Citation: JAMA, The Journal of the American Medical Association, May 20,
1992 v267 n19 p2573(2)
Title: Government extinguishes marijuana access, advocates smell
politics. (Medical News & Perspectives)
Authors: Cotton, Paul
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Full Text COPYRIGHT American Medical Association 1992
THE US Public Health Service is snuffing out new applications for
marijuana to be smoked as a form of therapy.
Critics contend that politics, not science, is behind the decision.
They say that, by denying access to what may be a useful treatment,
officials are allowing some of the nation's sickest patients to be
taken hostage in the war on drugs.
However, arguing that risks are great and benefits unproven,
officials have moved to reject 28 applications for marijuana therapy
that had been approved under a compassionate-use program. Thirteen
patients already receiving marijuana for glaucoma, acquired
immunodeficiency syndrome (AIDS), and nausea related to cancer
chemotherapy will continue to do so.
The Public Health Service acknowledges the timing of this latest
action was influenced by a deluge of applications from patients with
AIDS. They had, with the Alliance for Cannabis Therapeutics in
Washington, DC, figured out how to cut what had been a cumbersome
application that could take up to 50 hours to complete down to a
Food and Drug Administration-approved form that could be filled out
in less than 1 hour.
Anecdotal evidence suggests that marijuana, apparently through
appetite stimulation, may slow or even reverse weight loss in
patients with human immunodeficiency virus-related wasting syndrome,
for which there now is no approved therapy.
Preliminary studies suggesting a similar effect for dronabinol
(Marinol, Roxane Laboratories Inc [Boehringer Ingelheim Corp],
Columbus, Ohio), an oral preparation of marijuana's primary active
ingredient, [[Delta].sup.9]-tetrahydrocannabinol (THC), increased
interest in smokable marijuana. This is because it is more quickly
and readily absorbed than the oral preparation and, according to
marijuana therapy advocates, is easier for patients themselves to
titrate in order to avoid the mind-altering side effects.
But the compassionate access program was sending a "bad signal,"
says James O. Mason, MD, DrPH, assistant secretary for health in the
US Department of Health and Human Services and head of the Public
Health Service. He says that giving marijuana out as medicine might
create the "perception that this stuff can't be so bad."
Responding, Robert Randall, president, Alliance for Cannabis
Therapeutics, says: "Mason seems to be more interested in
ideological signals than in the welfare of desperately ill people."
Mark Kleiman, PhD, an associate professor of public policy at
Harvard University, Cambridge, Mass, adds: "I'm mostly a hawk in
the war on drugs, but this is gibberish." Kleiman says that "fact
sheets" released with the Public Health Service decision (describing
the dangers and alternatives to marijuana therapy) are "a mix of
things that are simply misleading, unpersuasive, or that completely
concede the case" for compassionate access.
"My field is drug enforcement," he says, "and, in my professional
opinion, it [medical marijuana] just doesn't matter with respect to
how much marijuana abuse there is."

Weak Data All Around
Unfortunately, there are very few well-controlled studies to
document either marijuana smoking's risks or benefits.
"The really striking thing" about marijuana research is its poor
quality, says Steven Karch, MD, editor of the Forensic Drug Abuse
Advisor.
Studies that suggest benefit often have not been well controlled,
he says. The few apparently well-done epidemiologic studies have
failed to confirm dangers predicted on the basis of in vitro
findings, especially of damage to the immune system.
"In vitro studies should not be the basis for making decisions
like this," says Karch, who is director of research at the
University Medical Center of Southern Nevada, Las Vegas, a clinical
facility of the University of Nevada School of Medicine, Reno. "I
find the whole thing really disturbing because it's a political
decision, it's not medical."
John P. Morgan, MD, associate professor of pharmacology at the
Mount Sinai School of Medicine, City University of New York, and
author of the latest Merck Manual's chapter on marijuana, says a US
government-funded study in Jamaica found no detrimental effect on
general health from marijuana.
The Multicenter AIDS Cohort Study, which has followed nearly 5000
homosexual and bisexual men since 1984, also finds no correlation
between use of marijuana and immune status or speed of human
immunodeficiency virus disease progression (JAMA.
1989;261:3424-3429).
Another ongoing longitudinal study has been looking for 4 years
now at how psychosocial and behavioral factors and immune changes
relate to human immunodeficiency virus infection risk in 373
inner-city teenagers in Newark, NJ. Investigators have found in
twice-yearly drug screens that marijuana use, regardless of the
amount, does not correlate to any immune system changes.
However, marijuana users do tend to have "risk-taking
personalities" and are more likely to engage in other behaviors that
increase risk for such infection, says Stephen Keller, PhD,
professor of psychiatry, University of Medicine and Dentistry of New
Jersey, Newark.
Shortly after the Public Health Service decision, Robert C.
Bonner, the Drug Enforcement Administration administrator, issued a
46-page ruling that also said marijuana "has no currently accepted
medical applications," and so must remain a Schedule I controlled
substance. Bonner issued the ruling because the US Court of Appeals
for the District of Columbia circuit had ordered the Drug
Enforcement Administration to clarify its 1989 ruling that marijuana
has no accepted medical use.
That 1989 ruling was made despite the opposite conclusion being
reached the year before by one of the agency's administrative law
judges who had held extensive hearings on the issue.
Judge Francis L. Young wrote in 1988 that marijuana "has been
accepted as capable of relieving the distress of great numbers of
very ill people, and doing so Young said the law "requires the
transfer marijuana from Schedule I to Schedule II," along with drugs
like morphine that have both high potential for abuse and for
medical utility.
Young said the argument that making marijuana a Schedule II drug
will "send a signal that marijuana is okay generally for
recreational use ... is specious. It presents no valid reason for
refraining from taking an action required by law in light of the
evidence.
"The fear of sending such a signal cannot be permitted to
override the legitimate need, amply demonstrated in this record
[from the hearings he had held] of countless sufferers for the
relief marijuana can provide when prescribed by a physician in a
legitimate case."
Bonner, however, apparently discounted most of this testimony of
marijuana's potential benefit.
"Any mind-altering drug that produces euphoria can make a sick
person think he feels better," says Bonner in the current ruling.
Perceptions of benefit "may be based on rationalizations caused by
drug dependence, not on any medical benefits caused by the drug."
Bonner says that, "beyond doubt, the claims that marijuana is
medicine are false, dangerous, and cruel. Sick men, women, and
children can be fooled by these claims and experiment with the drug.
Instead of being helped, they risk serious side effects."
He suggests long-time users "may eventually get cancer, glaucoma,
multiple sclerosis, and other diseases." He also says that
marijuana is likely to be more cancer-causing than tobacco, damages
brain cells, causes lung problems such as bronchitis and emphysema,
and may weaken lung antibacterial defenses. However, he provides no
documentation.
The dangers of and alternatives to marijuana are discussed in
five "fact sheets" issued at the time of the Public Health Service
decision by the National Institute of Allergy and Infectious
Diseases, the National Institute of Neurological and Communicative
Disorders and Stroke, the National Institute of Dental Research, the
National Cancer Institute, and the National Eye Institute, all part
of the National Institutes of Health, Bethesda, Md.
These fact sheets note that there are more than 400 compounds in
marijuana smoke including carcinogens, and that contamination of
marijuana with Salmonella and fungal spores has been reported. These
"would be a concern for anyone, but especially for patients with
compromised immune systems," they conclude. The inability to
standardize dosage with marijuana smoking is also said to be a
significant problem.
Steve Schnittman, MD, chief of the National Institute of Allergy
and Infectious Diseases' AIDS Division medical branch, says that is
a reason why his institute has plans to study only oral dronabinol
despite patients' reports that marijuana smoking is more effective
and easier for them to control. With the oral form, "we have much
more control over what exactly people are receiving," he says.
Institute officials say megestrol acetate (Megace, Bristol Myers
Squibb, Evansville, Ind), though not yet approved as therapy for
human immunodeficiency virus-wasting, provided benefit to two thirds
of patients with AIDS-related weight loss and anorexia in a
placebo-controlled trial with 278 subjects. The institute itself is
sponsoring further clinical study of dronabinol, but officials say
studies suggesting benefit so far have been less well controlled
than those for megestrol.
Institute officials acknowledge that marijuana smoking "results
in higher plasma levels of THC" than does oral administration. But
they say that deep inhalation may be impractical or unacceptable to
nonsmoking patients, and that the rapid onset of altered mental
status "may be disconcerting."

Smoking Better?

Those arguments have marijuana therapy advocates fuming. "They
need any kind of excuse," complains Morgan. "Smoking is probably
much better than oral administration, and is unquestionably helpful
to patients with AIDS."
Mark Harrington, AIDS Coalition to Unleash Power (ACT-UP), New
York, says: "It's clear the government's war on drugs is taking
precedence over any kind of medical rationality."
The argument that side effects outweigh benefit, he says, "is as
spurious for this indication as it is for withholding morphine from
people suffering extreme pain. The evidence is not there."
Harrington says access is being denied to an agent that "could
really improve the quality of [patients'] lives, and if it can
enable them to eat more, it may even extend their lives.
The National Cancer Institute's fact sheet states that scientists
there "believe marijuana-related compounds probably are not as
effective" as other antiemetics in patients suffering nausea after
chemotherapy. However, it says marijuana-related compounds "can be
useful" when nausea is not controlled by other antiemetics.
Institute officials say that while "THC is more readily and
quickly absorbed" from marijuana smoke, "for the most part" smoking
is "no more effective" than oral preparations.
Mary McCabe, RN, an institute clinical trials specialist, says
that increasing numbers of other effective antiemetic regimens, such
as ondansetron hydrochloride injections (Zofran, Glaxo
Pharmaceuticals, Research Triangle Park, NC), have diminished the
need for compassionate access to smokable marijuana. When asked
about patients who remain refractory to these other antiemetics, she
said that "on a personal basis you would like to offer them whatever
could be made available," adding that "the actual call of whether it
should be available" is not up to the institute.
Still, some oncologists apparently disagree with the Public
Health Service. A survey completed by 1035 members of the American
Society of Clinical Oncology found that 48% of those responding
would prescribe marijuana to some patients if it were legal, and 44%
said they had recommended its illegal use to control emesis in at
least one cancer patient undergoing chemotherapy (J Clin Oncol.
1991;9:1314-1319).
The authors caution that the survey response rate of 43% makes it
difficult to determine how accurately its results reflect opinion
among oncologists. They suggest the survey demonstrates that
oncologists' experience with marijuana is more extensive and
opinions more favorable "than the regulatory authorities appear to
have believed."
They add: "It appears that current regulations create the
somewhat anomalous situation that a substantial fraction of all
practicing oncologists at least occasionally commit an
act--counseling a patient to acquire and use a controlled
substance--that constitutes a crime and that at least in principle
could lead to the revocation of their licenses."
The National Institute of Neurological Disorders and Stroke says
the anecdotal reports of marijuana relieving pain and spasticity in
patients with multiple sclerosis "have not been studied in an
organized way." The National Eye Institute says that while
marijuana does lower intraocular pressure, its studies have not
shown that the pressure is lowered enough to to prevent optic nerve
damage from glaucoma. And it warns that the long-term usage
required to treat glaucoma puts the patient at risk of respiratory
system damage.
Morgan concedes that pulmonary damage is likely. However, he
says he has never seen "a convincing report of pulmonary cancer or
any evidence of chronic obstructive pulmonary disease or emphysema
in marijuana smokers" who did not also use tobacco.
He adds that the doses used to treat other diseases are probably
not great enough to make the risk significant.
"Criminalization is insane," says Morgan. "I do not advocate
marijuana use, but I am absolutely convinced this is a valuable
therapeutic agent which cannot be studied now because of the current
political climate."--by Paul Cotton

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Citation: The Economist, March 28, 1992 v322 n7752 pA23(2)

Title: The last smoke: medical marijuana. (American Survey)

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Full Text COPYRIGHT Economist Newspaper Ltd. (UK) 1992

MEDICINES often produce side-effects. Sometimes they are physically
unpleasant. Many doctors consider marijuana effective in relieving the nausea
of chemotherapy, treating glaucoma and helping AIDS patients gain weight. It
too has discomforting side-effects, but these are not physical. They are
political.

On March 18th the Drug Enforcement Agency (DEA) rejected the pleas of
medical-marijuana advocates to reclassify the drug so that it could be
prescribed by doctors. At present, marijuana is grouped with the most
disapproved-of drugs, such as LSD and heroin; cocaine and morphine, just as
illegal, may be used medically. Two weeks earlier, the Public Health Service
(PHS) had said it was curtailing a tiny "compassionate use" programme that
supplies marijuana, despite the law, to 13 patients. They will go on getting
their joints; no one else will.

The decisions come after a year of to-ing and fro-ing. Last June the PHS
hinted it might limit the compassionate-use programme because of a surge of
applications from AIDS patients. After loud protests from AIDS activists, the
PHS decided to review its policy. Pressure on the DEA came from elsewhere. In
1988 a federal administrative-law judge recommended that marijuana be
reclassified. The DEA disagreed, saying the drug had no "currently accepted
medical use". Last April a federal appeals court ordered the agency to think
again.

Now the government has in effect abandoned the "current acceptance" standard.
It had little choice. A recent study by two Harvard drug-policy researchers
found that almost half of 1,035 oncologists surveyed said they would prescribe
marijuana if it were legal. Indeed, 44% of them said they had advised patients
to smoke pot despite the possibility of prosecution.

The government's case against medical marijuana rests on an alleged lack of
systematic studies of its safety and efficacy. Pot smoke contains carcinogens,
says the PHS; it may harm the immune systems of AIDS patients; they may not
like the "high". Besides, marijuana's main active ingredient, THC, is already
sold in pill form, as Marinol.

According to the Harvard study, however, 77% of those oncologists who had an
opinion on the matter say smokeable marijuana is more effective than oral THC.
Because puffs are easier for patients to measure than pills, it is also less
likely to get them uncomfortably high. True, marijuana may be a carcinogen
(though that has not been proved). But AZT, the most effective AIDS treatment,
causes cancer in animals; and AIDS patients, in any case, are willing to risk
anything.

These concerns do not seem to bother the PHS and the DEA. They have other
things on their minds. Last year a PHS spokesman admitted that for the
government to say marijuana could ever be therapeutic would be an unwise
signal to send during a "war on drugs". Recently James Mason, head of the PHS,
said he feared that AIDS patients, crazed on marijuana, would be more likely
to practise unsafe sex.

Some sick people who would benefit from marijuana will be deterred by the ban;
others, desperate, will smoke it anyway. So far, 35 states have endorsed
medical marijuana. In San Francisco police have agreed to turn a blind eye to
it. Unless the government does something similar, smoking marijuana to relieve
intolerable discomfort will remain, incredibly, a crime.

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Citation: JAMA, The Journal of the American Medical Association, Oct 16,
1991 v266 n15 p2061(2)

Title: Current tobacco, alcohol, marijuana, cocaine use. (From the
Centers for Disease Control)

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Full Text COPYRIGHT American Medical Association 1991

PATTERNS of tobacco, alcohol, and other drug use usually are established
during youth, often persist into adult-hood, contribute substantially to the
leading causes of mortality and morbidity, [1] and are associated with lower
educational achievement and school droupout. [2-5] This report presents
selected data on current use of tobacco, alcohol, marijuana, and cocaine among
9th-12th grade students from two components of the Youth Risk Behavior
Surveillance System [6]: 1) the 1990 national school-based Youth Risk Behavior
Survey (YRBS) conducted during April-May 1990 and 2) similar surveys conducted
by departments of education in 22 states and four cities.

The national survey used a three-stage sample design to obtain a probability
sample of 11631 students in grades 9-12 in the 50 states, the District of
Columbia, Puerto Rico, and the Virgin Islands. The 26 state and local sites
used a variety of sampling schemes: 14 drew probability samples from
well-defined sampling frames of schools and students, allowing computation of
weighted results of known precision; nine drew probability samples of both
schools and students, but either low overall response rates or unavailable
documentation precluded weighting the data or making estimates of precision;
and three used nonprobability samples of either schools or students.

For the state and local surveys, school response rates ranged from 31% to
100%; student response rates ranged from 54% to 94%. Sample sizes ranged from
378 to 5675 students. Students in most samples were distributed evenly across
grades and between genders. The racial/ethnic characteristics of the samples
varied considerably.

Among the state and local surveys, rates varied for current tobacco, alcohol,
and drug use during the 30 days preceding the survey: 9%-37% of students
(median: 31%) reported smoking at least one cigarette; 1%-20% (median: 11%)
reported using smokeless tobacco; 28%-64% (median: 54%) reported having at
least one drink of alcohol; 17%-47% (median: 35%) reported having five or more
drinks on one occasion; 3%-17% (median: 12%) reported using marijuana at least
once; and 1%-4% (median: 2%) reported using any form of cocaine, including
powder, crack, or freebase. At most sites, more male than female students
reported these behaviors. The median prevalence estimates from the state and
local surveys were similar to the national prevalence estimates.

Reported by: J Moore, Alabama State Dept of Education. D Sandau-Christopher,
State of Colorado Dept of Education. J Sadler, District of Columbia Public
Schools. G Davis, Georgia Dept of Education. J Grosko, Kansas State Dept of
Education. I Mudd, Kentucky Dept of Education. T Dunn, Massachusetts Dept of
Education. A Jordan, Mississippi State Dept Bur of School Improvement. J
Owens-Nausler, Nebraska Dept of Education. B Grenert, New Hampshire State
Dept of Education. B Blair, New Mexico State Dept of Education. A Sheffield,
New York State Education Dept. P Hunt, North Carolina Dept of Public
Instruction. J Reynolds, Oklahoma State Dept of Education. P Ruzicka, Oregon
Dept of Education. M Sutter, Pennsylvania Dept of Education. J Fraser, South
Carolina State Dept of Education. M Carr, South Dakota Dept of Education and
Cultural Affairs. E Word, Tennessee State Dept of Education. L Lacy, Utah
State Board of Education. L Zedosky, West Virginia Dept of Education. B
Nehls-Lowe, Wisconsin Dept of Public Instruction. D Scalise, The School Board
of Broward County; AN Gay, The School Board of Dade County, Florida. D
Chioda, Jersey City Public School District, New Jersey. P Simpson, Dallas
Independent School District, Texas. A Blanken, Div of Epidemiology and
Prevention Research, National Institute on Drug Abuse, Alcohol, Drug Abuse,
and Mental Health Administration. Smoking and Health Office, Adolescent and
School Health Div, National Center for Chronic Disease Prevention and Health
Promotion, CDC.

CDC Editorial Note: Because the quality of the samples varied among the state
and local surveys, comparisons of data across sites should be made with
caution. Nonetheless, these results can be useful in planning and evaluating
broad national, state, and local interventions and monitoring progress toward
achieving National Education Goals and health objectives. Goal 6 of the
National Education Goals [7] aims to have every school in the United States
free of drugs and violence and offer a disciplined environment conducive to
learning by the year 2000. The results presented in this report will be
incorporated in the first progress report on the status of the National
Education Goals.

Year 2000 national health objectives are to reduce the use of tobacco,
alcohol, and other drugs among youth. [8] For example, objective 4.6 states
that among youth aged 12-17 the prevalence of alcohol use during the previous
30 days should be no more than 12.6% that of marijuana use no more than 3.2%,
and that of cocaine use no more than 0.6%. Prevalence rates from the national
YRBS for 9th-12th grade students were four times higher for alcohol and
marijuana use and three times higher for cocaine use than these objectives.
Furthermore, most states and cities that conducted a YRBS have not reached
these national objectives. To meet the National Education Goals and the
national health objectives, efforts to help youth reduce current use of
tobacco, alcohol, and other drugs will need to increase among federal, state,
and local education, health, and drug-control agencies; families; media;
legislators; relevant community organizations; and youth themselves.

References

[1] CDC. Results from the National Adolescent Student Health Survey. MMWR
1989;38:147-50.

[2] Jessor R, Jessor S. Problem behavior and psychosocial development: a
longitudinal study. New York: Academic Press, 1977.

[3] Kolbe LJ, Green L, Foreyt J, et al. Appropriate functions of health
education in schools: improving health and cognitive performance. In:
Krasnegor NA, Arasteh JD, Cataldo MF, eds. Child health behavior: a
behavioral pediatrics perspective. New York: Wiley and Sons, 1986.

[4] Dryfoos J. Adolescents at risk: prevalence and prevention. N NY: Oxford
University Press, 1990.

[5] Mensch BS, Kandel DB. Dropping out of high school and drug involvement.
Sociology of Education 1981;61:95-113.

[6] Kolbe LJ. An epidemiological surveillance system to monitor the
prevalence of youth behaviors that most affect health. Health Education
1990;21:44-8.

[7] National Education Goals Panel. Measuring progress toward the National
Education Goals: potential indicators and measurement strategies--discussion
document. Washington, DC: National Education Goals Panel, 1991.

[8] Public Health Service. Healthy people 2000: national health promotion and
disease prevention objectives. Washington, DC: US Department of Health and
Human Services, Public Health Service, 1991; DHHS publication no. (Public
Health Service) 91-50212.

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Citation: Scientific American, July 1991 v265 n1 p40(8)

Authors: Musto, David F.

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Full Text COPYRIGHT Scientific American Inc. 1991

Dramatic shifts in attitude have characterized America's relation to drugs.
During the 19th century, certain mood-altering substances, such as opiates and
cocaine, were often regarded as compounds helpful in everyday life. Gradually
this perception of drugs changed. By the early 1900s, and until the 1940s,
the country viewed these and some other psychoactive drugs as dangerous,
addictive compounds that needed to be severely controlled. Today, after a
resurgence of a tolerant attitude toward drugs during the 1960s and 1970s, we
find ourselves, again, in a period of drug intolerance.

America's recurrent enthusiasm for recreational drugs and subsequent campaigns
for abstinence present a problem to policymakers and to the public. Since the
peaks of these episodes are about a lifetime apart, citizens rarely have an
accurate or even a vivid recollection of the last wave of cocaine or opiate
use.

Phases of intolerance have been fueled by such fear and anger that the record
of times favorable toward drug taking has been either erased from public
memory or so distorted that it becomes useless as a point of reference for
policy formation. During each attack on drug taking, total denigration of the
preceding, contrary mood has seemed necessary for public welfare. Although
such vigorous rejection may have value in further reducing demand, the
long-term effect is to destroy a realistic perception of the past and of the
conflicting attitudes toward mood-altering substances that have characterized
our national history.

The absence of knowledge concerning our earlier and formative encounters with
drugs unnecessarily impedes the already difficult task of establishing a
workable and sustainable drug policy. An examination of the period of drug
use that peaked around 1900 and the decline that followed it may enable us to
approach the current drug problem with more confidence and reduce the
likelihood that we will repeat past errors.

Until the 19th century, drugs had been used for millennia in their natural
form. Cocaine and morphine, for example, were available only in coca leaves
or poppy plants that were chewed, dissolved in alcoholic beverages or taken in
some way that diluted the impact of the active agent. The advent of organic
chemistry in the 1800s changed the available forms of these drugs. Morphine
was isolated in the first decade and cocaine by 1860; in 1874 diacetylmorphine
was synthesized from morphine (although it became better known as hereoin when
the Bayer Company introduced it in 1898).

By mid-century the hypodermic syringe was perfected, and by 1870 it had become
a familiar instrument to American physicians and patients [see "The Origins of
Hypodermic Medication," by Norman Howard-Jones; SCIENTIFIC AMERICAN, January
1971]. At the same time, the astounding growth of the pharmaceutical industry
intensified the ramifications of these accomplishments. As the century wore
on, manufacturers grew increasingly adept at exploiting a marketable
innovation and moving it into mass production, as well as advertising and
distributing it throughout the world.

During this time, because of a peculiarity of the U.S. Constitution, the
powerful new forms of opium and cocaine were more readily available in America
than in most nations. Under the Constitution, individual states assumed
responsibility for health issues, such as regulation of medical practice and
the availability of pharmacological products. In fact, America had as many
laws regarding health professions as it had states. For much of the 19th
century, many states chose to have no controls at all; their legislatures
reacted to the claims of contradictory health care philosophies by allowing
free enterprise for all practitioners. The federal government limited its
concern to communicable diseases and the provision of health care to the
merchant marine and to government dependents.

Nations with a less restricted central government, such as Britain and
Prussia, had a single, preeminent pharmacy law that controlled availability of
dangerous drugs. In those countries, physicians had their right to practice
similarly granted by a central authority. Therefore, when we consider
consumption of opium, opiates, coca and cocaine in 19th-century America, we
are looking at an era of wide availability and unrestrained advertising. The
initial enthusiasm for the purified substances was only slightly affected by
any substantial doubts or fear about safety, long-term health injuries or
psychological dependence.

History encouraged such attitudes. Crude opium, alone or dissolved in some
liquid such as alcohol, was brought by European explorers and settlers to
North America. Colonists regarded opium as a familiar resource for pain
relief. Benjamin Franklin regularly took laudanum--opium in alcohol
extract--to alleviate the pain of kidney stones during the last few years of
his life. The poet Samuel Taylor Coleridge, while a student at Cambridge in
1791, began using laudanum for pain and developed a life-long addiction to the
drug. Opium use in those early decades constituted an "experiment in nature"
that has been largely forgotten, even repressed, as a result of the extremely
negative reaction that followed.

Americans had recognized, however, the potential danger of continually using
opium long before the availability of morphine and the hypodermic's
popularity. The American Dispensatory of 1818 noted that the habitual use of
opium could lead to "tremors, paralysis, stupidity and general emaciation."
Balancing this danger, the text proclaimed the extraordinary value of opium in
a multitude of ailments ranging from cholera to asthma. (Considering the
treatments then in vogue--blistering, vomiting and bleeding--we can understand
why opium was a cherished by patients as by their physicians.)

Opium's rise and fall can be tracked through U.S. import-consumption
statistics compiled while importation of the drug and its derivative,
morphine, was unrestricted and carried moderate tariffs. The per capita
consumption of crude opium rose gradually during the 1800s, reaching a peak in
the last decade of the century. It then declined, but after 1915 the data no
longer reflect trends in drug use, because that year new federal laws severely
restricted legal imports. In contrast, per capita consumption of smoking
opium rose until a 1909 act outlawed its importation.

Americans had quickly associated smoking opium with Chinese immigrants who
arrived after the Civil War to work on railroad construction. This
association was one of the earliest examples of a powerful theme in the
American perception of drugs: linkage between a drug and a feared or rejected
group within society. Cocaine would be similarly linked with blacks and
marijuana with Mexicans in the first third of the 20th century. The
association of a drug with a racial group or a political cause, however, is
not unique to America. In the 19th century, for instance, the Chinese came to
regard opium as a tool and symbol of Western domination. That perception
helped to fuel a vigorous antiopium campaign in China early in the 20th
century.

During the 1800s, increasing numbers of people fell under the influence of
opiates--substances that demanded regular consumption or the penalty of
withdrawal, a painful but rarely life-threatening experience. Whatever the
cause--overprescribing by physicians, over-the-counter medicines,
self-indulgence or "weak will"--opium addiction brought shame. As consumption
increased, so did the frequency of addiction.

At first, neither physicians nor their patients thought that the introduction
of the hypodermic syringe or pure morphine contributed to the danger of
addiction. On the contrary, because pain could be controlled with less
morphine when injected, the presumption was made that the procedure was less
likely to foster addiction.

Late in the century some states and localities enacted laws limiting morphine
to a physician's prescription, and some laws even forbade refilling these
prescriptions. But the absence of any federal control over interstate
commerce in habit-forming drugs, of uniformity among the state laws and of
effective enforcement meant that the rising tide of legislation directed at
opiates--and later cocaine--was more a reflection of changing public attitude
toward these drugs than an effective reduction of supplies to users. Indeed,
the decline noted after the mid-1890s was probably related mostly to the
public's growing fear of addiction and of the casual social use of
habit-forming substances rather than to any successful campaign to reduce
supplies.

At the same time, health professionals were developing more specific
treatments for painful diseases, finding less dangerous analgesics (such as
aspirin) and beginning to appreciate the addictive power of the hypodermic
syringe. By now the public had learned to fear the careless, and possibly
addicted, physician. In A Long Day's Journey into Night, Eugene O'Neill
dramatized the painful and shameful impact of his mother's physician-induced
addiction.

In a spirit not unlike that of our times, Americans in the last decade of the
19th century grew increasingly concerned about the environment, adulterated
foods, destruction of the forests and the widespread use of mood-altering
drugs. The concern embraced alcohol as well. The Anti-Saloon League, founded
in 1893, led a temperance movement toward prohibition, which later was
achieved in 1919 and became law in January 1920.

After overcoming years of resistance by over-the-counter, or patent, medicine
manufacturers, the federal government enacted the Pure Food and Drug Act in
1906. This act did not prevent sales of addictive drugs like opiates and
cocaine, but it did require accurate labeling of contents for all patent
remedies sold in interstate commerce. Still, no national restriction existed
on the availability of opiates or cocaine. The solution to this problem would
emerge from growing concern, legal ingenuity and the unexpected involvement of
the federal government with the international trade in narcotics.

Responsibility for the Philippines in 1898 added an international dimension to
the growing domestic alarm about drug abuse. It also revealed that Congress,
if given the opportunity, would prohibit non-medicinal uses of opium among its
new dependents. Civil Governor William Howard Taft proposed reinstituting an
opium monopoly--through which the previous Spanish colonial government had
obtained revenue from sales to opium merchants--and using those profits to
help pay for a massive public education campaign. President Theodore
Roosevelt vetoed this plan, and in 1905 Congress mandated an absolute
prohibition of opium for any purpose other than medicinal use.

To deal efficiently with the antidrug policy established for the Philippines,
a committee from the Islands visited various territories in the area to see
how others dealt with the opium problem. The benefit of controlling narcotics
internationally became apparent.

In early 1906 China had instituted a campaign against opium, especially
smoking opium, in an attempt to modernize and to make the Empire better able
to cope with continued Western encroachments on its sovereignty. At about the
same time, Chinese anger at maltreatment of their nationals in the U.S.
seethed into a voluntary boycott of American goods. Partly to appease the
Chinese by aiding their antiopium efforts and partly to deal with
uncontrollable smuggling within the Philippine Archipelago, the U.S. convened
a meeting of regional powers. In this way, the U.S. launched a campaign for
worldwide narcotics traffic control that would extend through the years in an
unbroken diplomatic sequence from the League of Nations to the present efforts
of the United Nations.

The International Opium Commission, a gathering of 13 nations, met in Shanghai
in February 1909. The Protestant Episcopal bishop of the Philippines, Charles
Henry Brent, who had been instrumental in organizing the meeting, was chosen
to preside. Resolutions noting problems with opium and opiates were adopted,
but they did not constitute a treaty, and no decisions bound the nations
attending the commission. In diplomatic parlance, what was needed now was a
conference not a commission. The U.S. began to pursue this goal with
determination.

The antinarcotics campaign in America had several motivations. Appeasement of
China was certainly one factor for officials of the State Department. The
department's opium commissioner, Hamilton Wright, thought the whole matter
could be "used as oil to smooth the troubled water of our aggressive
commercial policy there." Another reason was the belief, strongly held by the
federal government today, that controlling crops and traffic in producing
countries could most efficiently stop U.S. nonmedical consumption of drugs.

To restrict opium and coca production required worldwide agreement and, thus,
an international conference. After intense diplomatic activity, one was
convened in the Hague in December 1911. Brent again presided, and on January
23, 1912, the 12 nations represented signed a convention. Provision was made
for the other countries to comply before the treaty was brought into force.
After all, no producing or manufacturing nation wanted to leave the market
open to nonratifying nations.

The convention required each country to enact domestic legislation controlling
narcotics trade. The goal was a world in which narcotics were restricted to
medicinal use. Both the producing and consuming nations would have control
over their boundaries.

After his return from Shanghai, Wright labored to craft a comprehensive
federal antinarcotics law. In his path loomed the problem of states' rights.
The health professions were considered a major cause of patient addiction.
Yet how could federal law interfere with the prescribing practices of
physicians or require that pharmacists keep records? Wright settled on the
federal government's power to tax; the result, after prolonged bargaining with
pharmaceutical, import, export and medicinal interests, was the Harrison Act
of December 1914.

Representative Francis Burton Harrison's association with the act was an
accidental one, the consequence of his introduction of the administration's
bill. If the chief proponent and negotiator were to be given eponymic credit,
it should have been called the Wright Act. It could even have been called a
second Mann Act, after Representative James Mann, who saw the bill through to
passage in the House of Representatives, for by that time Harrison had become
governor-general of the Philippines.

The act required a strict accounting of opium and coca and their derivatives
from entry into the U.S. to dispensing to a patient. To accomplish this
control, a small tax had to be paid at each transfer, and permits had to be
obtained by applying to the Treasury Department. Only the patient paid no
tax, needed no permit and, in fact, was not allowed to obtain one.

Initially Wright and the Department of Justice argued that the Harrison Act
forbade indefinite maintenance of addiction unless there was a specific
medical reason such as cancer or tuberculosis. This interpretation was
rejected in 1916 by the Supreme Court--even though the Justice Department
argued that the Harrison Act was the domestic implementation of the Hague
Opium Convention and therefore took precedence over states' rights.
Maintenance was to be allowed.

That decision was short-lived. In 1919 the Supreme Court, led by Oliver
Wendell Holmes and Louis Brandeis, changed its mind by a 5-4 vote. The court
declared that indefinite maintenance for "mere addiction" was outside
legitimate medical practice and that, consequently, prohibiting it did not
constitute interference with a state's right to regulate physicians. Second,
because the person receiving the drugs for maintenance was not a bona fide
patient but just a recipient of drugs, the transfer of narcotics defrauded the
government of taxes required under the Harrison Act.

During the 1920s and 1930s, the opiate problem, chiefly morphine and heroin,
declined in the U.S., until much of the problem was confined to the periphery
of society and the outcasts of urban areas. There were exceptions: some
health professionals and a few others of middle class or higher status
continued to take opiates.

America's international efforts continued. After World War I, the British and
U.S. governments proposed adding the Hague Convention to the Versailles
Treaty. As a result, ratifying the peace treaty meant ratifying the Hague
Convention and enacting a domestic law controlling narcotics. This
incorporation led to the British Dangerous Drugs Act of 1920, an act often
misattributed to a raging heroin epidemic in Britain. In the 1940s some
Americans argued that the British system provided heroin to addicts and, by
not relying on law enforcement, had almost eradicated the opiate problem. In
fact, Britain had no problem to begin with. This argument serves as an
interesting example of how the desperate need to solve the drug problem in the
U.S. tends to create misperceptions of a foreign drug situation.

The story of cocaine use in America is somewhat shorter than that of opium,
but it follows a similar plot. In 1884 purified cocaine became commercially
available in the U.S. At first the wholesale cost was very high--$5 to $10 a
gram--but it soon fell to 25 cents a gram and remained there until the price
inflation of World War I. Problems with cocaine were evident almost from the
beginning, but popular opinion and the voices of leading medical experts
depicted cocaine as a remarkable, harmless stimulant.

William A. Hammond, one of America's most prominent neurologists, extolled
cocaine in print and lectures. By 1887 Hammond was assuring audiences that
cocaine was no more habit-forming than coffee or tea. He also told them of
the "cocaine wine" he had perfected with the help of a New York druggist: two
grains of cocaine to a pint of wine. Hammond claimed that this tonic was far
more effective than the popular French coca wine, probably a reference to Vin
Mariani, which he complained had only half a grain of cocaine to the pint.

Coca-Cola was also introduced in 1886 as a drink offering the advantages of
coca but lacking the danger of alcohol. It amounted to a temperance coca
beverage. The cocaine was removed in 1900, a year before the city of Atlanta,
Ga., passed an ordinance (and a state statute the following year) prohibiting
provision of any cocaine to a consumer without a prescription.

Cocaine is one of the most powerful of the central nervous system euphoriants.
This fact underlay cocaine's quickly growing consumption and the
ineffectiveness of the early warnings. How could anything that made users so
confident and happy be bad? Within a year of cocaine's introduction, the
Parke-Davis Company provided coca and cocaine in 15 forms, including coca
cigarettes, cocaine for injection and cocaine for sniffing. Parke-Davis and
at least one other company also offered consumers a handy cocaine kit. (The
Parke-Davis kit contained a hypodermic syringe.) The firm proudly supplied a
drug that, it announced, "can supply the place of food, make the coward brave,
the silent eloquent and...render the sufferer insensitive to pain."

Cocaine spread rapidly throughout the nation. In September 1886 a physician
in Puyallup, Washington Territory, reported an adverse reaction to cocaine
during an operation. Eventually reports of overdoses and idiosyncratic
reactions shifted to accounts of the social and behavioral effects of
and the increasing instances of cocaine being linked with violence and
paranoia gradually took hold in popular and medical thought.

In 1907 an attempt was made in New York State to shift the responsibility for
cocaine's availability from the open market to medical control. Assemblyman
Alfred E. Smith, later the governor of New York and in 1928 the Democratic
party's presidential candidate, sponsored such a bill. The cost of cocaine on
New York City streets, as revealed by newspaper and police accounts after the
law's enactment, was typically 25 cents a packet, or "deck."

Although 25 cents may seem cheap, it was actually slightly higher than the
average industrial wage at that time, which was about 20 cents an hour.
Packets, commonly glycine envelopes, usually contained one to two grains (65
to 130 milligrams), or about a tenth of a gram. The going rate was roughly 10
times that of the wholesale price, a ratio not unlike recent cocaine street
prices, although in the past few years the street price has actually been
lower in real value than what it was in 1910.

Several similar reports from the years before the Harrison Act of 1914 suggest
that both the profit margin and the street price of cocaine were unaffected by
the legal availability of cocaine from a physician. Perhaps the formality of
medical consultation and the growing antagonism among physicians and the
public toward cocaine helped to sustain the illicit market.

In 1910 William Howard Taft, then president of the U.S., sent to Congress a
report that cocaine posed the most serious drug problem America had ever
faced. Four years later President Woodrow Wilson signed into law the Harrison
Act, which, in addition to its opiate provisions, permitted the sale of
cocaine only through prescriptions. It also forbade any trace of cocaine in
patent remedies, the most severe restriction on any habit-forming drug to that
date. (Opiates, including heroin, could still be present in small amounts in
nonprescription remedies, such as cough medicines.)

Although the press continued to reveal Hollywood scandals and under-world
cocaine practices during the 1920s, cocaine use gradually declined as a
societal problem. The laws probably hastened the trend, and certainly the
tremendous public fear reduced demand. By 1930 the New York City Mayor's
Committee on Drug Addiction was reporting that "during the last 20 years
cocaine as an addiction has ceased to be a problem."

Unlike opiates and cocaine, marijuana was introduced during a period of drug
intolerance. Consequently, it was not until the 1960s, 40 years after
marijuana cigarettes had arrived in America, that it was widely used. The
practice of smoking cannabis leaves came to the U.S. with Mexican immigrants,
who had come North during the 1920s to work in agriculture, and it soon
extended to white and black jazz musicians.

As the Great Depression of the 1930s settled over America, the immigrants
became an unwelcome minority linked with violence and with growing and smoking
marijuana. Western states pressured the federal government to control
marijuana use. The first official response was to urge adoption of a uniform
state antinarcotics law. Then a new approach became feasible in 1937, when
the Supreme Court upheld the National Firearms Act. This act prohibited the
transfer of machine guns between private citizens without purchase of a
transfer tax stamp--and the government would not issue the necessary stamp.
Prohibition was implemented through the taxing power of the federal
government.

Within a month of the Supreme Court's decision, the Treasury Department
testified before Congress for a bill to establish a marijuana transfer tax.
The bill became law, and until the Comprehensive Drug Abuse Act of 1970,
marijuana was legally controlled through a transfer tax for which no stamps or
licenses were available to private citizens. Certainly some people were
smoking marijuana in the 1930s, but not until the 1960s was its use
widespread.

Around the time of the Marihuana Tax Act of 1937, the federal government
released dramatic and exaggerated portrayals of marijuana's effects.
Scientific publications during the 1930s also fearfully described marijuana's
dangers. Even Walter Bromberg, who thought that marijuana made only a small
contribution to major crimes, nevertheless reported the drug was "a primary
stimulus to the impulsive life with direct expression in the motor field."

Marijuana's image shifted during the 1960s, when it was said that its use at
the gigantic Woodstock gathering kept peace--as opposed to what might have
happened if alcohol had been the drug of choice. In the shift to drug
toleration in the late 1960s and early 1970s, investigators found it difficult
to associate health problems with marijuana use. The 1930s and 1940s had
marked the nadir of drug toleration in the U.S., and possibly the mood of both
times affected professional perception of this controversial plant.

After the Harrison Act, the severity of federal laws concerning the sale and
possession of opiates and cocaine gradually rose. As drug use declined,
penalties increased until 1956, when the death penalty was introduced as an
option by the federal government for anyone older than 18 providing heroin to
anyone younger than 18 (apparently no one was ever executed under this
statute). At the same time, mandatory minimum prison sentences were extended
to 10 years.

After the youthful counterculture discovered marijuana in the 1960s, demand
for the substance grew until about 1978, when the favorable attitude toward it
reached a peak. In 1972 the Presidential Commission on Marihuana and Drug
Abuse recommended "decriminalization" of marijuana, that is, legal possession
of a small amount for personal use. In 1977 the Carter administration
formally advocated legalizing marijuana in amounts up to an ounce.

The Gallup Poll on relaxation of laws against marijuana is instructive. In
1980, 53 percent of Americans favored legalization of small amounts of
marijuana; by 1986 only 27 percent supported that view. At the same time,
those favoring penalties for marijuana use rose from 43 to 67 percent. This
reversal parallels the changes in attitude among high school students revealed
by the Institute of Social Research at the University of Michigan.

The decline in favorable attitudes toward marijuana that began in the late
1970s continues. In the past few years we have seen penalties rise again
against users and dealers. The recriminalization of marijuana possession by
popular vote in Alaska in 1990 is one example of such a striking reversal.

In addition to stricter penalties, two other strategies, silence and
exaggeration, were implemented in the 1930s to keep drug use low and prevent a
recurrence of the decades-long, frustrating and fearful antidrug battle of the
late 19th and early 20th centuries. Primary and secondary schools instituted
educational programs against drugs. Then policies shifted amid fears that
talking about cocaine or heroin to young people, who now had less exposure to
drugs, would arouse their curiosity. This concern led to a decline in
drug-related information given during school instruction as well as to the
censorship of motion pictures.

The Motion Picture Association of America, under strong public and religious
pressure, decided in 1934 to refuse a seal of approval for any film that
showed narcotics. This prohibition was enforced with one exception--To the
Ends of the Earth, a 1948 film that lauded the Federal Bureau of
Narcotics--until Man with a Golden Arm was successfully exhibited in 1956
without a seal.

Associated with a decline in drug information was a second, apparently
paradoxical strategy: exaggerating the effects of drugs. The middle ground
was abandoned. In 1924 Richmond P. Hobson, a nationally prominent campaigner
against drugs, declared that one ounce of heroin could addict 2,000 persons.
In 1936 an article in the American Journal of Nursing warned that a marijuana
user "will suddenly turn with murderous violence upon whomever is nearest to
him. He will run amuck with knife, axe, gun, or anything else that is close
at hand, and will kill or maim without any reason."

A goal of this well-meaning exaggeration was to describe drugs so repulsively
that anyone reading or hearing of them would not be tempted to experiment with
the substances. One contributing factor to such a publicity campaign,
especially regarding marijuana, was that the Depression permitted little money
for any other course of action.

Severe penalties, silence and, if silence was not possible, exaggeration
became the basic strategies against drugs after the decline of their first
wave of use. But the effect of these tactics was to create ignorance and
false images that would present no real obstacle to a renewed enthusiasm for
drugs in the 1960s. At the time, enforcing draconian and mandatory penalties
would have filled to overflowing all jails and prisons with the users of
marijuana alone.

Exaggeration fell in the face of the realities of drug use and led to a loss
of credibility regarding any government pronouncement on drugs. The lack of
information erased any awareness of the first epidemic, including the
gradually obtained and hard-won public insight into the hazards of cocaine and
opiates. Public memory, which would have provided some context for the
antidrug laws, was a casualty of the antidrug strategies.

The earlier and present waves of drug use have much in common, but there is at
least one major difference. During the first wave of drug use, antidrug laws
were not enacted until the public demanded them. In contrast, today's most
severe antidrug laws were on the books from the outset; this gap between law
and public opinion made the controls appear ridiculous and bizarre. Our
current frustration over the laws' ineffectiveness has been greater and more
lengthy than before because we have lived through many years in which antidrug
laws lacked substantial public support. Those laws appeared powerless to curb
the rise in drug use during the 1960s and 1970s.

The first wave of drug use involved primarily opiates and cocaine. The
nation's full experience with marijuana is now under way (marijuana's tax
regulation in 1937 was not the result of any lengthy or broad experience with
the plant). The popularity and growth in demand for opiates and cocaine in
mainstream society derived from a simple factor: the effect on most people's
physiology and emotions was enjoyable. Moreover, Americans have recurrently
hoped that the technology of drugs would maximize their personal potential.
That opiates could relax and cocaine energize seemed wonderful opportunities
for fine-tuning such efforts.

Two other factors allowed a long and substantial rise in consumption during
the 1800s. First, casualties accumulate gradually; not everyone taking
cocaine or opiates becomes hooked on the drug. In the case of opiates, some
users have become addicted for a lifetime and have still been productive.

Yet casualties have mounted as those who could not handle occasional use have
succumbed to domination by drugs and by drug-seeking behavior. These addicts
become not only miserable themselves but also frightening to their families
and friends. Such cases are legion today in our larger cities, but the
percentage of those who try a substance and acquire a dependence or get into
serious legal trouble is not 100 percent. For cocaine, the estimate varies
from 3 to 20 percent, or even higher, and so it is a matter of time before
cocaine is recognized as a likely danger.

Early in the cycle, when social tolerance prevails, the explanation for
casualties is that those who succumb to addiction are seen as having a
physiological idiosyncrasy or "foolish trait." Personal disaster is thus
viewed as an exception to the rule. Another factor minimizing the sense of
risk is our belief in our own invulnerability--that general warnings do not
include us. Such faith reigns in the years of greatest exposure to drug use,
ages 15 to 25. Resistance to a drug that makes a user feel confident and
exuberant takes many years to permeate a society as large and complex as the
U.S.

The interesting question is not why people take drugs, but rather why they
stop taking them. We perceive risk differently as we begin to reject drugs.
One can perceive a hypothetical 3 percent risk from taking cocaine as an
assurance of 97 percent safety, or one can react as if told that 3 percent of
New York/Washington shuttle flights crash. Our exposure to drug problems at
work, in our neighborhood and within our families shifts our perception,
gradually shaking our sense of invulnerability.

Cocaine has caused the most dramatic change in estimating risk. From a grand
image as the ideal tonic, cocaine's reputation degenerated into that of the
most dangerous of drugs, linked in our minds with stereotypes of mad, violent
behavior. Opiates have never fallen so far in esteem, nor were they repressed
to the extent cocaine had been between 1930 and 1970.

Today we are experiencing the reverse of recent decades, when the technology
of drug use promised an extension of our natural potential. Increasingly we
see drug consumption as reducing what we could achieve on our own with healthy
food and exercise. Our change of attitude about drugs is connected to our
concern over air pollution, food adulteration and fears for the stability of
the environment.

Ours is an era not unlike that early in this century, when Americans made
similar efforts at self-improvement accompanied by an assault on habit-forming
drugs. Americans seem to be the least likely of any people to accept the
inevitability of historical cycles. Yet if we do not appreciate our history,
we may again become captive to the powerful emotions that led to draconian
penalties, exaggeration or silence.