March 31, 2011
Can "Pot Doc" be a Valid Speciality?
By FRED GARDNER
Every TV station from San Diego to Crescent City has run a segment in which a reporter with a hidden mike visits a local MD who is known to approve cannabis use readily. The reporter tells the doctor about an old injury that has left him in chronic pain. He says his records were lost when he moved or some such lie. The doctor issues an approval after only 6-7 minutes. Reporter is shown paying in cash. Back in the studio the reporter tells the concerned anchor person that the taking of vital signs had been perfunctory, it didn't feel like bona fide medical care, it's not what voters envisioned, etc., etc. The segment is likely to include footage of able-bodied young men in the MD's waiting room, faces out of focus to protect "privacy," or emerging from a dispensary with a paper bag in hand. Pan with the young man to a car where his friends are waiting to share the pot...
Among physicians in California and other states where the medical use of cannabis is quasi-legal, there are now three tiers of expertise. The doctor in our generic TV segment, who provides a quick, minimally-documented approval letter for $90, is in the middle tier. He understands that the adverse effects of ingesting Cannabis are so benign that he will be doing no harm in providing legal protection to users. He has learnt from his patients that although most use for pain and depression, there's a remarkable range of conditions for which cannabis provides relief.
This is significantly more than most California MDs were taught in medical school or have learned to date. Most know that Cannabis is on Schedule 1 -harmful and medically useless, as defined by the DEA, the agency that issues their licenses to prescribe. Most doctors simply don't discuss Cannabis use with their patients. And most patients are too embarrassed to raise the subject. "Don't ask, don't tell" is the rule.
So when it comes to understanding the medical use of Cannabis, physicians in the bottom tier predominate. They don't know the range of conditions for which it relieves symptoms. They know nothing about the cannabinoids and other plant compounds that exert effects within the body. They know nothing about the body's own "endocannabinoid" receptors and the endogenous compounds to which they respond. Yet they tend to be aggressive in their ignorance. Take, for example, Marci Dolin's regular doctor...
First, Do No Arresting
A blurry extreme close-up of Dolin lighting a roach appeared in the NY Times Sunday Magazine March 20. She is 71 and has MS. The photo by Steve LaBadessa was entitled "Self-Medicator, Rohnert Park, Calif." The caption was a quote from the subject: "I'm lying in my bed, smoking a joint. I smoke about eight a day and eat a marijuana cookie before I go to sleep at night. I like the peanut-butter ones. I've been using marijuana for about 35 years, ever since I was diagnosed with MS. It takes the pain and muscle spasms away. Without it, I would be living on morphine and other horrible drugs. I couldn't do that to my family. That's no life, and I would have ended it. That's the truth. I used to take a drug called Neurontin, and I just never stopped crying. I was in a fog, totally depressed. I told my doctor that I was going back to just marijuana; he said he would have me arrested if he could. What are they going to do? I'm 71 years old. Are they going to put me in jail? I'm not hurting anybody. It's just here in my own house."
At the other end of the spectrum from Marci Dolin's regular doctor are MDs who keep abreast of developments in Cannabinoid science by attending conferences, monitoring the literature and sharing findings and observations with colleagues in the Society of Cannabis Clinicians. The SCC met March 19 in Los Angeles. SCC president Jeffrey Hergenrather, MD, was a charter member in 2000 when Tod Mikuriya, MD, founded it as the "California Cannabis Research Medical Group."
The name got changed but research remains a primary goal. The SCC has developed a survey to assess patients' responses to Cannabidiol (CBD) as it becomes more widely available. ProjectCBD.org is promoting the survey.
Hergenrather began the March 19 get-together by passing around a handheld radiation detector made by a company he co-founded and in which he remains a partner. After the "event" at Three Mile Island, reasoning that the government couldn't be counted on to report radiation levels accurately, Hergenrather and a friend named Dan Sythe, a highly skilled and innovative electrician, built and sold detector systems. They successfully pitched two communities located near reactors -Seabrook, NH, and Three Mile Island itself. The company, Medcom, is still selling state-of-the-art detectors.
Hergenrather uses the RadAlert 100 and the Inspector Alert. "They are both Geiger-tube-based instruments," he says, "one with a small mica end-window, the other with a much larger tube, and consequently greater sensitivity. They are both designed to measure alpha, beta, gamma, and x-radiation. The Radalert (http://www.medcom.com/rad100.htm) has an alert setting, both have total and timer functions(http://www.medcom.com/inspect.htm) for averaging periods. Handheld geiger counters can be ordered from International Medcom (http://www.medcom.com/). Unfortunately, sales are up as the reactors get more out of control."
Werc Shop to Test For Terpenes
The guest speaker at the SCC meeting was Jeffrey C. Raber, 35, an organic chemist who a year ago started a lab in Southern California called The Werc Shop. Raber has a PhD from USC and a background in synthetic methods of making pharmaceuticals. His goal is to figure out which compounds in the plant are exerting which effects in which combinations.
The Werc Shop uses liquid chromatography to test for cannabinoid levels, Raber said, because gas chromatography involves heating the sample, which converts THC-acid and CBD-acid to THC and CBD in their neutral forms. William Courtney, MD, who thinks the acid forms have unique medical benefits, nodded approvingly. Also, Raber said, orally consumable products must be analyzed by liquid chromatography to determine the contents accurately.
"Now we've ordered the [GC/MS] equipment and are about to start testing for terpenes," Raber said, to a spontaneous burst of applause. Terpenes are volatile and aromatic -they give cannabis its smell. Small amounts can exert strong effects when ingested. The SCC docs are on exactly the same quest as Raber: to figure out which compounds within the plant are exerting which effects. The more detailed and precise their understanding, the more useful they can be to patients and the more respect will accrue to their specialty, "Cannabinoid Therapeutics."
The Werc Shop currently utilizes "an optical-based incubator system that can provide mold analysis in 48 hours," Raber said. He is also planning to test for more pesticides. "Which ones?" he was asked. "As soon as you say you're testing for these, they can use others," he said, realistically. "If we cast a big enough net we'll find the major players and through that we can delineate what a regulation should say."
Raber foresees the day when doctors and patients will know which compounds in the plant have which effects, and ingestibles will come with precise, accurate dosage info. SCC doctors, he noted, have a key role to play in collecting and aggregating patients' responses to various strains and products... Hergenrather promised that the SCC website, dormant since Dr. Mikuriya died in 2006, is about to get re-launched.
At LAX, flying back on Southwest, you have to go through the scanner or request a pat-down. Almost everybody does the former. Dr. William Courtney strode into the scanner, to my surprise -and then he had to wait while I got thoroughly groped in public by an embarrassed young man.
From the LA Times, Saturday March 19, read on the plane: "California regulators are taking aim at giant drug maker Bristol-Myers Squibb, accusing it of bribing doctors and pharmacists to use its products by offering thousands of cash kickbacks, gifts and 'happy hours' with the Los Angeles Lakers." Some 15,000 doctors accepted bribes from Bristol-Myers between 1999 and 2005, according to the suit filed by whistleblowing ex-employees and joined by the state Department of Insurance.
Among the plaintiffs are Lucius Allen, a great Lakers point guard in the 1970s, and his wife Eve, who originally set up the program with the Lakers. Lucius Allen worked for Bristol-Myers from 1997 to 2003 as a sales rep pushing cardiovascular and diabetes drugs. Eve, who left in 2002, pitched Bristol-Myers drugs to insurance companies whose willingness to reimburse is the key to profitability. (Bristol-Myers sales last year were $19.5 billion.)
Dr. Frankel's Victory With an Asterisk
The Medical Board of California has accepted Administrative Law Judge
Susan Formaker's proposed decision In the Matter of the Accusation and
Petition to Revoke Probation Against Allan I. Frankel, MD.
Formaker decided that the testimony of the Board's expert witness, a Beverly Hills psychiatrist named Daniel Fast, had been "substantially discredited on cross-examination." Frankel's attorney John Fleer had caught Fast contradicting himself repeatedly. Formaker's comments about Fast jibe with the reports we conveyed from people who attended the four-day hearing in Los Angeles.
The board had relied on Fast's assessment, based on one 70-minute interview with Frankel, to establish the latter's unfitness to practice medicine. "In view of Dr. Fast's problematic perceptions," wrote Formaker, "Dr. Fast's admittedly 'inaccurate' cannabis-related diagnoses and GAF scores assigned to Respondent, and the insufficiently supported diagnosis of Personality Disorder Not Otherwise Specified, Dr. Fast's conclusions regarding respondent's inability to practice medicine safely cannot be considered convincing."
Formaker went on to weigh "the question of whether a physician may
violate a probationary order issued by the Board solely through the
use of medical marijuana authorized pursuant to the Compassionate Use
Act." Her answer was yes -"technically." But in this case, when
Frankel and the Board entered into a stipulated settlement in 2009,
Frankel agreed to abide by a disciplinary order that did not
specifically rule out his using medical cannabis (which the board knew
he was using). "Fundamental principles of due process require," opined
Formaker, "before the Petition to Revoke Probation was filed,
Respondent should have been notified... that his use of medical
cannabis, in and of itself, constituted a violation... of the
We fear that from now on, when Pro-Cannabis MDs (and others) accept terms of probation, the medical board will duly advise them that they are relinquishing the right to use Cannabis as medicine under California law.
* John Fleer comments: "The decision does give guidance to how this judge thinks the MBC could better prohibit medical cannabis use by a physician on probation, but I think one could successfully challenge such an attempt as improperly interfering with medical decision-making of the recommending physician. My concern about the decision is that it does not go far enough in getting Dr. Frankel back in practice —it's an open question as to how the MBC will now proceed re his probation status."
Frankel says, "Even if nothing else good comes from my victory, it forces the medical board to come out and clearly state to any future docs that not using cannabis will be part of their settlement; they won't be able to set the doctors up. Had the Medical Board in fact told me that this were to be a restriction, I would have never settled... Also, the 'negative' is of great value in my opinion. Had I lost, things would be worse for everyone."
That is the truth.
Best case scenario: Allan Frankel resumes practicing medicine April 23, a year and a day after the medical board forced him to stop.
Fred Gardner edits O'Shaughnessy's, the journal of cannabis in clinical practice. He can be reached at firstname.lastname@example.org.