This pilot study provides an initial examination of the possible therapeutic uses of marijuana by persons with AIDS/HIV (PWAs) living in Honolulu, Hawaii. Its original purpose was to determine the existence of a group of medical marijuana users in Hawaii, and estimate their degree of political support for a legal reform campaign. A sample of 123 PWAs living in Honolulu, HI, answered a questionnaire survey about their knowledge' of medical uses of marijuana, especially in connection with AIDS/ HIV, their patterns of marijuana use, their preference for marijuana or Marinol for treating symptoms, their attitudes toward legal reform, and their level of political motivation on the marijuana issue.

Knowledge about medical marijuana was high: 98.4 percent had heard of medical uses for marijuana, and 86.9 percent had heard of marijuana being used specifically to treat AIDS/HIVrelatedsymptoms. Moreover, over one-third (36.9 percent) had used marijuana as therapy for AIDS/HIV, and of those who had used both marijuana and prescription antiemetics, marijuana was preferred by 80 percent. Nine of every 10 respondents favored legal reform to allow medical use of marijuana, even in the absence of conclusive testing. Respondents considered the therapeutic marijuana issue to be important to them (74.8 percent), and indicated a high level of political motivation: 72 percent were registered voters, 58.5 percent had voted in the most recent gubernatorial election, and 89 percent said they would actively support legal reform. The most striking finding was that respondents were more than twice as likely to have spoken with their friends (65.9 percent) as their doctor (31.7 percent) about medical marijuana. This pattern of communication held even for the 45 PWAs who have used marijuana to treat themselves, although to a lesser degree: 97.8 percent of this group had spoken with their friends, 66.7 percent with their doctor.

Absence of demographic questions and a control group are a limitation of this study. No claim is made about the relationship of the sample population to either the clientele of the AIDS outreach and casework organization from which the sample population was drawn, or to the population of persons with HIV at any other location or scale.

Background

The issue of therapeutic uses of marijuana is mired in political controversy (Hollister 1992; Grin-spoon and Bakalar 1993; Hall et al. 1994), and key agencies of the U.S. federal government have resisted facilitating a clinical assessment of marijuana efficacy (Lehrman 1995; Grinspoon et al. 1995; Abrams 1995). Even in the absence of such studies, however, a growing body of ethnographic evidence exists to support the assertion that marijuana can be a safe and effective treatment for a variety of medical conditions, including pain, glaucoma, muscle spacticity, nausea and the diminished appetite associated with AIDS Wasting Syndrome (cf. Randall 1991; Grinspoon and Bakalar 1993). With or without government sanction or regulation, some people are using marijuana to treat symptoms of their medical conditions. Marijuana is reportedly being used by some PWAs to control nausea and increase their appetites (Randall 1991; Grin-spoon and Bakalar 1993). Under the current system of marijuana prohibition, quasi-legitimate marijuana buyers' clubs have sprung up around the country to distribute marijuana to clients who demonstrate a medical need, and grassroots organizing has begun to introduce "compassionate use" legislation in some states that would allow persons with medical need to possess, purchase, and even grow marijuana for personal consumption.

Problem Statement

This study sought first to determine whether there is a group of PWAs who are informed about marijuana's possible use as medicine, who use marijuana themselves to treat their symptoms, and who are politically motivated. A secondary aim was to find out how these people shared information about medicinal marijuana.

METHODOLOGY

Subjects, sampling design and response rates

PWAs were contacted through a large Honolulu-based AIDS outreach and casework program. Four hundred questionnaire surveys and stamped return envelopes were distributed inside a monthly client newsletter. Three-hundred-and-seventy-four newsletters were delivered through the mail to 310 PWAs and to 64 HIV-negative persons also on the mailing list. Of these, four were separated from the newsletter in transit and returned by the post office undelivered. An additional 26 newsletters were distributed directly from the organizational offices of the outreach program, primarily to HIV-negative persons. It is not known with certainty how many of those questionnaires distributed at the office were received by PWAs and how many by other non-PWAs, although an organization representative estimated that very few were distributed at the office to PWAs who would have already received a copy of the client newsletter through the mail. Thus the total number of questionnaires distributed through the mail and from the office was 396. Overall, 140 questionnaires were returned, a response rate of 35.4 percent. Moreover, it is estimated that between 306 and 336 PWAs received a copy of the questionnaire (taking into account losses in mail transit and the unlikely possibility that all surveys from the office went to PWAs). One hundred twenty-three PWAs returned the questionnaire for a response rate of somewhere between 36.6 percent and 40.2 percent among the target PWA group.

Instrument

The instrument asked simple yes/no questions concerning PWAs' awareness of the medical marijuana claims, their patterns of communication with friends and doctors, whether they had taken prescribed antiemetics or marijuana to treat their symptoms, whether they had used marijuana non-medically, and their voter status. Respondents were also asked to complete five questions on a Likert-type scale about their attitudes toward various kinds of legal reform, the importance of the medical marijuana issue to them, and the estimated likelihood that they would use marijuana themselves if it were made legally available. A final question asked what level of activity they might take on to support a legal reform campaign. The instrument included a section for optional comments where respondents could make a personal statement of some sort.

The primary limitation to this study is the absence of demographic data. Because of the precarious social position of PWAs, and the currently illicit nature of the activity being studied, no demographic information was gathered. The primary concern of this study was to make an initial investigation into medical use of marijuana among PWAs. Although some demographic data could have been gathered without jeopardizing a person's identity, it was decided that the combined issues of AIDS and illicit drug use was so delicate that asking any personal questions might scare off respondents.

RESULTS

The questionnaire sought information in four general areas: awareness and communication about medical marijuana, patterns of therapeutic use and use for pleasure, attitudes toward legal reform, and political motivation. Descriptive statistics of their responses are presented below, along with some added remarks given by respondents in the optional comments section of the questionnaire. Fifty-six PWAs (45.5 percent) provided such comments.

Awareness and Communication

The first four questions deal with respondents' knowledge about medical marijuana and the people with whom they speak about their knowledge. Of the sample, 121 (98.4 percent) had heard that marijuana could be used for some medical purposes, and 107 (87.0 percent) had heard of marijuana's being used specifically in connection with AIDS/HIV. Respondents were more than twice as likely to have spoken with their friends (65.9 percent) than their doctors (31.7 percent) about potential medical uses of marijuana. Even persons treating themselves with marijuana were less likely to have spoken about it with their doctor (66.7 percent) than with their friends (97.8 percent).

Most of the comments offered that pertained to this section were informational items about marijuana's medicinal value. For instance one respondent said: "I believe the use of marijuana with HIV/AIDS victims is sometimes to offset the negative effects of medication, not symptoms of the disease directly [37]." Another commented about marijuana that it "certainly has less side effects than AZT and does seem to help friends feel and eat better [54]." Several respondents suggested the use of marijuana to elevate the mood of the sick person:

Marijuana is the only drug that takes the place of an aid for appetite, mood elevation, relaxation, or motivation. Used as a medication it's doctor-recommended, and in moderation a very unique, fast-acting, and useful helper 'When depressed from knowing you're dying, it really moves your mind to a better location [29].

I believe that marijuana has psychological benefits in addition to any physiological benefits. You just feel better; so many AIDS patients find it hard to cope with the general feeling of not being healthy on a constant basis. Relief like pot is a temporary godsend. They can feel "normal" for a few hours of their stress-filled life [7; emphasis in original].

Use Patterns

The use of marijuana was more prevalent among respondents than use of prescription antiemetics like Marinol. More respondents with HIV had used marijuana as a medicine (36.9 percent) than Marinol or other antiemetics (27.3 percent). A relatively small number (25), comprising 23.6 percent of the marijuana-informed respondents, had tried both marijuana and Marinol or another prescribed antiemetic drug. Of those who reported a definite preference (23), 20 (87 percent) reported that marijuana produced the more desirable effect. Two-thirds of respondents (66.7 percent) reported having used marijuana for non-medical purposes at least once in their lives.

Several respondents discussed further the relative worth of marijuana and Marinol (specifically) in their comments. For example:

Much suffering could be eased if marijuana could be furnished. Instead the [government] charges the taxpayer $400 a month for Marinol which 8 out of 10 times does nothing but intoxicate [136].

Whenever I am suffering from nausea or cannot eat, marijuana is the only thing thus far that has an immediate result and does not contribute to unpleasant side effects. Marinol has made me sick several times [39; emphasis in original].

Marinol is not an adequate substitute for marijuana. I had to stop taking it in the hospital. All it did was make me very groggy without enhancing my appetite [34].

Attitudes Toward Legal Reform

Questionnaire recipients were asked to give their opinions about legal reform issues on a Likert-type scale. Respondents expressed strong or some support for making marijuana legally available by doctors' prescriptions (91.1 percent) and even in the absence of conclusive tests on marijuana (93.5 percent). A .majority of respondents (68.3 percent) anticipated that they would be either "very likely" or "somewhat likely "to use marijuana if it became legal. Another eight percent were uncertain about how their use might change. A majority (59.0 percent) either strongly favor or favor somewhat legalization of marijuana for non-medical use.

Clearly there was overwhelming support for legal reform. Most of the comments addressed this issue, and several mentioned that this issue has broad appeal that crosses political boundaries. This respondent put it best:

I believe there are quite a number of people who oppose marijuana as a recreational drug but would support the use of marijuana for medical purposes — as long as there is some evidence to substantiate the claim [that marijuana is] medically beneficial. Even my straight-laced conservative mother would approve of using marijuana — "whatever it takes to make you better; "as she put it one day [49].

Others commented on why they make an exception in the case of marijuana. For example:

I consider marijuana an addictive drug that, when used for recreation, can very easily lead to more serious drug use. Jam a recovering drug addict (II years sober) and have seen this happen. However, I think special circumstances require special actions. Marijuana used medically could relieve suffering and should be legalized for that use [46].

Many others expressed exasperation about the difficulties of using marijuana as a medicine, and their support of making it legal:

Anything that can be done to help those who suffer should be available to them. Marijuana is used extensively by well persons, so why not legally for those who could benefit medically [38] ?

I feel in my heart that if this could help people like myself and my husband who have HIV, then it should by all means be legal for treatment only. We really must open our minds to what can be done for this disease [35].

Several respondents also explicitly referred to a perceived hypocrisy in the law. For example:

I find it crazy that thousands die each year from legalized alcohol — marijuana is a nature drug, which is a blessing for those of us who benefit from it [26].

I would really support the legalization of marijuana. It has helped me to sleep, relax, and eat more. There are legal things that are more harmful and that affect your mind worse than marijuana (e.g., cigarettes, liquor) [50].

On the other hand, some respondents expressed ambivalence on the issue and concern that medical use would not be properly regulated:

I am a recovering alcoholic and drug addict. I also work in the AIDS field. I feel the legalization of marijuana (medical) would be beneficial for some, but feel many would use their HIV status to perpetuate existing addictions for which Jam very unsupportive [57].

My concern ... with all the alcohol and drug abuse is that legalizing [marijuana] would only make it more available for the trade through unethical practices by patients and medical care persons. I know of persons using Marinol who don't need it but have found the access. Anything that would make my life seem better would be good, but I am more concerned about the masses than myself as a person [55].

Finally, in one notable exception, a respondent writes that:

There are other medications that treat nausea and other complications just as well if not better than marijuana. Marijuana is simply a drug to get high with. [People who] are seeking to get it for medical use are using their ailments for an excuse to get marijuana [32].

Political motivation

Respondents indicated a high level of political motivation: 92 (74.9 percent) claimed to be registered voters, although only 72 (58.5 percent) had actually voted in the most recent election for governor. Most (56.9 percent) considered themselves to be Democrats. Another 35 (30.2 percent) claimed to be "Independent" voters, and only 13 (11.2 percent) considered themselves Republicans. Two respondents (1.7 percent) were members of another political party. On the issue of medical marijuana, 92 people (74.8 percent) answered that it is either very (37.4 percent) or somewhat (37.4 percent) important to them personally. Moreover, 107 (89.1 percent) indicated that they would actively support a legalization campaign by "signing a petition" (38.3 percent), "calling representatives, writing letters to the editor or carrying a petition" (33.3 percent), or by some higher level of activity such as "organizing others, designing pamphlets, talking to groups," etc. (17.5 percent).

Some respondents explained why they considered this to be an important issue to them personally. For example:

The issue of marijuana used for medical purposes is an extremely important one. Those who say it's not might want to watch a close friend turn from a vibrant human being into a walking skeleton; they just might change their opinion. Anything that works is fine by me [36].

Several respondents suggested ways they would specifically like to help a legal reform campaign. Here are some notable examples:

I'm an entertainer in Hawaii and around the world. I'd love to do fund-raisers and anything else to help [139].

As a member of PWAC [Persons with AIDS Coalition] , I would like to publish articles in our newsletter to show medical value re: HIV, and in support of legalization [3].

They have a place in San Francisco called the Buyers' Club on Market Street that deals in this as a medical problem. Maybe we could get a program started here [28].

This is an issue that my company will support [521 2.

CONCLUSION

The pilot study succeeds in identifying a group of informed, politically motivated population of persons, many of whom are using marijuana illicitly for self treatment of their medical condition. Further study should be attempted to determine whether this group is representative of PWAs in Honolulu and Hawaii as a whole. •

Ben Wesner is one of the first place winners of DPF's Student Paper Competition.
* This research was completed with the assistance of the Drug Research Unit of the Social Science Research Institute, University of Hawaii, Manoa. Ben Wesner is working toward a Master's Degree in Geography. Address correspondence to Ben Wesner; Department of Geography, University of Hawaii at Manoa, 2424 Maile Way, Rm. 445, Honolulu, HI 96822.

1. This report does not presume to answer the question of efficacy or possible health hazards associated with marijuana use by persons with HIV By "knowledge" the study means the simple awareness among respondents that there is an ongoing debate concerning the use of marijuana as a medical therapy.

2 This respondent is not a PWA, but claims to use marijuana medically for another condition associated with Gulf War Syndrome.

REFERENCES
Abrams, D. 1995. "Marijuana, the AIDS Wasting Syndrome, and the U. S. Government." (Response to letter) New England Journal of Medicine 333: 10: 670- 71.
Grinspoon, L., Bakalar, J., and Doblin, R. 1995. "Marijuana, the AIDS Wasting Syndrome, and the U. S. Government." (Letter to Editor) New England Journal of Medicine 333: 10: 670-71.
Grinspoon, L., and Bakalar, J. 1993. Marihuana, the Forbidden Medicine. New Haven: Yale University Press.

Hall, W., Solowij, N., and Lemon, J. 1994. "The Health and Psychological Consequences of Cannabis Use." Australia National Drug Strategy Monograph Series No. 25. See the web site of Australia's Commonwealth Department of Health and Family Services publications page: health. gov. au/ hfs/pubs/abc pub. htm#m.

Hollister, L. 1992. "Marijuana and Immunity." Journal of Psychoactive Drugs 24: 2: 159-164.
Lehrman, S. 1995. "U.S. stalls over tests of marijuana to treat AIDS patients." Nature 374 (March 2): 8-9.
Randall, R. 1991. Marijuana and AIDS: Pot, Politics and PWAs in America. Washington, DC: Galen.