Benjamin Rush, physician and signer of the Declaration of Independence

The medical marijuana problem is a Janus-like conundrum; one view of the problem is seen through the eyes of patients and another through those of their government. One face regards with dismay the problem of denying marijuana to the growing number of pained, impatient patients who find it useful, often more useful, less toxic and cheaper than the legally available medications. Through the patients' eyes the problem is, of course, how to acquire and use this medicine without swelling the ranks (already more than 700,000 annually) of those who are arrested for using this illegal substance and how to avoid jeopardizing job security through random urine testing. The other face, the backward looking one, is that of an obdurate government as it defensively and inconsistently insists that “marijuana is not a medicine”, and backs up this ill-informed, arrogant position with the full force of its vast legal power as it is presently doing in the state of California. There are many thousands of patients who currently use cannabis as a medicine. Only seven are allowed to use it legally. They are the only survivors among the several dozen patients who were awarded Compassionate Use INDs during a period of time from 1976 until 1991 when the government halfheartedly acknowledged that marijuana has medicinal properties. This program was actually discontinued because of the exponentially growing number of Compassionate IND applications; the official reason was provided by James O. Mason, then chief of the Public Health Service: "It gives a bad signal. I don’t mind doing that if there is no other way of helping these people... But there is not a shred of evidence that smoking marijuana assists a person with AIDS". Each of the surviving IND recipients receives monthly a tin containing enough rolled marijuana joints to treat his or her symptoms for that month. Because the quality of the cannabis is poor, it requires more inhalation than a superior quality medicinal cannabis would. In fact, some of the recipients have been known to supplement this Government Issue with better quality street marijuana.

In 1985 the Food and Drug Administration (FDA) approved dronabinol (Marinol) for the treatment of the nausea and vomiting of cancer chemotherapy. Dronabinol is a solution of synthetic tetrahydrocannabinol in sesame oil (the sesame oil is meant to protect against the possibility that the contents of the capsule could be smoked). Dronabinol was developed by Unimed Pharmaceuticals Inc. with a great deal of financial support from the United States government. This was the first hint that the "pharmaceuticalization" of cannabis might be what the government hoped would solve its problem with marijuana as medicine, the problem of how to make the medicinal properties of cannabis (in so far as the government believes such properties exist) widely available while at the same time prohibiting its use for any other purpose. But Marinol did not displace marijuana as "the treatment of choice"; most patients found the herb itself much more useful than dronabinol in the treatment of the nausea and vomiting of cancer chemotherapy. In 1992, the treatment of the AIDS wasting syndrome was added to dronabinol's labeled uses; again, patients reported that it was inferior to smoked marijuana. Because it was thought that it would sell better if it were placed in a less restrictive Drug Control Schedule, it was moved from Schedule 2 to Schedule 3 in the year 2000. But Marinol has not solved the marijuana-as-a-medicine problem because so few of the patients who have discovered the therapeutic usefulness of marijuana use dronabinol. In general, they find it less effective than smoked marijuana, it cannot be titrated because it has to be taken orally, it takes at least an hour for the therapeutic effect to manifest itself and even with the prohibition tariff on street marijuana, Marinol is more expensive. Thus, the first attempt at pharmaceuticalization proved not to be the answer. In practice, for many patients who use marijuana as a medicine the doctor-prescribed Marinol serves primarily as a cover from the threat of the growing ubiquity of urine tests.

Most of the patients who use cannabis as a medicine smoke or ingest it in some form. In so doing they are in violation of federal law throughout the country and of state laws in all but nine states. In those states, notably California, which allow for doctor-recommended use of cannabis, buyers' clubs or compassion clubs have evolved as cannabis pharmacies for patients with appropriate physician documentation. Two distribution models have evolved. One is based on the conventional delivery system for medicine: a patient visits a buyers' club (read: pharmacy), where he or she presents a note from a physician, certifying that the patient has a condition for which the physician recommends cannabis (read: prescription). The proprietor of the club (read: pharmacist) fills the prescription and the patient leaves to use the medicine, presumably at home. This model preserves the medical profession's authority to decide who shall use a medicine and for how long. The pharmacy provides a source, in this case a nonprofit one, for the medicine. If the doctor and the pharmacist behave ethically, only those who have a medical need for marijuana can receive it. In turn, patients have a reliable source for the drug, relieving them of the stress of buying it on the street or secretly growing their own. The staid set-up of the club and the attitudes of the proprietors make it clear that the patient is no more expected to use his medicine there than he would be in a conventional pharmacy.