University Of Califoria, San Francisco School of Medicine Please address reply to the undersigned at: UCSF AIDS Program San Francisco General Hospital 995 Potrero Avenue Building 80, Ward 84 San Francisco, California 94110 April 28, 1995 Alan I. Leshner, Ph.D Director National Institute on Drug Abuse 5600 Fishers Lane Rockville, Maryland 20857 Dear Dr. Leshner, I am writing in response to your letter of April 19 regarding my request that NIDA consider supplying marijuana for the Community Consortium's proposed study in patients with HIV-related wasting syndrome. I was not only disappointed by the flat out rejection of the request, but also by the way this matter has been handled by your Institute from the onset. To receive the first communication from your office nine months after we sent the initial submission is offensive and insulting. I realize that this has been a very difficult decision for you to make because of all the nonscientific issues involved, but I am certainly not used to having no communication at all for nine months from someone with whom I had corresponded on an official matter. The apparent abscence of any possibility to discuss your concerns and to modify the protocol appropriately so that we may work together for the benefit of our patients is also unacceptable in my opinion. The National Institute on Drug Abuse has not been the first body to review our proposed pilot study. It has been reviewed and approved by the Committee on Human Research of the University of California, San Francisco, as well as by our own Scientific Advisory Committee and Community Advisory Forum. In addition, the study has been approved (pending location of the source of inhaled marijuana) by the California Research Advisory Panel. The US Food and Drug Administration has also been involved since the onset in developing the trial and has strongly influenced the study's design. The General Clinical Research Center at San Francisco General Hospital has agreed to collaborate in the study by providing dietary counseling and monitoring of patients, as well as performing the state-of-the-art composition measurements we intend to perform. Collaborating investigators at Chiron Corporation were also eager to participate in this study by donating their newly developed technology to assess HIV viral burden in patients randomized to receive marijuana. Hence, your concerns about the scientific merit of the study have not been shared by a number of competent reviewers and investigators. To respond to your concerns in a timely manner, I will address each issue you raise in turn. However, it is important to stress that this trial was designed as a pilot study to determine the feasibility of conducting a larger study and, in particular, the sample size required to evaluate the efficacy of inhaled marijuana. As you know, the use of a pilot study in clinical research is a well-established procedure. I am sure you would agree that it is a prudent strategy to conduct a small pilot trial of inhaled marijuana prior to launching the definitive efficacy trial that would require a much larger sample size. We fully appreciate that the current pilot study would not be adequate to "make any inferences regarding the dose-effect relationship." However, we would be able to determine whether a dose was associated with an intolerable rate of side effects, and that dose would then be eliminated from a larger efficacy trial. As indicated in the protocol, we plan to do intensive monitoring of pulmonary and immune function as well as HIV viral load in our patients. If we saw that inhalation of marijuana was detrimental to any of these parameters, that information would be crucial to share with others in order to protect the safety of patients who are already using inhaled marijuana (from other sources). The current pilot study certainly should be large enough (with 30 patients smoking marijuana) to assess such possible detrimental effects. The Community Consortium conducts community-based clinical trials of treatments that are being widely used by the patient population and, as I am sure you are aware, individuals with access are currently utilizing inhaled marijuana. Our aim is to assess the impact of treatments that we study in "real world" situations. As you know, with whatever drug one studies in a clinical trial, we can never be truly certain that patients are consuming 100% of their assigned doses. Even for treatment of Pneumococcal pneumonia, very few patients treated actually complete their full course of penicillin. Similarly, zidovudine (AZT) was approved as the first antiretroviral agent for treating HIV infectioin, and we know that compliance in those trials was not 100%. In our study, we plan to ask patients to quantitate how much of their allotted marijuana they smoked on any given day. We also plan to have patients return any unused marijuana so we can assess how much they actually usilized. Whether they actually smoked all that they were given at each visit is irrelevant when an intent-to-treat analysis is utilized for data analysis. Your concerns about total daily caloric intake and "the percentages of the composition of the foodstuffs" are a bit extreme, in my opinion, but do not present insurmountable problems for us. As the General Clinical Research Center at San Francisco General Hospital is our collaborating site where patients will go to be taught how to use the water pipe for inhalation, and where they will return for all of their follow-up evaluations, obtaining this dietary information is certainly possible. In fact, this is the sort of information that the GCRC specializes in collecting! Though we could add this requirement, it would be a major inconvience to these already ill patients to ask them to collect this information on a daily basis during the trial. Of course, another option is to admit all patients on the study to the GCR for the duration of their participation in the study, so that all intake and output can be accurately assessed. Once again, however, that is not how patients would be living while they utilized the intervention in the real world, so the value of data obtained in this fashion is, in my mind, unclear. It certainly does not reflect the "real world" usage. As an AIDS investigator who has worked closely with National Institutes of Health and the US Food and Drug Administration for the past 14 years of this epidemic, I must tell you that dealing with your Institute has been the worst experience of my career! The lack of any official communication for nine months is unheard of, even in the most cumbersome of government bureaucracies. In fact, I was so shocked to finally receive your communication that I failed to detach the green postcard to verify receipt. I apologize to you, and to your staff who called for three consecutive days to make sure the letter had arrived. Finally, the "sincerity" with which you share my "hope that new treatments will be found swiftly" feels so hypocritical that it makes me cringe. Believe it or not, I wish I had never needed to approach NIDA with this request. The Community Consortium had a source of marijuana established for this study from the onset. Unfortunately, the source was foreign and the FDA advised us that the DEA was having difficulty with the importation issue and suggested we contact you. (The DEA has also been less than forthcoming in responding to my request for a Schedule I license sent to them April 15, 1994.) Obviously, your letter leaves no door open for further discussion as to how this pilot study could be modified so that we could work together. Hence, I will not bother you further. Your letter will be widely distributed. You had an opportunity to do a service to the community of people living with AIDS. You and your Institute failed. In the words of the AIDS activist community: SHAME! Sincerely, [signed] Donald I. Abrams, M.D. Chairman, Community Consortium Assistant Director, AIDS Program San Francisco General Hospital Professor of Clinical Medicine University of California San Francisco cc: Philip R. Lee, MD Harold E. Varmus, MD