Gary Greenberg, a Mother Jones contributing writer, is a psychotherapist and professor of psychology, and the author of “Respectable Reefer,” in the November/December issue of the magazine.
Lester Grinspoon, M.D., is associate professor emeritus of psychiatry at Harvard Medical School, and the author of Marihuana Reconsidered, and Marijuana: The Forbidden Medicine.
Lester Grinspoon: Sativex is the kind of thing I was concerned about when I first spoke of the concept of pharmaceuticalization in 1985 to describe Marinol. At the time the federal government was under a lot of pressure to look at the medical uses of marijuana. So the government supported this little company Unimed to create Marinol, which is simply synthetic THC [tetrahyrdrocannabinol], which is identical to the THC that you find in cannabis. So Unimed comes out with it. It was very expensive, and I have yet to have a patient or to hear from a patient who thinks Marinol is as good as whole smoked herbal marijuana. With Sativex, Geoffrey Guy went to the home office and said in effect, “Look, everybody knows that cannabis has medicinal utilities,” and the British government, just like the U.S. government, was being pressed to do something about it. He then said, “I have the plans for a product which will deliver all the medical capacities of cannabis, but at the same time not impose on the medical user the two most frightful things about cannabis — the high and the pulmonary effect.” To me, that was based on a deception because we know now that the pulmonary problems are minimal. As for the high, I don’t believe that the high is a big problem in people with Crohn’s Disease or Multiple Sclerosis, who feel better when they smoke cannabis — that’s probably a function of the anti-depressant effect of this substance. What’s the problem with that?
Gary Greenberg: GW [Pharmaceuticals] claims that people who use this inhaler titrate to the point that they feel relief from their symptoms — which is MS pain or spasticity — don’t get intoxicated. What do you think about that?
LG: Well, if you can get relief from the spasticity without getting a high, then you could do the same with the smoked stuff. It’s much easier to titrate when you’re using the pulmonary system than when you’re using the sublingual [under the tongue] or oral system. You can feel it within seconds, whereas orally — that is if you swallow it — it’s going take an hour and a half. You take it sublingually, it’s maybe 15 minutes. It’s faster than oral. But it’s nowhere near as fast as smoking it. That to me is one of the great advantages of smoking cannabis — that the patient can have control. He can get just the right amount for his symptoms. You are not going be able to titrate it for a while if it’s going to take you 15-20 minutes to get an effect.
GG: GW claims that every patient has his own learning curve, so you figure out “Oh that time I took too much or this time I didn’t take enough” and eventually know exactly how much to take. The advantage of the sublingual preparation is that they’ve managed to make each spray contain a whole lot less THC than even one puff on a joint.
LG: But the same thing can be done with marijuana if you know what the potency is.
GG: So whatever is achieved with the sublingual spray could be achieved as well as or better with the old fashioned herbal preparation?
LG: Better and faster. And there’s another reason. The sublingual route was the idea with GW Pharmaceuticals, but the fact of the matter is you can’t hold it under the tongue very long.
GG: Is that because preparation stings or…?
LG: It has a dreadful taste.
GG: I see.
LG: Secondly, just try to hold anything under your tongue for a while, it leaks down into the esophagus and so an undetermined percentage of the stuff that’s supposed to be sublingual is really an oral use of a substance. Now, when you have an oral use, you’re talking about pushing the effect back an hour and a half. So now you’ve got two different curves, and I think it makes it much more difficult for the patient to find the right dose, no matter how good a learner he is. That’s complicated by the fact that the absorption rate from the gastrointestinal tract is quite variable—depending on the state of my GI tract, when I’ve eaten, and so forth—so even though you may take the same amount orally, you don’t get the same effect orally on any two occasions. Now the other thing GW Pharmaceuticals claims is that people can’t get high — that’s absolutely untrue.
GG: Yeah, they’re actually backing off of that claim.
LG: I mean for Christ’s sake…
GG: …it’s marijuana.
LG: It’s marijuana. It has THC, it has cannabinoids. It has all the stuff in it. In any event, it has THC you can get high on it.
GG: So what’s really going on here?
LG: Well I think that what’s going on here is that Geoffrey Guy hoped to make a lot of money. Frankly, I think they’re taking a real chance with their money because I believe that Sativex may end up the same ways that Marinol did.
GG: Unpopular with the target population?
LG: For several reasons. Don’t misunderstand me. I think there is a place for oral cannabis. If you are suffering from osteomyelitis, or any kind of osteoarthritis, and you need long-term relief, I think that oral cannabis maybe useful, although interestingly enough most of my patients with arthritis have used and liked to use inhaled cannabis. But when you’re talking about getting immediate relief from something and titrating it, the pulmonary approach is the best.
GG: Of course the product that Guy has come up with here is the full extract, right? So at least he’s got that over Marinol.
LG: It does, but you see it’ll run into the other problems of Marinol. First of all it’s oral or it’s a hybrid. Secondly, it will be expensive. Marinol, despite the fact that we the taxpayers paid for most of the development, is very expensive. It’s cheaper to buy marijuana even with the prohibition tariff. When our society becomes rational about this, marijuana will be maybe $25 or $30 for an ounce of good, quality marijuana. It’s less expensive now than Marinol even at, say, $300 an ounce.
GG: For GW, the big advantage of a drug like Sativex over herbal marijuana is that one will be legal and the other one won’t be.
LG: That will be the only advantage – and it’s a terribly important advantage…
LG: For the same the reason people use Marinol. I had a truck driver come up from West Virginia. He smokes marijuana because he suffers from arthritis. He’s afraid now that they just instituted random urine tests, that he’ll lose his job. What I do with those patients, I call their home doctors and tell them about Marinol and try to relieve their fear about it and with the exception I think of one physician, I’ve been able to persuade them to write Marinol for these people. The trucker called me and said, “Look the Marinol doesn’t work very well but what I’m able to do now is to use the prescription I have…”
GG: …to justify the drug test.
LG: Nobody can tell the difference. It’s a cover for using medical marijuana.
GG: Because you need the piece of paper.
LG: You need the piece of paper. Sativex may go the same way because I would challenge Sativex to compete against smoked marijuana in almost every one of the symptoms or syndromes…
GG: It doesn’t appear that they’re doing that.
LG: They’re absolutely not. They’re not running it against smoked marijuana. I think those results in Multiple Sclerosis would have been much better if those people had been allowed to use smoked marijuana. So, I think it’s going to become another kind of Marinol. Look what the cost to develop it — it has to be expensive. Do you know about the advanced dispensing system?
GG: Oh yeah. It’s a cell phone-connected thumb-print activated dispensing system that basically keeps you under surveillance.
LG: Exactly. It doesn’t allow for any titration. I, the doctor, tell you how much you’re going get. It allows the patient no control over it per se. In other words, it emulates the usual kind of prescription.
GG: You seem to be implying in fact that a lot of what happens in medical marijuana is getting high.
LG: No, absolutely not. Absolutely not. But let’s say we’re talking about migraine headaches now. I think there are lots of people, particularly people who get migraines sometimes at work, or they want to be able to treat the migraine, but without getting high. I think there are other symptoms and syndromes for which you may have to go into the area where you feel some high. Now let’s say you are treating insomnia, and they smoke it just before they go to sleep, they can get high, no question about it.
GG: But then you go back to saying so what?
GG: Well some people think it’s a problem.
LG: Can you tell me why?
GG: Well, partly because they feel that being high is incompatible with functioning.
LG: I for example, have never, ever used it when I was going to see patients or do any other work. The only time I used it for work, when I’m writing something. Because I honestly think, you know, like my close friend Carl Sagan said, that it does stir up the thought processes a bit.
GG: But there’s somebody who’s trying to deal with the pain while they’re trying to work who may operate heavy machinery, or for another reason needs a medicine that doesn’t get them high.
LG: How many airline pilots maybe take Valium?
GG: Yeah, I don’t want to know the answer to that question.
GG: So, part of what you’re getting at here is the way in which you think this drug is unsuited to the FDA approval process. It’s not just the business side of it, it’s also the regulatory side of it that you think doesn’t work for marijuana?
LG: It would be like trying to get FDA approval for aspirin.
GG: Yes, I think it’s an interesting comparison.
LG: Aspirin is “safe,” although it claims between 1,000-2,000 people per year. With cannabis, it’s been around for thousands of years. There has never been a death – never been a death. Is there any other substance in the pharmacoepia about which you can make that claim? I’m not sure there is.
GG: What kind of drug is marijuana in the post-prohibition era?
LG: Ideally it’s an over-the-counter [drug]. Ideally, it has nothing to do really with drugstores at all. It’s regulated, that is to say, it’s regulated in the way alcohol is. Now if some people use alcohol as medicine the way they used to in the 30s and so forth, fine. Some people use marijuana as a medicine, fine. But there’s no need for any kind of medical intervention.
GG: So really the medical issue is inseparable from the legalization issue?
LG: Exactly. You can’t say, “Okay, marijuana is medicine that’s going be distributed by pharmacies,” because it simply won’t work. People will have all sorts of fictitious ailments, and doctors don’t want to be the gatekeepers. It’s basically what’s going on in California. If you want to look for a place where you can prove that that model isn’t going work, it’s California. I had lunch with a woman the other day from California. She’s a high powered academic and she uses cannabis, and I asked her where she gets it, and is it easy to get in California? She took out of her wallet a card for a buyer’s club an says, “This is how.” I said, “What are you suffering from?” She said, “Well, I’m a little depressed.” Or something like that. She winked. That’s exactly what would happen if we tried to do it that way.
GG: So it would become a big cover?
LG:. Exactly. It would be hypocritical — it would be fraudulent, frankly.
GG: So one way to look at this is that the medical uses of cannabis is another argument against prohibition.
LG: Exactly. The medical uses are going be the undoing of the prohibition.
GG: In that respect, if GW comes in with clinical trials that show beyond a doubt that this is an effective medicine — whatever that means — isn’t that a good thing?
LG: Well now, let’s get back to my concern about pharmaceuticalization. That is: the extent to which drug companies get involved in this. Their success in peddling their products like Sativex or Marinol will depend on how strictly the prohibition is enforced.
GG: So, you’re saying that they have a vested interest in prohibition?
LG: Exactly. And these are powerful companies. They make a lot of money and they have a lot of money. The U.S. government saw [with Marinol] a chance to make something that [they] can control and put an end to the marijuana for medicinal purposes debate. And now here’s Sativex.”
GG: So you think it could actually work that instead of the medicalization working in favor of legalization, it could, if it’s in the hands of the pharmaceutical industry, work in the opposite direction?
LG: Absolutely. Its going work in both directions because, as I say, to the extent that people get the sense that cannabis is not this drug that’s going make your head fall off [they’ll start asking] what all the fuss [is] about. You know, I had an experience like this myself. My son suffered from acute lymphocytic leukemia in the last year and a half of his life; he hated the chemotherapy. He was threatening to stop doing it because he’d vomit right there in the treatment room and then going home and he’d have to be in his bed and he got it when he was ten years old. He’d be in his bed and we’d put a big pot and a towel on the floor. You know, he had the dry heaves then, but by then he’d vomited everything up.
One night, I was invited to a dinner party and I met an oncologist, Dr. Emil Frei. He had read Marihuana Reconsidered and was he said, “You know it isn’t clear to me from your book whether it was used in as anti-nausea.” I assured him that it was. He went on to tell me the story of a 17-year-old man who got to the point where my son had – he just refused to take the chemo. Each time it was a real struggle to find a way to get him to take it. Then one day he took it and got off the table and waved goodbye to them. No problems, smiling. Frei was amazed. The next time the same thing and finally he asked this boy and the boy said, “Oh I just had a few puffs on a joint 20 minutes before I came in here.” Frye said, “Do you think there is anything to that?” I said, “Well I think there very well may be something to it.” On our way home that night, my wife said to me, “Lester, why don’t we get…” I was really dying to try it, but I started from a position of thinking it was a terribly dangerous drug. Then, doing this research, I became convinced that I wanted to try this stuff. It was very interesting, but I didn’t do it because I knew I’d be testifying before court and be asked, “Have you ever used cannabis?” I wanted to be able to tell the truth. I said to her, Betsy, we can’t break the law and I don’t want to offend the doctors in the cancer section of the Children’s Hospital. They’d been so great. Well, my plucky wife, I learned later, had gone up to the high school parking lot with Danny on the way in to get chemotherapy a couple of weeks later and asked his friend if he could get a joint. Once he recovered from his absolutely overwhelming surprise that she would ask… Well, to make a long story short, Danny did smoke in the parking lot beforehand. He just got off the table and said, “Mom can we have a submarine sandwich on the way home?”
LG: It was unbelievable. So, I called Dr. Norman Jaffe, who was directly in charge, and I said, “I think I’m not going stand in the way of Danny’s doing this.” Danny had another session coming up in two weeks. He said, “Don’t.” Then he said, “Don’t smoke in the parking lot. Have him smoke in the treatment room. I want to see this myself.” So I began to think, there must be lots of people who are suffering unnecessarily because of this absurd prohibition.
GG:And even at that time, you were thinking that this should be available in the old fashioned way as an herbal remedy?
GG: Another claim about Sativex that GW makes is, “Hey look, we’ve got a very predictable form of pot. We know the THC to CBD ratio. It’s genetically identical to the last generation because we’re going from clones. So we know that the thing that you’re smoking is the thing that our clinical trials subjects smoked.” What do you make of that?
LG: I think that is all in the service of making it sound much more scientific and quantifiable than it really is. It’s marketing.
GG: If GW gets its product approved, what is the reason to use it rather than smoked or vaporized marijuana, aside from the legality issue?
LG: There is no good reason aside from the legality. So, you see my concern about pharmaceuticalization is that they are going to [use the argument that] “Oh, smoking is terrible!” Try to find anybody in this anti-smoking age who doesn’t think smoking is ….
GG: …right, you can’t go wrong with that argument.
LG: The whole thing was built on untruths and it continues to be.
LG: The biggest problem with [Sativex] is that it’s going to create another commercial pressure to keep the stuff prohibited—the government can do what it hoped to do with Marinol. It’s going to make it less possible to create an environment where people will be freely allowed to use cannabis responsibly for medicine or for anything else they want.
GG: That would be a pretty ironic outcome given the way that the medicinal issue has been taken up by the anti-prohibition people.
GG: So here’s something I didn’t know. You mentioned before when you wrote those books, when you wrote Marihuana Reconsidered, you hadn’t smoked pot?
LG: I had never smoked pot.
GG: Huh. So you started out – what piqued your interest in the first place?
LG: Well, here’s what happened. I was writing a book on schizophrenia. I finished my part — this is a seven-year study of schizophrenia — my co-writers told me that they were going to be 2-3 months behind the scheduled time. Now that was 1967, which incidentally was the same year that my son was diagnosed with leukemia. I was just concerned all these young people using this terribly dangerous drug marijuana. I went to the Harvard Library and said I was going to put this material together in a scientifically sound, hopefully objective way, which would hopefully be useful to some of these young people. I wanted to get it published in a vehicle that would reach college students and perhaps some of them would pay attention because I would demonstrate why the government is saying this. Well, I was absolutely amazed that despite my training in science and medicine, I discovered that I had been brainwashed like every other citizen in this country.
LG: I published a paper in The International Journal of Psychiatry -– it was about 80 pages long — but that was not a vehicle for college students. But Scientific American saw it and approached me and said, “Can you do a short version of that? It was published as the lead article in the December 1969 issue or something like that. Then Harvard University Press asked, “Look, you’ve already done an 80 page paper, expand it by three or four times and we’ll make it look like a book.” So I thought, “Hey, what the heck?” Well, it turns out that while marijuana is not addicting, learning about it is. I spent a couple of years really – you know the important thing to me was to have it ready. They agreed — I wanted to have it for Danny while he was still here. It was the one thing of my work that Danny was interested in.
GG: I think I understand why.
GG: So, you actually came to it not because you were an enthusiast of the effects who thought the prohibition was ridiculous, but because you learned that what you had been told about it was wrong?
LG: So wrong. I concluded the book by saying, “It’s not that this drug is harmless, but it’s so much less harmful than alcohol and tobacco. The real harm from marijuana is the way that we as a society are dealing with it.” At that time we were arresting 300,000 people. Now it’s up to over 750,000. That’s how much progress we’ve made with this. We know more about the toxic effects of marijuana than we do about any other drug. We know that it’s not very toxic at all. What we should be researching is how – what we can learn about how the brain works. The more we learn about it, the more we see that this is a very important part of brain function. Carl Sagan was always saying to me, “Lester, you know you’re missing something. You ought to try this.” I was always telling Carl, “You’re doing something. You’re going to hurt your lungs.” You know I was trying to discourage him and he was trying encouraging me to try it.
GG: So Carl Sagan was your peer pressure, huh?
LG: Right. [Laughs] I finally tried it in 1972 or ’73, sometime around when Danny did it for the first time. You know I remember the day very well because in testimony at that time, I was very often not always asked, “Have you ever used marijuana?” I was able to say no, but then there was one – in fact it was before this Massachusetts Legislative Committee and this very hostile Senator said to me, “Dr. Grinspoon, do you use marijuana? Have you ever used marijuana?” I said to him finally, “Look Senator, I’d be glad to answer that question, but first would you tell me if I answer affirmatively would that make my testimony more or less credible to you?” He got so pissed. He told me I was being impertinent and he stood up and walked out of the hearing. I came home and I said to Betsy, “You know, the time has come…. Let’s try it.” You know, every time we went to a party the Cambridge people would offer it to us, and people would often say, “You mean to say you wrote a book on marijuana and you’ve never used it?”
LG: I’d say, “Well I wrote a book on schizophrenia and I never tried that either.”