WISDOM FROM OUR PROVIDER

MEDICAL MARIJUANA: THE STIGMA, THE CONTROVERSY AND THE REALITY

BY

FIDELIS O. EJIANREH, D.O.

On April 17, 2016, SB 3, the Pennsylvania Medical Marijuana Act was signed into law by Gov. Tom Wolf. The law, which is a result of Pennsylvania’s compassionate medical cannabis legislation, went into effect on May 17, 2016, with the first dispensaries serving patients in April 2018.

This law marks a historic moment for use and access to cannabis in Pennsylvania for patients with “serious medical conditions”. The state of Pennsylvania is the first to approve medical marijuana for the treatment of opioid addiction. This is very much a welcome development in light of the national opioid addiction epidemic. This puts the state of Pennsylvania, along with 30 other states and the District of Columbia that have now legalized marijuana for medicinal purposes – and, the trend appears to be growing.

That is a good thing; especially, given the fact that the U.S. Government considers marijuana an illegal substance, and classifies it as a Schedule 1 drug, which means that it has no medicinal value and is highly addictive. Neither of which have been supported by scientific/medical research.

The Pennsylvania Medical Marijuana Act does not define what constitutes a “serious medical condition”, but simply lists 20 medical conditions that are limited to multiple sclerosis, Parkinson’s disease, glaucoma, autism, sickle cell anemia, to mention just a few.

Historically, marijuana has been used for medicinal and ceremonial purposes for centuries. Marijuana was legal in the state of Pennsylvania until the 1930s, when it was proscribed partly due to hysteria caused by the movie titled “Reefer Madness”. The town of Hempfield, Pennsylvania is so named because of its robust hemp production in the early 1900s.

THE STIGMA

Marijuana is not known to have the same psychological and physiological withdrawal signs and symptoms that are associated with other classes such as opiates and benzodiazepines. Yet, marijuana

has become very stigmatized partly due to the psychoactive effects of Delta-9 tetrahydrocannabinol (THC), its illegality under the law, hitherto, societal/communal morality standards, longstanding misunderstanding/disinformation and outright propaganda. The paucity of scientific evidence to support its medicinal uses, a consequence of lack of research funding, has created fear among practitioners, who believe, rightfully so, that prescribing marijuana may have a negative effect on their practice and personal reputation. Because most medical providers’ expectation that prescribing cannabis would attract the scrutiny of regulatory authorities and jeopardize their medical licenses, they tend to avoid such therapies.

THE CONTROVERSY

Because of the stigma described above, the debate about the use of marijuana for medicinal purposes has been muddied and controversial to the extent that the general society does not quite understand its benefits. And, without incontrovertible scientific evidence to support its efficacy, suspicion and discomfort amongst medical professionals appears to have heightened.

Clearly, a conglomeration of factors, coupled with illegality under federal law and the lack of a wider acceptance of the medicinal uses of cannabis, have contributed to the lack of research in the U.S.

Unfortunately, medical school curricula are conspicuously devoid of information on marijuana (alternative therapies, including homeopathy, in general for that matter), again, partly due to its federalized illegality and lack of scientific research foundation. Consequently, doctors who want to introduce this therapy in their practice often lack knowledge in the medicinal uses of cannabis.

THE REALITY

The United States seems to be on the way side, in terms of this therapy. Countries, such as Israel, Australia, Canada and Germany are currently leaders in research about medicinal uses of marijuana. It is believed that Israel is by far in the lead in this area.

Current cumulative research provides ample evidence that cannabis provides effective treatment for many conditions for which current therapies are inadequate. These include some types of cancer, neurological disorders, psychiatric disorders and chronic pain, to mention a few.

The lack of evidence-based information makes it difficult for doctors to confidently “recommend” (not prescribe) precise strain and dosage information to patients. Available information is mostly anecdotal at this time. The recommendation is for individuals to start slowly and titrate upwards as tolerated.

Unfortunately, most large healthcare institutions are not permitting their providers to “prescribe” medical marijuana, partly due to concerns about possible legal actions by the federal government, dearth of evidence-based information and the aforementioned stigmatization of marijuana.

Also, the state of Pennsylvania needs to revisit its policy because the administration of the program seems to be shrouded under unnecessary secrecy. For example, approved physicians are prohibited from advertising their services to certify patients for medical marijuana. Why? The directive states that patients can find approved physicians on the state’s web portal (medicalmarijuana.pa.gov), which

paradoxically lists the physicians’ phone numbers, but not their locations. Why the secrecy? If there was something nefarious about medical marijuana, why approve it in the first place? Authorities must overcome this antiquated mentality of cannabis and adopt more progressive ideas.

The qualities of cannabis and its pluripotent potentials should be advertised, not cloaked in secrecy. Research should be encouraged and funded robustly.

So far, at Toftrees Family Medicine (TFM), we have successfully helped five patients discontinue the use of their addictive prescription medications. That is a good thing – especially in midst of a deadly opioid epidemic. Our goal at TFM is to treat patients’ medical condition(s) and attempt to wean them off their addictive medications and/or at least, reduce their total medication burden. How can taking 20 or 30 or 40 different medications be good for any human being? This is phenomenon is not uncommon. Patients are generally happy with the prospects of being weaned off some of their medications.

The use of cannabis should be guided by evidence-based information (which I admit is currently scant) and not by fear and paranoia. A physician’s choice to participate in the medical marijuana program should be guided by the convictions of his or her conscience, medical ethics and ethos - not by the dictates of corporations he or she may be employed by.

Lastly, I end with these words of caution to patients: find a physician who is willing to think beyond the boundaries of traditional medicine; do your own research and share that knowledge with your physician, so that you make joint decisions regarding your care. Take charge of your healthcare!

THE OPIOID ABUSE EPIDEMIC: Matters Arising - 

A Doctor’s Perspective and Prescriptive Measures

BY

FIDELIS O. EJIANREH, D.O.

Opioid addiction and the recent epidemic spikes have received unprecedented media attention. The images in the media rightfully suggest that communities are heavily decimated by episodic incidents of opioid overdoses. And, unfortunately, data from the Centers for Disease Control and Prevention (CDC) suggests that opioid pain killer overdoses kill more Americans than heroin.

The impetus for this article is a report published in one of our local newspapers titled, “City robbery suspect accused of DUI”. In the article, the writer reported that the state police said the suspect was “high” on Suboxone. While this article is not intended to be a primer on drug addiction, it accentuates the problem with prejudicial precepts about this drug borne largely out of unfamiliarity, and in some quarters, ignorance.

Let’s be clear: one does not get “high” on Suboxone. One cannot overdose on Suboxone because it contains the opiate receptor blocker called Naloxone or Narcan. (Narcan is the drug that paramedics, law enforcement agents and even regular citizens are now allowed to carry, to quickly reverse opiate overdose).

Suboxone is not Methadone! Suboxone is a good and safe drug that has demonstrated unquestionable effectiveness in the treatment of opioid addiction.

It is high time we embraced addiction as a disease - no different from diabetes or hypertension! People afflicted with this disease should be treated with compassion, not contempt; understanding, not scorn; and dignity, not denigration. When society sees addiction as a self-inflicted “condition” (not a disease), and so called “addicts” as “bad people”, and the only “treatment” for them is incarceration, it represents a gross misunderstanding of this disease and makes the task of eradicating or combating it more difficult.

Combating an epidemic requires the involvement of everybody – not just the medical community – because the problem affects everyone directly or indirectly. This involves acquiring a basic understanding of addiction in general and opioid addiction in particular. And, while the eradication of this epidemic requires the combined efforts of the medical community, law enforcement and social services support; stigmatizing it is a disservice to the vulnerably afflicted who need support. Anything short of this tripartite approach is sure to fail.

First, let’s look at the role the medical community can play in this complex solution.

Unfortunately, the stigmatization associated with opioid addiction occasionally brands doctors who wish to help their patients as “pill pushers”. Therefore, many doctors are reluctant to treat addiction.

Other doctors who genuinely want to treat the afflicted may be afraid of being investigated by the regulatory authorities for treating an admittedly poorly understood disease that lacks standardized treatment guidelines as with other chronic diseases like diabetes and cardiovascular disease.

Clearly, despite these apprehensions, doctors should not abdicate their advocacy for their patients. After all, some of the so-called “addicts” may have been addicted by either complying with the prescribed regiment of narcotics and psychotropics by well-intended doctors who want to help resolve their patients’ chronic pain and psychiatric conditions.

So, how can doctors then, in good conscience, fail to admit their complicity in the addiction of these patients, and, worse yet, fail to treat their doctor-induced addiction?

Doctors should not be so intimidated that they fail to uphold the Hippocratic oath and their professional responsibilities to their patients’ well-being and health

Law enforcement certainly has a role to play in the eradication of this epidemic. Clearly, while incarceration is necessary or warranted if criminality is present, recidivism will be greatly reduced if treatment is provided as an associated part of incarceration. If we do not expect patients diagnosed with diabetes or hypertension to be cured without medical attention during incarceration, how then do we expect a different result for those who are opiate-addicted?

Lastly, we must equate the role social services support networks play in wellness and compliance. There is ample research evidence that suggests that social services and support networks are critical in the treatment of addiction.

For example, access to post rehabilitation services, such as drug and alcohol counselling services, availability of jobs, financial support, vocational programs provide necessary structure for sustained abstinence. Alcoholic Anonymous (AA), Narcotics Anonymous (NA) and similar organizations play vital roles, too.

Clearly, eradicating the opioid epidemic requires all vested stakeholders to work together and in tandem with familial and social support networks. Achieving this would also require public enlightenment about addiction, so as to begin discussions that would, hopefully, lead to destigmatized and demystified views about addictions.

In my view, the approach I have articulated here would help afflicted people and those with addictive personalities to seek treatment in a non-judgmental atmosphere and allow more doctors to feel comfortable treating addiction.