You'd think I'd be pleased to have my neck of the woods hit the front page of the national newspapers, but with these headlines, I'd rather stay anonymous:
- New York Times: Marijuana Hotbed Retreats on Medicinal Use
- Los Angeles Times: Marijuana 'grow houses' are creating problems in Arcata, Calif.
Both stories discuss a shift in attitude towards medical or compassionate-use marijuana. California passed proposition 215 in 1996, permitting marijuana use with a physician's prescription. Around here, these prescriptions are known as "215s" and are widely available, although not from me.
For the record, I support medical marijuana use for those patient populations for whom it was originally intended: for cancer and AIDS patients, in order to suppress nausea and promote appetite, and modulate pain symptoms. I have worked with these patients as a physician and a hospice volunteer, and I do believe marijuana is helpful for the nagging symptoms of people facing the end of life.
However, I do not believe that marijuana should be recommended generally for chronic diseases such as:
- Migraine headaches
- Anxiety disorder
- Dysthymic disorder/Major Depression
- Chronic Fatigue Syndrome/Fibromyalgia
- Irritable Bowel Syndrome
Now, if you live and practice medicine in a community outside the Emerald Triangle, you might snort at the idea of prescribing marijuana for these conditions, but around here there are doctors who will write 215s for these conditions and other chronic conditions that are largely characterized by anxiety and vague somatic symptoms.
Lately, however, the local progressive attitudes seem to be shifting away from the come-one-come-all mentality to a more moderate position. One reason is the negative impact of clandestine marijuana grow houses on residential neighborhoods. Grow houses require a large water supply and a huge amount of electrical power for the hydroponic systems that support the maturing marijuana plants. Growers often adapt a house's wiring in order to drive more lights, resulting in excessive loads. The NY Times has a photo gallery of marijuana grow houses and legal cooperatives. Check out the second photo, which shows an indoor grow house setup.
Local landlords are suffering from the actions of clandestine growers. Many growers rent houses and turn them into indoor hydroponic greenhouses, even though the profits of selling high-quality marijuana could certainly go towards buying their own houses. We've had a rash of house fires recently, many of which are attributed to the electrical gymnastics growers have to perform in order to get their crops to thrive.
Another problem associated with liberal marijuana prescribing is the impact on local students. Our local state university campus has the highest drop-out rate of all the California state universities. I know an administrator at the university, and she has told me that the school has no effective statistics to track why students drop out, but she suspects that many of them just stop showing up to class due to marijuana-induced academic apathy.
Finally, the medicalization of marijuana has also allowed many physicians to establish lucrative 215 practices, despite varying professional competence or standards. Kevin MD linked to a comment regarding the financial opportunity running such a practice creates, and believe me, I've often thought I could quit my current jobs, buy a big RV, paint a marijuana leaf on the side, and drive from county to county doing good-faith exams and issuing 215s. I call it my alternate retirement plan. The going rate for an annual 215 evaluation is $150--cash. You can see how attractive this option might be for physicians.
One of my friends has recently taken over the practice of a retiring 215 doctor. She doesn't use marijuana herself, and she did a lot of research before taking on the practice. She's an example of the principled 215 provider: she requires a review of medical records before seeing a patient, and she only prescribes for documented medical conditions. She told me of a recent encounter with a woman in her 20s:
"I need a 215 for my endometriosis"
"When did you have a laparoscopy?" my friend asked.
"A laparoscopy. That's a surgery to diagnose endometriosis."
"Oh no, I never had one of those."
My friend told the patient, no diagnosis, no 215.
I trust my friend's standards for prescribing marijuana, but I don't extend the same trust to other 215 providers. Because they place themselves clearly outside the reach of peer review or other types of collegial surveillance, 215 prescribers can easily practice without any oversight--unless the Medical Board catches up with them. Another local 215 doctor is prohibited from examining female patients, due to a prior sanction, but his prescribing practices recently came under scrutiny when a woman patient presented his 215 to an outside dispensary (story link). Now, I ask you, could a primary care provider get away with such behavior?
In the four years I've been out of residency, I've only approved one 215 for a patient with metastatic ovarian cancer. Now that I'm out of primary care, I'll probably keep my record at one. I hope the changing tide of opinion will create more oversight over the 215 process, because I'd like to see the option preserved for the patients who need it the most.