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Rocky Hoveland of Greensboro suffers pain from spine, neck and back injuries.

For a long time, he took prescription painkillers. But the drugs often left him dazed, if not null and void.

Then about 10 years ago, he began using marijuana to treat the pain. He found that it didn't eradicate the pain, but it made it more manageable.

"It keeps me from being in that haze of wanting to sleep all day or feeling hung over all day," he said. The prescription medications "were making me lay down, and I ain't one to lay around."

Hoveland and others like him are pushing for North Carolina to legalize cannabis for medical purposes. And they have become part of a national trend.

In November, Michigan became the 13th state to legalize marijuana for medical purposes.

That popular-vote referendum was just the most recent decision in a long-running debate: whether it should be legal for people to use, grow and sell marijuana for medicinal purposes.

On one side: sick, suffering patients, many of

whom are dying. For at least some of them, cannabis eases symptoms of illness or side effects of treatment.

On the other: a federal government that believes marijuana's benefits are too few and its side effects too risky for the drug to be legalized, even to the highly restricted level of cocaine.

Billy, a Davidson County man who didn't want his full name used , once took the prescription painkiller Dilaudid every day after lingering neck and wrist injuries, experiencing some of the same side effects as Hoveland.

Dilaudid "didn't do much" for the pain, he said. "And I got hateful. My family didn't want to be around me."

Marijuana has helped him, too, he said. "Now I'm up and around, hiking and fishing," he said. "Marijuana focuses my mind away from the pain. I'm still hurting, but it's not that important anymore."

Proponents of legalization in North Carolina are ramping up their efforts.

Representatives of the nonprofit N.C. Cannabis Patient Network have toured the state this winter, meeting with politicians, clergy and medical professionals and airing programs on local public-access TV stations.

On May 2, proponents are scheduled to march in Raleigh on behalf of legalization as part of a global one-day protest called the Million Marijuana March.

"We're looking forward to this becoming legal in this state so people can quit living in fear," said Jean Marlowe, the network's executive director. "We're returning dignity to these patients."

Marlowe, who lives in Polk County, has used marijuana since 1991 to treat muscular dystrophy, rheumatoid arthritis, degenerative disk disease, muscle spasticity and fibromyalgia. She says the authorities leave her alone because she has a letter from her doctor saying she needs medical cannabis.

Before using marijuana, she said, the side effects of her various medications left her practically disabled.

"I spent my time throwing up, dizzy," she said. "I couldn't cognize. I couldn't balance my checkbook. I spent my life in a chair, in the corner, with a trash can."

State Rep. Earl Jones, D-Guilford, introduced a bill in the 2008 legislative session to create a study commission to look at legalizing marijuana for medical purposes in North Carolina. Jones plans to reintroduce his bill this year .

"I think the legislature will do the right thing once they see it will benefit the public and they have been educated," Jones said.

But the U.S. Drug Enforcement Administration remains adamantly opposed to legalizing cannabis even for medical purposes. It continues to prosecute under federal law in some other states for growing and distributing the plants.

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The most comprehensive review of the possible medical benefits of marijuana remains a book-length report, "Marijuana and Medicine," published in 1999 by the Institute of Medicine . The institute is part of the National Academies, agencies that advise the government on medicine and other sciences.

That report, co-authored by a researcher at Wake Forest University Baptist Medical Center, examined marijuana use with respect to five areas:

• Pain, particularly nerve pain experienced by patients with AIDS and other diseases.
• Nausea and vomiting, often experienced by chemotherapy patients.
• Wasting syndrome and loss of appetite, often experienced by AIDS and cancer patients.
• Neurological symptoms, including muscle spasticity and multiple sclerosis.
• Glaucoma, excessive pressure in the fluid inside the eye. The condition can cause blindness.

In general, the report found that marijuana, though not a panacea, could help relieve some of these symptoms in at least some patients. In some cases, the report found, marijuana worked as well as or better than accepted treatments.

It also found that smoking treats symptoms such as pain and nausea more quickly and effectively than taking the medicine by mouth.

The report raised concerns about the long-term health effects of smoking marijuana, which, like tobacco, is associated with an increased risk of cancer. Such long-term risks probably don't matter for patients who already are dying, the report noted.

A synthetic form of marijuana's most active ingredient, THC, is available by prescription under the trade name Marinol. But it takes longer to work than inhaled marijuana smoke.

Also, taking cannabis by mouth can get patients "higher" than smoked cannabis - which many patients don't want. When THC is eaten, the liver, which smoking bypasses, breaks the psychoactive elements down into even more potent chemicals.

Another problem with synthetic oral cannabis is that it contains only a few active ingredients, while smoked marijuana contains more than 60.

The combination of those ingredients, not just one, may provide the most medical benefit, says Dr. Wilkie Wilson, director of the DukeLEARN neurological-research program at Duke University, who notes that drug companies are researching that question.

"What you need is something, maybe like an aspirator or an inhaler, that can deliver the drug better than a pill would," said Dr. Steven R. Childers, a professor of physiology and pharmacology at Wake Forest University's Bowman Gray School of Medicine. Childers co-wrote the 1999 Institute of Medicine report.

Wilson, co-author of "Buzzed: The Straight Facts About the Most Used and Abused Drugs from Alcohol to Ecstasy," says some patients prefer smoking because it gives them greater control over their dosage - they can choose to stop, or continue, at any time depending on how much relief they're getting.

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 Childers says the 1999 report's general conclusions remain accurate. Researchers have made some incremental advances, particularly in whether cannabis can ease some symptoms of multiple sclerosis. The nonprofit National Multiple Sclerosis Society is paying for a 10-year study, which began in March.

Also, Swiss researchers found in 2006 that cannabis taken orally can ease muscle spasticity in people with spinal-cord injuries. And after promising findings in rats and mice, Israeli researchers plan human trials to determine whether cannabis may slow or halt memory loss in people with Alzheimer's disease.

But U.S. government-sponsored studies since 1999 have been few and far between. The government grows little marijuana for research and tightly restricts its use. Currently, of 768 drug-related studies sponsored by the National Institute for Drug Abuse and registered at www.ClinicalTrials.gov, two pertain to medicinal marijuana.

Besides the possible direct benefits to patients, what are the arguments for legalizing medicinal cannabis?

For one thing, it may help patients for whom other drugs are ineffective or cause intolerable side effects. Its own side effects are relatively minor, the long-term cancer risk aside.

Cannabis is safer than many drugs now on the market. There has never been a documented death attributable to marijuana overdose, Wilson says.

And legalization would bring about standardized dosages and quality, aiding both treatment and research.

Critics argue that the drug is psychologically habit-forming. It can be, but it is less so than alcohol, tobacco and such drugs as heroin, the institute report found.

Some research subjects have reported unpleasant feelings or sensations after taking the drug. And some do not like the "high" that comes with taking the drug. That condition also can make it dangerous to drive or perform other skilled tasks and can hurt judgment and short-term memory.

Wilson points out that these ill effects are particularly dangerous in young people, whose growing brains must absorb not only academic knowledge but also social skills.

There is some evidence the drug can hamper the immune system in some patients.

And marijuana is considered a "gateway" drug - one that could lead to use of more potent and dangerous illegal drugs. The 1999 report found little evidence to support that claim on a pharmacological basis. It also observed that alcohol and tobacco are more widely used gateway drugs, particularly among younger people.

For those reasons and others, federal law classifies marijuana as a Schedule I controlled substance, the most restricted type. Such drugs are defined as having no currently accepted medical use in the U.S., a high potential for abuse, and no accepted safe approaches for use even under medical supervision.

Another Schedule I drug is LSD.

Proponents of medicinal marijuana want it reclassified at least as a Schedule II drug, the most restrictive category for addictive drugs with recognized medical uses. Examples include codeine, the active ingredient in many cough medicines, and the painkiller Dilaudid.

The U.S. Drug Enforcement Administration maintains that marijuana's risks are too great, and its medical benefits too few, to legalize it. Even in some of the 13 states that have legalized medicinal marijuana, DEA agents still arrest people on federal drug charges.

And the government can prosecute doctors who prescribe marijuana. To avoid arrest, doctors often give their patients letters stating that the patient needs marijuana, rather than a prescription.

Proponents of medicinal marijuana also argue that regulating the drug should be a state and local matter, not a federal one.

In 2005, the U.S. Supreme Court ruled in a case called Gonzales v. Raich that the federal government had the right to regulate marijuana even within a single state, as opposed to in interstate commerce.

But a more recent Supreme Court decision suggests that the days of such overarching federal regulation might be numbered.

On Dec. 1, the court refused to hear an appeal from the city of Garden Grove, Calif. That city was defying a state court's order to return marijuana it had seized from a man who had won dismissal of drug charges after he provided a statement from his doctor that he needed marijuana.

Proponents hope that these incremental steps will lead to a day on which no one need fear legal punishment for using medicinal cannabis.

"I'd like us to be united in compassion," Marlowe said. "Living in fear of the government is not what we want for people who are sick and dying."

Wilson says marijuana should be legally distributed through pharmacies just as other drugs are.

"We control amphetamines - my God, we give them to kids for attention-deficit disorder," Wilson said. "Just treat (marijuana) like any other regulated pharmaceutical. I don't see any reason not to do that. I just don't see the reason."

After her tour of the state, Marlowe said she is more hopeful than ever about legal medical marijuana.

"I can smell the finish line," she said. "I'm not going to be a criminal much longer."