Saturday, August 30, 2014

Reefer madness part 1

Early on in my career trying to treat people with chronic pain, people would tell me that the only thing that worked for their pain was smoked marijuana.  Of course people told me lots of other things that were the only thing that worked for their pain including alcohol, cocaine, injectable Demerol and 30 percocet a day.  I of course told them sorry I couldn't comply with their request.  Marijuana was illegal but as I told patients, if you believe it helps your pain, do it discretely.

Marijuana is still illegal in Canada.  The law is enforced with a certain lack of vigour and consistancy across the country.  Despite this Canada spends between $500 million and $1 billion dollars a year, arresting, proscuting and punishing people for possession of marijuana.

In 2001, courts in Canada decided that it was unconstitional to bar patients from using marijuana for their pain and the government of Canada was forced to design a process by which patients could receive medical marijuana.  This initially involved the signatures of 2 specialists and allowed the patient to grow his own supply, designate a supplier or buy from the government.  

One day in 2001 I got a phone call from the Public Relations department of the hospital.  "Would you like to be interviewed by the CBC?", they asked.  "You cannot however mention the hospital".  The interview was as I should have suspected on medical marijuana.  The regulations had at that time not been finalized, I had never actually prescribed marijuana to any patient and my only knowledge was what I had read or seen at meetings but I figured any publicity is good publicity and so I was interviewed live on the afternoon radio show at 1700 hours.  End of story?

Not really.  On Monday my wife phoned me at work,  "Your interview is on the CBC national radio news".  I was subsequently interviewed by both local papers and got to have my second 15 minutes of fame.  

Keep in mind that I still had not prescribed marijuana to any patient.

I soon started getting phone calls from patients desperate to get the authorization forms filled out yesterday.  I explained that they would need to have a referral from another doctor and that I had a wait list.  After about a year, I started noticing a certain type of new patient showing up.  These were usually men, men with pony-tails under leather ball caps.  They usually had some vague pain complaint, had not really tried anything else for their pain except marijuana which I could usually smell on them.  I patiently explained, that the regulations as I understood them only allowed medical marijuana after other treatments had been trialled and failed and offered to start these treatments.  That was usually the last I saw of them.  

At that time I practised at the Centre of Excellence in a an academic pain clinic with 3 other doctors.  Shortly after the new regulations came into effect, The Professor at a staff meeting sternly forbode us to sign any authorizations.  I felt that this was curious as he professed to be all about research and this was virgin research territory plus the publicity for the clinic but I kept my mouth shut lest I be verbally castrated which was (and still is) how he dealt with differences in opinion.

For the next year or so, I politely explained to all patients, legitimate or not that I could not fill out the authorization.  That was until a patient I had seen years ago came to see me.  He had what we called failed back syndrome after back surgery with quite severe pain and spasms.  He had been using marijuana which he grew in his house which had lead to his arrest.  He had not really had any treatments since the epidurals I had tried years earlier and so I explained that we actually had lots of great treatments now and that he should try them.  Not surprisingly the first two gave him severe side effects and no relief which sadly is true of most of the wonder drugs in chronic pain.  At that point, I just said shag it and signed the damn forms.  

At that time I had an out in that I worked in another clinic so I just directed the patients to that clinic away from the scrutiny of The Professor.  And I continued there in a small way.  I started doing talks on cannabinoids for Valeant which markets nabilone (Cesamet) in Canada.  I was very cautious with patients, I treated them like any other consult, I listened to their story, examined them and if there were treatments they hadn't tried, I suggested that they try them.  Wherever possible I tried to get them to try nabilone a cannabinoid which is available by prescription and covered under our provincial drug paln or Sativex which is not reimbursed.

A few doctors saw business opportunities in medical marijuana and set up clinics specifically for the authorization of medical marijuana.  Most of these clinics charged $400 for completion of the paperwork, some even allowed you to be interviewed by Skype.

Patients came in a variety of presentations.  Many were sketchy but had a legitimate problem, quite a few were straight-laced folks with intractable pain who had tried somebody's marijuana out of desperation and some were just plain crazy.

In the interim, the Canadian Tea Pary came into office and the idea of people smoking marijuana recreationally or otherwise gave them dyspepsia.  Their hands were tied however by the court decision and so they had to keep the program.  They did however find a way to modify it in a way to make medical marijuana less available as well as reward well connected businessmen.  Effective last April, patients can no longer grow their own or designate a supplier but must buy from a Government registered supplier of which there are about 10.  Doctors rather than fill out the paperwork, must now write a "prescription" which the patient can they send to one of the companies who will then courier the week.  This has upset many long term medical marijuana users who previously grew their supply but now have to spend money with one of the suppliers.  The suppliers are for the most part slick operators with nice glossy brochures, they now sponsor pain meetings and I met my first detail man the week before last.

The change in regulations also sparked responses from both the medical societies and regulatory bodies.  From a physician point of view, the new regulations are actually better.  The "prescription" which I now write is a lot shorter and less complicated than the form I used to have to fill out.  Further just as doctors chose in the past whether or not to fill out an authorization, doctors can now chose whether or not to "prescribe" medical marijuana.  This didn't stop our College (Medical Board) from publishing regulations and demanding that doctors register with them; something they hadn't done between 2001 and 2014.  The Canadian Medical Association or at least the miniscule fraction of the profession that attends its annual meeting condemned the smoking of any plant material.

As someone who has been in the Medical Marijuana trenches for over a decade opinions are extreme on both sides and I wish to comment on and maybe refute some of the myths in my next post.

1 comment:

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