most of which focused on relieving chemotherapy-induced nausea. Many of the mostly older participants in such trials dropped out after having adverse reactions to smoked marijuana (see Chapter 6). Other patients and their physicians were discouraged from participating by the burdensome paperwork involved. The fate of several moribund state programs was then sealed with the 1985 approval of dronabinol (Marinol), which led state boards of health to conclude that marijuana was obsolete as a medicine. As a result, by the time the spread of AIDS produced a new group of patients seeking help from marijuana, neither state nor federal Compassionate Use programs were available to them.

The demands of these patients, along with a general increase in marijuana 's medicinal properties, led voters in California to pass a state medical marijuana initiative in 1996. Known as Proposition 215, it permits patients and their primary caregivers, with a physician' s recommendation, to possess and cultivate marijuana for the treatment of AIDS, cancer, muscular spasticity, migraines, and several other disorders; it also protects them from punishment if they recommend marijuana to their patients. Since 1996, voters in five other states —Alaska, Arizona, Nevada, Oregon, and Washington as well as the District of Columbia—have approved similar measures, all in direct conflict with federal law. (Although exit polls indicated that voters in the District of Columbia approved the measure by a 69 percent majority, Congress refused to allow the ballots to be counted and nullified the referendum.)

Time has shown, however, that medical marijuana initiatives are much easier to pass than they are to implement. As long as marijuana remains in the federal government's Schedule I, the threat of prosecution to anyone involved with its procurement or use has deterred all but a minority of doctors, patients, and providers of medical marijuana from establishing public distribution contemplated by the new state laws.13

For physicians the potential consequences of recommending marijuana to patients include the loss of DEA licenses to prescribe controlled substances as well as cancellation of Medicare and Medicaid contracts. These were among the threats made by federal officials to California doctors following passage of Proposition 215, and they have apparently served to deter many physi-



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