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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  • DeceasedMD

    I am not sure how much rational medical opinions matter in this. MJ is a booming economy for many and many people (some addicts) and many not necessarily pts are lovin’ it. And why not under the guise of medicine? Makes it more legit.

    • ninguem

      The problem with “medicalizing” marijuana is if you want to exclude the use, say, maintain a drug-free workplace, you might encounter civil rights claims, disability discrimination.

      “I’m sick” with whatever flimsy “diagnosis” is attached to the “medical” marijuana certification, and you are denying me access to my “medicine”.

      • DeceasedMD

        Yes we are caving into drug seeking manipulators with the aide of good ol’ gov’t legislatures. You see a lot more of this than I. But the pts I have seen with medical MJ cards tend to be college students with addictions. I was once on a local college campus and there was a flyer on the ground explaining how to get a medical MJ card or MJ from another college kid with the card. I agree don’t involve physicians in this insanity.

  • ninguem

    My opinion was that the “medical” marijuana industry in Washington State would evaporate with the legalization of the drug.

    From what I read, not so sure. See, it’s turning out that the “legal” or “recreational” marijuana industry is tightly regulated, and the “medical” marijuana industry is not.

    Things like edible marijuana products as one example. What is allowed in the “medical” industry may not be allowed in the “recreational” industry.

    So, get your card, all bets are off, get whatever you want, whenever you want.

    In reality, I agree with the OP. Marijuana has little medical benefit, if any.

    Just bloody legalize it already.

    • Lisa

      Legalize it and tax it.

      • Thomas D Guastavino

        As long as the tax receipts are used exclusively for countering the negative effects.

        • Lisa

          As long as we do the same for tobacco and alcohol.

      • James O’Brien, M.D.

        I would advocate legalization under one condition. If you are young and healthy and you toke, you are not eligible for any form of public assistance.

    • buzzkillerjsmith

      I don’t prescribe MM. It’s basically a scam. We’ll see if legalization kills it off here in WA but I also expect it won’t. Money to be made by medical scumbags.

      But it’s easy here to not play the MM game, as I’m sure it is in OR. Just have your receptionists say no and the pt won’t even make an appt. A bit harder for established pts, but they’ll find some doceverythingsgonnabeallright in any case.

  • Kristy Sokoloski

    I found this piece to be very interesting because even though the main topic of this article was about the issue of medical marijuana it applies in other ways as well. Medicine by public opinion is a big thing these days and I see it quite frequently in various online support groups for different illnesses where people seem to think that they know more than the doctors. And then some get mad if they think that a doctor doesn’t know enough about a particular condition. They have the idea that when in Medical School and residency/fellowship training that doctors are taught everything there and that they should be taught about every single disease process out there. Doesn’t matter whether it’s the most common disease process (the horse) or the rare disease process (the horse) they expect that doctors are supposed to know how to handle this right from the time they come out of school. That is just not possible. We are always learning more about the way we understand both old and new disease processes. Yes, even the patients but it’s very frustrating when both sides clash creating so strongly. Instead of being a “support” group to try and help someone through the daily challenges of an illness such as to say “I am sorry that you are having a bad day” and then get comforting support now you get people who bash doctors on a regular basis, people who tell others what medicines they should or shouldn’t be on, others who are very much against medication all together in some cases. People being bashed if they choose to go on certain medications instead of other types of medications. Now you also have other people that instead of just asking what kind of experiences someone has had with a medication you have people asking what dosage of medication they should be on, whether or not they should stop the medications all together because they can’t handle the side effects. And that’s among a number of things that one should be asking of their doctor and/or pharmacist but instead of doing that they would rather ask other people in these groups who don’t know the full extent of the history of this person the way that their doctor does which in turn replaces seeking the advice of one’s own doctor. I had someone tell me once that because some people don’t have doctors to ask this is all they have, or that they have a question that they are too embarrassed to ask their own doctor. And yes, I realize some things can be embarrassing but if one is too embarrassed to ask their own doctor these questions that’s not a good sign at all. That’s why I love what someone here posted a while back about that if the patient knows more than the doctor that’s dangerous. I agree with that 100% in more ways than one.

    • SteveCaley

      The court of final appeal has shifted in America, across the board, to a community’s standard of conventional wisdom. We aggressively self-police for conformity. The German language has a crisp word for it – Selbstgleichhaltung. Quite ungainly in English, but with an exact meaning. A community engages in consideration of WWOS? (What Would Oprah Say?)

      Gone is the principle that a physician should practice medicine independently, and the duty is not to fall below the community standard of care. The current standard is to practice in such a way that the community opinion experts could not find any deviation from conformity in a certain means of practice.

      What to do when a patient says “I Need Cialis®” My convention has been to engage the patient in a discussion of erectile dysfunction, and consider what would be the best treatment for that particular person. That is now becoming perilous. CW states that one should give a prescription to the patient – after all, that is what good customer care is, isn’t it?
      The standard is to keep a low profile and practice unremarkable medicine – the same standard as one uses when riding the A Train in New York after sunset on a weekend. Don’t look like a target.
      Too much thinking in the clinic leads to individualized practice – and individualized care is frequently seen as deviant care.
      This is one of the strongest reasons for my intent to leave medical practice within six months. It is really becoming something that anyone can do with internet access and a certain degree of bravado and recklessness. Yes, medical marijuana, that’s the ticket!
      My legislature allows the prescription of marijuana for the DIAGNOSIS of HIV infection. No side effects needed! There’s the virus, here’s the doob!
      Between Legislatures and the “full scope of practice” arguments, there’s really no need to withhold most drugs behind the prescription veil. I am a strong advocate for delabeling most drugs into the OTC category, and “returning healthcare to the people.” Good luck, people! But I am done with it.

      • DeceasedMD

        Steve, have you seen Physics Professor DeBuvitz explanation of what you are describing?

        The heaviest element known to science was recently discovered by investigators at a major U.S. research university. The element, tentatively named administratium, has no protons or electrons and thus has an atomic number of 0. However, it does have one neutron, 125 assistant neutrons, 75 vice neutrons and 111 assistant vice neutrons, which gives it an atomic mass of 312. These 312 particles are held together by a force that involves the continuous exchange of meson-like particles called morons.

        Since it has no electrons, administratium is inert. However, it can be detected chemically as it impedes every reaction it comes in contact with. According to the discoverers, a minute amount of administratium causes one reaction to take over four days to complete when it would have normally occurred in less than a second.

        Administratium has a normal half-life of approximately three years, at which time it does not decay, but instead undergoes a reorganization in which assistant neutrons, vice neutrons and assistant vice neutrons exchange places. Some studies have shown that the atomic mass actually increases after each reorganization.

        Research at other laboratories indicates that administratium occurs naturally in the atmosphere. It tends to concentrate at certain points such as government agencies, large corporations, and medical institutions. It can usually be found in the newest, best appointed, and best maintained buildings.

        Scientists point out that administratium is known to be toxic at any level of concentration and can easily destroy any productive reaction where it is allowed to accumulate. Attempts are being made to determine how administratium can be controlled to prevent irreversible damage, but results to date are not promising.

        • rbthe4th2

          You needed a warning before posting that. If I had been drinking I would have waterfalled my monitor. ROFL.

          • DeceasedMD

            So glad you liked it. Got that when I was taking college physics and i never realized how that was later to come true in my life in medicine. I don’t know whether to laugh or cry honestly.

          • rbthe4th2

            So I wasn’t the only fool taking physics? Hope you didn’t go for multiple years of math like I did.

            Speaking of laughing or crying over education, I got this and oh how true it is for the medical profession:

        • Patient Kit

          I enjoyed the briefing on administratium. It made me think of a great production I saw of Vaclav Havel’s The Memorandum, his black comedy play about bureaucracy and conformity.

          • DeceasedMD

            wish I had seen it. where was it playing?

          • Patient Kit

            I saw a good production of it here in NYC a few years ago, Off-Broadway. It’s a terrific satirical play that really nails bureauacracy and conformity. Havel wrote it about Czech Communism but it is totally relatable to our American brands of workplace and government bureaucracy and conformity. Anyone who enjoys the story of administratium would love Havel’s play. If it’s ever staged anywhere near you, I highly recommend it.

          • DeceasedMD

            thanks. sounds very humorous

      • James O’Brien, M.D.

        Selbstgleichhaltung is the Zeitgest. The cult of Oprah is now a Gesamtkunstwerk opera of idiocy. That’s why many of us have a sense of Schadenfreude in Der Untergang of the media Ubermensch Dr. Oz.

        • SteveCaley

          German has a funny way of condensing many words into one. It looks silly and wiggy to us English speakers – the German citizens used to be considered the long-haired head-in-the-clouds type.
          They got much scarier when they cut their hair.
          Jargon is when the new big word says nothing more than just the parts. I used that German word because it means a lot. If one asked the question – “How did an intelligent and literate country like Germany wind up with the SA (Brownshirts) and Hitler? there’s a one-word answer, funny-looking and polysyllabic – but suddenly not so funny indeed.

          • James O’Brien, M.D.

            That word is now chambered in my vocabulary. I will reserve it for the right time and place. I’m sure I’ll screw up the pronunciation.

      • Patient Kit

        If you leave medicine, Dr Caley, it will be a major loss for your patients. On a minor sidenote, the A Train is fine after sunset. The subway is so crowded these days that it’s common to be unable to find a seat at midnight.

  • DeceasedMD

    thank you for the tip. I love your interests in history, philosophy, sociology that all tie in with the current critical morass in medicine. I will take a lookie at max Weber.

  • Daniel Lang

    To correctly understand “medical marijuana” it must be within the context of drugs in general, legal and illegal. “Medical marijuana” is a legitimate alternative to powerful pharmeceutical drugs which are the number one cause of death among all drugs legal or illegal. Marijuana does not cause overdoses. We need to get our priorities straight. When the prohibition of marijuana is lifted we need to do a much better job of education than we have with, say, the legal drug, alcohol.

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