For doctors such as Pradeep Chopra, long accustomed to prescribing carefully tested medications by the exact milligram, medical marijuana presents a particular conundrum.
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On Tuesday, the D.C. Council gave final approval to a bill establishing a legal medical marijuana program. If Congress signs off, District doctors -- like their counterparts in 14 states, including Rhode Island, where Chopra works -- will be allowed to add pot to the therapies they can recommend to certain patients, who will then eat it, smoke it or vaporize it until they decide they are, well, high enough.
The exact dosage and means of delivery -- as well as the sometimes perplexing process of obtaining a drug that remains illegal under federal law -- will be left largely up to the patient. And that, Chopra said, upends the way doctors are used to dispensing medication, giving the strait-laced medical establishment a whiff of the freewheeling world of weed.
Even in states that allow for marijuana's medical use, doctors cannot write prescriptions for it because of the drug's status as an illegal substance. Physicians can only recommend it. And they have no control over the quality of the drug their patients acquire.
"I worry about that," said Chopra, a pain medicine specialist. "That's what's throwing a lot of [doctors] off."
The District's measure, like those elsewhere, specifies certain conditions and illnesses that qualify for medical marijuana. A patient who has HIV, glaucoma, multiple sclerosis, cancer or a chronic debilitating condition will be able to receive a doctor's recommendation to possess up to four ounces in a 30-day period.
Unlike in many states, the District law would not allow patients and caregivers to grow their own marijuana, at least initially; an advisory committee would later decide whether to permit cultivation. Until then, patients could only acquire the drug illegally or from five to eight government-regulated dispensaries.
The bill goes to Mayor Adrian M. Fenty (D), who is expected to sign it and send it to Congress, which has 30 days to review the measure before it becomes law.
In the District, physician reaction was mixed.
Internist Mahmoud Mustafa said a few of his sickest HIV patients already smoke marijuana to ease pain and stimulate appetite. "I think it'd be great," he said. "I don't have to worry about [my patients] being arrested."
Hunter Groninger, medical director for palliative care at Washington Hospital Center, said he would be uncomfortable recommending marijuana because the medical community doesn't know enough about its benefits.
Because there are no uniform standards for medical marijuana, doctors have to rely on the experience of other doctors and their own judgment. That, they say, can lead to abuse.
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In California, "quick-in, quick-out mills" that readily hand out recommendations have proliferated, worrying advocates, including Frank Lucido, a physician who spends half his time evaluating patients for medical marijuana. The state, the first to legalize medical marijuana 14 years ago, allows for a wider range of conditions, including anxiety.
To guard against abuse, some doctors say they recommend marijuana only after patients exhaust other remedies. Some doctors perform drug tests as part of pre-screenings.
Under Michigan's law, all 200 of Sandro Cinti's HIV patients at his University of Michigan clinic would qualify for marijuana. But in the year since the law took effect there, he has signed off on just three or four patients suffering extreme pain in their fingers and toes.
Cinti, an infectious disease specialist, said some patients have acknowledged using marijuana all along for pain relief and weight gain, smoking it two to five times daily. He counsels them about adverse effects, including impaired mental state and lung disease. "We're using it as a last resort in patients who have not had any relief with anything else," he said.
If the experience of doctors from other states is any guide, some District doctors might be slow to recommend the drug -- and some patients reluctant to take it.
Chopra has approved the drug for five patients since Rhode Island's program began four years ago, he said. He recently turned down a request from a man in his 40s complaining of back pain. The man said he had tried chiropractors and physical therapy, but Chopra found no documented evidence. The patient then asked for a medical marijuana recommendation. Chopra refused.
Some patients decline the drug, he said, for fear of sending the wrong message. Last week, when he suggested pot to a patient after narcotics and surgery had failed to ease excruciating head and facial pain, she broke down in tears.
Her teenage son uses marijuana and she wants him to stop, she told him. " 'How am I going to look if I start taking it?' " he recalled her saying.
When Chopra suggested that another patient, Ellen Smith, 60, try marijuana three years ago, she was reluctant, as was her primary-care doctor. She is in constant pain from a rare degenerative disorder and is allergic to most pain medication, so there were no other options. She asked her four grown sons for help procuring the drug.
She now grows her own plants, grinds the buds to a powder that she adds to heated olive oil and mixes with apple sauce. Two teaspoons, strained, lets her sleep through the night.
"I don't look at this as pot: It's my lifeline," she said.
Some doctors describe finding themselves acting as intermediaries in families that have mixed feelings about marijuana use. Todd Handel, a Rhode Island rehabilitation specialist, recalls recommending marijuana to Chris Snow, 23, who has spina bifida and used the drug as a teenager. Yes, he would get stoned, Snow said, but pot also made the pain bearable. Only after consulting with Snow's mother and father -- a police sergeant -- did Handel recommend marijuana.
Snow, who lives with his parents, grows 12 plants -- the state's maximum allowed -- in the basement. He uses a vaporizer that heats the drug, releasing a mist that he inhales four breaths per session, two to three times a day.
His father, who did not want to be identified, said he was conflicted about his son's marijuana use initially, as was Snow's older brother, also a police officer, who moved out of the house in protest. But the father now supports the son because he is doing much better.
Still, Handel says he wishes he had more knowledge about marijuana and more control over dosage. But, like his patients, he is figuring things out as he goes along. "There isn't one dosage that works for everybody," he said.
By Lena H. Sun
May 5, 2010
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D.C. Council approves medical marijuana, posing challenges for doctors