Lester Grinspoon, MD and James B. Bakalar

ABSTRACT: Document on decriminalization of cannabis prepared for the 36th Congress of the Radical Party (Rome, Hotel Ergife, 30 April - 3 May)

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A fool, if he obeyed, may punish

crimes as well as another; But the

true statesman is he who knows how

to prevent them.

Rousseau

In the era of the Volstead Act, the American satirist HL Mencken said of the alcohol problem that between the distillers and saloonkeepers on one side and the prohibitionists on the other, no intelligent person thought there was any solution at all. The same may be true of the illicit drug problem today, with its traffickers and users on one side and its moralists and police on the other. Only the problem is perhaps more serious because the acceptable range of solutions is so narrow. There is very little effective opposition to prohibition.

The American war on drugs began with the Harrison Narcotics Act in 1914 and has escalated in the last twenty years. Federal, state, and local governments now spend an estimated eight to nine billion dollars a year on direct drug enforcement activities and millions more to house and feed drug dealers and users, who nnow constitute one-third of federal prisoners and contribute substantially to the need to build more prisons. It is sometimes said that the pendulum of public attutudes swings back and forth between harshness and leniency in the early 70s, it now appears to be going the other way, as indicated by growing demands for even more spending on law enforcement.

Drugs enter the United States at a growing rate despite the war effort, although that effort does inflate prices and keep the drug dealers' franchises lucrative. Another consequence is drug-related crime and violence, a product of the black market in alcohol in the 1920s. The threat to civil liberties grows as the warriors, already by necessity using entrapment and informers, now make plans to send in the army and examine everyone's urine periodically. They are already testing the urine of federal employees randomly. A society cannot be both drug-free and free.

Any serious approach to this problem (as opposed to the present one) demands a recognition of complexity and ambiguity. We may have to acknowledge that the use of drugs and alcohol has benefits as well as dangers. The main obstacle to thinking about any serious alternative to present policies is that no one in government wants to give up the symbolism of the criminal law or the commitment that has been made over the last 80 years, not only in the United States but all over the world, to treating drugs as a criminal problem.

But there is a great deal of public ambivalence, or, to put it less kindly, hypocrisy, where this issue is concerned. The moral consensus about the evil of drugs is often passionate but shallow. We pretend that eliminating the drug traffic is like eliminating slavery or piracy, or sometimes as though it were like eradicating smallpox or malaria. But no one would suggest that we legalize piracy or give up the effort to eradicate infectious diseases, yet conservative authorities like the economist Milton Friedman and the Economist of London have suggested legalization of drugs. Despite the hysterical rhetoric we often hear, drug control is not a settled issue in the same sense. Or rather, the need for that kind of rhetoric is a sign that it is not a settled issue. On the one hand, it is accepted in public discourse that everything possible has to be done to prevent everyone from ever using any of the controlled substances. On the other hand, there is an informal lore of drug use which is more tolerant. At

one time it looked as though the forms of public discourse and this private language were coming closer together. Now they seem to be drifting apart again. A type of pretense that we have long abandoned in the case of alcohol is still considered the only respectable position where other drugs are concerned. Ambivalence and hypocrisy have always been an underrcurrent in public attitudes toward drugs, even while the criminal control system becomes more and more entrenched. That undercurrent leaves room for the possibility of change.

The hypocrisy involved in prohibiting cannabis is particularly prominent, since almost everyone with the least sophistication about this drug knows that it is far less harmful than alcohol and tobacco. Furthermore, Amserdam has conducted a large-scale social experiment by making cannabis freely available over the last few decades. No individual or social harm has been demonstrated, and cannabis use has not even increased.

As evidence of the relative harmlessness of cannabis grows, more and more people are becoming dissatisfied with the prohibition system in both Europe and the United States. The most recent evidence of this dissatisfaction was the action of an appeals court in Lubeck, Germany, which struck down the country's laws against cannabis as unconstitutional. Judge Wolfgang Nescovic dismissed charges against a woman sentenced to two months for possession of a gram of hashish. He said that the cannabis laws violated the constitutional guarantee of equality before the law, because haschish was no more harmful than alcohol or tobacco. He also ruled that the cannabis ban violated the constitutional guarantee of personal freedoms that do not infringe on the rights of others.

Besides the civil libertarian pressures, there is a new and compelling reason to make cannabis legally available - the growing understanding that it is an effective medicine. Of all the bad consequences of government harassment of marihuana users, none is more tragic than the medical ban on cannabis. It has been well known for thousands of years that cannabis has more than one medical use. It is far safer than most medicines prescribed by doctors daily, and often works for patients who cannot tolerate the side effects of other drugs. In many cases no other drug will do the job as safely or as well.

Like other psychoactive drugs derived from natural plant sources, marihuana has long been used as medicine as well as an intoxicant. It was listed in an herbal published by a Chinese emperor that may go back to 2800 B.C. In Jamaica, where it was introduced in the 17th century by African slaves, it has become the most important popular folk medicine. Cannabis in the form of an alcoholic tincture was commonly used in 19th century Europe and the United States as an anticonvulsant, sedative, an analgesic. It was thought to be a useful appetite stimulant and a milder but less dangerous sedative than opium. It was used to treat tetanus, neuralgia, uterine hemorrhage, rheumatism, and other conditions. Between 1839 and 1900 more than a hundred articles on the therapeutic uses of marihuana appeared in scientific journals. After the introduction of injectable opiates in the 1850s, and synthetic analgesics and hypnotics in the early 20th century, the medical use of cannabis desclined. But even as late as 1937 extr

act of cannabis was still a legitimate medicine marketed by drug companies.

The greatest advantage of cannabis as a medicine is its unusual safety. The ratio of lethal dose to effective dose is estimated on the basis of extrapolation from animal data to be about 40,000: 1 (compared to 3-50: 1 for secobarbital and 4-10: 1 for alcohol). Huge doses have been given to dogs without causing death, and there is no reliable evidence of death caused by cannabis in a human being. Cannabis also has the advantage of not disturbing any physiological functions or damaging any body organ when used in therapeutic doses. It produces little physical dependence or tolerance; there is no evidence that medical use of cannabis has ever led to habitual use as an intoxicant.

A promising new medical use for cannabis is the treatment of glaucoma, the second leading cause of blindness in the United States. In this disease fluid pressure within the eyeball increases until it damages the optic nerve. About a million Americans suffer from the form of glaucoma (wide angle) tratable with cannabis. Marihuana causes intraocular pressure to fall and retards the progressive lose of sight when conventional medication fails and surgery is too dangerous. Tetrahydrocannabinol or THC (the main active ingredient of marihuana) eyedrops have not proved effective as a substitute, and as long ago as 1981 the National Eye Institute announced that it would no longer approve human research on these eyedrops. Studies continue on eyedrops containing other natural cannabinoids and synthetic cannabis derivatives.

Cannabis also has a use in the treatment of cancer. About half of patients undergoing chemotherapy for cancer suffer from severe nausea and vomiting, which are not only unpleasant but a threat to the effectiveness of the therapy. Retching may cause tears of the esophagus and rib fractures; vomiting prevents adequate nutrition and leads to fluid loss. For about a third of patients, the standard antiematics do not work. The suggestion that cannabis might be useful arose in the early 1970s when some young people receiving cancer chemotherapy found that marihuana smoking, which was of course illegal, reduced their nausea and vomiting. There is some controversy about whether THC is best taken orally or smoked in the form of marihuana. Smoking generates quicker and more predictable results in both glaucoma and cancer treatment because it raises THC concentration in the blood more easily to the needed level. Also, it may be hard for a nauseated patient in chemotherapy to take oral medicine. Most patients who u

se THC for this purpose prefer to smoke it in the form of marihuana.

Marihuana is increasingly recognized as a drug of choice for pain that accompanies muscle spasm. This kind of pain is often chronic and debilitating. especially in paraplegics, quadriplegics, other victims of traumatic nerve injury, and people who suffer from multiple sclerosis or cerebral palsy. Many of these patients have discovered that cannabis not only allows them to avoid the risks of opioids for pain relief, but also reduces their muscle spasms and tremors, and may improve their coordination enough so that they can leave their wheelchairs and walk.

The most rapidly growing group of medical marihuana users consists of people with AIDS. Smoked cannabis effectively relieves the nausea which is both a symptom of the disease itself and a common side effect of treatment with AZT. Weight loss is a serious problem for AIDS patients; cannabis enhances appetite, relieves diarrhea, and allows many of them to gain weight. The importance of cannabis to patients with this disease is illustrated by the case of an American physician suffering from AIDS who moved to Amsterdam so that he could use cannabis freely. THree or four cannabis cigarettes a day completely eliminated his nausea and diminished his diarrhea greatly. He regained weight and energy and said, "I felt as though I was dying with AIDS in the United States. In Amsterdam I feel that I am living with AIDS." Many people with AIDS are now using cannabis therapeutically; tens and perhaps hundreds of thousands will do so in the near future.

There are many other ways in which marihuana may be used to reduce human suffering. Anecdotal accounts strongly suggest that it has potential in treating other types of pain, as well as seizure disorders, tumors, and asthma. For many it is more effective than officially sanctioned medicines, and it is invariably less toxic. Most research is tentative and anecdotal, and initial enthusiasm for drugs is often disappointed after further investigation. But it is not as though cannabis were an entirely new agent with unknown properties. Studies done during the past ten years have confirmed a promise that is centuries old. The weight of past and contemporary evidence will undoubtedly prove cannabis and its derivatives to be medically valuable in many ways. (Lester Grinspoon and James B. Bakalar. Marihuana: The Forbidden Medicine. In press: Yale University Press.)

The effort to make cannabis available as a medicine in the United States began in 1972 with hearings before the Drug Enforcement Agency and the Food and Drug Administration. Over the past 20 years the issue has been reviewed by high federal courts on three occasions, all to no avail. In the most extensive hearings, which were held in 1986, the Administrative Law Judge wrote an opinion in which he asserted that marihuana should be available as a medicine and added that "... marihuana, in its natural form, is one of the safest therapeutically active substances known to man... One must reasonably conclude that there is accepted safety for use of marihuana under medical supervision. To conclude otherwise, on the record, would be unreasonable, arbitrary, and capricious." But the Drug Enforcement Agency refused to budge and remains adamant. The United States Government, which has been attempting to persuade its citizens for more than 50 years that cannabis is very harmful, is not about to acknowledge that it

is a relatively benign drug with many important medical uses. It now seems clear that as long as marihuana is prohibited for other reasons, it will not be legally available as a medicine.

Although we believe that use of the criminal law is wrong as an approach to all drugs, we are now convinced that we can no longer await a general policy of repeal before calling for the repeal of cannabis laws. It is unconscionable to criminalize the many thousands of people who now use cannabis as a medicine and to perpetuate the suffering of many more who would use it medically if it where legal. Opponents of medical marihuana sometimes say that its advocates are insincere and are only using medicine as a wedge to open the way for recreational use. Anyone who has studied the history of desperate efforts to obtain legal marihuana for suffering people knows that this is false. The attitude falsely ascribed to medical marihuana advocates is actually a mirror image of the government's own attitude. The government is unwilling to admit that marihuana can be a safe and effective medicine because of a stubborn commitment to wild exaggeration of its dangers when used for other purposes. Far from believing tha

t medical availability of marihuana would open the way to other uses, we take the position that free availability of cannabis may be the only way to make its judicious medical use possible.

For those who believe that cannabis should not be available without controls, we would like to suggest a noncriminal approach that we call the harmfulness tax. Cannabis would be legalized, its sale would be taxed, and the revenues would be used for drug education and for paying the medical and social costs of any cannabis abuse. Alcohol and tobacco would be treated in the same way. A commission would be established to determine these abuse costs separately for each of the tree drugs, and the rate of taxation woud be adjusted periodically to reflect the information gathered by the commission. Thus the government would acknowledge the impossibility of eliminating all drug use and use its taxing power and educational authority to encourage safer use.

To illustrate the kind of calculation involved, it was recently estimated that in the United States direct health care costs plus indirect losses in productivity and earnings due to cigarettes amount to as billion dollars a year, or about two dollars a pack. (The exact figures depend on how costs are defined; for example, the economic loss from smoking may be "balanced", in a perverse way, by the lowered cost of caring for chronic disabling diseases of old age in a society where many die young of smoking-related illness.) Such a taxation policy might be regarded as a way of making people buy insurance for the risks to themselves and others in their use of drugs. Life insurance companies already offer substantial discounts in their premiums for non-smokers, and this insurance preference is slowly being extended to fire and other insurance policies.

The three drugs could be sold through specially licensed outlets at prices determined by the commission. Advertising would be banned. Present prices might be maintained at the start. Then, as the commission collected more information, pricing could change to reflect social costs. If the system works, the data would eventually indicate that these drugs are causing less harm, and we could consider including other drugs.

Above all, legalization and use of the harmfulness tax would eliminate the expense, corruption, chaos, and terror of the war between drug traffickers and narcotics agents. In this war a kind of self-reinforcing cycle is developing, as drug enforcement operations begin to pay for themselves by funds confiscated from the drug traffickers whose operations they make enormously profitable. The taxing system suggested here would establish a different kind of revenue cycle, in which society would pay the costs of drug abuse by extracting them from drug users in proportion to the amount they contribute to the problem. The commission that supervised this taxing system would also serve as an educator and guide to society - an educator not constrained by the present totally unrealistic assumption, built into the criminal law, that any use of certain drugs must be evil or dangerous, while other drugs have a range of benign and harmful uses. Honest drug education would become possible. (Lester Grinspoon. The harmful

ness tax: a proposal for regulation and taxation of drugs. North Carolina Journal of International Law & Commercial Regulation, 15(3): 505-510 (Fall 1990).)

The decriminalization of cannabis is decades overdue and increasingly urgent now that its medical uses are becoming so important. The International Anti-Prohibitionist League (LIA) should vigoruosly press for marihuana legalization, either outright or with some government control (through the harmfulness tax or another system of constraints) as a first step in its campaign against drug prohibition.