General doubts

Sparking up the medical-marijuana debate with drug czar Barry McCaffrey

by Jason Gay

DRUG WAR

There's a thick cloud of smoke trailing US drug czar General Barry McCaffrey these days: a recent government-funded report on medical marijuana that concluded, among other things, that marijuana possesses "potential therapeutic value" for people suffering from cancer, AIDS wasting, and other serious illnesses.

Released in March, the $896,000 report, directed by the National Academy of Sciences' Institute of Medicine and authorized by McCaffrey himself, was widely seen as embarrassing to the drug czar, who had previously derided medical marijuana as a "cruel hoax that sounds like something out of a Cheech and Chong show."

D'oh. After piling on the rhetoric, General McCaffrey, whose official title is Director of the White House's Office of National Drug Control Policy, now finds himself spinning and backpedaling at the same time. While gently praising the IOM report, he plays down its conclusions about therapeutic effectiveness, and continues to insist that medical marijuana is a "peripheral issue" in the national drug-policy debate.

"I think he's shuffling pretty fast," says Tom Clark, an epidemiologist with Health Addictions Research, Inc., a Boston-based drug-abuse research group. "He's poking his way around various minefields, because the IOM report's findings are not what he wanted to hear."

Critics such as Clark believe that McCaffrey's hesitancy to embrace marijuana's potential as medicine undermines his credibility with the public, which is increasingly supportive of medical marijuana. Surveys have consistently shown that between 60 and 80 percent of Americans back legalization for medical purposes. Voters in seven states have approved measures legalizing medical marijuana, with more states expected to put it to a vote this November.

In other words, America's most significant drug discussion is already progressing -- with or without the assistance of the country's highest-ranking drug official.

"McCaffrey's forcing the [medical-marijuana] issue downstream to states and communities that have to deal with reality, and not bullshit," says Michael Cutler, a Brookline attorney who coordinates the Voluntary Committee of Lawyers, an organization of law-enforcement officials opposed to current national drug policies. "He's attempting to stop the conversation, but the conversation is happening all around him. He's making himself more and more irrelevant."

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McCaffrey doesn't see it this way, of course. Last Thursday, April 29, in the midst of a day-long visit to Boston that included speeches at Harvard and Suffolk Universities, McCaffrey told the Phoenix that time will show he's actually been receptive to medical marijuana. He said he supports the IOM report's recommendation that the government promote the creation of alternative delivery systems to smoked marijuana, such as inhalers, pills, patches, and gels. In the interim, McCaffrey said, he also intends to permit limited, carefully monitored studies of terminally ill patients who smoke marijuana for relief.

"Two years from now," McCaffrey said, "when I leave office and you give me a polygraph at that time, I will pass the polygraph test that [asks me] `Did I embrace the report and move to implement its findings?' "

Still, this drug czar isn't about to belly up to the bong. During a brief interview after his Harvard speech, McCaffrey chose to stress the IOM report's warning that smoking marijuana could lead to respiratory illness and other diseases. He maintained that the report didn't find marijuana to have anything more than mild pain-relief capabilities, saying there's "no indication that there's anything in marijuana that has curative powers." Finally, and most vehemently, McCaffrey disputed suggestions that the report dismisses the long-held theory that marijuana serves as a "gateway" to other, harder drugs.

"The report was quite clear -- it said you can't demonstrate a causal linkage between smoking a lot of pot in grade school and injecting heroin in your 30s, but the statistical correlations are overwhelming," said McCaffrey. "And the report did say that if you want to see the statistical predictors [of hard drug use], early and extensive marijuana use is one of them."

Comments like these only frustrate McCaffrey's critics, who see the drug czar, on the defensive because of the report, twisting its conclusions in order to dilute its impact. "The facts have shifted, and now he's shifting his arguments to fit," says Michael Cutler.

Take McCaffrey's comments about the statistical correlations between youthful marijuana smoking and later hard-drug use, Cutler says. Such neat correspondences are red meat for marijuana skeptics, no doubt, but they're not necessarily meaningful. To borrow an oft-used example, the majority of adults who use motorcycles rode bikes as children. Does that mean that children who ride bikes are more likely to ride motorcycles as adults than children who do not? Probably. But few would suggest that bicycles are a "gateway" to motorcycle use; many other factors are involved in such a complicated decision.

Cutler jokes that the majority of adult drug users were probably breast-fed -- does that make breast milk a "gateway" to drugs? "Correlation is not causation," he says. (Cutler and many other drug-policy reformers argue that if there's any meaningful connection between marijuana use and hard drugs, it's the fact that prohibition puts the marijuana user in closer contact with the users and sellers of other illegal drugs, thereby increasing the risk that he or she may try them.) But none of these statistical correlations are grave enough to warrant denying medical marijuana to people who are sick.

McCaffrey is more on target when he says the IOM report didn't conclusively find "curative" powers in marijuana, but again, that's far from saying the drug doesn't have any medical utility (which is what McCaffrey was arguing before the IOM report was released). Is the lack of "curative" powers a reason to prohibit a drug from being used? Plenty of commonly used medications, particularly analgesics, do not "cure" anything but are valued because they reduce suffering. Says Tom Clark, "If marijuana isn't curative, it's palliative, and that's certainly reason for someone to use a drug."

But it's McCaffrey's noisemaking on marijuana smoking that especially troubles his critics. Lester Grinspoon, a Harvard Medical School professor of psychiatry and author of such books as Marihuana, the Forbidden Medicine (Yale University Press), was asked to review the IOM report prior to its release. Calling it "embarrassingly timid," Grinspoon says that although there are legitimate health risks associated with long-term marijuana smoking, such concerns are overblown when it comes to medical marijuana use. It's hard to convince patients in the throes of cancer or AIDS that smoking marijuana will bring them serious harm, he says, especially because these patients rarely use more than one or two marijuana cigarettes a day. "Are we really worried about that?" asks Grinspoon.

Grinspoon and other critics believe that objections to smoked marijuana merely give cover to politicians like McCaffrey, who can now pass the buck to the FDA and the pharmaceutical industry to explore "alternative delivery systems" such as inhalers. But here lies the rub, as Joshua Wolk Shenk recently noted in an essay in Harper's: it's unlikely that the pharmaceutical industry will be in much of a hurry to replicate something that is already effective, reasonably inexpensive, and readily available, even if it's available only as an illegal substance.

"Opponents of medical marijuana claim that they simply want all medicines to be approved by the FDA, but they know that drug companies have little incentive to overcome the regulatory and financial obstacles for a plant that can't be patented," Shenk writes. "The FDA is the tail, not the dog."

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McCaffrey has shown he's capable of taking difficult positions as the country's drug czar. A much-decorated soldier, he admirably admonishes his colleagues in the enforcement business to drop their tired "war on drugs" jargon; McCaffrey prefers likening the nation's drug-abuse problem to a "cancer." He candidly admits that attacking merely the supply side of drug abuse is fruitless; he has vastly increased federal spending on drug treatment, rehabilitation, and education (though, as his critics point out, federal money spent on interdiction has risen proportionately over the same period).

On the issue of medical marijuana, however, McCaffrey continues to act with the wary suspicion of a highway cop. In Boston, he reiterated his long-held belief that, for some, the medical-marijuana debate is a front for full legalization. "I'm not paid to be naive," McCaffrey said. "So I'm watching the backfield in motion."

There's no doubt that some proponents of medical marijuana support legalization, but does that justify keeping it from sick people who, as the IOM report clearly states, find it useful? McCaffrey's critics note that the drug czar, despite his pronouncements about embracing the IOM report, has yet to back off his pledge to prosecute physicians who supply marijuana to their patients, even in states where voters have approved its medical use. Nor does he show any signs of changing marijuana's status as a Schedule I illicit drug, a classification that strongly inhibits its clinical study.

"He makes it sound as if the government's willing to fund research, when it's quite the opposite," says Tom Clark. "He makes it sound as if there's no interest. There's plenty of interest. But the government has been reluctant [to fund it] because of its long-standing bias against marijuana."

Indeed, instead of advancing the medical-marijuana debate, McCaffrey is busily boxing himself in. On one hand, he cannot promote marijuana's medical utility; doing so would contradict his previous statements to the contrary and alienate his boss, Bill Clinton, who is paralytically afraid of appearing soft on drugs. On the other hand, denying marijuana's potential makes McCaffrey appear out of touch with a population that sees little wrong with supplying it to the sick.

Make no mistake: medical marijuana is not a fringe countercultural issue. "I think we're starting to see a major change in the old Zeitgeist on the issue of drugs," columnist Molly Ivins wrote late last year. "This is one of those seismic shifts when the unsayable suddenly becomes sayable, when we notice that the emperor is wearing no clothes."

Nowhere is the emperor more naked than on the issue of medical marijuana. But to borrow a bit of military lingo, Barry McCaffrey still has the ability to change the rules of engagement and permit legal medical use. He needn't view such a move as a surrender. He would merely be a conscientious objector in a battle that he cannot possibly win.

Jason Gay can be reached at jgay[a]phx.com.