Spring 2004
O'Shaughnessy's
Journal of the California Cannabis Research Medical
Group
|
Cannabis in the Curriculum
On Feb. 13 students and faculty from the University of Southern California
Keck School of Medicine put on a half-day program devoted to the clinical
uses of cannabis and the relevant pharmacology. Some 30 first- and second-year
medical students attended the history-making event in McKibben Hall, which
was organized by Rolando Tringale, a second-year medical student, and Claudia
Jensen, MD, a Ventura pediatrician who is an Instructor in the Department
of Family Medicine.
Jensen teaches "Introduction to Clinical Medicine," in which first-year
students learn how to take a patient's history and conduct a physical exam.
Since the Fall semester of 2001 Jensen has spent a full day in the ICM class
talking about cannabis and bringing in patients for students to interview.
" They're open-minded and well educated," she says of her students. "And
they actually go on to teach their colleagues the truth about cannabis.
That's why Rolando wanted to do this presentation." (Tringale
had taken Jensen's ICM class last year.)
The Feb. 13 program started with first-person accounts from patients.
Jensen had invited Ishmael Gayes, "a paraplegic -a very beautiful, intelligent,
spiritual black man who was shot in the back over a woman when he was 17;" chronic
pain patient Lisa Cordova Schwarz, LVN; and glaucoma patient Jim Carberry.
Bill Britt, an activist from Long Beach who has post-polio syndrome and epilepsy,
also described his use of cannabis.
Rolando Tringale, a second year medical student
at USC Keck Scholl of Medicine, helped organize the Feb. 13
course on the medical use of cannabis. |
Joseph Miller, PhD, Associate Professor of Cell and Neurobiology,
discussed the pharmacology and biochemistry of the body's own cannabinoid
receptor system,
which is activated by THC and other compounds in the plant.
Miller's research has been funded over the years by the National Institute
on Drug Abuse (NIDA). "He's not a medical marijuana proponent," says
Jensen,"he's not in the movement. He's just an honest man with a balanced,
truthful perspective about drugs who was willing to be a speaker."
Associate Professor of Psychology Mitch Earley-wine, PhD, discussed the question
of safety. Earleywine, the author of "Understanding Marijuana" (Oxford,
2002), said that medical users could minimize negative consequences by vaporizing
instead of smoking. Earleywine also advocates "keeping dosage at a level
that relieves symptoms but doesn't create any impairment" and "monitoring
for any signs of craving that might indicate tolerance or withdrawal."
Earleywine has found that "the people who run into dependence problems
with cannabis are the ones who are drinking a lot of alcohol." He recommends
that medical cannabis users avoid alcohol consumption.
Attorney William Logan explained Proposition 215 -now California's Health & Safety
Code Section 11362.5- and recounted the court rulings that affect its implementation.
Jensen's talk -"Integration of Cannabis Treatment into the Practice of
Medicine," a version of what she teaches the first-year students- delved
into questions such as:
¥ How do you tailor a history and physical to a medical marijuana patient?
¥ What dose and strain and route of administration should a patient use?
She also discussed "the advantages and disadvantages of having medical
marijuana patients in your practice."
Jensen's Approach
Regarding dose and route of administration, Jensen says, "I make a decision
based on what their medical problem is, the duration of the effect that they
need, the strength of the effect that they need, and the quality of the effect
that they need. And then I advise them what to use based on what other patients
have taught me. One of the biggest problems is that I'm not getting this information
from scientific sources, I'm trusting the patients. This is a unique field
of medicine, where the doctors are actually learning from the patients.
" Instead of relying on data from placebo-controlled, double-blind clinical
trials conducted in some far-off academic ivory tower, it's from talking to the
patients and finding out what they do and how does that work?
" It's folk medicine with a trained listener who applies principles of science.
Basically, I'm doing my own studies."
Indica or Sativa?
Jensen regrets that California physicians have no way of analyzing the actual
cannabinoid content of the various strains patients are using. "Based
on what I've learned from patients," says Jensen, "The Indicas seem
to be better for pain, for insomnia and to calm their nerves. The Sativas seem
to work better to elevate mood and energy levels. But I see a higher incidence
of patients who are nervous and have anxiety and rapid heart rate and also
a high incidence of heartburn.
" I talk to them about how to pay attention to what they're using. I tell
them, "don't just buy any street weed. Find out, what are you smoking? White
widow? Chronic? Hindu Kush? Romulan? Know the name of it and try to develop your
own quality control standards because we can't go to a textbook for that."
To Tell the Truth
"How many of you use marijuana?" Jensen asked. She says, "Probably
seven students raised their hands. I told them 'I am very proud of you having
the courage and the integrity to tell the truth, because that's what this conference
is about.'" Jensen also asked how many had or knew somebody who had a condition
treatable by cannabis. About 90% raised their hands.
Physicians can help patients overcome social ostracism and embarrassment, says
Jensen. "When a physician takes responsibility for advising a patient
on cannabis as a medication, it helps legitimize for the patient that what
they're doing is okay."
Physicians themselves face ostracism for issuing cannabis approvals. "There's
this unspoken attitude," says Jensen, "-'she's not a real doctor,
she takes care of cannabis patients.' I'm the 'pot doc.' On the other hand,
I get referrals from all the local doctors -psychiatrists and family medicine
and oncology doctors sending me patients because they don't want to treat them."
Jensen thinks that many physicians who themselves use cannabis are "uncomfortable
writing notes because they don't want to attract any attention to themselves.
They don't want to take the chance because somebody might come and say 'Let's
test your urine.' There is a significant proportion of physicians who smoke
pot surreptitiously. They're afraid to write notes because they don't want
to be in anybody's database. So, the whole thing boils down to patient advocacy
vs. social ostracism. Cannabis-using physicians are afraid to come out of the
closet. And it's really a problem-it's harmful to the patients."
Jensen laments the "information vacuum" in which clinicians monitor
their patients' use of cannabis. "This is the only field of medicine where
the patient routinely has more knowledge than the physician. As a scientist,
that's a bitter pill to swallow. I can't go to a reference textbook. Where
do you go for information on something that you're not allowed to have information
on?"
Another disadvantage: lots of paperwork.
Jensen urges students to "remember what you went into medicine for is
to be an advocate for patients. You have to have the courage to do that even
if it's not socially acceptable."
She hopes that patients will "educate their famiy and friends -tell them
the truth- so they can use this as medication without sneaking around in the
back room."
Jensen had invited -after getting administrative approval to do so- Richard
Davis, proprietor of the USA Hemp Museum, who brought samples of hash, hash
oil and other cannabis-based products, as well as some plant strains (in jars),
providing, for some of the students, a first exposure to the once-prohibited
herb.
Jensen says that the USC administration has been supportive of her efforts
to introduce cannabis into the curriculum. Althea Alexander, Clinical Instructor
for Educational Affairs, attended the Feb. 13 conference and expressed gratitude
to the patients who took part. Alexander regretted that the event had been
scheduled for the getaway day of President's Day week-end; there would have
been a much heavier turnout, she said, on an ordinary Friday.
Jensen hopes that next year the conference will be held in October, "when
the students are freshest," and that it will be a requirement. (This year's
was not offered for credit.) Jensen had an insight about "elective" classes
when she was in med school at the start of the 1980s. "I took an elective
on 'Sexual Desensitization' and the only students who went to it were the students
who were comfortable with sexuality. All of the really up-tight people avoided
it. So I don't think cannabis should be an elective. I think it should be required
training."
CME class coming soon?
Jensen has also given thought to developing a continuing medical education
program for physicians, none of whom learned a thing about cannabis in medical
school. (Doctors are obligated to earn a certain number of CME credits annually.)
She has proposed to the administration that USC offer a CME course on cannabis.
Professor of Clinical Instruction Alan Abbott told her he was amenable and
would look into possible funding.
Jensen thinks her colleagues in the medical profession will take steps to educate
themselves on the subject of cannabis only when they are obligated to. And
she has a strategy to obligate them. "The Medical Board of California
has dictated that physicians have to take 12 hours in pain management in order
to maintain their licensure. My position is that any pain management presentation
that any physician takes is inadequate if it does not include discussion about
cannabis and cannabis compounds. The Medical Board should take the position
that cannabis teaching needs to be integrated into those pain management sessions
that physicians are already required by law to attend."
Jensen is a pediatrician whose special interest is in cognitive function and
development. She branched into treating adults as a result of her interest
in cognition. She says that with every patient she tries to figure out "the
habits that are keeping them sick."
Jensen spends an hour seeing each new patient. She learned recently that she
is under investigation by the Medical Board for allegedly providing substandard
care to three ADHD patients (whose cannabis use she approved).
Dr. Jensen's Syllabus:
Integration of Cannabis Treatment into the Practice of Medicine
I. Why is it important to evaluate and treat patients with cannabis?
A. patient advocacy
1. Safety profile; efficacy; quality of life
2. Abandonment by healthcare providers
3. Social ostracism, embarassment
4. Legal jeopardy
B. the patients need guidance
1. No standard of care in the community; cutting edge of medicine; need for
physicians to gain education, wisdom
2. Patient population; medical issues are "serious;" neuropsychiatric
consequences of cannabis use.
C. it's the law!
II What are the disadvantages of treating with cannabis?
A. legal jeopardy
1. Physician exposure
a. Courage/focus of patient advoacy
b. Medical Board of California
c. Drug Enforcement Administration
d. Social/Professional ostracism
e. Recreational use
2. Trusting your patient -the only field in medicine where you are expected
to distrust your patient.
B. information vacuum
(the only field in medicine where the patient routinely has more knowledge
than the physician)
C. responsibility
1. Lots of paperwork
2. Patients may require legal support
III. Advantages of having cannabis patients
A. to do a real complete history and physical exam; no need to depend on third-party
payers (at this time)
B. to develop trusting patient relationships
C. to educate patients, colleagues, public
D. to implement significant health changes/ heal
E. a chance to think and learn
IV. Implement Personal Standards of Care
A. learn how to use cannabis as a medication
1. No instruction manual
" Understanding Marijuana" by Mitch Earleywine, PhD;
website of the Cannabis Research Medical Group ([email protected])
2. Follow the law
3. Think. Adapt to your patient and yourself.
4. Develop an intake procedure that works for you.
B. Conduct a complete history and physical examination
1. Chief complaint
2. History of the present illness -Pay particular attention to why the patient
has chosen to use cannabis over other medications.
3. Past medical history -Be thorough with all the routine questions, plus:
a) childhood
b) Parenting, abuse
c) Academic performance, hyperactivity
d) Socialization
e) Mental health
4. Review of Systems -Take the time to ask about each system, especially pulmonary
and neuropsychiatric
5. Family history -Routine questions probably enough in most cases.
6. Social history -the most critical part of the history. Include all routine
questions with additional focus on:
a) Other substance use
b) Legal encounters, arrests, incarcerations, jail time, parole, probation
c) Support systems (spouse and children, especially)
d) Disability
e) Miliatry history
f) Work history, employment
g) Education
h) Exercise, recreation
i) Travel history
7. Physical Examination -May be complete physical exam or focused specialist
exam
a) General appearance
b) Nutrition
c) Hygiene
d) Activity
e) Attitude
f) Level of consciousness
8. Data collection
a) Medical records documenting medical condition
b) Mental health records
c) Legal/arrest record
d) Laboratory (if appropriate)
V. Develop an Impression/Assessment
A. Does the patient have a serious medical problem?
Is the patient able to live a functional life without medication?
VI. Evaluate treatment options ("Plan")
A. has the medical problem ever been successfully treated with cannabis?
You must rely on anecdotal as well as scientific evidence because of the history
of "scientific research" in the United States (not always factual:
Cannabis is classified Schedule I, no known medical uses)
B. Does the "safety/efficacy" ratio warrant approving cannabis?
C. Is cannabis compatible with the patient's other medications?
D. Choose a delivery method
1. Inhaled: shorter half-life, "higher" peak effects
a) water pipe/ bong
b) Pipe
c) Joints
d) Blunts
e) Vaporizers
2. Ingested: longer half-life, more generalized well-being.
a) Marinol (Solvay Pharmaceuticals)
b)Fat-based food (brownies, "mother's milk," etc.)
c) Sublingual tinctures, sugar-based drops
d) Teas
e) Candies
f) Hash-oil meds
3. Compresses: topical administration
E. Choose a cannabis strain
1. Cannabis sativa
a) Seems to work better with mood, energy, thinking problems (e.g., depression,
attention deficit disorder, anorexia)
b) Keeps patients awake at night
c) Can increase anxiety, heart rate, heartburn
d) More affordable
2. Cannabis Indica
a) Superior with somatic disorders: Pain, insomnia, spasticity
b) Outrageously expensive (more than gold per ounce)
3. Hybrids
F. "Choose" a dose (most patients have already done this for you)
1. ADHD and chronic pain patients need the most medication (generally an ounce
or more per week)
2. Insomnia, anxiety, nausea patients seem to need less (impossible to predict)
3. Most chronic pain and ADHD patients are grossly under-treated. Chronic pain
patients may be able to wean off narcotics entirely.
G. Arrange follow-up based on the patient's medical condition/experience with
cannabis.
VII Make a commitment
A. Give your patient a written letter of your intent to support him/her.