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Onward,
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Weekend
Edition
November 4 / 5, 2006
Dr. Mikuriya's Observations
10
Years of Legalized Medical Marijuana in California
By FRED GARDNER
Tod Mikuriya, MD (Berkeley), was the
first California doctor to monitor patients' use of cannabis
systematically. In the early 1990s his interviews with members
of the San Francisco Cannabis Buyers Club documented Dennis Peron's
observation that people were self-medicating for an extremely
wide range of problems.
The broad range of applications
confirmed what Mikuriya had learned from his study of the pre-prohibition
medical literature on cannabis, and so when Prop 215 was being
drafted, he urged that it apply not only to people with a list
of named conditions, but to those treating " ... any other
illness for which marijuana provides relief."
No sooner had Prop 215 passed
than top California law enforcement agents colluded with Clinton
Administration officials and Prohibitionist strategists from
the private sector to plan its disimplementation. On Dec. 30,
1996, Drug Czar Barry McCaffrey, Attorney General Janet Reno,
Health & Human Services Secretary Donna Shalala, and the
director of the National Institute of Drug Abuse, Alan Leshner,
held a press conference to threaten California doctors with loss
of their licenses, i.e., their livelihoods, if they approved
marijuana use by their patients. McCaffrey stood alongside a
large chart headed "Dr. Tod Mikuriya's, (215 Medical Advisor)
Medical Uses of Marijuana." Twenty-six conditions were
listed in two columns. ("Migranes" was misspelled.)
"This isn't medicine, this is a Cheech and Chong show,"
he said. Reno said prosecutors would focus on doctors who were
"egregious" in approving marijuana use by patients.
Dr. Mikuriya watched the press
conference on CNN at his home in the Berkeley Hills. "As
doctors become more fearful," he says. "I'll obviously
get more and more patients who are using cannabis or are considering
it. Will that make it seem that there's something 'egregious'
about my practice? You bet it will!"
>From the Attorney General's
office in Sacramento a memo went out from Senior Deputy AG John
Gordnier to district attorneys in all 58 counties asking them
to forward any cases involving Mikuriya. In due course, on the
basis of complaints from sheriffs, cops, and DAs, Mikuriya was
investigated by the medical board and found to have committed
"extreme departures from standard practice." He was
placed on probation and ordered to pay $75,000 for his own prosecution.
Over the years the number of
cannabis specialists among California doctors has risen slowly
but steadily. In 2000 Mikuriya organized a group, now known as
the Society of Cannabis Clinicians, to share data for research
purposes. More than 20 doctors have become involved with the
SCC. Collectively they have approved cannabis use by an estimated
350,000 patients. This summer, with the 10th anniversary of Prop
215's passage approaching, I surveyed the SCC doctors get their
basic findings. Here are Dr. Mikuriya's responses to the survey
he inspired.
Results reported are dependent
on the conditions and symptoms being treated. The primary benefit
is control without toxicity for chronic pain and a wide array
of chronic conditions. Control represents freedom from fear and
oppression. Control -or lack thereof- is a major element in self-esteem.
With exertion of control, with
freedom from fear of incapacity, quality of life is improved.
The ability to abort an incapacitating attack of migraine, asthma,
anxiety, or depression empowers.
Relief from the burden of criminality
through medical protection enhances a salutary self-perception.
Alteration in the perception
of and reaction to pain and muscle spasticity is a unique property
of cannabis therapy.
Patient reports are diverse
yet contain common elements. 100% report that cannabis is safe
and effective. Return for follow-up and renewal of recommendation
and approval confirms safety and efficacy.
Cannabis seems to work by promoting
homeostasis in various systems of the body. Its salient effects
are multiple and concurrent. They include- o Restoration of normal
functioning of the gastrointestinal tract with normalization
of peristalsis and restoration of appetite. o Normalizing circadian
rhythm, which relieves insomnia. Sleep is therapeutic in itself
and synergistically helps with pain control. o Easement of pain,
depression, and anxiety. Cannabis as an anxiolytic and antidepressant
modulates emotional reactivity and is especially useful in treating
post-traumatic stress disorders.
Patients treated for ADHD:
92 Patients using cannabis as a substitute for alcohol: 683.
The slow poisoning by alcohol with its sickening effects on
the body, psyche, and family can be relieved by cannabis.
Medications no longer needed?
Opioids, sedatives, NSAIDS (non-steroidal anti-inflammatories),
and SSRI anti-depressants are commonly used in smaller amounts
or discontinued. These are all drugs with serious adverse effects.
Opioids and sedatives produce depression, demotivation, and diminished
mobility. Weight gain and diminished functionality are common
effects. Cognitive and emotional impairment and depression are
comorbid conditions. Opioids adversely effect vegetative functioning
with constipation, dyspepsia, and gastric irritation. Pruritus
is also an issue for some. Circadian rhythms are disrupted with
sleep disorders and chronic sedation caused by these agents.
Dependence and withdrawal symptoms are more serious than with
sedatives.
Opioids are undoubtedly the
analgesic of choice in treating acute pain. For chronic pain,
however, I recommend the protocol proposed by a doctor named
Fronmueller2 to the Ohio Medical Society in 1859: primary use
of cannabis, resorting to opiates for episodic worsening of the
condition. Efficacy is maximized, tolerance and adverse effects
are minimized. (Neither cannabis nor human physiology has changed
since 1859.)
NSAIDs can be particularly
insidious for those who do not immediately react with gastric
irritation and discontinue the drug. Chronic irritation with
bleeding may produce serious morbidity. Most often, the dyspepsia
produced is suppressed with antacids or other medications. Many
patients tolerate acute intermittent use but not chronic use.
SSRIs, if tolerated, coexist without adverse interaction with
cannabis. Some SSRI users say cannabis is synergistic in that
it treats side effects of jitteriness or gastrointestinal problems.
Many patients report pressure
exerted by the Veterans Administration, HMOs such as Kaiser Permanente,
and workers' compensation program contractors to remain on pharmaceutical
regimens. A significant number describe their prescribed drugs
as ineffectual and having undesirable effects. "Mainstream"
doctors frequently respond to reports of adverse effects by prescribing
additional drugs. Instead of negating the problem, they often
complicate it. Prevailing practice standards encourage polypharmacy
-the use of multiple drugs, usually five or more.
Out of the ordinary conditions?
While all pain reflects localized immunologic activity secondary
to trauma or injury, the following atraumatic autoimmune disorders
comprise a group of interest: Crohn's disease Atrophie blanche,
Melorheostosis, Porphyria, Thallasemia, Sickle cell anemia,
Amyloidosis Mastocytosis, Lupus, Scleroderma, Eosinophilia myalgia
syndrome. These are all clearly of autoimmune etiology, difficult
to treat. Specific metabolic errors such as amyloidosis and certain
anemias warrant further study and may elucidate the underlying
mechanisms of the illnesses and the therapeutic effects of cannabis.
Multiple sclerosis with its range of severity varies in therapeutic
response to cannabis.
Demographics: male patients,
72; female, 28%. Women are more likely than men to use cannabis
for psychotherapeutic purposes (32% to 18%). Men are more likely
to use for harm reduction (4% to 1%). A roughly bell-shaped curve
describes the age of my patients. 0-18 years, 1%; 19-30, 19%;
31-45, 36%; 45-60, 37%; older than 61, 7%.
Additional Observations:
Proactive structuralism works.
Meaning: people can create something and by doing so, set a precedent.
Medical cannabis users are
typically treating chronic illnesses -not rapidly debilitating
acute illnesses.
The cash economy works better
than the bureaucratic alternative. Word of mouth builds a movement.
The private sector is handling
marijuana distribution because the government has defaulted.
Cannabis was once on the market
and regulated, then it was removed from the market and nearly
forgotten.
Not all that we've learned
in the past 10 years is new.
Once upon a time the California
Compassionate Use Act of 1996 became the law of the state. We
had the mistaken belief that civil servants, sworn to uphold
the law, would set about implementing the new section of the
Health & Safety Code. Hardly... Twenty California doctors
have been investigated by the Medical Board for approving cannabis
use by their patients. Limited immunity from prosecution for
physicians was either proclaimed invalid or, more commonly, evaded
by the Board and the Attorney General. They dissimulate, pretending
that it is not the physician's approval of marijuana at issue,
but his or her standard of practice. They then hold cannabis
consultants to a standard that most HMO doctors violate constantly.
The fix is in. The state criminal
justice entities share information and operate in concert with
the DEA. There has been a total end run around the injunctive
protection of the Conant ruling. [In Conant, a federal court
enjoined the government from threatening doctors who discuss
cannabis as a treatment option with patients.] General media
indifference enables this RICO under color of authority and the
continuing defiance of the will of Californians who spoke ten
years ago.
This is counterbalanced by
the rewards of helping patients with serious chronic aliments
who have adverse experience utilizing so-called main stream medicines.
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