Saturday, October 15, 2011

Against Medical Marijuana: A civil liberties argument against a humanistic farce (by Skylanda)

In 2007, medical marijuana became legal under a physician’s directive in New Mexico, one of sixteen states allowing some variation of medical use of ­­Cannabis sativa. Since then, regulation of medical marijuana in the state has swung with the political tides: founded and liberalized under former Democratic governor Bill Richardson, then tightening under current Republican governor Susan Martinez, who made a campaign vow to reverse the move toward medical legalization of marijuana altogether.

Caught in the middle of these political tides are the physicians who are asked to make the judgment call as to whether a patient is an appropriate candidate for medical marijuana. Predictably, medical providers fall into largely political camps in the decision whether to engage with the medical marijuana question at all – many refuse to sign the paperwork on an ideological basis, a few will sign any patient’s paperwork out of reverse ideological concerns, and a good number want nothing to do with it simply because they do not want the word to get out that every weed toker in town then come knocking on their door. The guidelines about who can prescribe for which conditions are only marginally helpful: a tangle of specialists needed for one condition, primary providers sufficient for another, and dual requirement from both for yet other conditions. The unifying theme behind these guidelines is that there is virtually no evidence behind a single one of them – to guide what conditions are covered, under what circumstances, and under the guidance of which specialists. In the era of evidence-based medicine, this is problematic.

But this problem is not accidental. Evidence is not a god-given entity; it is a good that must be gathered through clinical trials and observational data and then run through the grist mill of statistical analysis. The dearth of evidence for the safety and efficacy (or lack thereof) of one of the most frequently used mind-altering substances in the United States is due in no small part to a quirk of the way that the Drug Enforcement Agency classifies illicit substances: the schedule of controlled substances under the 1970 Controlled Substances Act. This law attempted to sort out serious drugs (and serious drug offenses) from drugs of more minor import, as well as drugs that have some dual role in both medicine and abuse. Schedule I drugs are the most serious offenders, with high potential for abuse and no role in medicine (they cannot be prescribed under any circumstance and theoretically cannot be permitted for research, though this rule is sometimes not strictly adhered to); Schedule V drugs are minor offenders with widely overlapping medical applications, and Schedule II-IV runs the spectrum between. You may be surprised to know that marijuana occupies a premium spot in the Schedule I category, right beside heroin, GHB, LSD, and ecstasy. You may be even more surprised to find that cocaine and methamphetamines are considered squarely less dangerous than marijuana, in the still-venerable Schedule II category (cocaine is used in some ear/nose/throat procedures; amphetamines are too close to a cluster of ADHD medications to make a useful distinction – thus the placement in Schedule II). Essentially, the DEA is far more vested in eradicating the scourge of marijuana than ridding the streets of methamphetamines and cocaine. (Interestingly, tobacco and alcohol were never rated by the DEA, probably because they are legal substances.)

It is because of this Schedule I placement that the feds take marijuana so seriously, and why state laws legalizing medical marijuana so flagrantly flout federal statute – and will likely eventually force a constitutional read of the issue at the SCOTUS level. (Several years ago, an acquaintance investigated the quandary of what to do with a notoriously brown-thumbed tenant who was producing a substantial quantity of the moldy pot plants in the drafty attic of his old San Francisco Victorian with a questionable grower’s license; in the course of his investigations, the landlord discovered that the city police didn’t care, the state law enforcement office reacted with studied indifference, the local housing authorities told him not to bother to get involved, but that every branch of the feds he contacted simply wanted to know the address so that they could initiate a bust immediately.)

It is because of this Schedule I status at the federal level that there is notably scarce data in the formal literature on the effect of marijuana on chronic pain, PTSD, depression, inflammatory conditions, asthma, palliative care, weight loss associated with cancer and AIDS, and the other conditions for which patients routinely request it of myself and hundreds of other physicians in the states where it is legal. American researchers are critically restricted from effective study of the medical effects of marijuana (except in the purified form of THC marketed as Marinol, marketed as an appetite stimulant and universally panned for its ineffectuality beside the supposed panacea of real marijuana) because forty years ago the federal government declared – in a nearly heroic accomplishment of circular reasoning – that there is no medical indication for marijuana.

And thus we set the stage for the farce that is medical marijuana. In New Mexico, physicians actually have a list of approved indications, which includes chronic pain, inflammatory arthritis, PTSD, glaucoma, painful peripheral neuropathy, and (in an ironic nod to the state’s epic battle with injection drug use) the discomfort associated with hepatitis C. We have no evidence that this substance is effective for any these conditions (nor any evidence that it is ineffective, or that it is harmful, nor that it is ineffective for a long list of excluded conditions), but someone came up with a list of inclusionary and exclusionary criteria, and there we are.

Because it is not produced uniformly and studied legally, I cannot come up with a reasonable dosing regimen at which I can expect results or move on to a different medicinal approach. I know roughly what twenty milligrams a day of Lipitor should do to your cholesterol, and how many milligrams of ibuprofen can reasonably be expected to turn off your headache pain before you risk an ulcer, but I can’t even hazard a guess at how many ounces of Mary Jane should evaporate your back pain, or alleviate your anxiety, or lighten up your mood. Because it is so poorly studied, I cannot give a patient a list of contraindications, side effects, or even long-term dangers (some claim, for example, that inhaled cannabis works well as a bronchodilator for asthma; not only do I find this disingenuous if there is no evidence to back it, there is reasonable cause to suspect that chronic marijuana smoking may be a culprit in emphysema just as well as cigarettes).

Without any kind of dosing standardization or quality control, handing out medical marijuana cards is essentially the equivalent of telling patients to open up a bottle of Jack Daniels, insert a straw, and start drinking until you feel better. Except that instead of properly bottled whiskey, make it the stuff that some guy stilled in an old bathtub out back of his cabin: it may be authentic, but the public health department isn’t exactly looking in to ensure he washed his hands first. (The state of New Mexico does license growers, but they are not inspected and regulated the way the FDA watches over pharmaceutical factories. Indeed, one of the little-spoken health concerns about marijuana is that large-scale illicit growers are not exactly environmentalists: you might be smoking some of the most potent pesticides and fertilizers on the market when you inhale a crop produced under the duress of a growing seasons shortened by the threat of federal surveillance.)

So what then to do with the patients who claim benefit from marijuana in all is chemical glory? Well, I say let ‘em smoke it. Or eat it, or vaporize it, or spread it on their toast in the morning in the form of weed butter. But get me out of the middle of it.

The medicalization of marijuana has been a shrewd and well-calculated move by the pro-legalization crowd to crow-bar the power of compassion for the terminally ill and fatefully traumatized into political capital toward the normalization – and eventually legalization – of marijuana. And fundamentally, I agree with that goal. Many decades ago, this country decided that the social cost of restricting your right to a mildly mind-altering substance was not worth the crime wave that came with trying to enforce temperance; prohibition only serves the task-master of organized crime, and in my lifetime I would like to see the United States of America come to the realization that if drinking a fifth of vodka does not warrant ruining one’s life with a jail sentence and one’s community with organized crime, neither then does smoking a joint.

But I don’t appreciated being used as a tool toward that end. The medicalization of marijuana means that I am forced into the farce of pretending that marijuana is modern medicine. Marijuana is medicine only in the way that opium poppies are medicine: there’s something in there that’s awfully potent, but I wouldn’t feed it to patients straight up if wanted a predictable effect from a set dose – which is the essence of what separates modern medicine from the stuff your great grandma boiled up in her kitchen to treat the neighborhood nose bleeds and fevers. Marijuana is medicine only in the way that that proverbial bottle of Jack is medicine: it sure does something, but as a doctor, I’m pretty sure that is a something I don’t want to be responsible for prescribing.

The medicalization of marijuana means that I spend appointment time with complex patients discussing – ad nauseum – the intricacies of who needs to sign the annual paperwork for their cards for their particular condition, instead of focusing on actual medical conditions. The medicalization of marijuana means that I field a fair number of patients who establish care only to ask for this service (only some proportion of whom are actually ill), who are severely put out to discover that I cannot provide it to them under the current guidelines and who are unafraid to tell me so in angry and explicit terms. The medicalization of marijuana means that I spend public dimes at the community clinic where I work explaining and re-explaining the guidelines and limitations of this program, verifying and re-verifying the changing landscape of requirements which – I think it is only mildly paranoid to suspect – the current right-wing regime in the state may one day use to punish physicians who veer at all from the exacting nature of the program. The medicalization of marijuana fundamentally means a large bureaucratic headache for an issue that I fundamentally feel is none of my business (and as a primary care physician, bureaucratic headaches are something I do not require any more of than I already have). Unless they are troubled by it or using it to an extent that is causing medical or mental health issues, I do not feel that marijuana use by my patients is my business, pro or con – much as a glass of wine with dinner does not concern me.

My only entry in this dog and pony show is as a half-hearted civil libertarian (of the kind that appreciates being left alone if I’m not hurting anyone else, but recoils at the rather horrifying spectacle of Tea Party libertarianism), and a fulltime harm reduction-ist, of the sort that heartily supports needle exchange programs and drug treatment over punishment for those in the throes of addiction. The full legalization of marijuana fits both those bills: get the government out of the business of busting people for a drug that is fundamentally about as harmful as alcohol and tobacco, and take the breeze out of the sails of the organized crime that has been the sole beneficiary (alongside, perhaps, the terrifyingly profitable privatized prison industry) of this late-date Prohibition. But the medicalization of marijuana defeats all these purposes: creating new headaches and bureaucracies without tackling any of the social ills of prohibition. Moreover, medical marijuana disingenuously asks doctors to play the mediator in the age-old cat-and-mouse game between stoners and law enforcement – trying to suss out whose pain is real, who is not just looking for a get-high-no-jail card – a role that I have no aptitude for and even less desire to engage in.

It is high time that the pro-marijuana crowd step up to the plate and aim their efforts at their true goal: legalization. (Or, in the interim, moving cannabis off the Schedule I list to somewhere more reasonable.) And please, spare me being shoe-horned into the middle of your efforts – I appreciate the core sentiment, but I do not appreciate the paperwork, the headache, or being used for purposes that defy the calling of my profession.

Let the ill have their relief and the hedonists have their day. And please: let the physicians practice their craft without pretending that unrefined herbiage is part and parcel of modern medicine.

Cross-posted from my recently relocated and relaunched blog, America, Love it or Heal It.