Holding the Center
“Drug warriors,” those who promote the misguided “war on drugs,” say, “Medical marijuana is just a ruse for drug legalization.”
Some in the “drug reform” movement (some of my good friends, by the way) might say that my concern about the minority of medical cannabis doctors who perform the shoddy three to fifteen minute “recommendations” is misplaced, since the whole disastrous war on drugs is immoral anyway.
I have never thought of myself as a centrist. I have always considered myself more of a liberal, maybe even a radical. But I want this article to answer criticism from both “drug warriors” and “drug reformers” and my answer comes from what I see as a centrist approach that balances the views of these positions.
My thirty-eight years of training and experience in medicine, medical ethics, and in medical-legal consulting has made it clear to me that when it comes to patient protection whether that be medical protection, or medical-legal protection, shortcuts are more apt to hurt the patient than to help.
The following vignette is a case where a patient consulted me after a “referral” from his family physician for evaluation of medical cannabis use.
Attached to a client’s letter, this note on a doctor’s letterhead
Re: Patient X
Mr. X has Chronic Obstructive Pulmonary Disease on Pulmonary Function Test and Chest X-Ray.
November 10, 2006 – The client letter
Dear Dr. Lucido,
I have been a patient of Dr. Y for 25 years and while he has expressed no opinion as to appropriateness of medicinal marijuana in my case, he has referred me to you for help with two medical problems he considers serious.
First, while I do not consider myself an alcoholic, Dr. Y thinks I drink too much. However, marijuana smoking helps limit my alcohol use, partly because I get sleepy when I do both and therefore never drink before 9:00 PM.
Also, I have been smoking marijuana for 49 years and nothing but marijuana for the last 30. I would like to continue to use cannabis in some form and would like your recommendations on harm-reduction measures such as vaporizers, use of smaller amounts of more potent pot and legal access to edible marijuana.
Dr. Y says that if you need further info, to call him.
November 11, 2006 – Telephone call to patient: Uses medical cannabis for COPD: breathes easier (plus plans to use Volcano vaporizer). Harm reduction: drinks less than he would.
Plan: Advised patient to obtain past 24 months medical records and I will review for documentation, or alternately, his primary care physician’s willingness to affirm benefit of medical cannabis to patient. Patient gives me ok to discuss with his physician.
December 1, 2006 – Telephone call to Dr. Y: I noted weak evidence of benefit in medical records, but was willing to accept Dr. Y’s attestation that patient is benefiting medically from cannabis if he thought this was the case. Dr. Y: “Frank thanks for holding the center.”
This is the story of a patient “referred” to me by his primary care physician. Referred is a generous term I use since the “referral” came as I documented it above: in a non-committal note on the primary care physician’s letterhead, “Mr. X has Chronic Obstructive Pulmonary Disease on Pulmonary Function Test and Chest X-Ray.”
The patient’s physician provided no support from his own observation of the patient for the patient’s claims of benefit from the use of medical cannabis. The patient’s own verbal report of his history with this physician suggested that the physician had some reservations about the patient’s cannabis use.
Unlike most specialties, medical cannabis patients are usually self-referred, because most have been self-treating with cannabis, having discovered that the cannabis benefits them without consulting a physician. I am pleased to see more and more referrals that do come from physicians, including psychiatrists, who recognize that patients are benefiting but still don’t feel comfortable making cannabis recommendations themselves.
Usually, when a physician refers to or consults another physician, it’s a good thing. Consultation with another expert is a very cost-effective approach to a complicated problem. Each of us has his or her areas of greatest interest, focus and expertise. Sometimes this is recognized by certification in a particular specialty, sometimes it a more informal process where colleagues know of one another’s areas of experience and/or interest.
If a referring doctor feels cannabis is an appropriate medicine or treatment, but is hesitant to personally write the recommendation, it is usually for one of three common reasons: fear of possible personal or professional consequences, lack of knowledge of the medical cannabis laws, or unfamiliarity with the use of cannabis as a medicine.
In this patient’s case, the referral seemed intentionally non-committal. This impression was confirmed in my discussion with the patient’s physician, in which it became clear that the primary care physician had misgivings about whether this patient’s use could be considered medical, or even beneficial. Yet, he passed the patient on to my practice anyway, perhaps because he had not succeeded in his previous attempts to address his concerns about the patient’s drinking and smoking. The primary care physician was unable to overcome the patient’s denial, and referred him to me without enthusiasm, thinking that the patient would do as he wished no matter what either of us said.
Some cannabis-recommending physicians to whom the primary care physician might have referred this patient would have written the recommendation, and taken their fee. “Compassion” might be their rationalization.
Following the standards of my practice, and my experience in medical-legal medicine, I concluded there was no credible evidence of positive benefits of cannabis use for this patient, either in my assessment or in that of his own physician. If I distort my ethics or compromise my integrity to allow patients to justify cannabis use that would otherwise be a misdemeanor, I not only undermine myself, I put the legitimacy of the entire medical cannabis movement into question. This would harm not only my own credibility, but also the value of my medical-legal work for my other patients, and play into the hands of the “drug warriors.”
Therefore, when it comes to the practice of good medicine, and making best use of the laws that support a patient’s right to medical cannabis, I hold the center.
Frank H. Lucido MD