Mary Jane Medicine
What happens when medicine and regulations clash.
You might say it was like a bad trip. One morning in 1997, family physician Robert Mastroianni arrived early at his office in tiny Pollock Pines, California, to find two agents from the federal Drug Enforcement Administration waiting for him. After a brief introduction, they began firing questions: Where had Mastroianni gone to school? Where had he done his medical training? One of the agents then handed the doctor a copy of a letter he had written recommending marijuana for a patient. Had Mastroianni actually prescribed pot, the agent asked, or had he only suggested it? Did he sell marijuana to his patients? Was he aware that marijuana was a deadly drug for which there was absolutely no medical use?
Mastroianni was stunned, then angered. He refused to answer further questions without a lawyer present. "Many of the agents' questions were professionally insulting," he wrote later. Worse, they revealed "a primitive and largely inaccurate understanding of medical practice." The agents requested Mastroianni's DEA number, a code that doctors must use when they prescribe any controlled substance. He complied, and the agents left -- but not before sending a chilling message to Mastroianni, and, when news reports about the drug agents' visit got out, to thousands of doctors nationwide.
What had Mastroianni done? Nothing that California's Proposition 215 -- the medical marijuana initiative -- said he couldn't do. Passed by the state's voters as the Compassionate Use Act of 1996, the law allows physicians to recommend cannabis, though not to prescribe it, for a wide range of medical ills without being "punished or denied any right or privilege." It also exempts from prosecution seriously ill patients who possess or cultivate the drug for medical treatment on the recommendation of a physician. (Arizona voters passed a similar law, later overturned by state lawmakers; neither law authorized the transportation or selling of marijuana as medicine.) In 20 years of practice Mastroianni had seen about 50 patients use marijuana to combat muscle spasms and chronic pain as well as the nausea caused by chemotherapy. "Patients report no other medications work as well," he wrote in an affidavit filed in a class-action suit.
Mastroianni's views hardly put him on the medical fringe. Physicians who treat cancer patients have long been aware that smoking marijuana can relieve the terrible nausea of chemotherapy, allowing patients to maintain the weight crucial for survival. In fact, a survey conducted by Harvard Medical School in 1991 revealed that 44 percent of oncologists had proposed marijuana use to their patients.
Even some drug enforcement officials have broken ranks to back the medical use of marijuana. In 1988 a DEA administrative law judge wrote that marijuana should be classified as a Schedule II drug -- one that's safe for limited uses. "Marijuana, in its natural form, is one of the safest therapeutically active substances known to man," he said. "[It] has a currently accepted medical use in treatment in the United States for nausea and vomiting resulting from chemotherapy." The DEA rejected his opinion, though, and recent attempts to have the courts reclassify marijuana have failed.
Most states, however, have their own laws regarding marijuana and physicians. Since the late 1970s, 34 states have passed laws -- 24 of which remain on the books -- that allow doctors to recommend marijuana or urge the creation of research programs on cannabis. The trouble is, state law is superseded by federal law, and the latter's position on pot is crystal clear: Marijuana is a Schedule I drug on the DEA's list of controlled substances, meaning it "has no currently accepted medical use" and cannot be prescribed under any circumstances.
Nonetheless, after the Compassionate Use Act became law, Mastroianni wrote letters recommending marijuana to three seriously ill patients. According to a source close to the case, one of these patients showed his letter to police after they pulled his son over and found a marijuana cigarette in the car. Police gave the letter to the DEA, whose agents paid a visit to the physician.
"It's a very frightening thing for a physician to be faced with," says Stephen N. Sherr, a San Francisco attorney. "On the one hand, you have the obligation to inform your patients of your knowledge of medical issues that bear on his or her case. And on the other hand, there is the potential criminal liability that could completely wipe out your career. Even if you win, going through a criminal action would be a nightmare."
That fear swept through the medical community after a 1996 news conference in which federal drug czar Barry McCaffrey called the California initiative "a Cheech and Chong show." He and Attorney General Janet Reno further warned that the Justice Department would prosecute doctors who recommend the drug. But if the government's intent was to stop doctors from discussing marijuana, the strategy backfired. The American Medical Association swiftly denounced the idea of restricting conversations between physicians and patients, and the New England Journal of Medicine declared in an editorial that the federal policy was "misguided, heavy-handed, and inhumane." The author of the piece and then Editor, Jerome Kassirer, M.D., a former professor of Mastroianni's at Tufts University, noted the government's hypocrisy in forbidding physicians from prescribing marijuana while permitting far more dangerous drugs such as morphine.
The medical backlash picked up steam in February 1997. A group of 11 physicians led by Marcus Conant, M.D., a clinical professor at the University of California at San Francisco's Medical Center and former director of the largest AIDS/HIV practice in the United States, filed suit to stop federal officials from punishing doctors who counsel patients to try marijuana.
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