When TV's Murphy Brown lit up a joint to puff away her chemo-induced nausea, the sitcom-viewing public got a dose of marijuana's medicinal potential. But despite a 1999 government report concluding that marijuana is effective not only for nausea but also for pain relief and appetite stimulation, cancer and AIDS patients are unlikely to hear about pot's benefits from their doctors. They also still risk arrest by federal agents if they use pot, even in states that have decriminalized possession for medicinal purposes.

The doctor treating San Francisco breast cancer survivor Judith Cushner, for example, never suggested to her that marijuana was an optional treatment to relieve the side-effects from her chemotherapy: severe retching and unremitting nausea, loss of appetite and energy, joint pain and loss of sleep.

Instead, her doctor prescribed more traditional drugs - which only created new side-effects. She had an allergic reaction to a shot of Compazine -- her heart raced and she got so weak she could barely make it out of the doctor's office and into the elevator. Another drug made her woozy. And Marinol, the so-called "pot pill" approved for use in 1985 by the U.S. Food and Drug Administration (FDA), made her very drowsy. Despite its nickname, Marinol is not the synthetic equivalent of marijuana. It contains only THC, one of about 60 active ingredients in marijuana known as cannabinoids. The role of the other cannabinoids in producing the effects of smoked marijuana has yet to be fully explored.

For Cushner, a pre-school director and mother of two children who were 13 and 11 at the time, constant drowsiness "was not okay. I wanted to be able to at least feel like I could be there for [my kids], but the more vulnerable they saw me, the more difficult it was for them -- and the more difficult it was for me. After taking Marinol, I wasn't even able to go to work."

Cushner was so debilitated that she considered terminating her cancer treatment altogether, a decision that might have cost her life. Then Cushner tried pot at the suggestion of a pediatric oncology nurse. After each chemotherapy session, she'd go home and take two or three puffs from a joint when her children weren't around. Her appetite and energy returned, and the nausea dissipated.

In light of a recent report by the Institute of Medicine (IOM), Cushner's experience is not surprising. The IOM reported last March that pot is useful for treating cancer pain, chemotherapy-induced nausea and vomiting, and the poor appetite and wasting caused by AIDS or advanced cancer. (The IOM is a branch of the National Academy of Sciences set up by Congress to advise the government on health policy issues.)

DOCTORS SILENCED

In an ideal world, doctors and patients make medication choices based on greatest efficacy, fewest side effects, and sometimes cost. But when it comes to marijuana, these criteria generally go up in smoke.

Under federal law, marijuana is listed as a controlled substance in the same category as heroin. Even in states that have passed medical marijuana laws, federal agents can still arrest people who use it for medicinal purposes. And doctors in "pot-friendly" states who prescribe marijuana face the threat of criminal prosecution. The Justice Department insists that doctors are not free even to discuss marijuana's medical benefits with their patients.

A class action lawsuit against the federal government's marijuana policy is pending, but a preliminary injunction against the feds is currently in force. According to Jonathan Weissglass, an attorney representing some of the plaintiffs, the case will clarify the free-speech rights of physicians to discuss medical options with their patients.

Four states -- Alaska, California, Oregon and Washington -- have passed laws decriminalizing possession of marijuana by ill people who have a doctor's prescription. Other states also have passed such measures, but they are either expressions of intent that do not remove criminal penalties for possession or have not taken effect for a variety of reasons. Nevada's proposition must be put to a second vote this year before it becomes law. About 20 other states have medical marijuana laws on the books, but they do not remove criminal penalties for possession, according to Chuck Thomas, a spokesman for the Marijuana Policy Project, an organization lobbying to reform marijuana laws.

In response to these state actions, the Office of National Drug Control Policy issued a strangely contradictory statement about medicinal marijuana, revealing that the feds are still trying to hash out a coherent policy. "The results of these referenda in no way alter the status of marijuana under federal law," the statement read, adding that, "The U.S. medical-scientific process has not closed the door on marijuana or any other substance that may offer potential therapeutic benefits." It went on to say that marijuana should be subjected to the same "rigorous" process for acceptability as a medicine as any other substance.

The IOM has called for additional research on pot to further establish its safety and efficacy, and the Clinton Administration responded by announcing that it would make government-grown pot available to private researchers. This change should have made it easier to conduct research, but other new policies continue to make it harder to conduct research on pot than any other pharmaceutical drug.

"The new federal guidelines still place a much greater burden on medical marijuana researchers than on drug companies that develop and study newly synthesized pharmaceuticals," says Thomas. Researchers working with hemp, for instance, have to seek approval not just from the FDA, but also from the National Institute on Drug Abuse (NIDA) and the Public Health Service, before marijuana can be purchased from NIDA. And that agency can't even guarantee a supply will be available for legitimate research.

Even the notion of what is "legitimate" research has been narrowed for marijuana. The Department of Health & Human Services says studies should be limited to the treatment of serious or life-threatening conditions for which there are no other FDA-approved therapies. This rule applies regardless of the seriousness of the side-effects of these approved therapies.

CURBING 'COMPASSIONATE USE'

The IOM also recommended that patients in dire need should be able to get marijuana through the FDA's compassionate use program. This program allows patients to use a drug before it has passed the complete approval process if it appears to be safe and beneficial. Many AIDS patients have gained access to new drugs, many of them toxic, for years through this program. In contrast to the toxicity of AIDS drugs, marijuana use has never been known to cause a single death, and the IOM report noted that "few marijuana users become dependent" on pot. Furthermore, the Institute said that withdrawal from use of pot "is mild and subtle compared with the profound physical syndrome of alcohol or heroin withdrawal." On the downside, the report warned of potential lung damage from smoking marijuana.

Despite this relatively benign report on the potential dangers of marijuana, The Department of Health & Human Services has issued complex research guidelines that bar patients from obtaining marijuana under the compassionate use program. The reason for this, according to the agency, is that giving marijuana to patients "would not produce useful scientific information."

Only one study of the safety of medical marijuana -- on the interactions between protease inhibitors and pot -- is currently under way. The National Institutes of Health funded it after researchers from San Francisco General Hospital wrangled with government agencies for five years.

FDA approval for marijuana as medicine seems unlikely and distant. It takes hundreds of millions of dollars to fund the approval process, and the IOM report cautioned that "cannabinoid-based drugs will only become available if public investment in [such] research is sustained" by private enterprise. Such investment is as unlikely for smokable marijuana as it is for vitamin C or any other non-patentable substance. Michael Onstott, director of the National AIDS Nutrient Bank, thinks developing a patentable form of marijuana could be difficult as well. "This is a very complex botanical drug, and to isolate all 60 cannabinoids and then to develop a delivery system -- the cost is unknown."

The American Medical Association takes the position that marijuana should remain a controlled substance until studies of its medicinal uses are completed. At the same time, however, the group's official statement says that discussions between doctors and their patients of treatment alternatives "should not subject either party to criminal sanctions."

THE LAW IS THE SIDE EFFECT

When Judith Cushner talks about the downside of smoking pot, it's not the physical side effects she describes at all, but the effect its illegality had on her family. (Cushner's cancer treatment pre-dated California's medical marijuana law.) At school, her son had heard a uniformed police officer say that all drugs were bad and that using them could land a person in jail. When he subsequently discovered his mom smoking pot, "he just freaked out," she says. It was traumatic enough seeing his mother lose her hair; now he had the additional worry she would be carted off to jail.

Since the days when Cushner was going through chemotherapy, new and more effective anti-nausea drugs have been developed. Dr. Debu Tripathy, an oncologist specializing in breast cancer at the University of California at San Francisco, says the new serotonin receptor uptake inhibitors leave about 80-percent of patients free of nausea.

But what of the 20-percent of patients who don't respond to them? In one of the few studies to look at smokable pot, 78-percent of patients whose nausea did not respond to standard anti-nausea drugs, not including Marinol, found some relief from marijuana. There were 56 patients in the study.

Most Americans apparently feel doctors should be able to discuss marijuana with their patients. A Lindesmith Center poll found that 60 percent of Americans favor allowing doctors to prescribe marijuana for medicinal purposes for seriously- or terminally-ill patients. And, according to the American Civil Liberties Union, 60 percent of Americans don't think patients should get arrested for using medical marijuana.

Those supporters include San Francisco Assistant District Attorney Keith Vines, the last person any medical marijuana coalition thought would join its side. He describes himself as a former "foot soldier in the war on drugs," an eager prosecutor of drug offenses. But Vines is HIV positive, and had wasted from 200 to 150 pounds by the time he enrolled in a human growth hormone study in 1993. In order to give the hormone a chance to rebuild muscle mass, he had to eat three meals a day. He tried Marinol to spark his appetite, but it made him too stoned to work. So one Friday night, still dressed in his suit and tie, he went straight from the D.A.'s office to a cannabis buyers club. "It was a pretty terrifying moment for me -- I was wasting. You could see bones in my body. But I realized that as a prosecutor, I was in jeopardy."