10 The Sacrifice of Our Sick — by Banning Hated Drugs in Medicine

ANOTHER VITAL ISSUE was raised in the brief dialogue between the Washington lawyer, the police captain, and that sick old man in the wretched Harlem tenement. As they looked at the shocking condition of the man's legs, Captain Sheridan suggested to Mr. Califano, "Ask him what caused all this."
I did.
"The needle," the addict answered.
"What about the heroin?" I asked.
"No, no. The mix was dirty," he said, referring to the quinine or whatever white powder had been mixed with the heroin to cut its strength.
"Addicts'll never blame the heroin," Sheridan said. Then, turning to the seated addict, he added, "Isn't that right?"
"Oh, yes. Heroin is good. No heroin caused this," he monotoned.

HEROIN IS GOOD ... IN MEDICINE

The incident reported by Mr. Califano provides additional insights into why we are in such catastrophic confusion regarding our drug problems. That poor old addict was correct. Volumes of scientific research, many of them listed in the appendix to Mr. Califano's large report, have concluded that no known organic damage is caused by the use of heroin. It is a physically benign, though powerfully addicting, substance. The organic damage does indeed come from injecting and from adulterants. Once again, we see how an important element of dominant social policy is based upon a hurtful myth—in this case, that heroin is organically harmful in and of itself.

The destructive impact of that myth forces us to reflect again on the irrational line between legal drugs, on the one hand, and illegal drugs, on the other. That line is a historical accident that bears little relation to science or reason. In the previous chapter, we looked at how sick people are harmed by the denial of drugs currently accepted as medicines. Here we look at the reverse side of this coin minted to support the drug war: the personal harm caused by the continued prohibition of hated drugs, especially heroin and marijuana, in the medical treatment of people acknowledged to be suffering from recognized diseases.

Let us start with heroin, the premier worldwide symbol of drug abuse, which is where my accidental involvement with drugs commenced in the early Seventies, when, full of drug innocence, I stumbled upon the prominence of heroin addiction in all major national crime-control strategy reports of the Nixon administration. My initial inquiries caused me a good deal of confusion. Heroin policy seemed to be based on half-truths and fears, not facts. Those distortions about heroin affected judgments, I started to see, about all illicit drugs. Eventually I came to agree with Edward Brecher, who declared in Licit and Illict Drugs that until society understands and accepts the reasons for the failure of the massive drive against heroin, "it can hardly formulate sound laws and policies with respect to any drug." It finally dawned on me that unraveling the enigma of heroin would be like the discovery of a Rosetta Stone for the hidden language of drugs.

I decided to read everything ever written on heroin by medical researchers and other professionals and to speak to as many addicts, narcotics police, and treatment specialists as I possibly could. This simple chemical compound, I found, had been restricted to legitimate medical use only by the Harrison Narcotic Act of 1914. In 1924, prodded by public and professional hysteria, Congress passed a curious law that prohibited the importation of opium for the purpose of manufacturing heroin. The intent was to outlaw heroin, and, in fact, the legitimate use of the drug diminished greatly. Despite widespread beliefs to the contrary, however, heroin remained legal in American medicine until November 18, 1956, when it was totally outlawed.

My inquiry soon led from America to the United Kingdom because the calm English have always taken a different approach to this drug than we wide-eyed Americans. In 1974, I began organizing international seminars or institutes in England so as to provide a firsthand view of British heroin-addiction treatment methods, primarily for American professionals. During that first institute, while we were relaxing over a midday beer, a young physician in Welwyn Garden City, an hour's ride north of London, said matter-of-factly, "In the first hospital I worked in, we gave cancer patients a bottle of syrup containing heroin, gin, and cocaine, and we told them to take some when they felt pain." That remark provided an epiphany for me, a flash of insight, one of many I was to enjoy during the years that I have tried to understand this feared drug. My interest in heroin originally focused on how that drug affected heroin addicts and crime. Now I immediately understood that I would also have to understand how it affected cancer patients and pain. Moreover, I would have to understand how events had unfolded about both sets of issues in at least two countries, England and the United States.

HEROIN REFORM IN THE UNITED STATES

After many years of research and discussion with frontline participants in the heroin scene, I have yet to discover one sound scientific reason for banning its use in medicine for the treatment of the organically ill or the addicted. All of the reasons in support of the prohibition are in reality moral, political, ideological, or criminological. On those grounds also my argument has been that reason should support the use of heroin in medicine. I have made that appeal, based upon science and my view of the ethics of the matter, in print and in the electronic media throughout much of the Western world starting in the early Seventies. Others have joined, often independently and on their own initiative, in this legal-medical reform movement with the result that now there are campaigns in many countries to bring this dreaded drug, this symbol of degradation, back into legitimate medicine.

Heroin reform is becoming a respectable, even a popular, cause, an event seemingly impossible just a few years ago. To an extent, support for this reform has come in the form of a call for wholesale legalization of all drugs on the theory that the free market is the best regulator of all commodities, including addicting drugs. This position, which goes far beyond mine and thus gives me the delicious feeling of being a moderate today, has been expressed by such conservatives as economist Milton Friedman and columnist William Buckley. (When I first met Mr. Buckley, I was, therefore, able to throw out the clever thought that his new position had upset my equilibrium because, "for as long as I can remember, I knew that the sun would rise in the east, it would set in the west, and all the time, William Buckley would be on my right." He smiled indulgently.) Complete legalization is also the posture of many members of the Libertarian Party, a small but prestigious organization. Other public figures have come out for legalization primarily to take the profits, crime, and corruption out of drug sales. Such were the reasons expressed, for example, by both Hugh Downs and Barbara Walters when they recommended, "we should legalize everything" on the ABC television show "20/20" on March 14, 1985.

Reform focused on rehabiliting heroin alone has been spearheaded in the United States by the Committee on the Treatment of Intractable Pain, which I formed in 1977 with Judith Quattlebaum, a neighbor of mine at that time in Bethesda, Maryland. The committee has been concerned almost exclusively with making heroin available to cancer patients. Because my concerns were considerably broader, I soon left the committee to Ms. Quattlebaum's energetic leadership, but have remained a committed supporter of its good work. Within a few years the persistent lobbying efforts of the CTIP had produced an historical event, the first bill in modern times that proposed the reintroduction of heroin into legitimate medicine. Hearings were held in 1980 and 1984 by a committee of the House of Representatives.

The 1984 version of the bill was called the Compassionate Pain Relief Act, which would have made heroin available to cancer patients in hospitals under a four-year experimental program. Leadership on the bill was taken by Rep. Henry A. Waxman (D-Cal.), the feisty chairman of the Subcommittee on Health and the Environment. In working with congressional staff on this bill, I saw that the major issues had very little to do with science, as in past history. Accordingly, I prepared my testimony with crime and politics in mind. In that testimony at the hearing on March 8, 1984, I decided to place side by side, first, the highest amount of legal heroin that, I estimated, might be needed to treat all the cancer patients requiring it each year and, second, the lowest official estimate of the total amount of illicit heroin imported annually into this country. Those numbers were, first, 502 pounds of pure heroin and, second, 4.08 metric tons. Then I posited the worst-case scenario: assume all of the newly legal heroin were diverted and sold by criminals on the American black market. That diverted heroin would supply, at most, 5.6 percent of the illegal demand. Thus it would barely be noticed.

This argument had some impact on the subsequent debate and was repeated in various ingenious ways. For example, Rep. John Dingell (D-Mich.) declared on the floor of the House that the four tons of illegal heroin in the country each year were at least "the equivalent of two elephants in weight." The amount necessary under this bill for cancer patients was "the equivalent of a pimple on the posterior of one of those elephants."

In my testimony and in public statements I attempted to counter another obstacle put forth by the Reagan administration: heroin was no better than other currently legal medicines, in particular Dilaudid-HP. This concentrated form of Dilaudid was being touted by Health and Human Services medical experts and their professional allies as the new, safe, legal answer to the need for another high-potency narcotic for cancer pain. This was, I pointed out, simply a rerun of an old movie. In 1924, the representative of the American Medical Association had solemnly testified, in support of the opium-for-heroin ban, that heroin could easily be replaced by codeine. This alleged scientific fact from a high authority proved to be false. In 1980, the representative of the National Cancer Institute had solemnly testified, in opposition to the first version of this bill, that morphine acetate, a highly concentrated form of morphine, was a perfectly good substitute for heroin. And now it was Dilaudid-HP. While these were good drugs, they were not the same, obviously, as heroin. And each drug affects each person differently and individually.

When, moreover, I turned away from the historical record and asked an addict informant for an opinion, she pointed out that while she preferred heroin, her most common purchase on the streets at the time was Dilaudid. She offered to take me to at least four street corners, all within a few miles of the Capitol dome, where she often bought a "D"—a four-milligram standard pill of medicinally pure Dilaudid—for $35. She could buy the pills at that price because she has been purchasing them from the same reliable Washington street merchant for seven years. The regular price to the hundreds of customers who patronize those street sellers daily is usually $40-45. My adviser confidently predicted that when the more potent Dilaudid-HP was marketed, the pure pills would appear and be snapped up by eager buyers on the streets of Washington and other American cities.

No American government has demonstrated the ability to stop the illict use of powerful narcotics by so-called street addicts. Street addicts, I argued, were not the issue in this debate. That issue was how this society should deal with the 5 to 10 percent of terminal cancer patients whose final agonies are not eased by conventional drugs. I insisted time and time again that I could find no scientific justification for sentencing 20,000 to 40,000 Americans annually to a painful death without even the possibility of relief from this very effective painkiller.

When I had finished my testimony before the committee, Congressman Waxman picked up that theme and put two pointed questions to the other members of the panel appearing with me, all nationally recognized medical experts on the treatment of cancer pain: "Is heroin a safe and effective analgesic for the treatment of severe pain due to cancer? And do you believe the American medical profession is capable of administering this drug safely?" All three doctors, including two appearing in opposition to the bill, answered in the affirmative to both questions. One of these two, the distinguished pharmacologist Raymond Houde of the Sloan-Kettering Cancer Center, added, "If heroin were not banned, I would probably use it, too."

Despite this apparent endorsement, these doctors, like virtually all of organized medicine in America, opposed this humane bill for a whole variety of other reasons, the most powerful seeming to be fear of diversion into criminal hands. The AMA representative, Dr. Kathleen Foley of Sloan-Kettering, also objected to the extra attention being given to heroin, claiming that the proponents were misleading the public, particularly cancer patients, by hailing the drug as a panacea. Dr. Foley, moreover, argued against the ease with which heroin would be approved and made available to doctors under this "extraordinary legislation."

At this point in the hearing, I confess that I had become truly fed up with the demeaning attacks being made repeatedly on the proponents of the bill by Dr. Foley, who was sitting next to me at the witness table. I grabbed the microphone we shared and shot back, "I know of no misleading of the public by any of the groups supporting this bill. I think they have indicated that it is not a panacea and that it is a small part of the picture [of cancer pain control], but it is an important part of the picture. I think it would be unfortunate to suggest that this is an extraordinary piece of legislation. It was extraordinary that in 1924 we demonized a perfectly good medicine. I think this should be viewed as an ordinary bill returning us to a level of sanity."*

However, irrational fears, especially of diversion and pharmacy robberies, demanded that the chemical demonology continue. The National Federation of Parents for Drug Free Youth was quoted during the floor debate later in 1984 as warning, "to falsely legitimize heroin sends the wrong message about this devastating and illegal drug to our youth." Rep. Hamilton Fish, Jr. (R-N.Y.) proclaimed, "This bill will send a signal to the youth of this nation that `heroin is ok.' "

Rep. Charles Rangel (D-N.Y.) fought against the proposed law during the debate with great passion, seeing the bill as the entering wedge for wholesale repeal of all the drug laws, the grand design of those who believed that enforcement had collapsed and was impossible to implement. Mr. Rangel claimed that behind this bill were a lot of people who would soon openly advocate that "we just start legalizing the entire illicit drug manufacturing and transactions in the United States," a movement that had to be stopped at this legislative pass.

The Reagan administration launched a fierce battle to defeat the bill, using all of these arguments. It promoted a lobbying campaign by Department of Health and Human Services regional offices around the country, which, according to Congressman Dingell, was not only immoral but also illegal under statutes prohibiting the use of government funds for lobbying. In one form letter it had prepared, that department, which allegedly contains the best medical and scientific brains in the world, fairly screamed to that world, "This bill, in essence, legalizes heroin!!"

On September 18, 1984, I saw the bill go down to a decisive defeat in the House of Representatives, 355 to 55, but not before the most far-reaching and revealing congressional floor debate in recent American history on the ideological foundations of national drug policy. A dozen or so of his colleagues later came quietly, shamefacedly, up to Henry Waxman and confessed that no, they did not doubt the medical value of heroin, and, no, they did not worry about the small amount that might be diverted to the street. "They explained to me that with the November election coming up, a vote for the bill would allow their opponents to brand them `heroin pushers,' " Congressman Waxman said.

On September 21, Harvey Elton Larsen, a 70-year-old cancer sufferer from the Eastern Shore of Maryland, wrote to thank me for my open support of the pain-relief bill. "I sort of feel that my death will be by cancer.... All should die with some dignity and if relief of pain can be done, it should be done, regardless of the drug utilized," he said. Then this sick old man added a very perceptive observation: "You must know that in some cases, it is being done. You certainly must know that some terminal patients are given heroin, legal or not."

At least I know of the stories, none of which I have been able to prove or disprove: The New York doctor who bought illegal heroin for his mother dying of cancer because the legal medicines he prescribed did not relieve her agony. The doctor who told the sons of another lady in her last painful days from cancer that they should cop some heroin on the streets of the Los Angeles barrio because the drugs he had given her did not work. I know also that many other people have threatened to do the same if the need arises. Whether or not the stories or the threats are actually true, they are consistent with one another and comport with my view of how I might behave in a similar situation.

There is no doubt of a broader, more optimistic reality. A historic shift has begun in American public opinion toward heroin and pain. In late 1984, Common Cause magazine summarized the major arguments put forth by advocates on all sides regarding the issue and asked its readers, most of whom are admittedly quite liberal, to send in a ballot. Eighty-six percent of those who responded came out in favor of allowing doctors to prescribe heroin to terminal cancer patients.

Clearly, the movement to bring heroin back into American medicine is not dead. Congressman Waxman has reintroduced the bill in the House and Daniel Inouye of Hawaii, a longtime advocate, has done the same in the Senate. All of the many American supporters in Washington and around the country will find a good deal of encouragement in the actions of some foreign medical associations and governments. They have listened to all of the arguments put forth on both sides of the American debate and come out for exactly the opposite course of action than that taken in this country.

In February 1979 the Australian Medical Association, for example, called for the lifting of the legal ban on the use of heroin for sick people in extreme pain, explaining that "to deny even a small number of patients a drug that may make their last days more bearable is not justified as a means of controlling drug abuse." In March 1985 the Human Rights Commission, an agency of the Australian government, formally recommended that all terminally ill patients, suffering not only from cancer but also other painful organic diseases, be provided heroin both inside and outside of the hospital. The commission based its recommendations in part on the novel grounds that international covenants on human rights might well be interpreted to mean that terminally ill patients should be considered "disabled persons" with a right to privacy, which could mandate that such patients have the privilege of choosing the painkilling medication that would best maintain their dignity during a time of severe pain and depression.

In its review of the medical evidence on the value of heroin, the commission adopted many of the conclusions of The Heroin Solution, including that which stated: "No scientific justification exists for continuing legal prohibition of the use of heroin in the treatment of the organically ill and the injured. Indeed, each patient in pain should be eligible to receive the drug in order to determine whether it provides particular benefits for him or her at that time."

THE SURPRISING CANADIANS

To my pleasant surprise, Canadians have taken some of the most far-reaching steps of any people in recent history toward more humane and more rational heroin policies. My surprise is based upon several recent trips to that country, and discussions with addicts, doctors, officials, and lawyers, many of whom were affiliated with the anti-prohibition Concerned Citizens Drug Study and Educational Society of Vancouver. They told me that addicts often were brutalized by the police without regard to any civilizing legal restraint. They and their families lived in constant fear. In one 1980 case, members of the Royal Canadian Mounted Police testified during a coroner's hearing that they had grabbed British Columbia heroin addict Dennis John Williams by the throat and had been holding him, in the words of one of the famed Mounties, "as hard as I could." This was a "common occurrence" and "standard operating procedure" in order to conduct a "mouth search" for drugs often stashed there. In this standard case, as it happened, the subject of the search choked on the package in his mouth and died.

Coroner D. J. Jack had instructed the jury, "It's a war between certain elements of society and law enforcement.... The men involved from a police point of view ... have to act with severity in combating this business. Draconian measures ... [are] obviously a must." The jury took 25 minutes to return a verdict of accidental death regarding Mr. Williams, who had not survived this standard operating procedure.

Every level of the Canadian judiciary, up to the supreme court of the country, approves harsh approaches to drug users and addicts. Accordingly, I had concluded that the frontier roughness and puritanical attitude of Canadian officials had created a vision of the American system gone mad. My conclusions were supported by leading Canadian academic drug experts, such as Drs. Barry Beyerstein and Bruce Alexander of Simon Fraser University.

It did not seem possible that out of this harsh martial mentality could come a direct frontal assault on the basic ideology of the drug war. I was wrong and, as I said, surprised. Some of the most prominent leaders of recent reform efforts have been doctors, who have fought the drug-war mentality with appropriate frontier vigor and almost religious zeal. In 1979, Dr. Kenneth Walker of Toronto commenced a relentless campaign to bring back heroin for cancer patients. He founded the W. Gifford-Jones Foundation and published a syndicated column, "The Doctor Game," under the same pseudonym. In the column and in paid advertisements, he pushed his cause so well that soon he had much political and financial support from Canada's citizens. Dr. Walker gathered 30,000 signatures on a petition which he presented to the government in 1982. At the same time, 20,000 letters of support flooded government offices. One young girl wrote, "I'm sending this letter for my dead father. He suffered indescribable agony when morphine no longer worked." Major Canadian newspapers editorialized repeatedly in support of bringing heroin back, as had leading U.S. papers. In May 1983, health and welfare minister Monique Begin announced that clinical trials would be held comparing heroin to Dilaudid.

Meanwhile, the Canadian Medical Association had been investigating the situation. Another forceful reformer, Dr. William Ghent of Kingston, Ontario, led the CMA Council on Health Care in a three-year examination of the historical record. The authoritative report revealed how politics and deception had permeated the Canadian decision in 1954 to ban heroin totally in medicine, a submission to U.S. pressure in international health and narcotics organizations, including the World Health Organization. When, in the early Fifties, the CMA had been asked its opinion on the worldwide U.S. campaign, that body had responded that it opposed prohibition because heroin was better than morphine in some cases and also because the U.S. experience had demonstrated that absolute prohibition had not controlled street abuse. When the matter came up in the House of Commons on June 1, 1954, government ministers misled the entire legislature by giving the impression that the organized physicians of the country supported prohibition. One official stated on the floor of the House, "We discussed it with the Canadian Medical Association," but never mentioned the fact that the CMA advice had been against prohibition.

"Thus, with a degree of duplicity, ... this useful drug was now criminalized and Canada joined the W.H.O., who had been persuaded by the United States that if all heroin was illegal, prosecution for possession would be easier and full worldwide control could be obtained and heroin addiction eliminated," stated the report of the Council on Health Care in 1984. The council recommended that heroin be licensed again immediately for medicine. In presenting a resolution to that effect to the annual meeting of the CMA in August 1984, Dr. Ghent observed, "We followed the U.S. like sheep and now, like sheep, we've got their manure to deal with." That fecal matter included, he explained, innocent patients in pain, a rising number of addicts, a criminal and corrupt black market, and many Canadian youth, who, far from being protected, were being enticed by the deviance of the heroin scene.

The debate at the CMA meeting focused primarily on the need to reverse the mistaken political decision of thirty years earlier so that addicts could be treated like sick people and not criminals. There was widespread support for that proposition because those doctors had concluded, as I have argued for years, that the fates of heroin addicts and cancer sufferers are inextricably intertwined when social policy is being decided. However, the resolution finally approved by the doctors of Canada was restricted to the need to approve heroin for treating pain. That overwhelming and historic vote on August 21, 1984, was soon followed by even more historic action by the Canadian government itself.

That government became the first of any Western democracy in modern history to take formal action in defiance of the American-led ban on a hated drug such as heroin in medicine. On December 20, 1984, the new conservative health and welfare minister, Jake Epp, announced in the House of Commons in Ottawa that heroin would soon be available to treat severe chronic pain whether due to cancer or another ailment. On September 19, 1986, the official Canada Gazette included four simple pages that contained an amendment that brought heroin formally back into medicine and set out the new regulations for its control. I later had a happy conversation about the historic event with Dr. Bill Ghent, who told me that he had already prescribed the medicine to a few patients, including one elderly lady whose pain was eased by a small amount of the drug taken infrequently. It was not a dramatic case. Indeed, it was a rather ordinary incident. But before the reform, the lady might have suffered more than was necessary.

The related issue of allowing heroin for treating heroin addiction has not yet been dealt with in Canada, although it was clear that the Canadians were thinking about it and were now also looking for guidance on that issue across the Atlantic rather than to their powerful southern neighbor, as they had done too often on drug matters in previous decades.

HEROIN IN BRITAIN: THE MYTHS PERSIST

Heroin in the United Kingdom has always been a subject of great controversy, even in regard to the most fundamental facts. American drug-abuse officials over the decades have consistently misstated those basic facts, not only about heroin but about the entire drug situation in England. They have often been aided in their deception by leading electronic and print journalists—and even worse, by leading scholars—who seem to take the official distortions at face value. During his 32-year reign as director of the Federal Bureau of Narcotics, Harry Anslinger sometimes had to argue down critics who opposed harsh law enforcement as the dominant American approach to drug issues and who proposed adopting elements of the more gentle British system. Director Anslinger often replied that "the British system is the same as the United States system," and, besides, the so-called British system of decriminalization of drugs has failed. Both statements have always been untrue.

Bureaucratic descendants of Mr. Anslinger have uttered pronouncements of the same doubtful veracity. In November 1984, then DEA administrator Francis M. Mullen, Jr., said he opposed the use of marijuana for medical purposes, adding the confusing thought that "decriminalization of drugs has been tried in a number of countries, England being one, and they now are aware that it has not worked." In November 1985, Mr. Mullen's successor, John Lawn, said in my presence to a seminar of journalists that marijuana, being much worse than alcohol, deserved to be kept illegal—and then immediately added the even more confusing thoughts (confusing to me, at least) that (1) "Great Britain tried heroin use for cancer patients and found it to be a failure"; and (2) the recent action of Canada allowing heroin for cancer patients had "the potential for a big problem.... I think it's a mistake."

Another major Big Confusion today, which I have heard in allegedly factual news stories on major television networks and from scholars, is that the British now have a heroin epidemic that was caused by their curious custom of allowing doctors to give addicts virtually all of the heroin they wanted. The British, the story continues, have come to their senses and have moved almost fully in the American direction of control.

It is difficult to straighten out the strands of half-truth and full-lie contained in these various confusing accounts, but here is a summary of the actual situation in that island kingdom. Marijuana barely figures in this discussion of the current British scene because it has been illegal for decades, has been decriminalized in no part of the U.K., and is rarely used in medicine. There is little discussion or conflict in that country about the use of marijuana in medicine.

Nor is there any conflict about the use of heroin, or any other powerful narcotic, by doctors in the treatment of the organically ill. It is, accordingly, a simple falsehood for DEA administrator John Lawn, perhaps the leading drug-enforcement officer in the world, to state publicly that the U.K. has concluded that the use of heroin for cancer sufferers has failed or even that any serious questions are being raised about its use for that purpose. The truth is just the opposite.

Approximately 95 percent of all the licit heroin used in the world within recent history has been prescribed by British doctors, primarily for cancer sufferers. Official reports reveal that total annual legal consumption of heroin in all types of cases, usually organically ill and not addicted patients, has been rising consistently in the U.K., from 41 kilograms (90.2 pounds) in 1971 to 228 kilograms (501.6 pounds) of the pure drug in 1985.

It is true, however, that many physicians have decided to cut down on the prescription of heroin for the quite legal purpose of the medical maintenance of addicts. In 1969, the first full year in which some new restrictions were in effect on the power of most doctors to prescribe to addicts, 1,466 addicts were receiving maintenance doses of narcotics at year's end, of whom 34 percent were prescribed heroin alone or in combination with other drugs. By the end of 1985, only 2 percent, 140 addicts out of a total of 7,052 receiving narcotics, were being prescribed heroin. Along with reductions in heroin prescriptions came similar reductions in prescriptions of all injectables for addicts, especially methadone, which most British addicts preferred to receive from their friendly local chemists in ampules along with clean needles, a shocking and illegal practice in America. Soon British experts began to view that practice in the same light. Oral methadone became the preferred prescription of British drug clinic doctors. Some of the most ignored victims of the American drug war have been British addicts and their families, who have been personally affected by the importing of rigid attitudes toward treatment.

It was during this period—the mid-Seventies to the midEighties—that there was a rise in crime by addicts and in the black market for drugs, and in concomitant cries by British leaders that the country had to get tougher with these deviants and adopt more American drug-war methods. What never seemed to dawn on opinion leaders—and on physicians and scholars—in both countries was
that the rise in addict crime and the drug black market took place in the wake of a tougher prescribing policy toward addicts regarding heroin and all narcotics. I do not mean to say that the tougher policies directly caused the rise in addiction and crime because I have never claimed to understand mass swings in drug use. During this period, I also saw, while on frequent visits to the country, the suffering imposed on the society by economic malaise, massive unemployment, immigration from countries like Iran with a history of high opiate use, and the spillover of supplies from the huge American market. Whatever the causes, it is highly likely that addict crime and black market violence will continue to be incited somewhat by the new British habit of seeking to impose American martial methods on a troubling but still relatively peaceful drug scene.

Even with a modicum of American methods in place, the current English drug system remains a marvel of gentleness as compared to the American and to almost any other on the face of the earth. With all of its current defects, which I have pointed out repeatedly in print and in the electronic media of the U.K., it would be marvelous to see it implemented in America. Any doctor in England has the power to decide which drugs patients should receive. If the patient is organically ill, the police tend to keep a decent distance and almost never bother either doctor or patient, no matter what drugs are being prescribed. Even if the patient is addicted to one of a wide variety of powerful narcotics, any doctor in England has the power to prescribe the drug of addiction for longterm maintenance so long as the physician keeps accurate records and notifies the Home Office when a new addict is encountered.

However, in regard to three drugs—heroin, cocaine, and dipipanone, the last a powerful narcotic known as Diconal, suddenly popular with British addicts—a special license must be obtained from the Home Office by a doctor who wishes to prescribe them to addicts for the purpose of maintenance. Approximately 100 doctors now hold such licenses, most of whom exercise the power only rarely. Yet any one of those doctors may do so at any time. On the basis of independent clinical judgments, licensed British doctors decided to reduce heroin prescribing to addicts without being required to do so by law, and they may resume without interference by the police.

In short, so long as a British doctor follows relatively nonintrusive regulations, there are no restrictions on the dosage or the form of prescriptions for addicts. For example, any doctor, even one in general practice and without a special license, could prescribe to any addict injectable morphine, methadone, or Darvon, which could land any American doctor in prison, along with the patient. This is not to say there is no risk of prison or professional censure for doctors who deal with addicts. There is, but it is a minimal risk. It rises somewhat in cases where the doctor, working outside the National Health Service, is "private" and thus charges fees—and especially where a patient of such a doctor has been caught selling some of his prescribed drugs. Such events now disturb even the calm British.

Another feature of the British drug situation which disturbs many people there is that the number of drug abusers is rising throughout the country. Pundits claim that this problem also has been caused by the failure of the old indulgent British system. However, not only has the apparent rise taken place during a decade of hardening hearts but also no expert in England can tell why there has been a rise, a weakness all of us alleged experts share, if we are honest about it. Moreover, there is no certainty about the actual amount of the rise in drug abusers hidden out there in British society. All we know for certain is that there has been a significant increase in the number of addicts in treatment, that is, receiving a prescription for legal drug maintenance, a figure which, as I said, was reported to be 7,052 at the end of 1985 by the Home Office Drugs Branch. Moreover, the latest expert guess is that there may be 30,000-35,000 addicts or regular users of narcotics in all of English society, a low number when compared to America and other countries.*
Even if that guess is true, many English experts agree that relatively few of them, unlike their American cousins, engage in serious crime. For example, it is a rare event, indeed, for the British police to arrest an armed addict-robber. In the great majority of cases, the British have accomplished the stunning feat in this modern world of separating the status of being a narcotic addict from the status of being a violent or predatory criminal.

If the current British drug-control system, warts and all, were applied in America, there is the good possibility that the poor addict in the Harlem tenement would be eligible for a warm bed and injectable drugs on a number of grounds. First, since he was clearly organically ill and visibly so, his doctors might have been allowed to prescribe drugs for him, perhaps even heroin in a hospital, without fear of being arrested by the police or defrocked by medical societies. Second, since he was addicted, any doctor could prescribe any drug, except heroin, cocaine, and dipipanone, for maintenance. This would include Dilaudid or Darvon, and any drug in between. A specially licensed doctor could also prescribe those three restricted drugs for maintenance.

Not only would that Harlem addict have been treated more humanely, so also would Dolores Koppinger, Harvey Rose and all his demeaned patients, Milton Polansky, and Kenny Freeman. All of these sick people would suddenly have the option of being treated as ordinary patients, with dignity and kindness. It is likely that more addicts, including some of those who infest our streets, might decide to accept those humane options if they were offered and to treat the rest of us better for having offered them. If addicts were being treated more humanely, so also would multitudes of patients, numbering perhaps in the millions, suspected of being addicts or potential addicts. And the momentum for this vast reform movement in the United States could commence with the medicalization of heroin, that simple chemical compound first stumbled on by an obscure English chemist in 1874.

MARIJUANA IS MEDICINE

Humane advances would also occur if another feared drug, marijuana, were to be made available to treat organically ill patients who might benefit from its therapeutic effects under the care of a doctor. As in the case of heroin, there is no scientific basis for the ban on marijuana in medicine, only politics and fear.

Most of the public debate on marijuana deals with the wisdom of banning its recreational use by perfectly healthy people who choose to use the drug as an intoxicant. While the ban on recreational use makes little sense, the ban on medical use makes less. It creates needless victims of sick people whose pain and suffering might be eased by this venerable medicine. Starting at least as early as 2737 B.C., references have been made to hemp or cannabis as a therapeutic agent to treat a wide variety of illnesses, including nausea, convulsions, dysentery, malaria, cholera, dizziness, and the pain of childbirth, among many others. Modern medical research has sharpened knowledge about the precise impact of the drug in medicine and has confirmed some of the historical confidence of primitive healers.

That massive body of scientific research documents medical uses that rarely get discussed even in arcane professional journals. In 1973, Tod H. Mikuriya, M.D., produced a compendium of some of that research, Marijuana: Medical Papers. For example, Dr. Van M. Sim reported in 1971 after a major study, "Marijuana ... is probably the most potent anti-epileptic known to medicine today." His conclusions were based in part on an earlier experiment that demonstrated that a substance related to THC, the major active ingredient in marijuana, controlled epileptic seizures in a group of children under study more effectively than did Dilantin, a commonly used and often beneficial anti-convulsive agent. However, the parents of epileptic children are rarely made aware of the medical value of pot primarily because the leading medicalb experts of the country have themselves been emotionally affected by the hysteria of the drug war. As in the case of heroin, the known and potential therapeutic benefits of marijuana are ignored by most medical scientists so that they cannot be accused of giving a wrong message to youth seeking an illegal high. It is a shameful story.

Even more shameful is the current record of the anti-marijuana crusaders, including a few in the White House, who continue to hound those who support the return of marijuana to medicine. Such reformers are consistently accused of simply using the medical argument as a cheap gimmick to slip pot to our schoolchildren—and sometimes of being marijuana addicts whose judgment is clouded with fumes of the deadly drug. I have personally observed such tactics directed against me and my colleagues. As a result of this type of irrational and harmful behavior, Americans who become organically ill are rarely informed, either by their doctors or by their government, that this medicine might ease their suffering.

Because mass social irrationality has been reflected for decades in government grants for scientific studies, almost all marijuana research funds have been devoted to the harm caused by the drug and how best to control it. Some years ago, for example, California police agencies were seeking to determine if they could discover pot-affected drivers by looking for dilation of their pupils, which would thus provide a legal basis for arrest. They asked a medical scientist to study this matter. In the course of his study, Dr. Robert Hepler, a neuro-ophthalmologist at the Jules Stein Eye Institute, University of California at Los Angeles, stumbled upon another important finding: cannabis lowers intraocular pressure and thus might well be important in the treatment of glaucoma, a dread disease that impairs vision and causes blindness in many people. Those unexpected though highly significant research results were reported by Dr. Hepler in the Journal of the American Medical Association in 1971. They were also duly noted in the collection of essays published by Dr. Mikuriya two years later.

ROBERT RANDALL: FIGHTING BLINDNESS IN AMERICA

When he started to lose his sight in the early Seventies, none of his doctors told Robert C. Randall about that article or about the vast body of scientific research indicating that there was a medicine that might help to stave off his impending blindness. That made him angry. What made him furious, and keeps his righteous outrage smouldering to this day, is the knowledge that government drug-abuse experts knew—they knew !—and they acted as if they had no responsibility to tell the millions of American glaucoma sufferers, many of whom were slowly going blind. At this point in his tale, the mild-mannered fellow becomes a steel-cold furious street fighter.

Mr. Randall starts telling his story, though, in the measured tones that reflect his education, a B.S. in political science and speech and an M.A. in rhetoric. In 1970, at the age of 22, he developed tension and what optometrists told him was "eyestrain" while writing a long research paper at the University of South Florida in Tampa. Sometimes he smoked a marijuana cigarette and on those occasions noticed that he was more relaxed and did not suffer so much from the eyestrain. He moved to Washington, D.C., in 1971 where he hoped to get a job as a political speechwriter. For a year and a half, as it happened, he smoked very little marijuana. In 1972, he noticed that he could not read a page with one eye because the print seemed shattered; it simply would not come into proper focus. He went to an ophthalmologist, who told him that the pressures in his eyes were double the normal level, that he had glaucoma, that the damage was 85 percent in both eyes already and that he was virtually blind in his right eye, and that he could expect to go totally blind in three to five years. On the day he received that news, Bob Randall was an otherwise healthy young man of 24.

He commenced studying his disease and eventually learned a great deal about it. Glaucoma is characterized by high levels of pressure inside the eyeball due to an impediment of the normal outflow of fluids within the body. All treatments, both through surgery and drugs, seek to lower that intraocular pressure by opening the blocked exit canal of the eye. None of these treatments constitutes a cure and the best medical science offers the victims of this disease is a holding action, the staving off of progressive blindness. A variety of drugs and medicines are used to carry out that holding action. What often happens is that they are tried by the physicians in series or relays. A patient will take several at once, develop tolerance to one, which will be diminished or eliminated, then have others prescribed in its place; then a new mixture is tried. Some patients try four or more drugs at once.

In many patients, the lack of control on the original disease is complicated by the side effects of the prescribed medicines. It took young Bob Randall a long time to learn about those harmful effects, which were often not fully explained by his doctors. He ended up doing research on the subject in medical libraries. The effects he discovered in the literature distressed him almost as much as the original diagnosis. Some of those medicines commonly used in glaucoma treatment, he found, could cause cataracts, retinal detachment, and death through respiratory, cardiac, or renal failure.

To add to his predicament, Bob discovered that most patients run through a number of drugs without exhausting the list of possibilities or suffering the worst side reactions because the great majority of patients are elderly when the disease is first diagnosed. Death, in effect, saves those older sufferers from having to face up to all of the complications of their medicines. In young patients, the disease often progresses toward blindness with fierce speed and as drugs are tried aggressively to retard the onslaught, the dangers of serious adverse drug reactions increase. To a young person like Bob Randall, then, glaucoma poses the danger of the rapid onset of blindness from the disease itself as well as further injury and even death from the standard medicines prescribed by doctors.

Of course, the many caring and competent doctors in the field felt the frustrations and tragedies of their patients. Those physicians knew that they were constantly balancing off the imponderables of nature and chemicals in the face of a relentless disease.
Bob Randall speaks fondly of the Washington doctor who discovered his disease and undertook his care initially. That doctor gave him a drug called pilocarpine. The young patient soon discovered that this standard medicine was "almost blinding" while it worked to prevent permanent blindness. Because he believed it to be a good medicine, and still does, Mr. Randall kept taking the drug, "but for about a year and a half, I lived, literally, almost blind." When pilocarpine proved inadequate, he was placed on a number of other drugs that did not cause additional, temporary blindness, but they had other side effects and dangers. "I was placed on all of the medications that were available at the time. They failed to work."

In the fall of 1973, at a time when he was seeing halos—a symptom of uncontrolled elevated pressure—and when his ability to see fluctuated daily, a friend gave him some marijuana to smoke. He went from the halos and haze "to clear vision, in 45 minutes." Mr. Randall was alone making an attempt to watch television and he suddenly realized, "Gosh, I can see well!" Then it clicked: "Marijuana's doing it; remember, in college, you used to smoke marijuana for eyestrain." The next morning, he began doubting the truth, and he then vacillated back and forth for months, now accepting the reality of the improvement and then doubting it. His resistance was based in part on his belief that marijuana was not a medicine at all but simply a social drug. How in the world could pot, a plaything, help him stave off blindness, a fate that all of medical science could not prevent? Then his marijuana supply ran out and with it his ability to see better. Randall found a new supply and soon his sight improved, again. He was convinced.

By late 1974, patient Robert Randall of the nation's capital city was regularly taking three standard prescribed glaucoma medicines plus his own prescription for three to five marijuana joints a day, which he smoked once every four hours. When he got high, he would stop smoking, since that seemed to indicate he had taken enough of his medicine. "My doctor was delighted because my eye pressure was suddenly under control for the first time since I'd been in treatment!" Yet he decided not to tell his doctor about his auxiliary treatment for fear of the legal and ethical complications this might present to the physician. (Despite falsehoods promulgated by anti-marijuana crusaders, Robert Randall has never stated that he saw marijuana as a cure or as the only medicine he needed to control his disease; on the contrary, he has always believed that he needed conventional medications as well. And he has always taken that position openly.)

To insure a continued quality supply of his new medicine he grew four marijuana plants on the sundeck of his apartment, which happened to be right across the street from the U.S. Marine barracks in southeast Washington, eight blocks from the Capitol. Everything in his life seemed to be settling down and he happily went away on vacation with his apartment mate, Alice O'Leary. During his absence, the police happened to see his plants, searched his apartment on the basis of a warrant, seized his plants, and left a surprisingly polite note suggesting he come down and turn himself in for arrest. "And so I came home from vacation and there was no marijuana to use. I immediately began having pressure problems."

Also, of course, he now had legal problems, since he had complied with the polite request and had turned himself in to be arrested for possession of marijuana. Instead of taking the advice of friends and simply pleading guilty and probably paying a fine, Bob and Alice decided to fight the case on grounds of medical necessity and hired local lawyer John Karr. The attorney said that his client had an interesting argument to use in his defense but that Mr. Randall would have to prove it first to him because "I'm not going to argue a looney case." Bob was thus faced with the urgent necessity of performing more in-depth research on the medical value of marijuana.

His search soon led to the NORML office, and he was pleasantly surprised that the founder and director, Keith Stroup, saw him immediately. Mr. Stroup told Mr. Randall of a suit by NORML in 1972 seeking to reclassify marijuana within the 1970 omnibus federal drug law, in which the Nixon administration had classified it in Schedule I, along with heroin, LSD, and other powerful drugs deemed so dangerous as to be unsafe for use in American medicine. NORML had been attempting for years to convince the government to come to its senses on this limited issue, and at least put marijuana into Schedule II, where it could be used in medicine but under tight controls; the government had been resisting this seemingly modest move bitterly—and has until this day in the late Eighties. Keith Stroup also gave him copies of articles supporting the proven value of marijuana in medicine, along with the names of federal drug officials.

IT'S REAL GOOD YOU'RE USING MARIJUANA

"I called five bureaucrats.... I said, `Hi, my name is Bob Randall, and I am a glaucoma patient and I've just been arrested for marijuana.' Three of the people, two from the National Institute on Drug Abuse and one from the Food and Drug Administration, immediately said words like, `Oh, it's real good that you're using marijuana, because we have lots of evidence which shows marijuana is effective in the treatment of glaucoma.' " Robert Randall now had two reasons to feel enraged and less secure about his life in this society. The first had been the arrest for possessing marijuana for his own use. While arrests for personal use of marijuana may seem trivial to some observers, they constitute the bulk of all drug arrests, now at least 400,000 every year, and are often traumatic and damaging. The second was the sudden knowledge that his government was, as a matter of high policy, deliberately withholding from him, a good citizen, a medicine that just might prevent him from going blind.

"I was already enraged that I had been arrested.... That made me feel insecure.... And when someone arrests you for something as meaningless as marijuana, you know they can get you for any reason.... It doesn't have to be rational. It doesn't have to relate to the facts," Bob Randall explained. And then there were all those other glaucoma victims sitting out there in society. (Eventually, Randall learned that there are at least two million glaucoma sufferers, that approximately 250,000 have serious sight impairment already, and that 75,000 are actually blind. Approximately 7,500 go blind every year from the disease owing to, in the opinion of government experts in the National Eye Institute, "inadequate medical therapies and surgical techniques." Perhaps 200,000 to 400,000 patients face the possibility of painful surgery to improve their condition. These patients seem to be prime candidates for trying a new medicine such as marijuana.)

It was at this point, in the year 1975, that this young man, originally from Sarasota, Florida, where his father owned a furniture store, and with no education in law or medicine, began to become one of the single most effective reformers of drug-control practices in modern American history. He faced the entire federal drug-abuse control establishment head on and beat it to its knees. Of course, he had a lot of help. But the story of Bob Randall must be seen in part as proof that one person can make a difference in the history of nations.

Even pleading the defense of medical necessity, which evolved out of old English common law, in a criminal case takes a good deal of courage. Few lawyers would even consider mentioning it because throughout the history of Anglo-American law it has so rarely worked. Its essence is that while the accused admittedly committed the act which ordinarily would be considered a crime, and was sane at the time, that should be excused because the actor was seeking to avoid an even greater evil. That may sound simple enough but if judges often allowed the defense, much of the criminal law could be eviscerated. One rare example of the successful use of the defense concerned a New Hampshire parent at the turn of the century who withdrew a child from school for health reasons and was deemed not guilty of violating a New Hampshire compulsory school attendance law. Bob Randall had to prove that he was going blind, that marijuana was not merely helpful but critical to prevent that event, that his violation of the drug law was an infinitely smaller evil than his going blind, and that this was one of those rare cases in which both the society and the law would benefit from the granting of the exception. This was a formidable and pioneering undertaking.

He contacted a number of medical research centers and underwent a variety of tests. His most significant medical adventure involved thirteen days of controlled experiments in 1975 under the direction of none other than Dr. Robert Hepler at UCLA, who was continuing his experiments on the effect of marijuana on eye pressure. Dr. Hepler had already expanded his data base to over 400 subjects. Marijuana provided by the doctor in the form of THC pills—generally favored by the medical establishment because they seem more like medicine and avoid problems of smoking—had no effect on subject Randall's eye pressure. Next, a single smoked joint had no measurable results. Both doctor and subject were confused.

"Finally, I said, `Put me in a room, give me marijuana, and leave me alone,' " Bob Randall explained to me during an interview. After seven joints, enough perhaps to make an entire fraternity float off the ground, Bob Randall was high, but his pressure was down to normal. At every step, he had been using conventional medications as well. Thus the doctor and the patient had powerful proof of marijuana's value. For Randall, THC alone was not a sufficient additive to the mix of medications. That substance was different in some unknown way from a marijuana cigarette containing hundreds of other ingredients that, all together, must have accounted for the impact on his eye pressure. Based on the objective data developed during the tests, Dr. Hepler provided an historic affidavit to the effect that smoked marijuana definitely helped this subject's eye pressure and was the only remaining medical means which might stave off the progression of his disease toward blindness.

Bob Randall gained something else at UCLA: the knowledge that for years the federal government had been growing legal pot for experiments, such as Dr. Hepler's, at its farm in Mississippi. After discussion with his lawyer, John Karr, he decided to confront his government directly and to ask for legal access to the finished product of that unique southern plantation. He petitioned the DEA on May 20, 1976, for access to government supplies of marijuana for use as medicine that would help prevent him from going blind. DEA officials ignored him, and it was then that Bob Randall started his unremitting press campaign by going to reporters. He wanted the publicity not only to help himself and other glaucoma victims, but also to help cancer sufferers, because he had found that many of them were able to endure chemotherapy without vomiting by using marijuana. Not only that: he also found that many cancer patients actually got the well-known "munchies" from pot and thus regained their appetites for food, a wondrous event for so many people who recently could not even look a decent hamburger in the face. Sympathetic stories appeared, even though DEA officials let the word out to the press that this fellow was both a looney and a criminal.

His trial on the possession charge took place in July before Judge James Washington, Jr., a prominent black jurist and a former dean of Howard Law School, without a jury. Again, there was a great deal of press coverage. Because of the novel and important nature of the defense, Judge Washington took the case under advisement before issuing his decision. In light of the fact that the jurist pondered his decision for so long, the federal enforcement officials soon got the message that a pioneering marijuana decision was about to be handed down which would make them unhappy. Bob kept up the personal pressure on agency officials. Because NIDA controlled the Mississippi marijuana farm, his demands became focused on the officials of that agency, but he also kept up the pressure on staff at the DEA and the FDA, both of which have authority in this arena.

As it sank in on NIDA officials that this Randall person might well win that case in Superior Court on that necessity defense, they told him that they were giving in on his related petition for access to legal marijuana. The government would treat him as a research subject under an IND (an investigational-new-drug protocol) application. All he had to do was find a doctor willing to accept the drugs and to supervise the experiment. The government saw this as a method for sticking to its position that marijuana must remain a Schedule I drug, one formally prohibited totally in American medicine, except in rare and closely supervised experiments. Because the improper use of such drugs is considered a serious crime and also because the administrative red tape is strangling, few doctors want to be involved in such experiments. Nor do patients.

The NIDA officials made demands of Bob Randall, in sequence, that he be hospitalized in order to be a research subject; or that he go to the hospital to smoke; or that he buy a 750-pound freestanding safe or a 250-pound safe embedded in concrete to store his medicine. He rejected all of these, in sequence and in the sulphuric terms they deserved, as being utterly impractical. The NIDA officials backed down again. Then, Bob Randall explained, "The final bargaining point the government had was, in effect, `We'll give you the marijuana if you never tell anybody.... You've figured out the game. You beat the system ... and just between you and us, we'll give you the marijuana. You can keep your sight. We can keep our classification [on marijuana as a prohibited drug in medicine].' " He went to the press immediately after hearing this proposed "deal made in Hell." He was determined more than ever that every glaucoma patient, every cancer patient, constituting millions of his innocent fellow citizens, should get to know from his case that marijuana was a medicine that might help them at least to some degree.

Meanwhile, with the help of the government, he made arrangements with Dr. John Merritt, an eye specialist at Howard University Medical School a few miles from his home, who agreed to take him on as a patient and research subject. While Randall is white, Dr. Merritt, who is black, was particularly interested in his disease because black men have a much higher incidence of it than other people. At the same time, the physician cared about Mr. Randall as a human being in trouble and wanted to help him in any event. At about the time he found Dr. Merritt, Bob learned that the marijuana he had requested was on its way to Washington from that government farm in the south. Someone, somewhere in the halls of power had made the historic decision to breach the wall of marijuana prohibition. "So I walked into Merritt's office one day, November 12, 1976, and walked out with forty marijuana cigarettes. And went home."

THE RIGHT TO HEALTH

More important victories were to come, starting at the end of the month. On November 24, 1976, Thanksgiving Eve, Judge Washington issued a decision of profound importance in United States v. Randall. "The evil he sought to avert, blindness, is greater than [the evil] that he performed to accomplish it, growing marijuana in his residence in violation of the District of Columbia code," the judge explained, as he found the defendant not guilty of the charge of possession. Yet today leading government officials still conduct drug enforcement as if that historic decision did not exist.

Robert C. Randall has continued to make history and has continued to broadcast and broaden his victories over the drug warriors. He is the only person I have discovered in America who has received steady prescriptions of marijuana cigarettes for glaucoma over a period of years, with only one brief interruption. It has been a stunning series of victories. Yet none of them has ever been fully secure. Even the liberal Carter White House drug policy chief, Dr. Peter Bourne, threatened to cut him off because he kept appearing on television shows and in the press, telling the world and other sick people about the value of his medicine. Dr. Bourne wrote to federal research subject Randall on June 6, 1977, "Publicity in this case has forced consideration of tightening up the dispensing of your supplies." When Dr. Merritt took a new job out of the city in January 1978, the Carter administration terminated Bob's supply on the day the doctor left and told him that he would have to survive without his medicine until he found another doctor. Thus the United States government invited this patient to buy his blindness-prevention medicine on the street. He refused the invitation and managed to find a temporary alternate source through a network of contacts.

Bob saw that he might have to go through with a full legal suit to insure access to his medicine. Luckily, a leading Washington law firm, Steptoe and Johnson, agreed to take this new case on a pro bono publico basis. A young lawyer, Thomas Collier, was assigned to the case and he proved also to have an extraordinary impact on the course of events. But he also did not work alone, being helped at times over the ensuing weeks and months by at  least two dozen of the firm's lawyers and paralegal assistants, all of whose time and expenses the firm contributed for the good of the public.

Tom Collier prepared a comprehensive suit against the DEA, NIDA, and the FDA that would guarantee formal approval of Mr. Randall's right to receive marijuana as medicine under an IND protocol. This new suit argued that there is a constitutional right to health and to the available medicines to secure it. The government did not have the power to deny a patient medicine when it knew that the denial would cause that person to go blind, Mr. Collier further claimed. While such claims make good ethics and simple common sense, they have never been fully established in the law. It was just possible that they were about to be, since the massive pleadings had been well prepared and bore the imprimatur of a major establishment law firm. Such a constitutional finding might have gutted the enforcement of whole sections of major drug laws. However, the full implications of this suit were not realized.

The Carter administration dragged its feet, demanded more scientific proof, and as a result the hapless research subject had to undergo yet another experiment with yet another new drug that had been discovered and yet another research doctor, this one at Duke University. For the first time in years, while in North Carolina under the care of that university research doctor, Bob Randall stopped taking marijuana for a long period, three weeks in this case; instead, he relied on the new legal medication, Timolol, and his regular regimen of conventional medications.

"Did you suffer withdrawal?" I asked. "From marijuana, no. I almost suffered withdrawal from vision," the patient answered. "The bureaucrats wanted to find out if I would really go blind," Randall insists. The government officials again had their answer: if this citizen did not have marijuana, he would go blind. (Often, these same officials had asked him in exasperation why he did not simply buy his marijuana on the street, like everyone else.)

The Duke doctor declared the experiment with Timolol a failure. The research subject came back to Washington on a Friday. On the next Monday afternoon, May 6, 1978, attorney Thomas Collier filed his powerful brief in federal court.

However, the case was never argued in court. On Tuesday, May 7, the United States government surrendered to Citizen Randall, telling him he could get his marijuana as a research subject under any reasonable conditions he suggested. Through the use of this tactic, the government prevented all of the assembled evidence and witnesses, including glaucoma and cancer sufferers, from appearing in court—and forestalled the probability of a major court decision upholding the rights of our sick to hitherto forbidden medicines.

Since then, on the basis of a negotiated out-of-court settlement, Randall has received a stream of monthly prescriptions from a Washington, D.C., doctor which are filled at a local hospital pharmacy. Mr. Randall refuses to divulge the name of either doctor or pharmacy—because the government insisted on nondisclosure in the settlement agreement. He receives a tin of 300 neatly rolled marijuana cigarettes from the U.S. government every month, and says matter-of-factly that he smokes ten a day.

"Ten? Every day?" I asked incredulously. He explains patiently, "I'm almost impervious to getting high. I marvel at social smokers, who pass half a joint around 20 people.... Everyone's high! ... Ten a day without a break since May of '78." Then he adds that, of course, he no longer is dry in the throat or red-eyed, as are many regular social pot smokers, nor does he have a feeling of different consciousness or loss of short-term memory—or drooling from the mouth, as he believes some people suspect.

I can provide eyewitness testimony that this gentle man in his late thirties, who walks around with his neat government marijuana joints in an old cigarette package, talks and acts as naturally as any person I have ever known. He believes that the only impact that this massive ingestion of the smoke of a normally intoxicating drug has on him now is to reduce his eye pressure and thus prevent him from going blind. When pressed, however, he admits that he is aware that this steady intake of smoke may well cause organic damage such as cancer or heart disease somewhere down the line. Patient Randall chooses now to fight off his blindness and to face up to those other health problems later, if and when they develop. To each day the evil thereof.

Over a period of many hours of discussions, I saw him seemingly disoriented, even slightly, only once. That was when I introduced him to a large university class in April 1985. In my remarks I mentioned Peggy Mann's new book, Marijuana Alert, which had a foreword by Nancy Reagan and a good deal of discussion about how the movement to have marijuana brought back into medicine was a red herring inspired by the marijuana lobby to give pot a good name, particularly to our youth. I then read this section: "In 1979 Robert Randall, who suffers from glaucoma and who is on the advisory board of NORML . . ., sued NIDA.... He won the suit.... It is interesting to note that according to the FDA, despite his professed faith in marijuana as a cure for glaucoma, Randall continues to take traditionally prescribed medications for his disease."

When I read those lines to him, Robert Randall seemed momentarily stunned by the distorted and unkind picture they contained, especially since Ms. Mann had never even bothered to interview him. Ms. Mann was wrong when she implied that NORML had inspired his suit; wrong when she stated that he believed marijuana was a cure; wrong when she implied that he lied that he took only pot and not other medications; and she was even wrong on the date of his suit. At that moment, Bob Randall did indeed appear disoriented—but not as a result of smoking pot.

Those quoted lines were only a small part of a chapter which reveals the cruelty resulting from the drug-war mentality, even when expressed in the apparently loving language of the First Lady. The entire chapter is devoted to the proposition that sick people seeking to obtain marijuana as medicine are either faking or are being used by the drug lobby. It is replete with supporting statements from leading physicians such as Dr. DuPont, who declared, "Today, `medical uses' has become the symbol behind which the pro-pot activists are marching."

LYNN PIERSON: CANCER VICTIM

Bob Randall continues—despite years of record ingestion of a weed that leading medical experts claim should have rendered him totally useless by now—to fight such cruel distortions with intelligence and patience on many fronts. One of his most loved comrades in this battle was a young man named Lynn Pierson, whom he met in Washington in 1977. Lynn was a Vietnam-era veteran who discovered one day in 1975 at the age of 24 that he had testicular cancer and perhaps only six months to live. He underwent surgery and then chemotherapy. The elemental idea behind these powerful anti-cancer drugs is that the body as a whole is more powerful than the cancer cells—since the medicines kill both cancer and healthy cells alike. The hope is that the total body will survive the onslaught while the cancer cells are killed. It does not always balance out that way. All that is certain is that many patients become terribly ill and nauseated from the medicine, some losing all of their hair or going into convulsions.

To convey the real human situation even more precisely, imagine if you will this scene. The cancer patient sits at the dining room table with the pill in front of him or her and thinks, sometimes out loud: I am feeling fine now, but I know if I take this damned pill, I am going to start to feel miserable again. Why should I take this poison for the next two weeks, when the doctor does not know if it will do any good? Screw it! I'll take my chances without it. And so the patient sweeps the pill off the table and flushes it down the nearest toilet, still agonizing about it.

That is what happened to young Lynn Pierson. He simply could not tolerate the harsh impact on his body of the medicines prescribed by his doctors. Then he discovered, at his doctor's suggestion, that smoking marijuana held down his nausea and made him feel able to tolerate the medicines that might, just might, save his life.

Bob is still emotional about Lynn. "The first minute I met Lynn I knew I had been waiting for him to come along," he says. Lynn was a true ally and a good complement to Bob's basically calm nature. Lynn was a fighter from the start, full of rage that he had to go out and buy his medicine illegally. They combined their anger and their drive. Soon, they were talking virtually every night on the telephone from Washington to New Mexico, where Lynn lived. Rather than petition DEA as Bob had done, they decided that Lynn should seek to get a medical-use bill through the state legislature. That would open up a new arena of drug-law reform.

New Mexico was ideal because it was a small state with a narrow media market. The gaunt six-foot-three cancer patient stalked the halls of the legislature, talking to every member, demanding that they pass the bill prepared largely by Bob and himself. The bill passed, and was signed into law on February 21, 1978, the first of its kind in the nation allowing the medical use of marijuana. It was a far-sighted law since it provided that the drug could be used not only for research but also as a simple medicine that would be available virtually to any organically ill patient, including those suffering from cancer, glaucoma, and other diseases. Federal administrative red tape proved more formidable than imagined, however. Lynn continued to smoke illegal marijuana and died in August 1978, never having obtained the medicine legally. He was 27 years old. Three hours after his death, an FDA official called to say that the state's plan had been approved. Even that approval was pulled back because of some technicality by federal officials, who sometimes create bureaucratic obstacles to such programs and always deny they do so. When the program finally we nt into operation a year later, state officials named it in honor of Lynn Pierson.

To continue the nationwide reform effort, Robert Randall created a new organization in 1980, the Alliance for Cannabis Therapeutics, or ACT. It has a single goal—to reclassify marijuana as a medicine. The work of ACT and Bob Randall along with NORML has produced dramatic results. Thirty-three states have approved the use of marijuana for glaucoma and cancer chemotherapy patients. Those state laws alone, of course, do not free up the drug. Federal approval is always needed for each state program, all of which are considered experimental exceptions to the national rule of marijuana prohibition.

On its part and to its credit, the federal government has made a major effort to provide THC pills to a large number of cancer specialists for distribution to those patients who might be helped. The entire program was begun by the Carter administration in the form of a giant research project. The Reagan administration has continued this humane effort and in 1986 went even further when it approved a synthetic THC pill, known as Marinol, for use in medicine as a Schedule II drug. This represented the first time in history that the government had down-scheduled any form of a drug that was originally in Schedule I. However, all other forms of marijuana and natural THC remain mired irrationally in the "prohibited" category. Each of the many thousands of patients receiving the natural THC pills is formally considered a research subject. Thus, even though there is compassion among the drug bureaucrats, the federal legal feet are still planted in the irrational concrete; technically, marijuana remains a Schedule I drug.

THE ONLY ONE IN THE LIFEBOAT

The number of patients who have been able to obtain legal marijuana joints from the federal government for any purpose seems likely to total only in the hundreds. These are primarily cancer patients. While Dr. Edward Tocus, a key FDA decision-maker on this matter, has assured me that there are many glaucoma patients out there who are receiving legal marijuana cigarettes, as opposed to THC pills, and while I want to believe him, he could not name any, nor have I yet found one. I suspect that some glaucoma patients have received joints for a while in research projects, but did not use them for long, certainly not for a period of years. So far, Bob Randall apparently remains virtually alone in terms of longterm use, as he claims.

That bothers him. He told me that he keeps asking, "Why am I the only one in the lifeboat?" To enlarge that boat and to haul others into it, ACT has pushed a federal bill that would reclassify marijuana as a Schedule II drug. When Rep. Stewart McKinney (R-Conn.) reintroduced the bill on March 23, 1983, he estimated on the basis of federal data that at least 500,000 sick people would benefit from legal joints every year-50,000 chemotherapy and 50,000 radiotherapy patients who normally suffer intense nausea, plus 400,000 glaucoma victims.

Said one of those victims recently, "If we can find something better than my smoking ten joints a day, I am all for it." In the absence of that discovery Bob Randall continues to smoke his marijuana, to lobby for humane legal reforms, and to counsel many patients who call him for guidance and caring words from all over the country. When I asked him what reflections he had about his status as a victim of the war on drugs, he objected to my threshold thought. The manner in which he explained his objections raised my spirits as have few statements from people I have interviewed in recent years. He reminded me that he had beaten by a couple of country miles the medical prognosis of 1972 that he would be blind in three to five years.

Then Robert Randall continued: "I have been victimized but I am not a victim. Most of the people who call me for advice are victims.... However, I win every day. I can still see. Seeing is winning."

JOSEPH HUTCHINS: TRYING TO GET INTO THE BOAT

Joseph Hutchins is one of those people who have called Bob Randall for guidance on how to get into that lifeboat. Up to now, Mr. Hutchins remains a victim of the drug war. Mr. Hutchins's story explains why there is a need to establish explicitly the right of all patients to receive officially hated drugs in medicine for a wide variety of illnesses, including some that few drug-abuse experts have ever even heard about. Scleroderma, for example. I could claim total ignorance of the disease until early in 1985 when Kevin Zeese of NORML told me that the organization was trying to help a fellow in Massachusetts who claimed that marijuana was helping him fight off the ravages of a rare disease that affects few people, perhaps 250,000 in the entire country. I first met Joe Hutchins at the 1985 NORML convention in Washington, D.C. He is a tall, straight-arrow fellow, 41 years old, with a strong Bay State accent that reminds me of home. I learned that he was divorced and lived with his girlfriend a few miles from his ex-wife and three teenage children, with whom he had a good relationship, in the northeast corner of Massachusetts near Newbury and Newburyport. That day I heard Mr. Hutchins plead with the members of NORML to help get laws passed that would allow him to use the medicine that was keeping him functioning.

Joe Hutchins believes he contracted his disease while serving in the Navy in the Caribbean during the Cuban missile crisis of the early Sixties. Also known as progressive systemic sclerosis, scleroderma is a tissue disease that literally means "hardening of the skin." Neither the cause nor a cure is known, although it is known to be fatal to some sufferers. The Navy discharged Hutchins because of his illness but he was still able to work. From 1969 to 1978 he worked as a machinist at the General Electric plant in Lynn and had an excellent performance record. By 1978 his disease had progressed to the point where he had to stop working. The Veterans Administration then began paying him a 100 percent disability pension and he also commenced receiving Social Security benefits. Thus he had no great financial problems. However, his illness remained severe and he was placed on a wide variety of narcotics by his doctors, who were fighting a battle to hold back the unknown effects of the disease.

In November 1973, ten years after the initial diagnosis, his doctor, John G. Sullivan, chief of surgery, St. Elizabeth's Hospital, Boston, advised him that it was necessary to remove his esophagus and replace it with a segment of his intestine so as to restore his ability to swallow. His body was, in a word, disintegrating. So also was his mind, for he was disoriented by the array of legal prescribed drugs, including Darvon, Valium, and Ritalin, that he was taking every day. "I was a vegetable," Joe Hutchins told me. He considered himself a legal drug addict and a guinea pig for the Veterans Administration doctors who were attempting to treat him.

Some friends suggested that marijuana might help to relieve his symptoms, which included nausea, vomiting, loss of appetite, inability to swallow, hypertension, and anxiety. It did (which should have been no surprise to anyone with a knowledge of the history of the medicine). Accordingly, for a decade now, this American citizen has been obtaining illegal marijuana and treating himself more effectively than some of the best medical talent in the country had been able to do. Joe Hutchins found that he could lead a relatively normal life, that he had an appetite, and that he could keep his food down. The surgeon's knife was not necessary nor were narcotic drugs. All of those powerful treatments were replaced by one infinitely less drastic, marijuana—plus one regular prescribed medicine to control his blood pressure. His doctors have signed affidavits swearing that while they did not understand the precise process, marijuana seemed to have some relationship, in the words of Dr. Sullivan on June 25, 1985, to "Mr. Hutchins's remarkable remission."

His psychologist, Dr. Stephen Boy of Haverhill, has stated that it was impossible to draw any broad conclusions from Joe's case. Yet, he stated emphatically, "His emotional and physical situation are probably better than they have been in 20 years." Then Dr. Boy added a significant observation: "If I were diagnosed with scleroderma and had symptoms like Joe's, I would think about using marijuana."

None of this powerful human testimony or medical evidence has impressed the legal authorities of the sovereign Commonwealth of Massachusetts. On October 29, 1984, Newbury police chief George Riel led a raid that netted a claimed five pounds of marijuana, including two of high-grade sinsemilla, at the home of Joseph Hutchins. Although no buyers of his medicine have ever been produced, the chief lodged the felony charge of "possession with intent to distribute" and supported a $5,000 bond and the threat of a five-year sentence. Mr.Hutchins was kept in a cold cell all night without a blanket; the cold and his poor circulation left "my feet and hands black all night." He has consistently claimed that he had grown the marijuana in his backyard for his own use because his VA doctors had refused his persistent written demands that it be prescribed legally and because he did not want to purchase it on the illegal market. The police had taken, he said, his "entire winter supply" which he had just harvested.
The police action was consistent with the views of many medical experts who doubt the efficacy of Joe Hutchins's illegal medicine. The established medical opinion is that marijuana is a questionable treatment for scleroderma. One of Joe Hutchins's own doctors, Juan J. Canosa, then chief of rheumatology at the VA Medical Center in Boston, has stated he was "skeptical" of the beneficial effects of marijuana in dealing with the symptoms of his patient's disease. That skepticism accounted for the fact that Dr. Canosa never supported his patient's requests to him for access to federally grown marijuana.

At Hutchins's trial in Newburyport District Court on July 24, 1984, Judge Francis P. Cullen refused to allow the defendant to present the defense of medical necessity, which would have been supported by an impressive group of expert witnesses, including Dr. Norman Zinberg of Harvard Medical School. In a bench trial without a jury, the jurist convicted Mr. Hutchins of the serious offense of possession with intent to distribute. Judge Cullen also ordered him committed to a state psychiatric hospital for 40 days' observation because Joe had testified that he had been suicidal years earlier while on the VA medicines. The staff soon saw that this was unfair and unnecessary—and released him after 15 days. Shortly thereafter, a sentence was imposed: two years of probation and a $400 fine. The criminal appealed for a new trial—which is allowed in such cases under state law—in Haverhill District Court, whereupon in October 1985 Judge William Sullivan also refused to hear the defense of medical necessity and sentenced Joseph Hutchins to 30 days in the House of Correction.

During a brief stay of that sentence, Mr. Hutchins made urgent calls for assistance around the country, including one to Kevin Zeese of NORML in Washington. Mr. Zeese contacted one of the most prestigious law firms in the country, Covington and Burling of Washington, D.C. Lawyers David B. Isbell and Michael G. Michaelson, who is also a medical doctor, entered the case pro bono on behalf of Joe Hutchins, arguing in their first memorandum of law filed in November 1985 that the defense of medical necessity should be heard. A judge issued another stay of the sentence and the case is now on appeal.

The lesson of Joe Hutchins's torment is not simply that marijuana should be reclassified as a legal medicine for any sick person who might benefit from it. That indeed is part of the lesson but the narrowest element of it. The broader lesson is that his ordeal illustrates the immense amount of intolerance and ideological bias regarding all drugs and drug users that must be overcome even to begin to help the sick people who are victims of the drug war.

I saw face-to-face and felt directly a small piece of that inhumanity on October 30, 1985, during a live television show, "People Are Talking," in Boston on WBZ-TV regarding the subject of making so-called street drugs legal. Representatives of the drug-freeyouth movement had been invited to sit in the audience. So also had been local resident Joseph Hutchins. As fate would have it, the quiet man, in suit and tie, was seated amidst the anti-drug crusaders, immediately next to a proper, middle-aged Massachusetts matron. During the show, I pointed out that one of the worst aspects of the war on drugs was that sick people were sometimes made to obtain their medicines illegally—and that one of these hapless victims was sitting in the audience.

I also observed that I sympathized with the concerns of the drug-free-youth movement and that I believed that many of the parents and leaders were quite decent people. "You say they're decent people, but they say—I've been talking to them during the break—that anyone who supports legalization is probably a drug user," countered host "Buzz" Luttrell. The implication was made clear by the anti-drug representatives present: users' minds and judgments were twisted as a result of the chemicals they took and thus they were not decent people, a category into which Kevin Zeese and I, sitting at the front of that audience, should also be placed.

Mr. Hutchins then was given the opportunity to explain his disease and the treatment he received. "The Veterans Administration gave me a regimen of drugs for seventeen years which ruined my life. The side effects took my mind away," he explained. Mr. Luttell asked, "Marijuana doesn't do that?" Joe replied, "Marijuana doesn't do that." The people sitting around the sick man started to smirk, some to laugh openly.

Buzz Luttrell turned to that Massachusetts lady sitting next to Joe and asked, "Why are you laughing?" "Because marijuana is a mind-altering drug," she replied, seeming to imply that Mr. Hutchins was pulling a grand scam to obtain his recreational drug of choice; clearly, he also was not a decent person—and perhaps he was unable to think clearly due to the drug.

I interjected from the front of the studio, "Do you want him in jail, ma'am?"

The drug-free matron shot back at me, "That's a crock! In plain English. The major drug traffickers aren't in jail. Don't tell me people go to jail for using marijuana!"

"I just got sentenced to jail for using marijuana," Mr. Hutchins quietly told his neighbor.

She replied, "I don't believe it.... Anybody who needs marijuana for medicine can get it!"

One of the most important launching pads for the reform of American drug laws should be the reality underlying this Boston lady's disbelief. There should be no reason to believe that any sick person would face jail in America for seeking to obtain medicine. Nor is there any reason for that threat to continue to exist in a civilized society.

* Dr. Foley is a caring doctor and a committed pain researcher. Our emotional interchange illustrates how there can be heated, honest disagreement over these issues of life, death, and human suffering. The doctor is also a courageous professional reformer in her own way. In 1986, Dr. Foley and Dr. Russell Portnoy of Sloan-Kettering published a seminal article in the professional journal PAIN reporting on an experiment with 38 patients. Among its radical conclusions: opiate maintenance of patients with chronic pain, not involving a terminal illness, was appropriate over the long term. The drugs were powerful narcotics currently available in American medicine. While some doctors and laymen alike may ask "so what?" the report was a breakthrough for American medicine, and the application of its recommendations would have saved Dr. Rose and many other doctors and patients much agony.

* I am reluctant to push such comparisons too far because the items compared involve such murky data. Some estimates talk of all "narcotic" addicts rather than only "heroin" addicts. Since heroin is only one of the narcotics addicts often use, the comparisons become quite imprecise. More imprecision is found in the fact that few people are willing to reveal their bad habits to researchers and government officials. Thus, the estimates are based on guesses about hidden activities. For what it is worth, however, official estimates state that there are perhaps 500,000 heroin addicts in the United States out of a population of 238,900,000-209 per 100,000 of population. This is over three times the English rate of 62 per 100,000, based on 35,000 addicts and a total population of 56,400,000. I have made other calculations over the years that have produced vastly higher rates of addiction in the United States as compared to England. I have confidence in the precision of none of these calculations by me or anyone else—and believe that all we know with certainty is that the addiction problem is much worse in America than in England.