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November 07, 2005

Defining "Medical"

One fundamental problem in the 'debate' over medical marijuana  is that no coherent definition of  'medical' has been accepted by all parties. Indeed, those with opinions seem to have chosen arbitrary positions for which they  then advocate without first coherently defining . Thus it's no wonder that  attempts at scientific 'debate' quickly become political arguments over who is ' "sick" enough to be exempted from the usual criminal penalties. When one considers the contentious history of cannabis prohibition, the earliest realization  that California's Proposition 215 had created an opportunity to study pot use clinically should have provoked far more curiosity than it has, especially from reformers-- to say nothing of academics  affiliated with the various endowed schools of 'Public Policy' at major universities; all of  which have been claiming to favor 'evidence based' policies since  about the same time the drug war was launched.

An indirect  example of this controversy appeared recently in the Orange County Register; it has since been picked up by several other newspapers. What is unusual about it is that one of the more prolific evaluating physicians revealed his own position, albeit indirectly. That allows me point out just why I take issue with him-- and all who tacitly agree with him.

I should  also point out that I consider allowing a reporter's presence at such evaluations poor judgment at best- perhaps even unethical at worst; not only are those medical exams highly unusual, they almost always involve an admission of illegal drug use. This isn't the first politically slanted article by a medically untrained reporter to be facilitated by this particular physician; a similar piece by Carol Mithers appeared in the LA Weekly in May 2004.

The reporter first describes two two young skate-boarders ("skater dudes") in terms that clearly indicate his own prejudice. He then agrees with the physician's summary rejection of the first one's insomnia as a valid reason  for pot use- an opinion first expressed by Barry McCaffrey in 1996. None of the three: McCaffrey, the physician nor the reporter,  seem even remotely aware that chronic insomnia is considered by modern Psychiatry to be a cardinal symptom of depression. Nor could they possibly know that its very effective palliation by cannabis is easily elicited from 90% of those I take histories from.

The reporter also shares the physician's sympathetic attitude toward the second skater, who is said to have "aggressive metastatic bone cancer" despite looking exactly like the first. I have no disagreement with that decision, but I do have a very different perspective on the clinical evaluations described. Primarily, I disapprove of what appears to be a politically correct rejection based on mere inspection and the eliciting of a 'chief complaint;' that's not how clinical medicine should  be practiced. I also know, with considerable certainty, that both applicants were almost certainly treating the same underlying emotional symptoms with cannabis well before the second one developed what is, very likely,  an osteogenic sarcoma.

In addition, when the same the same physician  practiced in Northern California, he was one of the few then recommending pot for large numbers of applicants; thus many of his former patients saw me for "renewals" when I began screening applicants toward the end of  2001.  In fact, I still  occasionally see some. I can thus say unequivocally that more than a few resemble the first "skater dude," right down to the tattoos and the chief complaint of insomnia.

To be more specific, I have screened hundreds of applicants who obtained recommendations from other physicians- some considered stalwarts of the medical marijuana movement, and  others regarded sneeringly as 'scrip docs.' What I can say unequivocally is that there are no discernible differences in their patients and the ones who have sought me out primarily. In other words, chronic pot users applying for recommendations seem to have remarkably uniform medical and social histories. Their pot use also seems to have been far more beneficial to their health than the many other drugs most of them tried- whether prescribed by physicians, or used on their own initiative.

Finally, this physician's age and his own history of discovering pot while a teen-aged Naval enlisted man during the Viet Nam war places him in the exactly the right place at the right time: he fits the same profile as many others I have seen who were inclined to see  their own use as as "recreational"  until closely questioned about certain important details.

Such is the nature of denial.

Tom O'Connell MD

Posted by tjeffo at November 7, 2005 04:21 AM