WASHINGTON - Paul Boone says he never intended to start smoking marijuana. But last summer, when the cancer that was attacking his liver made him so nauseated that he lost 40 pounds, he became desperate.
So the 35-year-old computer consultant searched the Internet for a local head shop. He drove to Fells Point, bought two pipes and called a friend who had offered to find marijuana for him. In September, when he lighted up for the first time, the relief was almost instant, he says.
"I couldn't believe how fast it stopped my nausea," says the Harford County resident, who has since regained 20 pounds despite six rounds of chemotherapy. "I still can't believe it works. I didn't believe it at the time."
Boone is one of many patients in Maryland and across the country who say they have come to depend on marijuana as part of their treatment. Cancer patients smoke it to cope with the effects of chemotherapy, AIDS patients to stimulate hunger and gain weight, and people suffering from neuromuscular disorders to ease pain and muscle spasms.
The growing demand of such patients for marijuana has led to a striking reform of state criminal laws. In the past five years, eight states have approved measures allowing patients with certain medical conditions to smoke marijuana under a doctor's supervision. Legislatures in five other states, including Maryland, have begun to consider the matter.
But the federal government continues to classify marijuana as a Schedule I narcotic, meaning that its use is a crime under any circumstances. And in a case pending before the Supreme Court, the government is trying to undercut the state measures and put an end to the medical use of pot.
The case involves six "cannabis clubs" that sprang up in California after the approval of Proposition 215, the first of the state initiatives to legalize medical marijuana. Started by local activists, the clubs began growing marijuana and selling it to patients whose doctors had cleared them to use the drug.
Local officials gave their blessing to that arrangement, and county prosecutors agreed not to interfere. But the Justice Department sued three years ago to shut the clubs, saying their activities violated federal laws against possessing or distributing marijuana.
A U.S. district judge initially granted the government's request. But after being reversed by an appeals court, he ruled that the clubs could continue to serve patients who faced imminent harm and had no other choice. The government appealed to the Supreme Court, which will probably issue a decision by early summer.
The stakes are high. If the court sides with the government, it will significantly disrupt the medical marijuana movement. Though the case involves only the right of clubs to distribute marijuana - not the right of patients to smoke it - closing the clubs would leave patients with no legitimate source.
If the court rules for the clubs, it could put a stamp of legitimacy on medical marijuana. It could also rejuvenate efforts to legalize its use for patients nationwide.
"It would be tremendous," says Alan St. Pierre, executive director of the National Organization for the Reform of Marijuana Laws. "It would galvanize and institutionalize the concept that marijuana is medicine."
When the case was argued before the Supreme Court last month, the justices sent conflicting signals. A few appeared sympathetic to the claim that marijuana is sometimes medically necessary, but others seemed skeptical. And some justices, while allowing that the drug might have benefits, questioned whether it was possible to distinguish between those patients who need it and those who simply enjoy it.
The dispute among the justices reflects a larger societal rift. Since rising to national attention in the late 1980s and early 1990s, the medical use of marijuana has been vigorously debated.
Supporters say marijuana is an ancient remedy that has been classified unwisely as a dangerous drug. They say it stops nausea, stimulates hunger, relieves pain and soothes nerves, all of which can help the seriously ill cope with their diseases and the often brutal treatments for them.
They also argue that marijuana is valuable in treating glaucoma, epilepsy and multiple sclerosis.
Most opponents don't deny that marijuana provides benefits. A study commissioned by the federal government concluded that the drug has "potential therapeutic value." But they argue that any benefits are outweighed by other considerations.
For one thing, critics say, smoking marijuana - like smoking tobacco - can lead to lung cancer and other respiratory diseases.
They also argue that marijuana has undesirable side effects, such as paranoia and dizziness.
Their biggest fear is that the medical use of marijuana would increase drug use in general. They express particular concern that if children saw adults smoking pot to treat illnesses, they would be encouraged to smoke it themselves.
"When we have mixed messages on the street, that has an impact on kids," says Robert L. Maginnis, a vice president at the Family Research Council, which supports the government's case. "It's a public policy trade-off.
"If officials excuse the use of marijuana for a limited number of people, they risk the negative impact on a particular segment of the population."
Maginnis argues that the government should not run that risk until it has exhausted other options. He notes that researchers are studying ways to replicate the benefits of marijuana without the hazards. Until they succeed, he says, other medicines can help patients cope with their suffering.
Hormone pills, for instance, help build muscle mass and increase weight, and prescription drugs such as Zofran ease nausea. Marinol, a drug that contains one of the active ingredients of marijuana, helps stimulate hunger.
Doctors say such drugs have drawbacks. Testosterone causes mood swings and often leads to prostate enlargement, which, some doctors fear, raises the risk of prostate cancer. Zofran costs about $30 a pill.
Many patients say Marinol makes them sleepy. In addition, it takes up to two hours to start working. Marijuana provides almost instant relief.
"I have yet to meet a patient who has used both marijuana and Marinol who will say that Marinol is better or as good," says Lester Grinspoon, a Harvard psychiatrist who interviewed dozens of patients for his book, "Marijuana: The Forbidden Medicine."
Dale Cunningham, an acquired immune deficiency syndrome patient in Virginia, agrees.
"I have been prescribed Marinol," says Cunningham, who is often nauseated from the 27 pills he must take daily. "I've tried Compazene. I don't know, the list goes on. But the only thing I've found that helps is natural marijuana."
The debate over medical marijuana has been conventional in many ways, with conservatives on one side and liberals on the other. But there have been surprises. Some who support medical marijuana are self-described conservatives who reversed field once they became sick or met someone who was.
Del. Donald E. Murphy, a Baltimore County Republican in the Maryland House of Delegates, says he never considered legalizing pot for medical use before being introduced to Darrel Putman, a former Green Beret who developed non-Hodgkin's lymphoma. But when Putman described how smoking marijuana had allowed him to gain the weight he needed for a vital operation, Murphy was persuaded.
He promised Putman he would introduce a bill to legalize medical marijuana if Putman would testify before the General Assembly. The former soldier died before he could do so, but Murphy went ahead with the proposal anyway. Now, he finds himself defending the proposal against fellow conservatives who think he's gone soft.
"This is very much a conservative position," Murphy says. "You trust a person with a deadly weapon, but not with pot for cancer. It's certainly not as deadly as a firearm."
Murphy's bill stalled in the legislature this year, in part because of uncertainty about how the Supreme Court would rule on the California cannabis clubs. He plans to reintroduce it next session and says a favorable Supreme Court ruling could give it a boost.
In the meantime, he has recruited another patient to take Putman's place as a witness. He heard the story of Boone, the Harford County man, on a radio call-in show last year and was so moved that he asked him to appear before the General Assembly.
Boone says he's an unlikely spokesman for the medical marijuana movement. Though he tried marijuana once in high school, he has always opposed drugs and used to think that medical marijuana was just an excuse for "hippies" to get high.
When he became ill and got no relief from other medicine, Boone says, he changed his mind. Now, he's frustrated that a drug that helps him so much is still illegal. "I'm not a kingpin or anything," he says. "I'm just a guy with cancer."