Looking through the smokescreen at marijuana laws

This is not a prescription, per se, but rather a validation that the patient has a medical condition that would possibly benefit from the use of marijuana. The list of conditions that qualify for the permit is specific but with enough vagaries within it that anyone who has chronic pain could take the paperwork to his or her physician and plead a case for permission to toke. Buying the marijuana is illegal, but the patient may grow his or her own or obtain it from a person designated as the patient's grower.

Well, after a lot of thought, I decided that I was not going to recommend marijuana for any of my patients. I do little end-of-life terminal care, and I am so anti-smoking that I could not imagine that I would think it was a good idea for anyone to smoke anything. Those who wanted to consume their marijuana, as in baked goods, could just as easily take the drug in pill form. The drug dronabinol (Marinol, Solvay Pharmaceuticals) has synthetic tetrahydrocannabinol, or THC, as its active ingredient and can deliver the same effect in a controlled dose without the contaminants and carcinogens in a marijuana cigarette.

So I was surprised when "Mike" came in with his wife and that was their only request. They would not tell the receptionist or the nurse the reason for their visit, saying it was "too personal." When I entered the room, he told me he needed the marijuana for his "constant and intractable pain." The wording was right off the state's Web site about the law.

He had never mentioned anything to me about chronic pain. He is in his 50s and is reasonably adherent in his annual exams. I was shocked to hear about his problems.

He described aching joints, which sometimes swell, turn red and hot, and keep him from sleeping very well. So far, he had been able to work and, not needing any excuses for absences, he had not told me about it. He described a symmetrical inflammatory arthritis, a pretty good description of rheumatoid arthritis.

"That's what I thought," he said. "My mother had it, and it seemed like hers."

"So why didn't you tell me about it?" I asked.

"Well, there was really nothing they could do about it for her, so I figured, 'Why bother?'" he replied.

We did the work-up, and he has rheumatoid arthritis. He is now under the care of rheumatologists and feeling better. But had he never brought it up to me, how long would he have gone, suffering in silence, believing that because 50 years ago his mother had little available treatment, his fate was the same?

It made me change my instructions to the staff in the event a patient asks to use medical marijuana. They can tell the patient that I am against it, but urge them to come in to discuss the alternatives. I assumed, as did many of my colleagues, that the requests would come from regular users who just wanted tacit permission to continue their nightly tokes. "Mike" opened my eyes to the fact that the law gave me a great opportunity to discuss the problems that would drive a patient to ask me about it - and lead to an investigation and/or discussion about alternatives.

So, do I see myself completing the paperwork for a patient to apply for a permit for medical marijuana? Nope. But I am looking forward to the conversations we'll have as we explore the reasons for the request and the safer alternative treatments I can recommend with a clear conscience.

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