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Category: medical ethics (page 1 of 8)

Medical Marijuana: Not Up to the Standard

This year Oklahoma voters made a clear choice to legalize medical marijuana, joining thirty other states that permit cannabis for medicinal use.

Unsurprisingly, immediately in the vote’s aftermath, patients began asking me to ‘prescribe’ medical marijuana licenses, as the new law stipulates users must have as a precondition for legal purchase. The new law does not, however, specify qualifying diagnoses for which medical marijuana might be clinically indicated.

My answer thus far has been, “Not now. Likely never.”

This has not been a popular response. One patient looked at me as if I’d put a lump of coal in his Halloween bag.

I’m not a fan of medical marijuana for several reasons. The main issue is the lack of proven medical efficacy. I know there are thousands of anecdotes from people whose pain or anorexia has been diminished by marijuana–and I’m genuinely glad for them. But I’d like to see better powered controlled trials of cannabis products head-to-head with accepted therapeutic agents. Having the FDA weigh in on marijuana’s safety and efficacy would also go a long way toward legitimizing pot’s medicinal use.

Another major problem is smoking the stuff. If we had proven, standardized dosing of edibles, I’d be more supportive of medicinal use. But smoking anything–tobacco, marijuana, vapor juice–is not a healthy practice, and one I counsel patients to avoid. I hear the arguments about the purity of pot and how it’s ‘more natural’ than manufactured tobacco products. The bottom line is that inhaling burning plant matter into your lungs is a terrible idea–regardless of the herb.

If voters want to legalize marijuana for recreational use, I have no objection–provided we put in place a legal framework to make sure that people don’t get hurt. Standardized dosing and measures to assure product consistency would be integral. And we’d need adequate enforcement to make sure that people aren’t impaired when at work or in other situations in which their marijuana use could jeopardize others.

Putting doctors in the middle of what amounts to a political, legal, social, and economic debate steers the medical profession in a race to the bottom–and let’s face it–our profession has enough problems already without being the gatekeepers of grass.

Remember that marijuana is still scheduled by the Drug Enforcement Administration as a Class I narcotic, defined as having “no accepted medical use and high potential for abuse.” So even though medical weed is now legal in my state, I have no interest in violating or abetting violations of federal law.

In fact, as it turns out, since I work at a university, our legal counsel is of the opinion that no provider in our system shall recommend marijuana, since our institution has numerous federal grants and funding streams and must therefore comply with all federal rules and regulations.

Some have suggested that given our national opioid epidemic, marijuana can serve as a safer alternative for pain control. Since most cannabis is homegrown, and where legalized a tax revenue source–this does make medical marijuana a more appealing alternative to propping up the seemingly ubiquitous heroin/fentanyl drug cartels.

This argument makes pot part of a harm reduction strategy, which I’d be more supportive of if the evidence were stronger.

Right now I see the pot economy as a Wild West with hundreds of entrepreneurs and medical professionals looking to stake claims in this new quasi-legal economy.

Get back to me when we have more state/federal legal congruence and clarity on the stuff’s true medical benefits.

This essay originally appeared as a Doximity Op-(m)ed.

Solid Reporting on Liquid Gold

A thousand or more cups of urine arrive most nights by express mail to Comprehensive Pain Specialists clinics. The samples are tested for narcotics and other drugs, both legal and illegal. (Heidi de Marco/KHN)

In a beautifully reported investigative piece, Fred Schulte and Elizabeth Lucas of Kaiser Health News detail the explosive growth of the urine drug testing industry in the U.S.

We’ve written about this once before (more than 4 years ago!), but the growth of the industry fueled by taxpayer dollars (Medicare payment for drug testing) appears to be continuing unabated.

In this new piece, Schulte and Lucas do an expose on an outfit called Comprehensive Pain Specialists, a physician-owned outpatient pain management practice with 54 clinics across 10 states in the southeast U.S.

Let me be clear that CPS is not being singled out for malfeasance — rather, the point of the article is that they are emblematic of a huge surge in Medicare spending for expensive urine drug tests — many of which may be unnecessary.

Ay, there’s the rub. From the piece:

     …there are virtually no national standards regarding who gets tested, for which drugs and how often. Medicare has spent tens of millions of dollars on tests to detect drugs that presented minimal abuse danger for most patients, according to arguments made by government lawyers in court cases that challenge the standing orders to test patients for drugs. Payments have surged for urine tests for street drugs such as cocaine, PCP and ecstasy, which seldom have been detected in tests done on pain patients. In fact, court records show some of those tests showed up positive just 1 percent of the time.

The other thing that has government watchdogs and other observers worried is that for many pain specialists, the lion’s share of their revenue is earned by these drug tests. Remember, reasons to order these tests are twofold:

  1. Make sure patients ARE taking the drugs that you are prescribing (therefore suggesting that said drugs are not being diverted–e.g. sold on the street).
  2. Make sure patients AREN’T taking drugs of abuse (which for many pain clinics is a violation of the clinic-patient ‘pain management contract’).

As one government attorney was quoted:

“We’re focused on the fact that many physicians are making more money on testing than treating patients,” said Jason Mehta, an assistant U.S. attorney in Jacksonville, Fla. “It is troubling to see providers test everyone for every class of drugs every time they come in.”

The excellent bar graph attached below is included with the KHN story– and clearly demonstrates the trend. What are your thoughts?

 

 

Wrestling with My Inner Trump

medical-deportation_wide-d8d3587daba3c4885aabbfe681ada9e50a893091-s800-c85In a new NPR column I recall a time when my team and I had to decide on the best hospital discharge plan for a newly disabled, undocumented immigrant.

Immigration is always a pretty hot-button issue, never more so than during Presidential elections.

Wonderful accompanying art by Lorenzo Gritti.

When medicine and commerce collide, who is lost along the way?

Posted by NPR on Sunday, April 10, 2016

RIP: Richard Fine (1940-2015)

I didn’t know him, but was inspired by the life story of Richard Fine, which I came across while reading his obituary in the San Francisco Chronicle.

Dr. Fine grew up in Cincinnati, and was educated at Cornell — first the college in upstate New York, then the medical school in New York City. He moved to California in 1966 for medical training, and never left.

920x920Like Zelig or Forrest Gump, he was seemingly ubiquitous at major historical events around that time: He volunteered to provide medical care at Altamont, where the Hell’s Angels, working as security for the Rolling Stones, killed a concert goer. He served as a physician to members of the Black Panthers, who were unable to get medical care in more traditional venues. He also ran a clinic for American Indians during the siege of Alcatraz from 1969-1971.

In addition to his medical leadership, he was widely known for his casual dress (bowling or mechanic’s shirts) and riding a motorcycle as his main form of conveyance.

He challenged the leadership of San Francisco General Hospital to provide care for the poor and uninsured, something we take for granted today but wasn’t at all a given when he was starting out. He was instrumental in helping start both a clinic and a residency program to train young doctors in the principles of social medicine — looking beyond the direct biological causes of illness to social causes, institutional discrimination, and beyond.

As you might imagine, he championed the cause of AIDS victims during the early part of the epidemic when other facilities would find excuses not to care for those infected with HIV. He also was known for improving the care of those jailed in San Francisco, making the case that incarcerated individuals still need care. When Type I diabetics were denied insulin and wound up hospitalized or dead, it made more sense for city supervisors to allow Dr. Fine and his trainees to develop better and more humane care plans for those in jail.

I was touched to read that Dr. Fine’s proteges at UCSF and San Francisco General Hospital were able to name their clinic in his honor. They announced that to him at the debut showing of a documentary film made about him last summer, so he was able to learn of the honor before his death due to cancer.

#MacLean15

IMG_0536Recently I attended the annual conference of the MacLean Center for Clinical Medical Ethics at the University of Chicago. I was a fellow there a decade ago, spending a year steeped in study of the history and mechanisms of making complicated medical choices and attempting to resolve seemingly irreconcilable choices.

The center began in the 1980s, and has trained nearly three decades worth of fellows. As such, the annual event brings back many alumni but also outside speakers and attendees from across not only the U.S and Canada, but also from Europe and Australia. The conference took place at the University’s Law School, where I snapped the accompanying photo of one of the Law School’s most noted former lecturers outside of Classroom V, which was apparently his favorite place to teach.

There were many interesting topics covered at the conference. Among them:

  • Persons donating kidneys are more likely to eventually need dialysis and transplant themselves, and should be informed of such. (Sounds intuitive, but had not been scientifically proven before.)
  • In spite of massive effort, compliance rates for hand washing in hospitals continues to hover near 30% of available opportunities.
  • Frustration with insurance companies approving expensive drugs for conditions like inflammatory bowel disease led one doctor-researcher to ask, “Do insurance companies have medical ethical standards?” (Apparently not; they only have ‘business’ ethical standards.) He used social media to positive effect for some of his patients to get them ‘restricted’ but indicated medication.
  • A physician with a strong humanist bent shared how his frustrations with the practice of modern medicine (productivity constraints, feeling more like a widget in a system than a professional) were put in context by a trainee of his undergoing excruciating treatment for cancer who maintained a wonderful attitude about his life despite his suffering.
  • Several sessions focused on the struggles of the most vulnerable — and providing care for them — children, elderly, veterans, the mentally ill.

That is only a sample of the presentations. Since the center and the conference are underwritten by benefactors, attendance is free and only requires registration.

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