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Winter/Spring 2005
O'Shaughnessy's
Journal of the California Cannabis Research Medical Group

A Cautionary Tale (For Doctors and Patients)

By Frank H. Lucido, MD
with Mariavittoria Mangini, PhD, FNP

Cannabis may be used safely and effectively to treat a wide variety of complaints, but evidence is accumulating that patients should continue to receive periodic follow-up by their own physician for their serious medical problems.
Unless a recommending physician is taking responsibility for the patient’s primary care or the treatment of his or her serious illnesses, cannabis consultants should advise patients to follow their illnesses with whomever else is providing this care. This advice can benefit both patients and providers.
Here is an interesting case in which reassessment of a patient’s condition as part of a medical cannabis consultation may have had a significant impact on his care.
Presenting History:
The patient is a man in his mid-20’s who was first seen by me in October 2003 when he sought a medical-cannabis recommendation for a number of complaints. Other providers had suggested diagnoses of asthma, depression and anxiety. He was not satisfied that any of these diagnoses fully explained his symptoms of hoarseness, nasal and throat “congestion,” difficulty taking a full breath, and a “dry, scratchy” voice.
He had never had these symptoms prior to 2002.
The patient had been a cannabis user prior to August 2001, but had used no cannabis for several months at the time when he first noted the symptoms. He had used cannabis two times since: once in Amsterdam in February 2003 when he found that he breathed easier, and his nose and throat felt clearer. He tried cannabis again July 2003 with questionable benefit. (see footnote 1)
His asthma, as diagnosed by his primary care practitioner, had been unresponsive to Singulaire, albuterol, Astelin nasal spray, Flonase, Rhinocort, and Clarinex.
His primary care practitioner also diagnosed anxiety and depression as a cause of his symptoms, but the patient doubted these diagnoses.
He planned to transfer care to an HMO soon and be examined by a new primary care practitioner.
His past history was otherwise unremarkable
Positive Findings on Physical Exam:
Vocal quality: slightly hoarse (see footnote 2).
Neck: A firm mass was felt in the right thyroid lobe.2
Lungs were clear, without wheezing.
Breathing was not labored. The patient spoke in full sentences.
Outside records: TSH (thyroid stimulating hormone) in the upper range of normal, August 2003.
Impressions:
Questionable History of Reactive Airway Disease (Asthma).
Questionable History of Allergic Rhinitis.
Questionable History of Depression with Anxiety.
Thyroid mass.

Plan:
Discussed pros and cons of medical cannabis.
In view of the patient’s self-report of some symptom improvement following cannabis use, but lacking a definitive diagnosis, a time-limited (three-month)3 recommendation for medical cannabis was provided, with a plan for re-evaluation of the patient and his medical records at his three-month followup.
I advised patient that he would be required to present evidence of having obtained follow-up with his primary care practitioner and/or specialist for his apparent thyroid mass in order to renew his medical cannabis recommendation beyond three months.
Subsequent course:
When the patient’s further records arrived in my office, they showed that he had been diagnosed with metastatic papillary cancer of the thyroid!
At his recommended follow-up visit, his physician had noted the right thyroid abnormality.The following tests had been obtained with results as follows:
Esophogram: “small hiatus hernia noted. Also, an extrinsic impression under the esophagus was noted”.
Upper Gastrointestinal Endoscopy: no abnormal findings except enlarged right thyroid.
Fine Needle Biopsy: malignant right thyroid mass: papillary cancer.
In mid-December 2003 the patient underwent a complete thyroidectomy; papillary cancer had spread to neck lymph nodes.
Nine days after surgery at CT scan a small nodule was identified in each lung; the cancer was thought to have spread diffusely to lungs in a miliary pattern.
In early February 2004 a bilateral neck node dissection was performed to remove the cancerous lymph nodes and any remaining thyroid tissue
Rather than wait for his upcoming follow-up appointment in my office, I telephoned the patient. He stated that he had had a “total thyroidectomy with neck dissection,” and was scheduled to be treated with radioactive iodine soon.
He had not had much opportunity to use cannabis, but did have post-operative pain, and hoped that cannabis would help this pain.
I then extended his recommendation to a full 12 months.

I recently saw the patient for his yearly follow-up. He looked quite well, with his neck showing bilateral, large healed surgical scars.
He still had neck pain in the scarred areas, and cannabis does help this pain.
I have now renewed his recommendation for an additional year.
He is still under the care of his primary physician and specialists through his HMO.

Discussion/Footnotes
1. When a patient presents for symptom management using cannabis and the diagnosis is in doubt, a further work-up may be needed. If you are not taking primary care responsibility for the serious illness whose symptoms the patient will be treating with cannabis, make sure to advise/order patient to continue follow-up of the illness or symptoms with his or her own primary care provider.
2. A gravelly or hoarse voice, especially in view of a thyroid mass, suggests a mass of some kind affecting the recurrent laryngeal nerve.
3. One of my requirements in medical cannabis consultations is that the patient thave a documented source of primary health care. (Although testimony by the Medical Board of California’s own experts has held that advising the patient to obtain or maintain such care is sufficient, as patients are free to reject a physician’s advice.)
In this case, I gave my standard recommendation that the patient continue seeing his primary physician.
Although I had the patient’s report that cannabis had helped (or might help) alleviate his symptoms, because of the unclear diagnosis I planned to see him and his interval medical records again in three months for reassessment (prior to extending his recommendation for 12 months). This was to assure myself that he was receiving adequate ongoing primary care from his own physician and that cannabis was providing relief for his symptoms. Limiting the recommendation to three months gave me more leverage to assure that the patient would soon follow-up with his own doctor, which he did.
Dr. Lucido can be contacted at drfrank<AT>drlucido.com or by calling 510-848-0958
www.MedicalBoardWatch.com

 

 

O'Shaughnessy's
O'Shaughnessy's is the journal of the CCRMG/SCC. Our primary goals are the same as the stated goals of any reputable scientific publication: to bring out findings that are accurate, duplicable, and useful to the community at large. But in order to do this, we have to pursue parallel goals such as removing the impediments to clinical research created by Prohibition, and educating our colleagues, co-workers and patients as we educate ourselves about the medical uses of cannabis.
 
SCC
The Society of Cannabis Clinicians (SCC) was formed in the Autumn of 2004 by the member physicians of CCRMG to aid in the promulgation of voluntary standards for clinicians engaged in the recommendation and approval of cannabis under California law (HSC §11362.5).

As the collaborative effort continues to move closer to issueing guidelines, this site serves as a public venue for airing and discussing these guidelines.

Visit the SCC Site for more information.