I am a family medicine doctor with a specialty in Addiction Medicine and I am a clinical research physician. I spend the vast majority of my clinical life thinking about and working to help people not die from the self administration of intoxicating substances. To be sure, the dramatic and devastating nature of alcohol, stimulant and opiate dependence make it easy for most everyone to agree that these substances are extremely dangerous. We should not forget to mention nicotine, which annually claims more lives than all of the aforementioned combined, but I digress. We are supposed to be considering marijuana.
I live and work in Los Angeles, which in case you had not heard, seems to be the hot bed of medicinal marijuana. There are literally hundreds of Cannabis “pharmacies” that allow medicinal users, i.e. any person who has received a medical recommendation, to freely obtain marijuana products in a retail setting. These retail settings drive traffic with green neon signs, large green crosses and clever ganja-related names, and are seemingly more prolific than Starbucks (the official “Starbucks store locator” gave me 49 locations). On the OCNORMAL Website, I counted more than 100 pharmacies in L.A., not counting the Valley and surrounding areas, with about 15 that offer delivery service. A recent L.A. Times article stated that there were as many as 530 dispensaries. A basic Google search reveals many, many services that offer access to a doctor who will recommend marijuana for what ails you.
Although no one seems to get a marijuana recommendation from their “regular” doctor, there is no shortage of physicians willing to provide them. According to the advertisements, all it takes is somewhere between $120 and $50 to get a medical recommendation. The California law that makes the medicinal use of marijuana legal lists the following diseases and conditions for which medical marijuana is permitted: cancer, glaucoma, HIV-AIDS, Cachexia, severe or chronic pain, severe nausea, seizures, anorexia, severe muscle spasms, arthritis, migraine and the big one: “any other chronic or persistent medical condition, if the condition substantially limits the ability of the patient to conduct one or more major life activities as defined by the Americans with Disabilities Act 1990, OR if the condition is not alleviated, may compromise the patient’s safety or cause serious harm to the patient’s physical or mental health.”
What does that mean? Basically that means that in California, almost any diagnosis that people can generate can fit into the definition. Anxiety, yes. Depression, yes. Insomnia, yes. Social anxiety, yes. ADHD, yes. “I want to get high with my friends,” no! Unfortunately, there is little that can be done to prevent individuals from not telling their marijuana-recommending doctor the truth, the whole truth and nothing but the truth.
The other issue that I am sure goes through the mind of the “marijuana-recommending doctor” is that doing something to prevent your patient from being prosecuted by the law for something they are already doing is probably a good thing. I am no expert in criminal justice, but I don’t really see how individuals or society are served by criminalizing and incarcerating so many potential tax-generating adults. Who really benefits from having marijuana users clogging up our courts and jails?
There remain serious problems with medicinal use of marijuana. For instance, every prescription for FDA-approved and over-the-counter medication that doctors recommend to their patients includes clearly defined information. The exact medication, the exact dose, the frequency of dosing and the duration of dosing all must be clearly delineated. For medicinal marijuana recommendations, doctors only state that, “in my medical opinion, this patient has the potential to benefit from the medicinal use of marijuana.” There is no guidance for the patient about what exact strain to use; there are literally hundreds of different strains of marijuana, all with slightly different properties. There is no guidance for the patient about how frequently to use, how much or for how long. Clearly, the guidance and supervision must be improved in order for the medicinal benefit of marijuana to be considered on par with other medications.
The federal Controlled Substances Act (CSA) classifies marijuana as a Schedule I drug — one with a high potential for abuse and “no currently accepted medical use” — and criminalizes the acts of prescribing, dispensing and possessing marijuana for any purpose. This designation limits the ability for the research and testing that is necessary to clearly illustrate the risks and benefits of marijuana use. Some testing has been done, but much more is needed if marijuana can be efficiently and effectively used as medication.
In the short run, what is a caring, compassionate, well-informed physician supposed to do when his or her patient asks about marijuana? The answer is far from clear. The evidence is not there. With such ambiguity, many doctors don’t feel comfortable recommending marijuana. I think that is reasonable, but many other doctors are very comfortable recommending cannabis. So in the end, the patient is left to decide whether or not to seek the counsel of a physician who is known to recommend marijuana or not. That leaves the decision-making to the patient. Which for the moment, is probably not so bad.
In my humble opinion, if every single patient who is currently addicted to alcohol, stimulants and opiates were to suddenly become addicted to marijuana, the world would be a better place. I am not advocating for more stoned Californians or dismissing the addictive dangerous nature of marijuana, but clearly the criminalization path has not worked well at all. I think we need more, better information to help individuals and their caregivers make the best possible choices to treat their illnesses.
