Medicine by public opinion: Where are the doctors?

Recently I was the only witness to testify against local medical marijuana legislation.  The bill, already endorsed by all members of the Council of the District of Columbia, would allow use of marijuana for “any condition for which treatment with medical marijuana would be beneficial, as determined by the patient’s physician.”  As I waited hours for my turn to highlight the medical evidence about marijuana’s health effects, I sat silently, taking in the testimony of numerous advocates.

Witness after witness reported that marijuana was the only thing that helped treat their health conditions from endometriosis to PTSD to epilepsy and lupus.  Compelling personal stories were supported by information from the internet and CNN documentaries featuring Dr. Sanjay Gupta.  Marijuana industry workers explained that they talk to patients at dispensaries about their lifestyles and needs before deciding what strain of marijuana and what form of delivery (edible, smoked etc.) to recommend for each.  Access to marijuana for HIV/AIDS patients, it was claimed, improves their mental and behavioral health and could reduce HIV spread.  All of these benefits occur, purportedly, with minimal to no downsides.

Besides the legislation under discussion, witnesses testified that the only thing standing in the way of their access to marijuana was getting doctors to agree to recommend it for them.  The main reason cited for physician reluctance was institutional policies prohibiting recommendations for fear of legal consequences.  Others felt the health department hadn’t done enough to provide physicians with continuing medical education (CME).

“Or maybe the doctors aren’t convinced that marijuana is an appropriate treatment” I wanted to scream.

When it was finally my turn to testify, I urged the council not to use medicine to justify increased access to marijuana.  Being a plant containing substances with medicinal value doesn’t make something a medicine, I argued.

To support my testimony, I provided the legislators with copies of a new article by Nora Volkow, director of the National Institute on Drug Abuse, from the New England Journal of Medicine entitled “Adverse Health Effects of Marijuana Use.”  I cited other peer-reviewed publications documenting risks to youth from expanded medical marijuana programs.  I pointed out that choosing “strains” and routes of delivery in a dispensary is nothing like picking up a prescription from a pharmacy.  I noted that I participate in lots of CME, including review of medical journals, and that is precisely why I don’t recommend marijuana to my patients.  Finally, I stated my concern about legislators being able to declare what is and is not medicine without regard to critical components like assurance and standardization of active ingredients and high quality evidence documenting both efficacy and side effects.

My comments were too little too late.  After my testimony, one member remarked that “the one thing” she could agree with me on was that we need to be mindful about the messages we send to youth. Science and peer-reviewed publications are irrelevant to the opinions of legislators who have decided that marijuana is a medicine.

But how much can I blame them?  Well organized advocates have waged a long-term campaign touting the benefits of marijuana and citing minimal to no downsides.  Those advocates have successfully framed this debate and convinced increasing numbers of voters of their point of view.  The voices of physicians have been too quiet.

As a physician this makes me anxious.  In my first half day of clinic this week, I saw two teenagers unable and unwilling to quit their daily marijuana use in spite of their poor functioning in school and at home.  The data tell us that one in six teens who start using marijuana regularly will become dependent.  Data also suggest that decreased perceptions of risk among youth are related to increased likelihood of marijuana use. Calling marijuana medicine contributes to that risk misperception.

Legislation declaring marijuana medicine is just one in a string of efforts to define the practice of medicine by public opinion.  In other states, bills would ban FDA approved contraceptives, mandate clinic standards that don’t improve patient care, and compel women to undergo unnecessary invasive procedures.  If we as physicians don’t participate in these debates, others will decide how they are framed and the important steps we take to make careful decisions for our patients will be thwarted.

Krishna Upadhya is an adolescent medicine physician. 

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