Wednesday, February 15, 2012

Should State Legislators Determine Indications for Medical Treatment?

The FDA evaluates studies on medications and deems them safe enough to justify use.  They also determine the "indications" for using any particular medicine, and once that's done, physicians will often use a medication 'off label.'  That means that Medicine A was found to be safe (or relatively safe, because even over-the-counter meds can be fatal for the wrong person at the wrong time), and it works better than a placebo at treating Disease A, but some studies have found it useful for Disease B, but the FDA hasn't gotten to approving it for this yet, and perhaps never will, but docs use it for Disease B anyway.  This is very common with the SSRI's, where one has been approved for a condition, but maybe the patient isn't tolerating that one so well, so the doc uses another SSRI with a different side effect profile, even though that particular med has not been approved for that particular condition.  Just an FYI, the SSRI's are : Prozac Zoloft Paxil Luvox Celexa Lexapro.   

So the FDA says inhaled marijuana (as opposed to Marinol, a pill form of cannabis) has no medical uses and the discussion is ended.  It can't really be studied at this point, because it has no medical value so your local university can't grow or get any weed and do studies on it, because it has no medical value.  And the federal government says it's illegal.   I do believe that with 16 states disagreeing, that perhaps the FDA should reconsider this stance and repeat a study or two on inhaled cannabis for nausea induced by chemotherapy or anorexia in AIDS so that medical marijuana can be studied, monitored, grown in a pure regulated way, prescribed for a known and proven condition with some parameters like other medical interventions: 30 day supply, directions on how much and how often to smoke it (ah, the pharmacy could roll for you), reassessment so that if your doc decides to give it to you "off label" for your low back pain, and that pain is so much better but funny, you've stopped working, you lie on the couch all day playing Grand Theft Auto, and your life has virtually stopped, the doc can say, "Glad it's helped your pain, but it's put you into an apathetic, amotivational state and your life has now gone down the toilet, I'm stopping this so you can go back to work and pay the mortgage and feed those hungry children."  Or for us shrinks, "Funny, but you didn't have schizophrenia until you started smoking this stuff, let's stop it."  Obviously, if the person has become addicted (and yes, you can get addicted to weed), they'll get it illegally, but the same is true of benzos or opiates, and really medical marijuana just can't be any worse then the fiasco we've had in this country with oxycontin, especially when it gets mixed with a bit of also-legal Xanax and also-legal Vodka, and I can give you a long list of names of people who can no longer testify to this, famous and otherwise.  

So for the moment, the demand for legalized Medical Marijuana is left in the hands of our legislators.  Who better to determine medical indication, necessity, length of treatment, and methods of monitoring.  In Maryland, there was a study group led by the state's health secretary, Joshua Sharfstein.  The plan called for going slow, required training of docs to prescribe it, and required that it be distributed through academic centers.  Two legislators who are pushing bills to legalize medical marijuana called it Misguided and Heartless.

Delegate Glenn of Maryland has proposed House Bill 15, a Medical Marijuana Act.  It provides that marijuana could be used for a variety of conditions.  They include: 

  1. (I)  CANCER;
  2. (II)  GLAUCOMA;
  5. (V)  HEPATITIS C;

    On the positive side, the law does require that "compassion centers" to either grow or distribute marijuana be at least 500 feet from pre-existing schools.  Because children can't walk 600 feet?  

    I'm told this bill won't pass, but another one, with out the listed psychiatric indications for the use of medical marijuana, may well pass.  I might be more pro-MMJ if the stats didn't reveal that 2% of recipients in Colorado have cancer and AIDS, and that many people are prescribed marijuana by non-psychiatrists for psychiatric reasons, including insomnia.  And if medical marijuana was distributed by a pharmacy with directions on how much and how often to use it.  The one-year toke your heart out cards with the boutique flavors all as part of "wellness" don't fly so well with me.  If people want marijuana to be legal, then legalize it, but this type of legislation puts physicians in the middle as an agent.  Really, if we were talking about people smoking a little during their cancer treatments, this just wouldn't be the issue that it is.

    Okay, so my questions for you:

    1) A person gets medical marijuana for back pain or anxiety or whatever.  He gets arrested.  Should it be continued in jail?  Prison not be such a bad experience if you get to be high the whole time?

    2) Shrink Rap readers don't really like uninformed consent with meds.  How do we feel about giving it to agitated Alzheimers patients and how would that work?  Can you smoke in nursing homes?  Do they have to taken outside in restraints?  Agitation is not usually associated with early Alzheimers.

    3) Do we think it's just a little weird that a state legislator is making laws listing which medical indications a drug should be used for?  I must have missed those lectures in residency where pot is the treatment for depression, etc.   Can legislators also decide that methotrexate should be legal for the flu?  I sort of don't get it.  

    Okay, my rant for the day.


Anonymous said...

Huh? Universities cannot get the pot for research purposes? Have they tried the dorms? Plenty of pot and other stuff in there.

Anonymous said...

"And the federal government says it's illegal. I do believe that with 16 states disagreeing ..."

In my state, medical marijuana legalization came through a citizen initiative after it failed to pass repeatedly in the state legislature.


rob lindeman said...

"Should State Legislators Determine Indications for Medical Treatment?"


wv = hypolub; less-than-effective couples' lubricant

Anonymous said...

Question #1 is kind of interesting. In my state, medical marijuana is permitted. There was a case reported recently where an individual on probation for a number of offenses involving home invasions had the terms of his probation modified to allow him to smoke medical marijuana. The judge said he couldn't interfere with the physician's judgment in prescribing the pot.

The home invasions were reportedly done to feed a drug habit. And they weren't non-violent. One of them involved a murder.

But I think the judge would have reached the same conclusion if the prescription had been for seroquel(for example) instead of mj. So I'm not really sure it's the wrong result, though there was some outrage expressed in the local press.


Anonymous said...

In regards to question #1

In parts of Oregon, if you get pulled over for some traffic violation, and are found to have some weed in your possession, they won't even arrest you if you have less than 1 oz. even if you do not have a medical marijauna card. LEO's are overworked and don't have the time & resources to arrest and haul someone off to jail for every minor infraction. There isn't funding for the jails, so most people that are arrested for minor violations are booked and streeted. So there would be no "continuing the pot in the jail," even if it was warranted.

I just don't see it happening, even with someone going to the state pen. on a long term basis, that is in there for a massive marijauna grow or something else, but that's my opinion.
The smell of weed makes my stomach flip. Blech . IMO, I would rather take a non-smelly pill for pain then inhale pot.

interesting food for thought.

Sunny CA said...

The mention of Alzheimer's patients smoking marijuana made me laugh. Baby-boomers (major users while teens of MJ) are approaching nursing home age and when we get there, the nurse's aides will be passing out joints. Of course those already partially confused will be totally gone once they smoke a joint. No matter. Pass the brownies.

I agree with your point #3 about the strangeness of a legislator creating a law stating how a pharmaceutical may be used. I expected to see a short list, but the list seems long to me.

I do not have a medical marijuana license because I am a teacher and don't want to do anything that might affect my livelihood, but many friends of mine here in California do have licenses. On route 680 Southbound from Sacramento to the SF Bay Area there are very large billboards advertising doctors who make a business of writing medical marijuana prescriptions with a fixed fee for the appointment, so it is not realistic to think that people will get a prescription from their family doctor who will then monitor their level of motivation. My friends did not go to their doctor, they went to a marijuana "specialist".

Liz said...

i have seen the negative influence of pot-- a friend who started college and smoking regularly at around the same time still smokes regularly ten years later but never finished his degree.

i have also seen the positive side of pot... my grandmother benefited from its medicinal effects (particularly relaxation and munchies) during the few months before her death.

i don't understand why alcohol is legal but pot isn't...

Jane said...

For question 1, I see no reason why prisoners should not be allowed to smoke their medicine. There are different kinds of weed to smoke, and they have very different effects. I know. I live in CA. I don't think this is the same with marinol. There is only one kind of marinol.

2) On the Alzheimers thing, if there is a problem with smoking it indoors, maybe a smoking section with air filters and good ventilation could be designated?

3) State legislators can approve an indication if there is evidence that it helps for the condition. It might help if doctors try to say marijuana is contraindicated for people with mental disorders, even though it has been shown to help the person. The first person I ever met with a prescription had it for bipolar disorder. I later met a counselor who told me that she had seen how effecive it is in reducing racing thoughts in people with bipolar disorder. I actually don't know if any studies have been done, but I would hate to tell all of the people who cannot tolerate psychiatric meds that they cannot at least try marijuana in order to get some relief from symptoms.I think the evidence is there that it helps. If state legislators want to affirm that is it indeed helping these people, then I am fine with that.

Liz said...

my friend's dad smoked to self medicate for bipolar disorder (no prescription of course) as a vietnam vet with serious emotional issues, his family used to say it was the weed that had prevented him from killing someone for so many years. but i read somewhere else that there is a correlation between smoking weed and new onset bipolar disorder, so that rather scares me.... i'm not sure if these people were self-medicating for already existing symptoms, or if the smoking triggered the symptoms...

Anonymous said...

I'm a bit wary of weed for psychiatric disorders. In my somewhat professional experience, it seems to be extremely helpful, or extremely harmful. In my personal experience, it made me so paranoid I hid under a blanket until I managed to fall asleep.

I don't buy in to the weed as the magic cure for everything like some folks, but it isn't nearly as harmful as a lot of things. I can definitely see it being beneficial for pain, considering how NSAIDS can trash your body, steroids can induce rage, opiates are considerably more addictive, antidepressants are hell to discontinue, and rheumatoid arthritis drugs are very expensive.

Honestly, I wish they'd just make the stuff legal. As long as adults aren't doing it around kids and aren't driving, I don't really care. Beats alcohol.