marijuana before—have reported that smoking marijuana or taking oral THC made them feel so uncomfortable that they never wanted to use either drug again. Rather than calming them, marijuana or THC seemed to make these people even more anxious; they also described feeling dizzy, disconnected from reality, even psychotic. According to medical marijuana advocates, such patients rarely experience adverse psychological reactions if they are given adequate guidance about what to expect before using marijuana for the first time. This claim has not been objectively tested, however.

The fact that the psychoactive effects of marijuana vary widely from user to user must be anticipated among the potential side effects of any marijuana-based medicine. Unquestionably, marijuana compromises users' cognitive abilities but it remains to be determined whether long-term marijuana or cannabinoid use actually causes structural damage to the brain (see Chapter 3).

REDUCING MARIJUANA'S RISKS

While the possibility of cognitive impairment may deter some people with HIV from using marijuana-based medicines, this hazard pales in comparison to the health risks incurred by smoking marijuana. As discussed in Chapter 3, harmful smokeborne chemicals and contaminants in crude marijuana can represent a serious danger to anyone with a weakened immune system. Research indicates that people with HIV who regularly smoke marijuana suffer higher rates of opportunistic infections and Kaposi's sarcoma.

Smoking is a very efficient way to get the active chemicals in marijuana into the bloodstream, but the long-term damage smoking causes makes it a poor drug delivery system, particularly for patients with chronic illnesses such as HIV. By comparison, oral cannabinoid preparations, such as Marinol, are slow acting and difficult to dose properly. A safe and effective alternative to both routes might be a smokeless inhaler that delivers cannabinoids in an easily absorbed aerosol spray. Such devices, which are already used to administer antihistamines and asthma medications, might



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