Cancer Patient Denied Liver Transplant After Using Medical Marijuana

[MooseMom]

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. 

[MooseMom]

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.

[MooseMom]

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.

[cariad]

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. 

[Hemodoc]

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."

[cariad]

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.

[Hemodoc]

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.

[cariad]

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.

[cariad]

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

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.

[Hemodoc]

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

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.

[cariad]

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?

[Bill Peckham]

Peter I think your data is incomplete. There have been discoveries recently, the most interesting the discovery of the  the cannabinoid receptors 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 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.

[Hemodoc]

Peter I think your data is incomplete. There have been discoveries recently, the most interesting the discovery of the  the cannabinoid receptors 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 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.

[okarol]

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.

Comments 182 Share 849 

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)

http://www.latimes.com/news/local/la-me-transplant-20111126,0,3264105.story