White Coat Underground

I’ve written previously about my decision not to assist patients in obtaining medical marijuana. My decision is based on my interpretation of the data and of medical ethics. This decision is independent of any opinion I may have about legalization.

But other doctors may see things differently. The data are clear to me, but the plausible nature of many of the claims made about marijuana make it anything but a no-brainer.

That’s one of the reasons why a story out of New Mexico is disturbing. New Mexico has a medical marijuana program. Doctors who work for the Veterans’ Administration are being told the following:

General Counsel has held that: “VA should not authorize completion of forms seeking recommendation or opinions regarding” participation in medical marijuana programs and that “applicable statutes and regulations do not require VA physicians to complete such forms.”

Further “A VA physicians’ completion of a form that would permit a patient to participate in a state medical marijuana program could result in DEA action to seek actual or threatened revocation of the physician’s registration to prescribe controlled substances as well as criminal charges.”

The language in the New Mexico form requires physician certification that “the potential health benefits of the medical use of marijuana would likely outweigh health risks for the patient.” Informal advice received from the DEA suggests that the Department of Justice may seek civil or criminal penalties for Federal physicians and other practitioners who complete forms that either recommends the use of medical marijuana or forms that describe the patient’s physical condition in order to facilitate the patient’s entry into a state medical marijuana program.

New Mexico law permits medical marijuana with a doctor’s certification. The VA is claiming that a doctor’s status as a federal employee supersedes all other considerations. That is disturbing.

I have no doubt that there are doctor’s out there running pot certificate mills, but I doubt they make up the majority of those filling out pot certificates. The Feds have created an ethically untenable situation. If state law allows a doctor to certify someone as benefiting from pot (not prescribing it), and the doctor truly feels the data support this certification, who should bend? Many veterans get all of their care from the VA system.

An analogy could be made that since heroin is an excellent analgesic, doctors should be allowed to prescribe it, and while this analogy is tempting, marijuana, for social, legal, and scientific reasons, is not perfectly analogous to other narcotics. Any physician certifying someone for marijuana use should be aware that the data are thin, and that health risks, including addiction, are real. But this comes very close to forbidding a doctor from giving advice as they see fit.

Comments

#1 Dan
February 22, 2010

For historical interest, heroin was prescribed as recently as the 1970′s, in the form of Brompton’s cocktail and other mixtures for the treatment of pain in cancer patients. It might eventually have been used for this purpose in the US if the studies done did not indicate that heroin offered no benefit over other narcotic analgesics in the various “cocktails.”
#2 G
February 22, 2010

So…I read the other post and the comments, and I have a question. Aren’t there other countries where marijuana is less restricted? If the hangup in getting in-depth clinical information is related to drug restrictions, why haven’t studies been done there?
#3 Wow
February 23, 2010

Just goes to show how huge a power and money stake the DEA has in keeping pot illegal. They’re fighting tooth-and-nail to keep the Mexican drug cartels, drug dealers, inner-city gangs, drug kingpins, growers, pharmaceutical companies, textile companies, hemp producers in CHINA, anti-drug propaganda groups, drug rehab groups, cops, sheriffs, judges, prisons and shady “lawyers”, and MORE, in business, aren’t they? What a game they’re playing on the American people. It’s time Americans wake up and smell the truth. Humans and cannabis evolved symbiotically for hundreds of thousands, if not millions of years and now, all-of-a-sudden, the GOVERNMENT decides it’s time to keep the plant from everyone? HMMMMMMMMMMMM… that should make people wonder what the REAL reason is for prohibition, because they surely DO NOT care about you and me.
#4 Mu
February 23, 2010

Many European countries have dropped enforcement of marijuana laws for small quantities. This does not mean it’s legal and more readily available as a drug for testing. There’s also the issue of standardization of smoked marijuana for medical testing; to get real accurate data you’d probably need to extract the THC and add it back it at precise levels.
#5 Dacks
February 23, 2010

This is an odd position to take. In your analysis, marijuana is not a good treatment for pain relief (for various reasons) so you will not prescribe it. OTOH, you feel that doctors should not be kept from prescribing it by the Fed thugs. So you support the freedom of docs to prescribe something that you feel is not a good treatment?

It sounds like your problem with the injunction is its reliance on the criminal aspect of marijuana, not on its questionable medical use. If the Feds had said “we don’t want VA docs to certify patients for marijuana because we judge it as a poor treatment” would you still feel so outraged?
#6 PalMD
February 23, 2010

If marijuana were a prescribed medication, the VA could either include it or exclude it from its formulary based on cost, effectiveness, moral stupidity, whatever. But since the doctor is simply being asked to sign off on an opinion, I see this as almost a free speech/doctor-patient relationship issue. If I were on the VA’s P&T committee, i might vote to exclude pot from the formulary, but that’s not the issue.
#7 St Thomas
February 23, 2010

Heroin, or rather diamorphine is quite legal to prescribe in Britain (You need a special licence to do so for addiction, but anyone who is licenced to practise medicine can prescribe it/ administer it where appropriate. It’s a class A controlled drug and record keeping must be pristine, or you’re in trouble
#8 Dacks
February 23, 2010

FWIW, that was sort of a devil’s advocate question. I tend to agree with you on both the unsettled question of whether to prescribe medical marijuana, and the free speech issue. But I bet your support for free speech would be tested by a physician who recommends echinacea, or ginko, both of which are legal.
#9 daedalus2u
February 23, 2010

What the DEA is criminalizing is having a clinical opinion and writing it down on a form. The physician isn’t prescribing, providing, administering, growing, selling, or otherwised involved in the sale or distribution of MJ.

All the VA phsyician is doing is expressing the clinical opinion that the health benefits of MJ would likely outweigh the health risks. What can be illegal about that?

If they can criminalize one medical opinion, they can criminalize any medical opinion. The criminalization isn’t based on any science, it is based on political whim.
#10 PalMD
February 23, 2010

But I bet your support for free speech would be tested by a physician who recommends echinacea, or ginko, both of which are legal.

For better or worse, there is no specific law that I’m aware of that forbids doctors from being wrong. There may, however, be consequences, which is why I take this shit so seriously.
#11 DrJ
February 23, 2010

The discovery of the cannabinoid receptors, and the increasing understanding of their important role in the mediation of pain / nausea / inflammation / etc., seem to make arguments that cannabis has no therapeutic use or potential moot and outdated. It’s time to recognize the Catch 22 for what it is – we have limited data because we have not been allowed to generate data. We cannot implement a rational plan for the use of medical cannabis because of cultural baggage, but let’s keep trying.
#12 shatfat
February 28, 2010

Dr J, just because something is natural and your body has receptors for it doesn’t mean it’s good. Caffeine combined with exercise has been shown to reduce risk of sunburn; caffeine taken after surgery has been shown to increase recovery time. Caffeine may keep me alert on the night shift (by blocking certain hormones) and prevent me from causing a fatal accident, but it also contributes to elevating my blood pressure in a bad way and interfering with sleep.

I have a lot of sympathy for people with severe, chronic pain (or cancer) who turn to pot for relief and to stimulate appetite. However, I take issue with your dismissal of PalMD’s legitimate concerns as “cultural baggage”. Smoking weed does have negative side effects. (Any pharmacologically active substance has friggin’ side effects.) Furthermore, you’re getting a drug cocktail when you consume or smoke any herb with variable dose amounts. That is a serious concern as well.

As an aside: if it did turn out that THC was responsible for some of the positive effects (as well as the “high”), what would be wrong with that? (Aside from certain risk of addiction.) Benadryl, guaifenesin, codeine, and when you’re hungry, even glucose : the list goes on and on of useful drugs that can make you loopy.
#13 shatfat
February 28, 2010

As an aside to my aside: I wonder if addiction is not really a disease, but a coopting/misuse/faulty application of pathways in our brains that exist to ensure we receive enough nutrients?

It was long ago suggested that tobacco induced such a severe addiction in teenagers because it supplies some B-vitamins, which are necessary nutrients. It thus hijacks a system meant to ensure adequate nutrition. “Addictive” eating may in part stem from both reward and hunger systems run amuck, due to faulty signals (for example, lacking satiation signals) or by messing up pleasure/reward pathways.

I’m not talking about physical dependency, which happens when the body adjusts to a certain dosage of a drug and goes into withdrawal symptoms when it’s taken away. From what I’ve read, I couldn’t say if dependency is well understood but it is well-managed by gradually reducing the dose.