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By Richard Karel
Physicians have no First Amendment right to discuss the medical benefits of marijuana with their patients, according to Steven Dilts, M.D., president-elect of the American Academy of Addiction Psychiatry (AAAP).
"We have a responsibility to our patients to offer them science," said Dilts at a symposium on medical marijuana at APA's annual meeting in Toronto in June. The symposium was jointly sponsored by APA and the AAAP. "The First Amendment rights and all that is a red herring. As M.D.s we have earned no right to do anything; we have to get a license. Licenses in every state are granted by the people of that state through their legislatures. So the legislatures in all of our states plus Congress dictate what we do as physicians whether we like it or not."
Citing a recently published study that found teenagers with serious behavioral problems vulnerable to marijuana dependence (Psychiatric News, May 1), Dilts stated that marijuana's role as a "gateway drug" is "related to what I think is an oxymoron, which is the phrase `medical marijuana'. . . . Medical marijuana is not a phrase I really want to talk about. I'm more interested in medical THC or whatever derivative of the hemp plant is actually active and useful. So it's science I'm interested in."
The conflict between law and medicine came to a head in November 1996 when California voters overwhelmingly approved Proposition 215, legalizing personal use and cultivation of marijuana upon the recommendation of a physician. In response, Barry McCaffrey, the head of the federal Office of National Drug Control Policy (ONDCP), threatened federal disciplinary action against any physician who recommended marijuana to patients. The threat included the possibility of criminal prosecution and revocation of the physician's authority to prescribe controlled substances. A lawsuit by a group of California physicians against the ONDCP led to an injunction barring the federal government from punishing physicians for discussing marijuana. But the threats galvanized the medical community, Galanter commented.
"The issue of potential criminal sanctions against physicians for discussing marijuana as a medical option with patients was one that really raised the hackles of organized medicine overall, because it was felt that besides this being a First Amendment issue, it also was one that would seriously restrict the doctor-patient relationship," said Galanter.
Richard Frances, M.D., chair of AAAP's policy section, said that despite the controversy over marijuana, physicians should be free to discuss its possible therapeutic benefits with patients without fear of legal reprisal. In response to an initiative raised by panelist Thomas Ungerleider, M.D., professor emeritus of psychiatry at UCLA, the APA Board of Trustees subsequently approved a revision in APA's policy guideline on medical marijuana. The revision states that "effective patient care requires the free and unfettered exchange of information on treatment alternatives; discussion of these alternatives between physicians and patients should not subject either party to criminal sanctions."
McCaffrey's action transformed the war on drugs into "a war on physicians," said Ungerleider, who was one of the pioneers of medical marijuana research. His early studies affirmed marijuana's medical utility as an antiemetic, antispasmodic and appetite stimulant, he said.
The campaign leading up to the passage of Proposition 215 changed the tone of the political debate over marijuana and the drug war by providing an opportunity for "marijuana users to appear on national television not as hippies, not as deviants, not as bad kids admitting to their marijuana addiction, but as normal, ordinary, decent Americans using this substance as a medicine and being treated like criminals by a federal and state government that had just taken this drug war too far," said panelist Ethan Nadelmann, J.D., Ph.D., director of the Lindesmith Center, a New York-based drug policy reform organization. Although marijuana has tremendous symbolic resonance in American society, its medicinal use is "not unlike all the other issues of herbal medicine" including the use of St. John's Wort (Psychiatric News, August 21).
Federal officials and others who now insist that further research is necessary before marijuana can be rescheduled as a prescription medicine are employing a delaying tactic, as did federal officials opposed to needle exchange programs to fight the spread of HIV infection, said Nadelmann (Psychiatric News, May 15).
In 1996 more than 640,000 people were arrested for marijuana offenses, 85 percent for possession, compared with a total of fewer than 200,000 in 1970. The notion that it is acceptable for physicians to stand aside from this issue ignores the related social problems they don't see in their offices, said Nadelmann. "What are the health consequences [and] medical consequences of being arrested, of going through that process, of having your life disrupted? . . . . Is there no principle here that doctors adhere to? And when the government is pursuing a range of policies that are having dreadful consequences on people's lives, isn't there some obligation on the part of doctors to speak to that?"
It is difficult to get funding for research on the benefits of marijuana in the current political climate, said Galanter. "If you only reward investigators who find studies that are popular in terms of what Congress wants to hear, which is definitely the case, you generate a very significant bias. So we do live in an era when objective research can be the handmaiden of policy and not the other way around."
Some opponents of medical use of marijuana have suggested that many of those using the drug are not really ill, so panelist John Mendelson, M.D., an internist from the University of California at San Francisco, set out to survey medical marijuana users.
Mendelson and colleagues recruited 100 members of the San Francisco Cannabis Cultivators' Club.
An overlooked function of the club was that it gave very ill people who otherwise might have become socially isolated a chance to socialize and enjoy themselves in a positive setting, said former patient David Nash.
The 29,000-square-foot club enrolled 8,000 patients before it was shut down May 25 by the San Francisco County Sheriff following a state court order. Federal officials had also filed a civil suit.
Patients reported they were using marijuana for HIV-related conditions (60 percent), psychiatric disorders (29 percent), and musculoskeletal disorders (24 percent), with some people citing more than one diagnosis. Additional conditions cited included migraine and other neurologic disorders and multiple sclerosis. Among those with psychiatric disorders, "depression was the principal disease entity," said Mendelson.
Eighty three percent of those with psychiatric disorders had an Axis I diagnosis, and 11 percent showed signs of psychosis at the time of the interview, he added. "I should point out that this is a pretty sick group," Mendelson remarked.
Panelist Robert Millman, M.D., a professor of psychiatry and public health at Cornell Medical School, took issue with the assertion that the drug war has become a war against physicians. "What's really happened is the doctors have gotten caught in a religious war," said Millman.
"Medicalization" is not the path to legalization, he continued. As physicians, "we should keep our eye on the patients, not get into the religious war, although we can do the religious war as civilians."
If marijuana is a gateway drug, it is not in the sense of causing a progression to other drugs, said Millman. It is "in the sense that positive experiences with one drug are likely to lead you to experiment with others. That doesn't imply dependence. . . ." But for medical use, the gateway issue is not germane, he asserted.
The AAAP Web site is members.aol.com\addic-psych\private\homepage.htm. The Lindesmith Center's web site is www.lindesmith.org.