Cancer Patient Denied Liver Transplant After Using Medical Marijuana

[okarol]

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

[MooseMom]

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. 

[okarol]

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."

[MooseMom]

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!

[jbeany]

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.

[okarol]

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

[Bill Peckham]

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.

[MooseMom]

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.

[cariad]

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.

[cariad]

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.

[Bill Peckham]

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 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.

[noahvale]

^

[cariad]

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.

[noahvale]

^

[Hemodoc]

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. 

[Hemodoc]

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.

[Hemodoc]

Here is a good review of Aspergillosis in liver transplant patients associated with marijuana use.

http://naltsw.org/liver_muse.html

[Bill Peckham]

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

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, 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.

[cariad]

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
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.

[cariad]

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!!!!

[MooseMom]

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.

[okarol]

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!!!!

I never heard that - isn't this crazy??

[Hemodoc]

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.

[Hemodoc]

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.

[MooseMom]

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.)