Cancer Patient Denied Liver Transplant After Using Medical Marijuana

[MooseMom]

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.

[okarol]

I'll bet you could be a Vicodin addict (but not an occasional marijuana user) and be approved for a transplant.

[Hemodoc]

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

[okarol]

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?

[MooseMom]

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.

[Hemodoc]

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.

[MooseMom]

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?

[Hemodoc]

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.

[MooseMom]

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.

[Hemodoc]

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.

[MooseMom]

Well, I can understand your scepticism.  I wonder how many people have even heard of marinol?

[Hemodoc]

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

[MooseMom]

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.

[Bill Peckham]

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.

[Hemodoc]

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

[Bill Peckham]

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.

[Hemodoc]

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

[cariad]

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.

[cariad]

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

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.

[cariad]

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.

[noahvale]

^

[Bill Peckham]

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?

[MooseMom]

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.

[cariad]

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 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 She has taken a lot of abuse over it, it sounds like.

[Hemodoc]

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.