Pubdate: Sat, 17 Dec 2011
Source: Seattle Times (WA)
Copyright: 2011 Los Angeles Times
Contact:  http://seattletimes.nwsource.com/
Details: http://www.mapinc.org/media/409
Author: Anna Gorman

MEDICAL MARIJUANA ADDS CRIMP TO LIVER TRANSPLANT ELIGIBILITY

A new twist in a long-running debate within the transplant community: 
Should people whose use of drugs or alcohol may have contributed to 
liver problems be candidates for transplants? And if so, how long 
should they be clean before becoming eligible for a new organ?

LOS ANGELES - Norman Smith, who has liver cancer, was placed on the 
transplant list at Cedars-Sinai Medical Center last year.

But early this year, doctors removed him because he was using medical 
marijuana and failed to show up for a drug test.

To get back on the list, Smith, 63, has to spend six months avoiding 
medical marijuana, submitting to random drug tests and receiving 
counseling. He is still undergoing chemotherapy and radiation for the 
cancer, which recently returned after being in remission. Smith has 
asked Cedars-Sinai to reconsider and reinstate him.

"It's frustrating," he said from his home in Playa del Rey. "I have 
inoperable cancer. If I don't get a transplant, the candle's lit and 
it's a short fuse."

Smith's case highlights a twist in a long-running debate within the 
transplant community: Should people whose use of drugs or alcohol may 
have contributed to liver problems be candidates for transplants? And 
if so, how long should they be clean before becoming eligible for a new organ?

With the ubiquitous presence of medical marijuana, doctors say 
patients like Smith who have prescriptions increasingly are showing 
up at transplant centers seeking new livers. Statistics on such 
requests aren't available, but experts agree the prescription 
medical-marijuana cases are forcing doctors to revisit medical and 
ethical questions surrounding drug use and transplantation.

There is no standard on transplants regarding the use of medical 
marijuana or other drugs, according to the United Network for Organ 
Sharing, which manages organ transplantation for the U.S.

Instead, transplant centers make their own decisions on which 
patients are the best candidates for new organs, meaning policies 
vary from center to center.

'Social' or 'medical'?

Livers are highly sought-after organs. More than 16,000 people are in 
line for livers nationwide and the average wait is about 300 days, 
according to the network.

"We have to do a prioritization, like you literally do on a 
battlefield - who can die and who can survive, because we don't have 
enough livers," said Dr. Goran Klintmalm, chief of the Baylor 
Regional Transplant Institute and an expert in liver transplantation. 
"As long as we have patients who die on the list waiting for organs 
. is it right to give (to) patients who have a history of drug use? 
You can discuss until the cows come home if it is social marijuana or 
medical marijuana."

Transplant doctors said one of the main concerns is compliance with a 
complicated regimen of post-transplant medications.

"If you are drunk or high or stoned, you are not going to take your 
medicine," said Dr. Jeffrey Crippin, former president of the American 
Society of Transplantation and medical director at Washington 
University in St. Louis.

Cedars-Sinai spokeswoman Sally Stewart said federal law prevented her 
from talking about Smith's case.

"Our concern is strictly for the health and safety of our patients," she said.

Prescriptions suspect

At Cedars-Sinai, if patients who need a transplant initially test 
positive for marijuana, they can still be listed but must sign a 
statement agreeing not to use the drug. Then, if they fail a random 
drug test or don't show up for one, they are bumped from the list.

"There have to be guidelines in order to give people the best chance 
at surviving a transplant," Stewart said.

UCLA Transplantation Services has an even stricter policy, requiring 
six months of sobriety before a patient can be listed. Dr. Douglas 
Farmer, a transplant surgeon and surgery professor at UCLA, said that 
drug and alcohol use is a "huge issue" and that patients on medical 
marijuana have also come to UCLA seeking transplants.

Farmer said, however, that many patients with medical-marijuana 
prescriptions are not "legitimate," and transplant surgeons can't 
risk wasting a precious organ on someone who is going to continue 
abusing alcohol or drugs. "There are a significant number of people 
who come in for liver transplants who have a substance-abuse history," he said.

Any delay in getting Smith a new liver could mean the "difference 
between life and death," said Joe Elford, an attorney with the 
medical marijuana advocacy group Americans for Safe Access, which is 
representing Smith and considering a lawsuit against the hospital.

Smith's oncologist, Dr. Steven Miles, an attending physician at 
Cedars, refilled the prescription for medical marijuana to manage his 
patient's pain. Miles, who is in private practice, agreed that by 
missing his drug test Smith raised concern about his patient's 
post-transplant compliance with medical instructions.

Nevertheless, Miles said his patient will die without a new liver. 
"Without a transplant, it is basically 100 percent fatal," he said. 
"It's just a matter of time."

Smith, a former precious-metal trader, acknowledged that he didn't 
follow the rules. He said he used medical marijuana after having 
unrelated back surgery and weaning himself from prescription pain 
pills. "I was in extreme pain and physical anguish," he said.

In April, he wrote a letter to the head of the liver transplant 
program at Cedars, Steven Colquhoun, asking to be re-listed.

Smith, a recovered alcoholic, said he used marijuana recreationally 
in the past before getting a prescription for medical marijuana. He 
also has cirrhosis of the liver and previously had hepatitis C. Smith 
said he stopped using marijuana in August and is attending Alcoholics 
Anonymous meetings to satisfy his counseling requirement.

Smith is hopeful that he will get a transplant in time and that his 
fight will raise awareness for others with medical-marijuana 
prescriptions. "That's why I am going through this challenge, at the 
very least to make it easier for the next guy," he said.
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MAP posted-by: Jay Bergstrom