.;" She doesn't recommend the medicinal use of marijuana. "From a smoking standpoint, on a chronic basis, I don't know that you're doing your patient any good. You might be alleviing one thing but then inducing something else."

But many patients and doctors don't like synthetic THC, saying it's unpalatable and, if they're trying to control nausea to be able to take oral medications, ineffective. "When people are taking 40 pills a day or more, or on chemotherapy, they have so much nausea that they can't even take those pills, including the synthetic form (of THC). That's where we have the problem," says Kilby. "They're taking their joint about half an hour before they take their pills and then there is immediate relief of nausea and there's stimulation of their appetite and they tend to be able to hold down, not only the pills, but hold down some food as well."

There's one other reason why some prefer cannabis to drug company products, according to Beyerstein -- "Marinol is very expensive, and marijuana is very cheap." Kilby notes the appetite stimulant he usually prescribes for AIDS patients, Megace, costs up to $3,000 a month, and is not covered under Quebec's drug plan.

Even if marijuana use was allowed, would physicians prescribe it appropriately? Before giving a patient marijuana, Hindmarsh says he'd want to know, "What physicians have dealt with him? I'm not saying anything against general practitioners at all, but has (the patient) been treated by specialists? Have they exhausted all the possibilities that are available?" Alan Young scoffs at the suggestion. "e;I have to work on the assumption that doctors are going to do their job properly, and if not it's a matter for the College of Physicians and Surgeons. Doctors can prescribe a lot of narcotics, and that isn't a reason to take away that power from them."

Whether doctors will ever get the opportuntity is another matter; 25 years after the Le Dain Royal Commission advocated decriminaliztion, penalties for possessions can still result in a criminal record, and the maximum penalty for trafficking is life imprisonment. While some police force officials on Ottawa and Vancouver have downplayed marijuana possession as a priority, its use, medical or not, carries a risk. "If the law's there we're going to enforce it," says Gilles Brunet, national coordinator of the RCMP's drug awareness program. "If it's still a criminal offence we can't ignore it. I don't think things change because of (the Parker decision)."

Some say government policy could change under new Health Minister Allan Rock, who has already shown support for the herbal medicine industry. In an interview with the Ottawa Citizen, Rock said he would "look seriously and with an open mind at the evidence in deciding on whether the government should get out of the way and permit the use of a substance for medical purposes." Another Liberal MP, Toronto doctor Carolyn Bennett, has come out in favor of cannabis use by multiple sclerosis patients. "(Allan Rock), of all ministers of health, is probably in the best postion to make a change to the law," says Aaron Harnett. "Nobody, I think, who looks at the issue carefully, wants to put someone in a jail cell for a month because they've got an ounce of marijuana."

If there are any legal changes, pharmacists will have some work to do. Hindmarsh concedes it's "not really a major part of our curriculum. I teach toxicology here at this university to the pharmacy students, and that's sort of the last area to be covered." Though their curricula would likely differ, decriminalization advocate Beyerstein agrees. "It would be a good idea to do a little bit of postgraduate work, because that probably wasn't covered in the standard curriculum, but that information is certainly widely available," he says. "They're professionals, that's what they do well, and I think that information should be made availalbe to them through their continuing recertification or professional education."

What virtually everyone can agree on is that, with buyers' clubs, requests to government for marijuana and a growing line of court cases, the idea is not going away soon. Thw question for pharmacists is what position they'll take. "You have a lot of parents that are concerned about their children, and they're not going to give up quietly," says Hindmarsh. "My only hope would be that the debate is a good debate that is based on scientific principles and not just on feelings."

Says Harnett, "I imagine we can return to a time when the pharmacist would also be the producer of some of the herbs and medicines. I take it that's where their origin comes from."


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