I Hate Dialysis Message Board
Dialysis Discussion => Dialysis: News Articles => Topic started by: okarol on November 26, 2011, 10:09:10 PM
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Cancer Patient Denied Liver Transplant After Using Medical Marijuana
Doctors at Cedars-Sinai Medical Center removed a cancer patient from the liver transplant list in February for using medical marijuana and failing to show up for a drug test. Last week the 63-year-old patient, Norman Smith, asked the medical center to reconsider reinstating him.
Smith has been fighting inoperable liver cancer for two years and is in need of a new liver. He scored a spot on the transplant list last year but was removed after the drug test incident. Toke of the Town said Smith did test positive for medical marijuana. Cedars-Sinai transplant policy states that patients are still eligible for a transplant if they initially test positive for marijuana, but they must sign a statement promising not to use the drug. If they fail a random drug test or, like Smith, are a no-show for a test, they are bumped from the list. In order to be placed back on the list, Smith was ordered to abstain from using medical marijuana for six months, submit to random drug tests and undergo counseling.
Smith, who is currently undergoing chemotherapy and radiation, told L.A. Now, "It's frustrating. I have inoperable cancer. If I don't get a transplant, the candle's lit and it's a short fuse." His cancer recently returned after being in remission.
Joe Elford, an attorney with the medical marijuana advocacy group Americans for Safe Access, represents Smith and says that any delay in the transplant could be the "difference between life and death." Smith and Elford are considering a lawsuit against the hospital.
L.A. Now says that, according to the United Network for Organ Sharing, there is no standard policy on transplants and the use of medical marijuana. Due to the high demand for liver transplants nationwide, medical centers must prioritize. Over 16,000 people are on the national wait list for liver transplants. The average wait is approximately 300 days.
Dr. Goran Klintmalm, chief of the Baylor Regional Transplant Institute and an expert in liver transplantation, said, "As long as we have patients who die on the list waiting for organs... is it right to give [to] patients who have a history of drug use?"
One of the main concerns with granting a medical marijuana user a transplant is whether or not the patient will follow the complicated medication regimen post-transplant. Dr. Jeffrey Crippin, former president of the American Society of Transplantation and medical director at Washington University in St. Louis, claims, "If you are drunk or high or stoned, you are not going to take your medicine."
Cedars-Sinai spokeswoman Sally Stewart told L.A. Now that medical marijuana users can be exposed to a species of mold that can cause fatal disease among patients with weak immune systems. Patients are also susceptible to a fatal lung infection post-transplant. Stewart added that the center does not "make a moral or ethical judgment about people who are smoking medical marijuana" and that their "concern is strictly for the health and safety of our patients."
Dr. Steven A. Miles, Smith's oncologist, said, "Without a transplant, it is basically 100% fatal. It's just a matter of time."
Americans for Safe Access Chief Counsel Joe Elford wrote in a letter to Cedars-Sinai, "Cedars-Sinai would not be breaking any laws, federal or otherwise, by granting Norman Smith a liver transplant, and it's certainly the ethical thing to do."
Smith said he started using medical marijuana while suffering "extreme pain" and "physical anguish" after an unrelated back surgery. Miles approved of his patient's medical marijuana use to manage his pain plus the effects of chemotherapy and refilled Smith's medical marijuana prescription. Smith stopped using the drug in August and is hopeful for a liver transplant.
http://laist.com/2011/11/26/cancer_patient_denied_liver_transplant.php
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I don't know anything about marijuana, medical or otherwise, so I have some questions.
First, if taking medical marijuana is legal and has been prescribed by a physician, why would other physicians object?
Second, is it true that taking marijuana to relieve pain and nausea caused by chemotherapy makes you too high or stoned to remember to take your post-transplant drugs? If this is not true, then Dr. Crippen should recant. This seems like an awfully sweeping statement to me. Can anyone enlighten me?
Thirdly, I am not sure that using prescribed medical marijuana should give you a "history of drug use." That' just doesn't sound right.
Fourthly, I am uncomfortable with the idea of denying someone with inoperable liver cancer anything what would relieve their suffering or denying them a transplant on these grounds.
I do, however, think that Mr. Smith should not have been a no-show for the drug test.
This is an interesting topic for discussion.
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Jenn was told something similar to this regarding marijuana and kidney transplants. "Cedars-Sinai spokeswoman Sally Stewart told L.A. Now that medical marijuana users can be exposed to a species of mold that can cause fatal disease among patients with weak immune systems. Patients are also susceptible to a fatal lung infection post-transplant."
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Jenn was told something similar to this regarding marijuana and kidney transplants. "Cedars-Sinai spokeswoman Sally Stewart told L.A. Now that medical marijuana users can be exposed to a species of mold that can cause fatal disease among patients with weak immune systems. Patients are also susceptible to a fatal lung infection post-transplant."
It seems to me that Mr. Smith's immune system is already compromised because he is undergoing chemotherapy. This is causing side effects for which his physician is treating with medical marijuana, yet this physician doesn't seem concerned about this mold species. I don't know for sure, but I would have thought that marijuana sold for medical use should be tested for mold. I would guess that maybe the marijuana is inspected for this mold at some point, and if a buyer/patient is concerned, he should make sure that what he is buying is safe just like we all do when we are buying fruit.
Patients are suspectible to all sorts of fatal infections post-transplant, so I'm not sure I buy this particular argument. If Mr. Smith was allowed to get his liver transplant, then I would guess that he wouldn't need the medical marijuana anymore.
Again, I know nothing about this topic, and perhaps there are very good reasons for kicking someone off the list for using legally prescibed marijuana, but this article doesn't supply those reasons. I'd love to hear from someone who knows more!
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MM, it says he's using the mj because of back pain from an unrelated surgery. A liver transplant isn't going to fix that, so there's no reason to think he still won't want it after the transplant. And yes, having watched a friend with cancer use it - no, it's not conducive to keeping track of time or responsibilities. When it's legally prescribed, the docs simply give permission to smoke it. There's no dosage instructions about how much, how often, or when like there are with pain killers.
Medical Marijuana is legal here in Michigan. It's home-grown, not produced by a company. You either grow your own, or can buy it from a caregiver who grows it for you. The only inspections are about how many plants and if they are properly secured, and if the grower is only selling to those who can legally use it. The drugs are never tested for quality. There's no way to avoid the mold risk.
Chemo does suppress the immune system - but it's not something intended to be used on a daily basis for the rest of the patient's life, nor is it a consistent dose taken on a daily basis. Infection risks from immuno drugs never go away.
I don't have much sympathy here. They are telling him if he wants on the list, he has to find a different treatment for his back pain because his current pain med will create side effects that are too high risk to give him a liver that he might destroy shortly after he gets it. It's a hoop he has to jump thru to get on the list. Those of us who have been on the list get that sometimes you have to do things their way. Period.
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I found this from earlier this year: Medical Marijuana and Organ Transplants: Will It Affect Your Chances? http://www.mcsocal.com/blog/medical-marijuana-and-organ-transplants-will-it-affect-your-chances
this is from last year: The Denial of Organ Transplants to Medical Marijuana Patients http://www.huffingtonpost.com/russ-belville/the-denial-of-organ-trans_b_435348.html
and from 3 years ago: Organ prospects go up in smoke http://articles.latimes.com/2008/may/19/nation/na-transplant19
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The mold issue is a bogus concern. I'm not sure why someone would smoke moldy weed, you also shouldn't eat moldy bread. But if that is the primary concern then there are all sorts of baked mj goods that carry no mold risk. When I read these stories what I see is nanny state tut tutting.
I watched Ken Burns' Prohibition documentary and I see very little difference between today and the period between the 18th and 21st amendment. The vast sums the state spends on persecuting pot smokers employs tens of thousands of people, and it are these self interested rent seekers that drive the foolish policy forward with all its tragic effects - denying transplants to people is on that list.
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Smith said he started using medical marijuana while suffering "extreme pain" and "physical anguish" after an unrelated back surgery. Miles approved of his patient's medical marijuana use to manage his pain plus the effects of chemotherapy and refilled Smith's medical marijuana prescription. Smith stopped using the drug in August and is hopeful for a liver transplant.
I understand that we have to go through hoops, but surely those hoops must have some rationale behind them.
I also understand that the tx people might want him to find different treatment to treat his pain, but since they seem to have so much skin in this game, maybe they should be the ones to prescribe what they think is both effective and safe. If an alternative is various narcotics/opioids or other meds that carry the risk of addiction, then are they really doing this patient any favors? Or are they quite happy to let him suffer? I know that opioids make me terribly sick, and I'd hate to have those be my only alternative.
I'm just uncomfortable with having tx centers condemn their patients to more suffering in order to qualify for a transplant. I thought that doctors were supposed to relieve suffering, not exacerbate it or deny treatment for it. It just feels like the tx centers are playing God more than usual in these cases.
Okarol, thanks for those links. It must be awful, awful, awful to have to endure months of needless suffering just to have the chance to have your life saved by transplant.
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Oh for flip's sake! I am so bloody sick of being treated like second class citizens because we are unlucky enough to need an organ transplant.
This is horrifying. I've got news for Cedars and any other center that would deny a patient a chance at a transplant over taking a LEGAL pain medication: not one effective pain med is conducive to keeping on top of anything. Better marijuana than these dangerous opioids.
So they've found a mold to blame their medical prissiness on. MM, absolutely right, there are manner of risks to taking immunosuppresants, some of them deadly. Why should we not be trusted to assume these risks as we choose? I am a competent and educated adult, I do not need my doctor to act as surrogate babysitter for me. I do not smoke marijuana and never really did - a few times at school - but I have been in the same room with people smoking at would assume that that is a risk as well. It's about one billionth the risk of driving a car no doubt, but what do they care when they are on some power trip.
I have heard of people being denied for this before and it enrages me every time. Back pain is nothing to scoff at. How dare they try to take something that helps this person with pain.
One thing I have wanted to discuss on here but don't really have the time/energy to be bothered with it is an article that came out about Steve Jobs dying of a very treatable pancreatic cancer, one that he refused to seek well-established treatments for because he apparently only wanted to take alternative meds. This article, very well-written by a doctor who quickly admitted that he was never a physician for Steve Jobs and had no inside knowledge of his care, said that it takes a long time to die of this cancer. How on earth was Steve Jobs allowed on the list if he had untreated, ultimately lethal pancreatic cancer?? Let's not kid ourselves. If this man were of any importance to Cedars they would keep him on the list. They should be ashamed. I met those doctors and i also met their little social worker who called my brother a 'coke addict' which is a phrase I never used and do not agree with. My brother is certainly selfish and has taken drugs before, but where in the hell did this man get off diagnosing someone he's never even met, from a single statement I made about my brother? These are the people who get to make these life or death decisions, and they make it into 'prove you're worth it' despite the ugly history where I THOUGHT all parties involved had agreed that morality judgments have no place in transplant.
This story makes me very sad. I hope he sues. There is nothing fair nor equitable about how they apply their draconian rules.
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The mold issue is a bogus concern. I'm not sure why someone would smoke moldy weed, you also shouldn't eat moldy bread. But if that is the primary concern then there are all sorts of baked mj goods that carry no mold risk. When I read these stories what I see is nanny state tut tutting.
I watched Ken Burns' Prohibition documentary and I see very little difference between today and the period between the 18th and 21st amendment. The vast sums the state spends on persecuting pot smokers employs tens of thousands of people, and it are these self interested rent seekers that drive the foolish policy forward with all its tragic effects - denying transplants to people is on that list.
Thank you, Bill. I agree with this. I had heard about the mold risk on this site but did not know enough about it to comment. If it is a risk one does not want to take, then by all means, do not use it. But sheesh. "There is a risk of death involved, so rather than treat you, we're going to have to kill you. Slowly and painfully."
I agree with all you've written as well, MM. That is a great point about chemo. Prograff and CellCept are but TicTacs next to chemotherapy. This is a mind-boggling abuse of power.
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It does seem like these transplant docs see themselves as God's Gift to humanity and as God's Gift they feel perfectly justified making sure only the chosen are granted access.
EDITED TO ADD: Where are the case studies of cases of mortality or graft loss due to this mold? My 10 or so Google attempts turned up nada.
Wikipedia (http://en.wikipedia.org/wiki/Effects_of_cannabis) notes: Aspergillus mold species can infect the lungs via smoking or handling of infected cannabis and cause opportunistic and sometimes deadly aspergillosis.[citation needed] Some of the microorganisms found create aflatoxins, which are toxic and carcinogenic. Researchers suggest that moldy cannabis thus be discarded.[citation needed]
Even Wikipedia can't put forward a citation. You'd think there would be dozens of cases a month if it is a real concern.
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My advice was to find another transplant program. I referred him to Pittsburgh. He went up for an eval about 2 weeks later and was immediately listed. Also, only "cost" him $150K. Received his transplant less than 3 months after that, was out of the hospital in 2 weeks and back home in six weeks. Even received a refund. A happily ever after story? Nope. Began drinking again about a year after transplant, got sloppy w/his meds and experienced irreversible liver damage a few months later. He never made it for a second transplant.
Bottom line - There is more to Mr. Smith's story than what is being told in this article.
You cannot know that. Just because you know one person who relapsed on alcohol does not give you special insight into the use of medical marijuana as regards transplant. Alcoholism is completely different to using marijuana. By your calculus, it would seem that no one who has to take any prescription drugs of any kind should be given a transplant. Makes for an interesting paradox since slavish devotion to medication regimens is an expectation after transplant. Marijuana does not lead to dependency the way that opioids do, and further, where is the evidence? When did we become a country that finds it satisfactory to deny treatment to someone, condemning them to death, with no evidence that this issue presents any real threat and only assumptions about their possible, future behaviour?
As for the "mold" issue, we do not know in what context it was brought up. Maybe it was one of numerous questions asked of the Cedars spokesperson and this was the only one the article's author wished to quote. There is a bias and agenda to this story.
There is a bias and agenda to your story, too.
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Noncompliance with medications is at the heart of the testing for illicit drugs since several studies show that this is a strong predictor of graft failure. To simply state, you are a drug addict and leave it alone at that would not be right. Instead, they are always offered the opportunity to prove abstinence over a period of time that varies from center to center. Not addressing the potential of true substance abuse would not be appropriate nor responsible on the clinics part. Understanding the pain and suffering of an acute rejection reaction not the least of which the medical complications that can be life threatening, transplant center rightly have a fiduciary duty to assess psychological and social aspects of each candidate in light of extensive research showing definable risk factors ahead of time. Substance abuse is one of the most predictive factors in a failed graft from noncompliance.
That is why it is so restricted in the transplant world based completely on expected and predicted clinical outcomes. It is up to the patient to make his own choices. I would suggest faced with life with a transplant or death with continued drug abuse, it should be a no brainer, but many people die every year from their substance abuse from poor decisions. In the case of liver transplants, it is often substance abuse that put them in the need of an organ in the first place. It is notedly a sad situation, but one at the control of the person with a substance abuse in the first place. I have had patients that refused to stop drinking even knowing that they would not be eligible for a transplant. In a couple of cases, their abuse killed them before the liver disease.
Medical marijuana is a fraud in my opinion since the DEA already went to great lengths to make Marinol available to any patient through prescriptions just as writing narcotics is one of many controlled substances. In all my years of practice, I never needed to resort to Marinol since I always had alternative meds that worked better and with fewer side effects. In all my years of practice, I only had one or two patients DEMAND medical marijuana. I promptly offered alternative medicines with higher efficacies than "medical" marijuana. They likewise declined and instead went off to see if another doctor would prescribe. These patients also had a long history of substance abuse making prescription of controlled substances illegal in the first place on my part. Most people are completely unaware of the laws associated with physician prescribing that can land doctors in jail.
In addition, I believe it is 14 states that allow "medical" marijuana, but the Feds prohibit it in all states leading to the threat of prosecution of both user and prescriber in those states as well. All transplant centers rely heavily on Federal funding making the loss of Federal funding a real issue should they support behaviors that the Feds declare illegal. I believe that if you delve into this issue further, that the threat of loss of Federal funding is also an important aspect of the criteria as well since all of this is under the scrutiny of Federal regulators.
So from a clinical standpoint, illicit substances significantly worsen graft survival and from a legal standpoint, transplant centers cannot survive without the Federal funding and cannot in their policies support any illegal activity.
There are many criteria that a person must meet in addition to drug free and substance free status and these are all based on granting the person getting a limited supply of organs that has the best survivability. In the end, the organs that go to patients with substance abuse that quickly fails is a wasted organ that could have saved another life. It is due diligence and fiduciary responsibility to honor the gift of life from these donors that motivates centers to place restrictions and rightly so in my opinion. Some patients simply never exhibit self protection skills and instead have self destructive behaviors that cost society greatly from crime to health care costs picked up by the public tax payor. If folks wish to toke away, that is their choice. If they need an organ, what is more important, toking away on pot, or meeting the strict criteria of the center. I know how I would answer that question myself. Kind of a no brainer in my opinion.
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One more issue, the mold that they are talking about is actually an incredibly deadly pathogen, Aspergillosis which is reportedly present in a lot of the marijuana. Patients that are immunosuppressed are at a high risk of this without marijuana use in the first place and it is indeed a deadly disease. I don't know how frequent it occurs, but for those that contract this, it can be fatal in up to 90% of patients who get it in the lungs. In any case, I don't have any studies on how common this is in transplant patients, but it should be quite easy to search for that in the medical literature.
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Here is a good review of Aspergillosis in liver transplant patients associated with marijuana use.
http://naltsw.org/liver_muse.html
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Medical marijuana is a fraud in my opinion since the DEA already went to great lengths to make Marinol available to any patient through prescriptions just as writing narcotics is one of many controlled substances.
I guess we need randomized controlled trials because we should never believe the experience reported individuals. And since there are no RCTs we should just leave things as they are because people aren't able to decide these things for themselves. ::)
Here is a good review of Aspergillosis in liver transplant patients associated with marijuana use.
http://naltsw.org/liver_muse.html (http://naltsw.org/liver_muse.html)
That was an interesting overview. This included vignette is more shocking than the case that started this thread:
"Dr. Jay Cavanaugh (6), head of the American Alliance for Medical Cannabis who is also Hepatitis C positive argues that removing liver transplant patients from the list who use Marinol or prescribed medical marijuana is tantamount to meting out a death sentence. Dr. Cavanaugh presents a case entailing an Oregon resident that returned from serving in the Viet Nam war now diagnosed with end stage liver failure. The patient, Dave Myers, was evaluated and denied by Oregon Health Service Unit (OHSU) in Portland because he acknowledged taking the prescription Marinol, a synthetic cannabis compound. Myers was accused of being a marijuana smoker despite his assertion that he stopped smoking marijuana 15 years ago when he was first diagnosed with liver disease. Dr. Jack Ham who pushed for the patient's denial believed him to be actively smoking marijuana despite Myer's willingness to submit to a lung biopsy and polygraph test. Dr. Cavanaugh argues that, "there is no evidence that marijuana has any negative effect on the liver". He states that a 1970 study and some more recent studies actually show that cannabinoids and other compounds in marijuana are actually protective of the liver and reduce inflammation associated with cirrhosis.
Despite attempts to overturn the decision, even with various agencies advocating for him, Myers was unsuccessful and was told to find another center. OHSU was the most practical option for him regarding support and resources needed. Dr. Cavanaugh's findings regarding whether or not a patient is ruled out due to marijuana use pointed to a disparity among transplant centers. "
That policy is insane.
I did find a review of Aspergillus Infections in Transplant Recipients (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC544171/), with the full text available. Turns out this Aspergillus mold is everywhere and is why post transplant people are not suppose to vacuum. But this statement stood out, "A vast majority of the patients who developed invasive aspergillosis had never left the intensive care unit after liver transplantation surgery"
Obviously these patients were not 'toking'. Smoking pot is a risk factor for these infections but it is not possibly the cause of the vast majority of the infections. And again, the option of eating mj is also banned, even the use of Marinol is banned. Moralists like Dr Hamm are active throughout transplant programs ready to tut tut people off the list. Given the medications that transplant centers allow people on their list to use - from opiates to antidepressants - focusing on mj is unwarranted.
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Peter, that actually was a pretty good article - written by two social workers I assume, and it did also voice some of Jay Cavanaugh's argument that this is lunacy. Cavanaugh makes excellent points, and in this article, a doctor told a patient (who is now deceased) that Marinol would suppress the immune system and the patient had this statement on tape.
http://stopthedrugwar.org/chronicle-old/299/notransplant.shtml (http://stopthedrugwar.org/chronicle-old/299/notransplant.shtml)
I think what is most striking about the article that you linked is that it admits that this mold can come from a variety of places, including construction areas. I used to play in a construction zone with my original donor when I was on high dose immunosuppresants. Patients who play in construction zones probably have a higher incidence of this condition, too. I have also, as I've said, smoked marijuana. Shame it's too late to deny me a transplant. Where does the need to exert control over patients end?
What you've said about noncompliance being a predictive factor for graft failure requires rigid citation. What are we calling non-compliance here? Were these people screened before transplant, and if so, wouldn't that suggest that their screening process is faulty? I was a flagrantly non-compliant patient with my first transplant, but of course no one managed to pick up on that because I am not stupid enough to admit it in an eval. My GP and I both agreed that my non-compliance was probably partially responsible for my remarkable success with my first kidney transplant.
These sorts of rules are not evidence-based and suggest that we are dealing with doctors who, like Bill mentioned, feel they have a right to stand between a patient and treatment. This marijuana was legally prescribed and in my very informed opinion is far less dangerous than opioids, which have expected dependency, oh, and nearly killed me in 2007. Plus, he was rejected for failing to take a test, not for a relapse. Wow, I would be dead many times over if any little drop of non-compliance had meant that I was denied treatment. I know that I read somewhere that you were labeled non-compliant by your dialysis unit - it can happen to anyone.
Someone who uses medical marijuana is by definition not 'abusing' a drug so long as they are using it for its prescribed purpose. Trying to slyly change that to 'abuse' as that article does is just an attempt to elicit moral outrage from people who do not think marijuana should be legal.
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Oh my GOD!!!! Transplant recipients are not supposed to vacuum? Why was this information kept from me when it could have done me some good?? Why is it only the fun things that everyone tries to order you not to do?? If anyone tells me that transplant patients are not supposed to change dirty diapers I'm filing a lawsuit!!!! :rofl;
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Hemodoc, I can certainly understand why a tx center wouldn't want to give a new liver to an alcoholic, but the original article about Mr. Smith never made the claim that substance abuse was the cause of his liver failure. There was also no claim that Mr. Smith "abuses" marijuana. I admit that I am not really sure exactly what the difference is between using marijuana as directed by a doctor and "abusing" it, as I am sure there are many people that feel that using marijuana in any context IS drug abuse. So I am not sure it is fair to assume that Mr Smith regularly engages in behaviour that would compromise the gift of a new liver.
I am thinking that since Mr. Smith had previously been listed, the tx center had not seen evidence of behaviour that would indicate non-compliance in taking post tx medications.
Articles like this one always seem to raise more questions than they answer.
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Oh my GOD!!!! Transplant recipients are not supposed to vacuum? Why was this information kept from me when it could have done me some good?? Why is it only the fun things that everyone tries to order you not to do?? If anyone tells me that transplant patients are not supposed to change dirty diapers I'm filing a lawsuit!!!! :rofl;
I never heard that - isn't this crazy??
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Medical marijuana is an issue that is used as a civil rights issue which instead of a medical need. In such, people have very ingrained reactions. On the clinical side, I just saw no use for Marinol which I could have prescribed as easily as prescribing vicodin under my DEA license. In my experience and that of my peers, even when offered Marinol, most patients simply refused and demanded medical marijuana. Sorry, I have an issue with that since it seems that they are looking for more than just a medical treatment alternative.
Marijuana smoked has a very high pulmonary toxicity more so than cigarettes. Most are looking at appetite and nausea treatment more so than pain relief with marijuana. In that case, I have much better alternatives that work better and without the side effects of Marinol. If I had a patient that only had the option of Marinol, I would certainly consider that, but in over 20 years of medical practice, there simply wasn't ever a clinical indication in any of my patients.
As far as aspergillosis, the issue was that it was more commonly associated in marijuana smokers in the transplant population. If that is true, that by itself offers sound reason for prohibiting a recreational drug of really no clinical significance in the transplant population.
Lastly, people can make their own choices. If they wish to smoke pot, that is their issue. The Feds declare it illegal and that is the law of the land whether folks like it or not. Transplant centers have little choice but enforce Federal regulations or risk defunding from the Feds. If folks wish to change the transplant center guidelines, I suspect that they will first have to change the Federal laws. I am obviously opposed to that myself personally, but if that is the will of the majority, then so be it. It is simply not the law of the land right now.
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The opening post and article actually spell out noncompliance with a drug test as the reason he was dropped from the list, not actual marijuana use. There may be more to the story than what we are hearing about in the news which is pretty standard in most news stories.
If folks wish to smoke pot, that is their own choice which I have no obligation to support it as a physician any more than I would support alcohol use are tobacco abuse. There are consequences of our personal choices. When it comes to participation in transplant programs, some are more stringent than others. Most urban centers have more than one transplant center in the larger cities. Entering a transplant list is really a contractual relationship where patients must adhere to the program. I would think that Noahvale's experience above is educational on the issue of how difficult it is to accept patients as good candidates that will benefit the most from organs in poor supply. I believe that the centers not only have a right to define their criteria, but a duty to make sure each organ has the greatest chance of survival in the patients chosen. I seriously doubt that transplant centers will ever engage in an RCT on this issue since it is a behavior that involves risk with little expected survival benefit if not instead diminished survival with marijuana use. I doubt anyone would approve that in an medical ethics review of such a study.
So, strong feelings on an issue popular in many places, but very void of true clinical benefits above and beyond other alternative meds. If folks really want safe options for marijuana, ask for marinol instead of pot. I just don't have anyone asking for marinol which is the safe choice for this indication if there truly is an indication that exceeds the alternatives. It simply was not a useful med in my practice.
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This is a really, really interesting conversation!
Hemodoc, I don't disagree with anything you've posted, and I particularly agree that there is probably more to this story than meets the eye. There usually is. I have to wonder about this particular patient, though. I wonder if he regularly used marijuana for mere recreational use, or did he only start using it as a way to combat pain and nausea? I have taken vicodin for post-surgery pain, and it made me take to my bed as standing made me feel like I was in a small boat in a gale 5 storm. Now, I have never used marijuana or any other recreational drug, and in my middle aged years, I have pretty much stopped caring about what other people want to do. I don't remember the last time I drank a whole glass of wine! Wine makes me squiffy, so you can imagine what vicodin does to me, and perhaps Mr. Smith has a similar reaction to this class of pain med. I don't know, and this article didn't make that clear.
I do understand the significance of adhering to the program when you are on any transplant list, but I do have concerns about how a patient's suffering while waiting is addressed. I also understand how a tx center would want to offer organs to the very best candidates, but this smacks a bit of cherry-picking which we hate so much when it comes to how dialysis centers treat their patients. I do realize, though, that offering an organ and offering dialysis are two different things, so please, no one try to catch me out on that analogy. Again, I am uncomfortable with the ethics of allowing a patient to suffer needlessly as a result of creating yet one more hoop through which he must jump. If conventional meds cause even more side effects when combined with back pain AND chemotherapy, then why does a tx center insist that an alternative shall not be permitted if a patient wants to remain listed?
Does needing a new organ just subject you to more suffering because the tx center says so? Does a tx center care more about a patient post-transplant than pre-transplant?
I am not a marijuana advocate, but neither do I like the idea of a group of medical professionals (the tx center) treating a patient's suffering due to hepatic cancer with such disregard. I know that centers have a right and a duty to get the best candidates, but it strikes me that some of these people might be hiding behind rules and regulations so that they don't have to show some compassion and common sense.
If the tx center has good evidence that Mr. Smith has had a long history of drug abuse and that he has not been compliant with his chemotherapy schedule, then they have good reason to feel that he would not be a good transplant candidate after all. But absent of that kind of evidence, I think that maybe they should take a closer look at this particular patient. None of us like to be "cookie cut". (I do agree that not showing up for the drug test was a bad idea.)
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To add...your point about federal funding is a good one, though. I don't know if that is a true problem, but if it is, it's interesting that they didn't say so in this article.
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I'll bet you could be a Vicodin addict (but not an occasional marijuana user) and be approved for a transplant.
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I'll bet you could be a Vicodin addict (but not an occasional marijuana user) and be approved for a transplant.
Karol, not according to the UCLA guidelines:
Contraindications for Kidney/Pancreas Transplantation
Insufficient cardiac reserve:
non-correctable coronary artery disease.
ejection fraction <40%.
recent myocardial infarction.
Extensive peripheral vascular disease.
Lack of well-defined secondary complications.
Ongoing substance abuse.
Debilitating psychiatric illness.
Significant obesity (body weight >100 kgs).
http://transplants.ucla.edu/body.cfm?id=81
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Yes, but they would likely not know unless the patient told them, and it would not be caught in a drug test, or would it?
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If hypothetically a patient could hide a vicodin addiction, and this patient got a transplant, would continued use of vicodin compromise the allograft? Does a pain med like vicodin interact badly with the typical post-transplant meds? I'm just curious.
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Yes, but they would likely not know unless the patient told them, and it would not be caught in a drug test, or would it?
Opiate screening is part of the evaluation and review of med lists. Vicodin abuse is one of the difficulties of medical practice sorting out tolerance issues that require higher dosages of opiates to achieve the same effects from vicodin vs those that have drug seeking behaviors. Usually, it is readily definable who is who. Compliance is one of the factors that comes into play when evaluating this. I believe through the new DEA system, you can actually find all narcotic prescriptions given to an individual patient or so I was told before I left practice a few years ago. In that case, if you can access that information, you would be able to quantify if the patient is getting multiple prescriptions from multiple doctors.
In those suspected cases, I always referred the patient to a pain management expert to evaluate for alternative meds/treatments and to set up a narcotic contract. If the patient violated the contract, they would not get any further prescriptions. That happened more than once. Essentially, the transplant unit are making a similar contract with patients for consideration of the transplant list at that center. Patients that cannot adhere to the stringent requirements before transplant have been shown to be at high risk of graft failure from failing to take medications and adhere to the stringent requirements after transplant. Since the center has limited availability of organs, finding the best candidates when they can't serve every candidate is mandated by their fiduciary responsibilities to everyone on the list. It truly is a situation where you get with the program or you are off the list.
One of the nurses in our clinic ended up dying from vicodin abuse and liver failure. She was on the transplant list with drug testing. She opted to continue her drug abuse and did not make it to transplant. She died in the ICU from liver failure even though she had just recovered a month earlier from another bout of liver failure from tylenol overdose. She simply could not give it up. In her last hospitalization, because of her multiple documented issues with active drug abuse, she was not considered a candidate for transplant with two episodes of tylenol overdose in less than one month. Quite a sad case but at the heart of the issue was her own personal choices that she made for herself. There are consequences to our decisions. Giving a patient like this is most likely an effort in futility since her drug abuse will render her transplant moot in a short period of time not only from the tylenol overdosage issues, but compliance with medications as well. Many studies show this to be the case.
Once again, harsh realities, but plain and simple truth. Being on a transplant wait list is essentially a contractual agreement. Getting with the program or exerting your civil rights to do what you want without any regard for the stipulations of that contract will likely have an adverse effect on staying on the transplant list. Ultimately, it comes down to personal choice and responsible actions. With so many patients with drug seeking behaviors and substance abuse, the transplant centers truly have no other choice but to set these firm guidelines given to all patients. Within these guidelines are also provisions for treatment and second chances if not third chances. Once again, our actions and decisions have consequences which is something that most people with substance abuse have never incorporated into their lives in the first place. For the nurse who died from two tylenol overdosages in one month from vicodin abuse, she is ultimately responsible for her own demise. Harsh facts, but reality. She had several years of interventions prior to losing her job at Kaiser and a couple more years of interventions after. She made her choice which in the end was a very bad choice.
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Hemodoc, I hear you regarding "entering into a contractual agreement" and personal responsibility and all of that. But I'd really like to talk about the original patient, Mr. Smith, who does not seem to have a history of drug abuse as you seem to be defining it, nor does his use of medical marijuana seem to have been the causal agent for his liver cancer, nor do other, conventional meds seem to work to reduce his back pain nor the nausea caused by his chemotherapy. So, what would you to for such a patient? Do you think his transplant center should take over the treatment of his pain and nausea so that they can ensure he is not abusing any substance? Which medical person is responsible for treating Mr. Smiths pain and nausea?
The harsh reality here is that Mr. Smith is suffering, but his suffering doesn't seem to register with the transplant center. They do not seem to care that much about the 300 days that Mr. Smith will continue to suffer until stats say he may get a liver transplant.
What would you suggest he do? It does him no real good to lecture him about tx center rules or contractual agreements or good personal choices. The man is sick and he hurts. How should he deal with this particular harsh reality?
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Hemodoc, I hear you regarding "entering into a contractual agreement" and personal responsibility and all of that. But I'd really like to talk about the original patient, Mr. Smith, who does not seem to have a history of drug abuse as you seem to be defining it, nor does his use of medical marijuana seem to have been the causal agent for his liver cancer, nor do other, conventional meds seem to work to reduce his back pain nor the nausea caused by his chemotherapy. So, what would you to for such a patient? Do you think his transplant center should take over the treatment of his pain and nausea so that they can ensure he is not abusing any substance? Which medical person is responsible for treating Mr. Smiths pain and nausea?
The harsh reality here is that Mr. Smith is suffering, but his suffering doesn't seem to register with the transplant center. They do not seem to care that much about the 300 days that Mr. Smith will continue to suffer until stats say he may get a liver transplant.
What would you suggest he do? It does him no real good to lecture him about tx center rules or contractual agreements or good personal choices. The man is sick and he hurts. How should he deal with this particular harsh reality?
Hard to really know what is going on in the OP article. Just don't have all of the information. It may be possible that he does have a history of illicit drug use or perhaps not. Medical marijuana is not really an accepted part of medical practice in general. In addition, it is illegal. Lastly, it is excluded from use by the Feds. Lastly, there is evidence that marijuana use in medical literature reports increases the risk of medication noncompliance. Once again, we all have choices. It is apparent that he understood that the center did not want him using marijuana and he knowingly declined a required drug test. Even without any marijuana use, that behavior by itself is enough to violate the contractual relationship with the transplant center.
As far as who manages the pain, that would most likely be in the hands of his primary care, but given his known marijuana use, a consult with a pain specialist would have been in order. Once again, hard to make an clear distinctions when you don't have all of the evidence. If the man had requested marinol, that might have been a different issue approved by the transplant center. But once again, I just didn't have folks come and ask me for marinol, they simply wanted me to legitimize their pot use. If they were really interested in the clinical benefit of pot, then marinol is the best choice.
I don't believe that this whole medical marijuana issue is about clinical outcomes, it is simply an excuse to have legal pot. With marinol available by prescription, how can anyone call for marijuana itself? Sorry, I just don't buy these so called arguments. The DEA has already provided it for them. However, the majority don't want a pill.
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Despite the fact that I know that a little bit of information gleaned from the internet can be a dangerous thing, I have tried to educate myself on marinol vs marijuana because until now, I'd never heard of the former and knew very little about the latter.
By what I can tell, and please tell me if I am wrong, there doesn't seem to be a great deal of difference between these two substances in the way they work or how they affect a person. I can understand that smoking marijuana carries more respiratory risk simply because there is smoke involved which is rarely a good thing, but wouldn't ingesting marijuana take care of that? I also learned that marinol, being legal, can be covered by insurance whereas "medical marijuana" obviously is not. So quite frankly, I can't really tell why marinol would be legal and marijuana not be. Marinol seems to affect you in the very ways that make marijuana illegal in that it runs a risk of dependency and it impairs judgment and mental acuity. I can see where marinol might be safer because it does not have the other numerous elements one sees in a plant, but it does seem to have the same affects as marijuana. What am I missing here?
This is where I got my information...
http://www.themarinol.com/marijuana-vs-marinol.php
I can't claim to be an expert after reading this site, so if you have other information that I'm obviously missing, please let me know.
In summary, I guess I am not really clear on why marinol would be legal and marijuana would not be. There doesn't seem to be a vast difference between the two substances. Does the medical literature even ask/examine the issue of medical non-compliance in a patient taking marinol?
I just think this is a really interesting topic; I don't mean to be a terrier with a bone, but I am interested, in light of this story, in learning more about the role of the tx center in the treatment of patients who are already sick. Again, I can't help but feel that this particular tx center is placing more importance in a liver than in a man's suffering and are conveniently hiding behind their curtain of regulations. It feels punitive to me, and I don't like that. This tx center symbolizes that characteristic that I am seeing more and more in our society, and that is a mindset of thoughtless judgment and cavalier punishment. This tx center is making the life-altering judgment that this particular patient's marijuana use will result in non-compliance with a post-tx drug protocol, and I am not sure that is necessarily an accurate judgment. I just hope that this tx center will look at the patient and not just at their rulebook.
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Despite the fact that I know that a little bit of information gleaned from the internet can be a dangerous thing, I have tried to educate myself on marinol vs marijuana because until now, I'd never heard of the former and knew very little about the latter.
By what I can tell, and please tell me if I am wrong, there doesn't seem to be a great deal of difference between these two substances in the way they work or how they affect a person. I can understand that smoking marijuana carries more respiratory risk simply because there is smoke involved which is rarely a good thing, but wouldn't ingesting marijuana take care of that? I also learned that marinol, being legal, can be covered by insurance whereas "medical marijuana" obviously is not. So quite frankly, I can't really tell why marinol would be legal and marijuana not be. Marinol seems to affect you in the very ways that make marijuana illegal in that it runs a risk of dependency and it impairs judgment and mental acuity. I can see where marinol might be safer because it does not have the other numerous elements one sees in a plant, but it does seem to have the same affects as marijuana. What am I missing here?
This is where I got my information...
http://www.themarinol.com/marijuana-vs-marinol.php
I can't claim to be an expert after reading this site, so if you have other information that I'm obviously missing, please let me know.
In summary, I guess I am not really clear on why marinol would be legal and marijuana would not be. There doesn't seem to be a vast difference between the two substances. Does the medical literature even ask/examine the issue of medical non-compliance in a patient taking marinol?
I just think this is a really interesting topic; I don't mean to be a terrier with a bone, but I am interested, in light of this story, in learning more about the role of the tx center in the treatment of patients who are already sick. Again, I can't help but feel that this particular tx center is placing more importance in a liver than in a man's suffering and are conveniently hiding behind their curtain of regulations. It feels punitive to me, and I don't like that. This tx center symbolizes that characteristic that I am seeing more and more in our society, and that is a mindset of thoughtless judgment and cavalier punishment. This tx center is making the life-altering judgment that this particular patient's marijuana use will result in non-compliance with a post-tx drug protocol, and I am not sure that is necessarily an accurate judgment. I just hope that this tx center will look at the patient and not just at their rulebook.
It is another of many controlled substances. Poppy plants grown in the home are not legal, yet a proper prescription under the care of a qualified doctor for morphine is. Marinol comes in prescribed dosages with assured purity. Why wouldn't you prefer that to unknown purity of pot with question of what sort of pesticides and other contaminants. Marinol is simply a purified form of THC, the active ingredient in pot. Because there may be some medicinal applications of pot, the DEA developed and approved this for controlled use. However, the folks even when advised it is available in my experience didn't want anything to do with marinol. Just give me my legal pot doc. Sorry, it just doesn't ring the right way in my opinion. Since we already have "legal" marijuana in all 50 states with marinol, what is this silly quest to legalize marijuana all about? Sorry, I just don't believe it is legitimate in my opinion.
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Well, I can understand your scepticism. I wonder how many people have even heard of marinol?
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Here is a review of Marinol by the DEA. It pretty much sums up the entire medical marijuana issue quite well. Medical marijuana is the same absurdity as calling smoking opium medical. If there really is an indication and a failure of much better meds in most patients, so be it, prescribe marinol. In 20 years of medical practice, I had no need to ever once write a prescription for marinol to the best of my fading memory.
http://www.justice.gov/dea/ongoing/marinol.html
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Oh, thanks for that very interesting link. Maybe Mr Smith's physician should encourage marinol instead of marijuana. I wonder why he does not recommend this route. I hope that Mr. Smith is readmitted to the list.
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People who have tried Marinol, switching from using mj say it does not have the same effect and does not bring the same relief. And that is all I need to know. If people say smoking pot (eating pot) gives them relief then that's enough for me. If people say that by smoking pot they no longer need dozens of other pills and that they are fully aware of the risks of smoking pot - risks that pale compared to the risks of those dozens of pills - then that is all I need to know,
I give very little weight to DEA published material; their policies are a result of politics not science. For the last 50 years it has been impossible to research mj in the US except under very tightly controlled conditions. There is a lack of science because the research has not been allowed.
This is a clear area where politics is trumping science and politics is trumping patient rights. Peter, as a doctor you are under no obligation to prescribe or countenance the use of pot, but at the same time the system, the medical system, can and should allow it when it works.
The drug war's cost far out weighs it's value and no where is that more striking than in these hysterical anti pot policies. To then extend the anti pot hysteria to medicine and the comfort of the ill is tragic.
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Bill, there has actually been quite a bit of testing of marinol for pain, nausea and appetite and it is quite effective in these limited uses. It is also used in glaucoma patients as well.
Aspirin comes from willow bark, morphine from opium plants, cocaine is actually one of the best topical anesthetics for nasal surgery, paclitaxol, digitallis, atropine, ephedrin, quinine, and I believe a total of about 120 FDA approved drugs are plant based in origin.
Understanding the chemistry and clinical effects of these medicines titrated by dosage and the pharmokinetics and half lives so that we can know how often to dose can only occur when you use a purified form of these meds. None of the above meds would be of much clinical use without taking them from the raw material and quantifying and purifying each one.
There is a first pass effect of Marinol as it is absorbed in the stomach and intestines and passing through the liver first before going into the general circulation. Doses are based on how quickly the drug is metabolized. I suspect that what you have heard from these other folks relates to the fact that they don't get as good a buzz off of marinol becuase it first goes through the liver while pot smoked does not have that first pass effect since it is absorbed directly from the lungs and goes directly to the brain. Sorry, but the speaks of drug seeking behavior in my opinion instead of true clinical effects since marinol can be titrated to the desired clinical effects.
The biggest single final vote against plant based marijuana aside from the contaminant issue is that of the carinogenic nature of smoking pot which is the preferred delivery. For this reason alone, I would never prescribe marijuana when I have purified THC tablets called marinol. Yes, the DEA has kept back research on marijuana, but there is no such proscription against marinol which is legal and available in all 50 states here today. In reality, the whole legal marijuana movement has nothing to do with medicinal value. I am certain I could titrate Marinol to the desired clinical effects without difficulty. It is instead a social issue using the guise of medical marijuana as an excuse for legalization.
If folks wish to legalize pot as a social issue, that is in the providence of the people participating in a democracy. However, using medicinal value arguments of pot when we do have marinol that is safe, effective by many, many well done medical studies, then I call that a fraud since most people that support medical marijuana use have never once even heard of marinol.
I have dealt with drug seeking patients for over 20 years and quite frankly I have absolutely no patience for any of them any longer. I have spent a great deal of my time as a doctor being manipulated and lied to by this group of patients. I have yet to see anything objective to tell me that the medical marijuana movement is anything more than an excuse to seek legalization of pot. There is indeed no medical justification for it and in fact there are many medical issues and risks ruling against such a primitive way to ingest medicines that increases the risk of cancer and cardiovascular disease.
I guess you and I willjust have to agree to disagree on this issue. Something we don't do that often. I just cannot support this movement whatsoever and I truly question their motives and tactics which I personally believe are fraudulent in nature. The DEA already made it available legally to all that wish to seek it lawfully and in concert with a doctor overseeing this medication watching for signs of abuse as we are trained to do. Sorry, I just don't buy the argument whatsoever any more than I would ever prescribe smoking opium for any of my patients.
I appreciate your point of view, but I guess we will just have to agree to disagree.
God bless,
Peter
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As you say people were offered Marinol, yet they continue to use mj instead. To me that is saying that the point is not the THC, or it is not the THC entirely. I see the reluctance to use Marinol as more evidence that the point is not the buzz but the relief. There is more to pot than THC. One of the more organic (vs political) reasons it is hard to study.
But really. The mold. Marinol. The worry about carcinogens. It's none of that right? The ban is on the plant not the way it is used. Vaporizers and baking are banned too. The dangers and alternatives are all things thrown up so that the underlying objection remains unaddressed. It's the hippies, right? It's hippie hatred. If official policy isn't that pot use is evil it will mean the hippies win.
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As you say people were offered Marinol, yet they continue to use mj instead. To me that is saying that the point is not the THC, or it is not the THC entirely. I see the reluctance to use Marinol as more evidence that the point is not the buzz but the relief. There is more to pot than THC. One of the more organic (vs political) reasons it is hard to study.
But really. The mold. Marinol. The worry about carcinogens. It's none of that right? The ban is on the plant not the way it is used. Vaporizers and baking are banned too. The dangers and alternatives are all things thrown up so that the underlying objection remains unaddressed. It's the hippies, right? It's hippie hatred. If official policy isn't that pot use is evil it will mean the hippies win.
Actually, the hippies have won, they are in Washington right now. LOL
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But really. The mold. Marinol. The worry about carcinogens. It's none of that right? The ban is on the plant not the way it is used. Vaporizers and baking are banned too. The dangers and alternatives are all things thrown up so that the underlying objection remains unaddressed. It's the hippies, right? It's hippie hatred. If official policy isn't that pot use is evil it will mean the hippies win.
Ah yes, finally someone has come out with it.
I have been in severe pain, pain so bad that with my first instance of it my mind went to suicide inside of a minute. If I had found marijuana had helped and then some doctor had decided that I could not be trusted with it because they had some personal problem with it, he would not see me for the dust. To borrow an oft-used theatre term: Next!
The harsh reality is that some doctors, like the ones mentioned in this article, get high on the power of forcing their decisions and biases on others. I have run into these, they are the ones who immediately want to get into a pissing contest with me over who knows more about what works for my body. Any time patients can manage their own health problems without being at the mercy of corporate drug and health insurance interests, this particular type of doctor sees a bleak future in which no one needs their precious permission to feel better.
The further harsh reality is that this is what is wrong with the whole concept of a transplant eval. They encourage the "team" (Did you know you're the most important member of the team? It's true! That's not the least bit condescending either! Trust us, we're doctors, we know these things!) to make guesses and assumptions about people and their possible, future behaviour, and then withhold treatment on this basis alone. Not even the law is allowed to condemn someone over something they have not done yet, but transplant workers are, and they fiercely guard this power. It is this notion that anyone who claims to be in pain cannot be trusted because they are liars that forces migraine sufferers to carry signed statements around with them wherever they might go. And they still are called liars and drug seekers.
In researching for a recent anthro paper I happened upon this, a guide for transplant social workers. These were reasons to reject a candidate for transplant: The recipient says he or she does not care whether there is family emotional support because "It's my body, I can do what I want with it." - Health & Social Work, Vol 31, No 2 May 2006
Guess what, transplant social workers, doctors, nurses, physicians assistants, receptionists, cleaning crew, orderlies, lab techs, donors and other recipients: It's my body and I can do what I want with it! Having a transplant does not negate my right to my own physical autonomy.
MM is absolutely right. There is more concern about damaging the body part of a cadaver than there is for the quality of life of a sentient human being.
One of the reasons I would choose marijuana over marinol is because I prefer a natural herb to a synthetic. I choose natural, alternative treatments whenever possible. I have not tried medical marijuana because THANKFULLY I have no need for it. I have been accused of lying about pain (I wasn't) I have been accused of being drug seeking (right before a viral meningitis diagnosis and a horrific allergic reaction to morphine which they assumed I was already accustomed to taking being the junkie that they so obviously assumed I was.) An alternative medicine practitioner once told us (my husband and me) that one should always choose to eat or drink herbs rather than consume them in capsules because if you start to react badly to a substance, you can stop eating or drinking before things get really bad. With capsules and other drugs, it is too late, you are going to just have to ride it out. I had to do that with morphine, dilaudid, and fentanyl and it nearly killed me. Also, as I think someone has mentioned, there are other substances in marijuana not replicated in marinol, and they seem to provide some benefit that marinol does not. Transplant hospitals should understand this, they don't even want you take to generics. Then again, the control freaks among them also clutch their pearls over eating sushi, enjoying a buffet or gaining five pounds (as they struggle to button their white coats over their ever-expanding frame).
Transplant centers have little choice but enforce Federal regulations or risk defunding from the Feds.
Oh, please! The Feds don't even intervene when doctors are caught offering to sell organs to people (read the report from famous anthropologist Nancy Scherper-Hughes), when a UCLA doctor performed 4 liver transplants on notorious Japanese gang members barred from entering the US (we'll just hide behind the fact that we did not know they were barred - it's not like we famously take any time to get to know the patient before transplant) and when USC transplanted the wrong flipping kidney, a staggering error even by USC's gutter standards. No one at the federal level is the least bit interested in shutting down transplant programs because a recipient or two takes medical marijuana that was not even prescribed by the transplant physicians. These are excuses to make moral judgments. If this man were Steve Jobs, Mickey Mantle or George Best they would go out and pick the marijuana for him.
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Ms. MooseMom, I don't know if you've already seen this article, but I thought you might find it interesting as it relates to the use of medical marijuana and autism.
http://www.doublex.com/section/health-science/why-i-give-my-9-year-old-pot (http://www.doublex.com/section/health-science/why-i-give-my-9-year-old-pot)
I think I've only read the first three parts to her story, but anyhow, I found it to be a fascinating story about situations where it would be easy to judge this woman as an unfit parent until you take the time to hear her out. I just hope that it continues to work for her and her son. I don't think it mentions Marinol and if I were in her situation, I would not tamper with what is working, especially as she got the wrong kind of mj at one point and everything fell apart.
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Sorry, should have reread the above article before commenting. Here is what the woman says about her once-violent, autistic son J and his use of Marinol:
A prescription drug called Marinol, which contains a synthetic cannabinoid, seemed mainstream enough to bring up with J’s doctor. I cannot say that with a few little pills, everything turned around. But after about a week of playing around with the dosage, J began garnering a few glowing school reports: “J was a pleasure have in speech class,” instead of “J had 300 aggressions today.”
But J tends to build tolerance to synthetics, and in a few months, we could see the aggressive behavior coming back. One night, I went to the meeting of a medical marijuana patient advocacy group on the campus of the college where I teach. The patients told me that Marinol couldn’t compare to marijuana, the plant, which has at least 60 cannabinoids to Marinol’s one.
[**a few paragraphs down**]
And yet, I still hesitated. The Marinol had been disorienting enough—no protocol to follow, just trying varying numbers of pills and hoping for the best. Now we were dealing with an illegal drug, one for which few evidence-based scientific studies existed precisely because it is an illegal drug. But when I sent J's doctor the physician’s form that is mandatory for medical marijuana licensing, it came back signed. We underwent a background check with the Rhode Island Bureau of Criminal Identification, and J became the state’s youngest licensee.
If medical marijuana works on chronic, debilitating pain, then doctors need to listen to their patients and stop indulging paranoid fantasies that we are all secret drug addicts. Yes, even we loser organ-failure patients deserve this small courtesy.
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^
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Based on my years of work in addiction treatment there is no difference between alcoholism and substance abuse - and in the case of Mr. Smith, we do not know if he crossed the line between using medical marijuana for legitimate reasons or using "extreme pain" and "physical anguish" as a way to get the pot legally for recreational use.
You're 1) deeming recreational marijuana use as substance abuse 2) that there is no difference between alcoholism and recreational pot use. Do I understanding your position? That there is medical use of marijuana, outside of that any other use is abuse, thus any other use of marijuana is no different than alcoholism.
Have I stated your professional judgement correctly?
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Cariad, thanks for that article. I would guess that yes, many parents would deem this mom as an unfit parent, giving her autistic son marijuana. One has to be very careful in dosing autistic children. Conventional drugs of all sorts seldom work in autistic kids as expected. I had an aquaintance long ago whose young son was autistic; her husband was from Saudi Arabia and spent most of the year there, whereas my friend, who was English, spent most of the year in the UK. Strange arrangement, but whatever. Anyway, this family had a lot of money, and she and her son would frequently fly, first class, to Riyadh to see dad. The boy would sometimes become agitated on such a long flight, so she got a prescription from the doctor for a mild sedative for her son. Well, that plan backfired; the sedative made him just climb the walls, so you can imagine what THAT journey must have been like! So ever since then, I've been very sympathetic to parents who are looking for something that works for their child, particularly if that child has global communication difficulties and cannot verbally express pain or illness.
Bill, you've asked something about which I've always wondered. Is recreational marijuana use, in fact, substance abuse? Is having a cocktail at a club also "substance abuse"? If not, why not? What is the fundamental difference between eating a brownie laced with pot and having a whiskey to relax? This is a real question...I honestly don't know as I have never smoked pot nor have I ever had a whiskey.
I agree with noahvale that there are a lot of unknowns here. I would be very interested to know more, but I do find it interesting that this patient HAD been previously listed at his tx center, so I am assuming (perhaps wrongly) that they had not found any evidence of a history of substance abuse.
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Hemodoc posted the transplant center's contraindication protocols for liver transplantation (http://transplants.ucla.edu/body.cfm?id=81). Maybe one or more of these applied to Mr. Smith. I happen to believe it has to do with either a history of substance abuse or ongoing substance abuse (legal or illegal) and an unwillingness to cease using. He already admitted to failing to show up for a drug test. Was it because he would still test positive for marijuana or other substances as well? These are legitmate issues the LAist writer chose not to address.
Not to nitpick, but that link is for UCLA, not Cedars. I have been to Cedars, I know their protocol very, very well, as does Gwyn. I also know that they were so furious with me for daring to take my insurance money elsewhere that the donor coordinator shouted down the phone at my husband when we were forced to move cross country over job issues. Extremely unprofessional. I had absolutely no problem with the doctor there, I have an enormous problem with the social worker diagnosing my brother with, of all suspicious things, a drug addiction! He has never met my brother, never will meet my brother, and my brother, if he ever was diagnosed as a "coke addict" rather than just a "selfish idiot", this information was never shared with me and certainly never shared with the social worker. That does not give me a lot of confidence in their judgement. Anyone with any history of social work, like myself, knows that you do not diagnose people based on zero evidence. Which brings me to your further comments.....
Based on my years of work in addiction treatment there is no difference between alcoholism and substance abuse - and in the case of Mr. Smith, we do not know if he crossed the line between using medical marijuana for legitimate reasons or using "extreme pain" and "physical anguish" as a way to get the pot legally for recreational use. Besides, there are legitimate studies showing the deleterious effects of marijuana on the body. Also, you might want to do the research on the numbers of people who only smoke pot recreationaly and the numbers of those who use marijuana and other substances. That and possible abuse issues seem to be of concern to the transplant center.
I agree with you - why wouldn't I - that alcoholism and substance abuse are the same, that seems pretty obvious that alcohol is a substance, a drug. As Bill has pointed out, you are conflating substance abuse with recreational use, like telling me that the glass of wine I am sipping right this instant means I'm an addict. If you think there is no difference there, I totally, emphatically disagree. There are loads of studies on the deleterious effects of Prednisone, Imuran, CellCept, and Prograf on the body, too. That does not mean you don't take them. Whether or not mj is a gateway drug is irrelevant, just as whether or not Dilaudid is a gateway drug is irrelevant when you are in excruciating pain.
Your comment that, "By your calculus, it would seem that no one who has to take any prescription drugs of any kind should be given a transplant," makes no sense in my argument. There is a huge difference in recreational drug use/addiction and the body needing medication to control pain due to illness. The latter does not lead to addiction if the body is crying out for relief.
I disagree with this.
From your earlier post:
Just because a drug is "prescribed," doesn't mean it can't lead to abuse (ask Rush Limbaugh about his former oxycodone dependency).
So, with the risk always there (and from what I know, Rush Limbaugh, much as a detest that particular vile, race-baiting monster, did have legitimate pain) and only a person's testimony to go by when it comes to recognising whether someone is in pain or not, you are saying that the transplant centre that just is not equipped to diagnose substance abuse, that is not what they do, can decide that they know the difference between someone in legitimate pain and someone who is abusing something based on a single visit. I think Bill rephrases your position better than I did. Perhaps you should go talk to him.
Relating what happened to the person I knew is not anecdotal. From some of the literature I have read on liver transplantation up to 20% lose their grafts because of substance abuse and alcohol relapse. My only bias as it relates to this article is again, not having the full story.
Look, I'm not going to look up another word for you, but any story that begins "I knew a guy once who...." is anecdotal by flipping definition. www.merriam-webster.com (http://www.merriam-webster.com) There is no science to it and it is a population of one. Anecdotal. Your talk with your liver doctor, also anecdotal. Interesting that he called California transplant hospitals liberal as there are quite a number of them (11 in SoCal alone) and they differ quite dramatically. To say you are magically unbiased when you admit, as does Peter, that you worked with this very frustrating population of addicts says a lot about your willingness to address how your life experiences have shaped your views. It comes off as rather arrogant that you accuse a journalist, who will be trained to address bias in his piece, as biased but you won't admit that working with addicts perhaps would color anyone's view of them and drug use in general. Addiction is a recognized disease, with recognised genetic aspects, so if a person is addicted, their past addiction should not be grounds for denying them a transplant so long as their disease remains controlled. So I disagree that any past drug abuse is of any consequence beyond needing to consider whether or not it remains properly controlled, just as you would check that cancer remains in remission (*cough cough* Steve Jobs *cough cough*) before transplant.
MM, thanks for sharing your views on marijuana with autistic children. Her last article was from May of this year, and apparently the marijuana is still really helping her child. http://www.slate.com/articles/double_x/doublex/2011/05/why_i_give_my_autistic_son_pot_part_4.html (http://www.slate.com/articles/double_x/doublex/2011/05/why_i_give_my_autistic_son_pot_part_4.html) She has taken a lot of abuse over it, it sounds like.
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Cariad, anyone that has spent any time dealing with drug abusing patients understands it is a very frustrating and usually unfruitful experience in the vast majority of patients. I have had patients try to ruin my career and in fact in one case where the patients father was a 2 star general, her outrageous accusations against me and another doctor who bent over backwards to help her and her family led to a Presidential inquiry by Bill Clinton that involved dozens of people, wasted time and enormous resources for a patient completely out of control and exhibiting homicidal behavior at the time of the incident.
Nevertheless, it was a part of my job that I engaged in completely and wholeheartedly and at times was pleasantly surprised by a positive result. Unfortunately, there are many in the "medical marijuana" movement that are nothing more than recreational drug users trying to game the system one more time. Separating true patients with pain from those simply seeking drugs is a very difficult task that must be done BY LAW. It is unlawful to knowingly prescribe any controlled substance to an active addict, plain and simple. Doctors have lost licenses and had criminal charges for such situations. It is a part of our job we must pay close attention period.
I had one patient who had a known history of active IV drug abuse with heroin come in for pain in his hip. The orthopedist doctor declared his symptoms not physiologic. Under that advice, I stopped his IV morphine. 24 hours later, the MRI returned positive for an active infection in his hip. When I saw him the next morning with the MRI results in hand, the man cried with large tears down his face and told me why did you stop my pain meds? I had no good answer for him. I shall never forget that chilling episode ever. In such, I will tell you that the majority of doctors diligently try to control patients pain and symptoms until it is completely obvious that the patient is simply drug seeking which is a very difficult task at times to discern knowingly.
I had another patient who shot his finger off with his own hand gun. He worked in a high security job and interestingly, I had actually completed his discharge physical from the military several years prior before I moved to my civilian position where he also had insurance. Long story, he had escalating demands on his chronic pain meds and multiple prescriptions from multiple doctors. I referred him to a pain medicine specialist who significantly increased his pain medicines to cover for the possibility of tolerance. I saw him a few months later. He was no longer seeing the pain specialist, he was divorced because of his drug problem, he had lost his job and he was getting methadone at a heroin addicts clinic. The suspected drug seeking behavior he had was confirmed and he refused inpatient rehab, choosing instead to go to a public methadone clinic to continue his illicit drug use. Nevertheless, over a course of two years, this patient consumed huge amounts of prescription narcotics, office visits with me every two weeks as well as the specialists I consulted on numerous occasions.
Yes, Cariad, dealing with drug addicts is a very frustrating and unfruitful venture. However, that does not in the least mean I have a biased view that does not have any validity. In my experience, the only patients who ever approached me for "medical marijuana" had long standing histories of recreational drug use. Sorry, but I choose not to participate in such behavior especially when thy refuse any trials of alternative meds with excellent results for the symptoms complained of and absolutely refused to consider marinol as well. Sorry but that appears to be fraudulent requests in my opinion. I would feel better about this entire issue if the patients had a history of failing standard treatments. In the few patients I encountered, that was not the case. If there are patients that have a true need but likewise refuse a trial of marinol, I would not ever resort to an illegal substance not approved by the DEA. Sorry, but that is the way it is plain and simple.
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Cariad, I just finished reading all four parts of this story, and it really is fascinating, isn't it? While other parents, undoubtedly with "neurotypical" children, reading about this on a computer obviously feel free to voice their disgust, the teachers and doctors in J's life have seen the improvement in his behaviour, probably as a result in the decreased pain he is experiencing. How awful it must be to feel such gut pain and not be able to communicate that. Can you close your eyes and imagine what that must be like? I really do shudder thinking about it.
J is lucky that his parents are intelligent and well educated people who probably can converse easily with teachers and doctors and other specialists. Many people are intimidated by "experts", and the "experts" pick up on this and then don't truly listen. I had no experience whatsoever with babies or young children before I had my son. But I just instinctively knew how to communicate with him, and I knew how to read him. I could feel from where challenges and obstacles would come. For instance, I wondered if my son would ever learn to drive. I felt he would learn how to operate a car, and I knew he had an amazing sense of direction; I knew he could learn the rules of the road, but I always suspected that he would have trouble anticipating danger and risk because it was/is hard for him to empathize, and you have to have that "theory of mind" to imagine what another driver is about to do. And sure enough, he almost passed his driving test but got just one fault too many, and it was in anticipating risk while on the road. My point is that there really is this innate knowledge of our children, and a good doctor and/or teacher will use the parents as their main source of information. This is something that the author pointed out, and she is right!
My son really never experienced sensory overload, although when he was young, certain types of melodies would make him cry. I honestly don't think it was from pain or discomfort; it looked like certain elements in music would make him sad, so he'd cry. So I have no experience with autism as severe as J's, but I have seen it in other children, and it is overwhelming. I could feel my shoulders relax as I got to the end of the story and saw that J continues to be helped by this particular kind of medical marijuana. And I was really touched that the Organic Guy would spend so much time and effort to cultivate a crop just for this boy.
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Hemodoc, when you have time, would you mind very much reading the story about the autistic boy whose mother is giving him medical marijuana? Cariad's post has the links. I'd be very interested in your take on this. Is this something that you might have seen in your practice? Thanks.
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Oh wait a minute...I just learned something. Marijuana is a schedule 1 drug, along with heroin and LSD, whereas schedule 2 drugs (which can be legally prescribed) include cocaine, morphine and opium. So, the thinking is that marijuana is as dangerous as heroin but less so than cocaine? Is this true? Can someone explain this to me? Thanks.
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Yes, Cariad, dealing with drug addicts is a very frustrating and unfruitful venture. However, that does not in the least mean I have a biased view that does not have any validity.
Peter, I never, not once in this discussion, have said that your view or anyone else's 'does not have any validity'. I did not say that nor do I believe that. So there's the back half of your statement negated. The first part of that sentence is so completely gobsmacking that I scarcely know where to begin. Here is a plain and simple conjugation for you to illustrate the point:
I am biased.
You, Peter, are biased.
He (the author of this piece) is biased.
We ALL are biased.
You all who are having this discussion with me are biased.
They who disagree with you are biased.
Bias is a given in my ba-zillion years of social science work and study, to the point that defining all of the different types of bias is a study unto itself, including a term for what you are doing, falling victim to a bias blind spot (you can easily look this up). This is so utterly fundamental that if we cannot agree that all people everywhere, including you, are biased, then we have no logical basis with which to proceed. Bias is a reason that studies are double blinded when possible. Bias in no way translates to invalid statements nor research. That is a blatant misunderstanding of what we are talking about here. Noahvale said there was a bias to the piece - that statement is even more obvious than 'alcohol and substance abuse are the same thing' or however he put it. He then wrote that the writer had an ‘agenda’ which is going to be more difficult to prove unless you can claim to be a mind reader, but then I think noahvale has an agenda as well, and the first item on that agenda is to try in any way possible to discredit the author. He used the word bias as if that immediately invalidates anything that the author wrote, when in fact that argument is ludicrous.
If there are patients that have a true need but likewise refuse a trial of marinol, I would not ever resort to an illegal substance not approved by the DEA. Sorry, but that is the way it is plain and simple.
You have stated that you do not want to see marijuana legalized, and that is informing your opinion - you are biased against medical marijuana users because in your experience marijuana users are by and large manipulative liars. You have set up this little test that you believe can weed out (HA!) the honest from the frauds. That is what transplant evals try to do, and I truly believe that they fail more often than they succeed. We do not know if the subject of the story tried Marinol, but then that misses the point because he had already been allowed to use medical marijuana and is not seeking it from these doctors anyway. Your experience cannot be substituted for information about this person, nor can mine. Recognizing one’s own biases actually strengthens an argument, not to mention any research one does, which is why journalists and scientists are trained to address, control for, and minimize those biases. Note I said minimize, one can never eliminate them. It is not possible. If you believe otherwise, you are wrong. Sorry, but that is the way it is, plain and simple.
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Yes, Cariad, dealing with drug addicts is a very frustrating and unfruitful venture. However, that does not in the least mean I have a biased view that does not have any validity.
Peter, I never, not once in this discussion, have said that your view or anyone else's 'does not have any validity'. I did not say that nor do I believe that. So there's the back half of your statement negated. The first part of that sentence is so completely gobsmacking that I scarcely know where to begin. Here is a plain and simple conjugation for you to illustrate the point:
I am biased.
You, Peter, are biased.
He (the author of this piece) is biased.
We ALL are biased.
You all who are having this discussion with me are biased.
They who disagree with you are biased.
Bias is a given in my ba-zillion years of social science work and study, to the point that defining all of the different types of bias is a study unto itself, including a term for what you are doing, falling victim to a bias blind spot (you can easily look this up). This is so utterly fundamental that if we cannot agree that all people everywhere, including you, are biased, then we have no logical basis with which to proceed. Bias is a reason that studies are double blinded when possible. Bias in no way translates to invalid statements nor research. That is a blatant misunderstanding of what we are talking about here. Noahvale said there was a bias to the piece - that statement is even more obvious than 'alcohol and substance abuse are the same thing' or however he put it. He then wrote that the writer had an ‘agenda’ which is going to be more difficult to prove unless you can claim to be a mind reader, but then I think noahvale has an agenda as well, and the first item on that agenda is to try in any way possible to discredit the author. He used the word bias as if that immediately invalidates anything that the author wrote, when in fact that argument is ludicrous.
If there are patients that have a true need but likewise refuse a trial of marinol, I would not ever resort to an illegal substance not approved by the DEA. Sorry, but that is the way it is plain and simple.
You have stated that you do not want to see marijuana legalized, and that is informing your opinion - you are biased against medical marijuana users because in your experience marijuana users are by and large manipulative liars. You have set up this little test that you believe can weed out (HA!) the honest from the frauds. That is what transplant evals try to do, and I truly believe that they fail more often than they succeed. We do not know if the subject of the story tried Marinol, but then that misses the point because he had already been allowed to use medical marijuana and is not seeking it from these doctors anyway. Your experience cannot be substituted for information about this person, nor can mine. Recognizing one’s own biases actually strengthens an argument, not to mention any research one does, which is why journalists and scientists are trained to address, control for, and minimize those biases. Note I said minimize, one can never eliminate them. It is not possible. If you believe otherwise, you are wrong. Sorry, but that is the way it is, plain and simple.
Dear Cariad, thank you for your response, but I never said I didn't have a bias, just that my views even if biased are not invalidated. I would point out that you brought up the issue of bias and accused me of having a biased view. Yes, but that does not invalidate my views as irrelevant.
Secondly, I stated I would never prescribe a substance that is illegal. I didn't really get into the entire legalization issue which is a political discussion. If the will of this democracy is to legalize, that is the will of the people. The simple point is it is an illegal substance today whether folks like that or not.
Thirdly, I NEVER accused all patients seeking medical marijuana as manipulative liars. I stated those in my experience did not appear to have legitimate requests. Please don't wrongly attribute statements that I have not stated nor agree with. In all chronic conditions, there are some unfortunate patients who fail to respond to any given therapy opening the doors to seek anything available, legal or illegal. Proven or unproven.
Lastly, I cannot point to any studies in the US or elsewhere showing other active substances in pot that has medicinal values beyond THC. What are these so called therapeutic substances? What are they called, and what is their chemistry? Where is the evidence above and beyond anecdotal evidence for any of these claims. Sorry, I just don't see that anywhere.
So instead of getting into emotional and personal issues, what is the evidence that pot is superior to Marinol above and beyond purely anecdotal evidence. In addition, how will you separate drug seeking, fraudulent "medical marijuana" patients from patients with legitimate needs. Please remember that is a requirement of all doctors who prescribe controlled substances. Please advise how you would address this legal mandate if you had the opportunity to prescribe "medical marijuana."
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Dear Cariad, thank you for your response, but I never said I didn't have a bias, just that my views even if biased are not invalidated.
Fair enough, but I also never used the term biased to equal invalid.
I would point out that you brought up the issue of bias and accused me of having a biased view.
Actually, it was noahvale that brought up bias first. Go back and read. I mentioned you only to illustrate that it was not just him that was biased, it was also everyone who agrees with him (and disagrees with him). Therefore, in this context, pointing out bias is not an accusation. It is an observation. noahvale stated that his only bias was not having the full information or something. That is ludicrous. You work with any population and you are going to form opinions about them that are colored by your own experiences. Pointing out the author's bias as if this were some stellar critique and not just a fact of life tells me that there were some misunderstandings about what it means to point out bias. By all means, point out biases in an article but then be prepared to address your own especially in a political argument.
Lastly, I cannot point to any studies in the US or elsewhere showing other active substances in pot that has medicinal values beyond THC. What are these so called therapeutic substances? What are they called, and what is their chemistry? Where is the evidence above and beyond anecdotal evidence for any of these claims. Sorry, I just don't see that anywhere.
You know, I would love to know the answer to that as well. I would love to know why it was that the little autistic boy in the articles that I linked (totally off topic, but I couldn't resist, it is such a fascinating case) does so well with marijuana but was not helped long term by marinol. Clearly there is something about not only marijuana but the specific mix of marjuana he was taking that worked for him on his severe pain. Logic would point to the idea that it is one of the 60 other canibinoids that the author mentioned are present in marijuana and not Marinol. She also states that few studies have been done on marijuana because it is illegal. I do not have the time to research this right now and chemistry was not one of my fortes in school, but I will see what I can dig up in, well, I cannot put a date on it right now. I am facing some massive life changes so I cannot get into making any promises that I'll probably forget I made anyway. If I do find something (since I have library privileges, I can access almost any research out there with ease) I will post it if I remember.
So instead of getting into emotional and personal issues, what is the evidence that pot is superior to Marinol above and beyond purely anecdotal evidence. In addition, how will you separate drug seeking, fraudulent "medical marijuana" patients from patients with legitimate needs. Please remember that is a requirement of all doctors who prescribe controlled substances. Please advise how you would address this legal mandate if you had the opportunity to prescribe "medical marijuana."
I don't see that I have gone into any more personal issues than anyone else. It can feel personal when someone vehemently disagrees with you, but I see it as all business in the end. Most of us are on the same side when it comes down to fundamentals, and I fully recognise the potential for misunderstandings over the internet. Emotional, well, this is an emotional issue. The topic is about when it is OK to tell someone that we are happy to watch you die without intervention, which is also illegal for certain medical professionals. So which illegal trumps which? And the law as I understand it has doctors simply 'recommending' marijuana, not prescribing it. Is there a single case of a doctor being charged for signing a medical marijuana application in California? I don't think marijuana should be illegal. I think it is one of the stupidest, costliest, most time-consuming laws to enforce all so that, as Bill put it, the hippies won't win.
I would like to think that I would follow my own moral convictions and prescribe something that the state of california has deemed legal and would trust in my own ability to argue the medical opinion that would inform my choice. Pain control is of paramount importance. In every hospital I've been to in recent memory (the past 10 years) there have been notices up that pain control is considered to be critical and that they are committed to treat any pain that you rate a 4 or above. This was helpful to have this stated outright, because I would decide in my head before answering whether or not I wanted intervention for the pain. (Likert scales are not really much use on an individual basis, so I was trying to answer the underlying question - do we need to treat this or not?)
That is what I can guess I would do if it really matters to this discussion. The doctors at Cedars are not being put in this position though, so it does not really pertain to the initial article.
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I would point out that the Medical Board of CA does not license me to issue controlled substances. That is entirely under the province of the DEA alone. CA can declare it legal as much as they want, but their jurisdiction does not supersede the Feds on this limited issue. Until the time that the DEA legalizes marijuana, all that the states are doing is setting up continued conflicts with the Feds. The last time I looked, the Feds are aggressively enforcing these regulations.
I would further advise you to take a look at the number of doctors prosecuted for prescribing legal controlled substances every year let alone illicit and illegal substances declared legal by these individual states yet not by the Feds. SCOTUS upheld the DEA's right to declare marijuana illegal in 2005 I believe. It is settled matter of law even if society has not settled this issue in a limited number of states.
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I would point out that the Medical Board of CA does not license me to issue controlled substances. That is entirely under the province of the DEA alone. CA can declare it legal as much as they want, but their jurisdiction does not supersede the Feds on this limited issue. Until the time that the DEA legalizes marijuana, all that the states are doing is setting up continued conflicts with the Feds. The last time I looked, the Feds are aggressively enforcing these regulations.
I would further advise you to take a look at the number of doctors prosecuted for prescribing legal controlled substances every year let alone illicit and illegal substances declared legal by these individual states yet not by the Feds. SCOTUS upheld the DEA's right to declare marijuana illegal in 2005 I believe. It is settled matter of law even if society has not settled this issue in a limited number of states.
I really don't need to be 'further advised' on anything. Not sure why you ignored my questions but expect me to do all of this extra reading and research.
Yet again I will point out that the doctors at Cedars ARE NOT BEING ASKED TO PRESCRIBE MARIJUANA. You seem to want to make this about legalizing marijuana rather than about transplant centers overstepping their bounds (my opinion) or not (your opinion). That is the core issue that I get from this article and what brought me into this conversation.
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I decided to answer my own question and did a search for prosecutions of doctors in california for prescribing medical marijuana. It came up with this Wikipedia article: http://en.wikipedia.org/wiki/Legal_and_medical_status_of_cannabis (http://en.wikipedia.org/wiki/Legal_and_medical_status_of_cannabis)
It states: There is a split between the U. S. federal and many state governments over medical marijuana policy. On June 6, 2005, the Supreme Court, in Gonzales v. Raich, ruled in a 6-3 decision that Congress has the right to outlaw medicinal cannabis, thus subjecting all patients to federal prosecution even in states where the treatment is legalized
All the articles denouncing the law for intimidating and pursuing doctors were old - 2005 or thereabouts. It would seem that it is patients who currently bear the risk of accepting this treatment. I don't think there should be any risk at all, but I've stated that countless times. It is cruel to condemn someone to chronic pain if they can be helped with marijuana, crueler still to deny them a transplant and condemn them to death.
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I decided to answer my own question and did a search for prosecutions of doctors in california for prescribing medical marijuana. It came up with this Wikipedia article: http://en.wikipedia.org/wiki/Legal_and_medical_status_of_cannabis (http://en.wikipedia.org/wiki/Legal_and_medical_status_of_cannabis)
It states: There is a split between the U. S. federal and many state governments over medical marijuana policy. On June 6, 2005, the Supreme Court, in Gonzales v. Raich, ruled in a 6-3 decision that Congress has the right to outlaw medicinal cannabis, thus subjecting all patients to federal prosecution even in states where the treatment is legalized
All the articles denouncing the law for intimidating and pursuing doctors were old - 2005 or thereabouts. It would seem that it is patients who currently bear the risk of accepting this treatment. I don't think there should be any risk at all, but I've stated that countless times. It is cruel to condemn someone to chronic pain if they can be helped with marijuana, crueler still to deny them a transplant and condemn them to death.
Sorry, I never had any patient condemned to chronic pain that we did not go to extensive lengths to help in any manner we had available. I liberally consulted with pain management specialists who never once resorted to Marinol let alone pot for pain relief. The majority of patients had significant improvement in their symptoms. Just never had a situation where pot was the recommended treatment of choice in 20 years of practice.
The patient in question actually was not "condemned to death" for marijuana use. He failed to keep a drug test. Big difference despite the fact that everyone is focussing on the medical marijuana issue. He failed to keep an agreed upon condition of the transplant list at Cedars. He alone bears responsibility for his own actions. He is free to seek help at USC, UCLA, Loma Linda or the centers in San Diego if he doesn't agree with the program at Cedars. His situation is not without remedy even after dismissal from Cedars.
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Sorry, I never had any patient condemned to chronic pain that we did not go to extensive lengths to help in any manner we had available. I liberally consulted with pain management specialists who never once resorted to Marinol let alone pot for pain relief. The majority of patients had significant improvement in their symptoms. Just never had a situation where pot was the recommended treatment of choice in 20 years of practice.
The patient in question actually was not "condemned to death" for marijuana use. He failed to keep a drug test. Big difference despite the fact that everyone is focussing on the medical marijuana issue. He failed to keep an agreed upon condition of the transplant list at Cedars. He alone bears responsibility for his own actions. He is free to seek help at USC, UCLA, Loma Linda or the centers in San Diego if he doesn't agree with the program at Cedars. His situation is not without remedy even after dismissal from Cedars.
He failed to keep a drug test that was ordered for him because of his use of medical marijuana. I have pointed out numerous times that prescribing marijuana is not the issue, you do not seem to be reading nor addressing what I have actually been saying. You continually focus on what you would have done in your own practice with regards to prescribing marijuana, which sorry, IS in fact irrelevant when there is no issue of prescribing it.
Ah, the old 'he can get care elsewhere' argument. Are you familiar with his insurance? Does he have the time to transfer? UCLA takes months to get into, in fact in my case it took months to even get them to respond with a quick message about how I should call them later. Then before they will even schedule an eval you must attend a four hour orientation which only occurs several times a year. This patient does not have that sort of time. Cedars took months to get into and the woman who answered the phone wanted to dismiss me with 'you're going to have to send us all of this information first'. It was only by blurting out 'I already passed an eval at USC, I have been transplanted over 30 years and I'm only XX years old' that she decided she had better start this process right then and there. Even then, I called them some time before Christmas (maybe late November) and did not get an appointment until January.
I have to suspect that you understand that once one transplant center takes you off the list, you have been branded. Have you ever been through a transplant eval?
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Peter I think your data is incomplete. There have been discoveries recently, the most interesting the discovery of the the cannabinoid receptors (http://en.wikipedia.org/wiki/Cannabinoid_receptor) which "are a class of cell membrane receptors under the G protein-coupled receptor superfamily." Marinol is a drug that undoubtedly has some uses but it isn't cannabis. Patients report cannabis works better. Cannabis has a long history of medical use by humans and it has an unfortunate political history in the US.
This recent letter to the editor (http://www.cato-unbound.org/2011/11/30/the-editors/letter-to-the-editors-dont-forget-our-history/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+cato-unbound+%28Cato+Unbound%29) puts the politics of cannabis in context. I thought this was particularly well said:
"one might characterize U.S. policies as harm maximization — turning substance with relatively few intrinsic dangers into one that carries many externally imposed dangers." Yes one might, if one wished to describe the world as it is.
One externally imposed danger is that use could lead to exclusion! by transplant programs. The decision by transplant groups to focus on pot use, is not justified by the science, it is the result of the politics. Distorted, crippled, unscientific, politics.
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Peter I think your data is incomplete. There have been discoveries recently, the most interesting the discovery of the the cannabinoid receptors (http://en.wikipedia.org/wiki/Cannabinoid_receptor) which "are a class of cell membrane receptors under the G protein-coupled receptor superfamily." Marinol is a drug that undoubtedly has some uses but it isn't cannabis. Patients report cannabis works better. Cannabis has a long history of medical use by humans and it has an unfortunate political history in the US.
This recent letter to the editor (http://www.cato-unbound.org/2011/11/30/the-editors/letter-to-the-editors-dont-forget-our-history/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+cato-unbound+%28Cato+Unbound%29) puts the politics of cannabis in context. I thought this was particularly well said:
"one might characterize U.S. policies as harm maximization — turning substance with relatively few intrinsic dangers into one that carries many externally imposed dangers." Yes one might, if one wished to describe the world as it is.
One externally imposed danger is that use could lead to exclusion! by transplant programs. The decision by transplant groups to focus on pot use, is not justified by the science, it is the result of the politics. Distorted, crippled, unscientific, politics.
Bill, that is an interesting review of cannabinoid receptors. That follows the previous discoveries of naturally occurring endorphins that have receptors throughout the brain and body. There are also nicotinic receptors that make tobacco so addictive but without nicotine, they have a completely independent function. The nicotine simply attaches itself to this receptor. I would be hard pressed to relate the presence of nicotinic receptors to a need for nicotine. The first aspect of the cannabinoid receptors is to discover the underlying brain physiology already present outside of exposure to marijuana. Obviously, marijuana works on some innate physiology of the brain, but its clinical application is yet to be defined in total.
Time will tell what comes of these receptors and how they tie into clinical effects from interventions.
Thanks for the link.
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Here's an expanded story and photo from the Los Angeles Times.
Medical marijuana jeopardizes liver transplant
A cancer patient is removed from the transplant list at Cedars-Sinai for using medical marijuana and for failing to show up for a drug test. He is hoping the hospital will reconsider.
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By Anna Gorman, Los Angeles Times
December 3, 2011
Norman Smith, who has liver cancer, was placed on the transplant list at Cedars-Sinai Medical Center last year.
But early this year, doctors removed him because he was using medical marijuana and failed to show up for a drug test.
To get back on the list, Smith, 63, has to spend six months avoiding medical marijuana, submitting to random drug tests and receiving counseling. He is still undergoing chemotherapy and radiation for the cancer, which recently returned after being in remission. Smith has asked Cedars-Sinai to reconsider and reinstate him.
"It's frustrating," he said from his home in Playa del Rey. "I have inoperable cancer. If I don't get a transplant, the candle's lit and it's a short fuse."
Smith's case highlights a new twist on a long-running debate within the transplant community—should people whose use of drugs or alcohol may have contributed to liver problems be candidates for transplants? And if so, how long should they be clean before becoming eligible for a new organ?
With the ubiquitous presence of medical marijuana, doctors say patients like Smith who have prescriptions increasingly are showing up at transplant centers seeking new livers. Statistics on such requests aren't available, but experts agree the prescription medical marijuana cases are forcing doctors to revisit medical and ethical questions surrounding drug use and transplantation.
There is no standard on transplants and the use of medical marijuana or other drugs, according to the United Network for Organ Sharing, which manages organ transplantation for the U.S. Instead, transplant centers make their own decisions on which patients are the best candidates for new organs, meaning policies vary from center to center.
Livers are highly sought-after organs. More than 16,000 people are in line for livers nationwide and the average wait is about 300 days, according to the network.
"We have to do a prioritization, like you literally do on a battlefield — who can die and who can survive, because we don't have enough livers," said Dr. Goran Klintmalm, chief of the Baylor Regional Transplant Institute and an expert in liver transplantation. "As long as we have patients who die on the list waiting for organs … is it right to give [to] patients who have a history of drug use? You can discuss until the cows come home if it is social marijuana or medical marijuana."
Transplant doctors said one of the main concerns is compliance with a complicated regimen of post-transplant medications.
"If you are drunk or high or stoned, you are not going to take your medicine," said Dr. Jeffrey Crippin, former president of the American Society of Transplantation and medical director at Washington University in St. Louis.
Cedars-Sinai spokeswoman Sally Stewart said federal law prevented her from talking about Smith's case. But she said marijuana users can be exposed to a species of mold that can cause fatal disease among patients with compromised immune systems. They also run a risk of a fatal lung infection after transplantation, she said.
"We do not make a moral or ethical judgment about people who are smoking medical marijuana," she said. "Our concern is strictly for the health and safety of our patients."
At Cedars-Sinai, if patients who need a transplant initially test positive for marijuana, they can still be listed but must sign a statement agreeing not to use the drug. Then, if they fail a random drug test or don't show up for one, they are bumped from the list. "There have to be guidelines in order to give people the best chance at surviving a transplant," Stewart said.
UCLA Transplantation Services has an even stricter policy, requiring six months of sobriety before a patient can be listed. Dr. Douglas Farmer, a transplant surgeon and surgery professor at UCLA, said that drug and alcohol use is a "huge issue" and that patients on medical marijuana have also come to UCLA seeking transplants.
Farmer said, however, that many patients with medical marijuana prescriptions are not "legitimate" and transplant surgeons can't risk wasting a precious organ on someone who is going to continue abusing alcohol or drugs. "There are a significant number of people who come in for liver transplants who have a substance abuse history," he said.
Any delay in getting Smith a new liver could mean the "difference between life and death," said Joe Elford, an attorney with the medical marijuana advocacy group Americans for Safe Access, which is representing Smith and considering a lawsuit against the hospital.
Smith's oncologist, Dr. Steven A. Miles, an attending physician at Cedars, refilled the prescription for medical marijuana to manage his patient's pain. Miles, who is in private practice, agreed that by missing his drug test Smith raised concern about his patient's post-transplant compliance with medical instructions.
Nevertheless, Miles said his patient will die without a new liver. "Without a transplant, it is basically 100% fatal," he said. "It's just a matter of time."
Smith, a former precious metal trader, acknowledged that he didn't follow the rules. He said he used medical marijuana after having unrelated back surgery and weaning himself from the prescription pain pills. "I was in extreme pain and physical anguish," he said.
In April, he wrote a letter to the head of the liver transplant program at Cedars, Steven Colquhoun, asking to be relisted. In his response, Colquhoun wrote, "More than other organ programs, liver transplant centers must consider issues of substance abuse seriously since it does often play a role in the evolution of diseases that may require transplantation, and may adversely impact a new organ after transplant."
Smith, a recovered alcoholic, said he used marijuana recreationally in the past before getting a prescription for medical marijuana. He also has cirrhosis of the liver and previously had Hepatitis C. Smith said he stopped using marijuana in August and is attending Alcoholics Anonymous meetings to satisfy his counseling requirement.
Smith is hopeful that he will get a transplant in time and that his fight will raise awareness for others with medical marijuana prescriptions. "That's why I am going through this challenge, at the very least to make it easier for the next guy," he said.
PHOTO BELOW: Norman Smith goes through medical records at his home in Playa Del Rey. "If I don’t get a transplant, the candle’s lit and it’s a short fuse,” he said. (Christina House / For the Los Angeles Times / November 21, 2011)
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