Pubdate: Tue, 28 Jul 2015
Source: New York Times (NY)
Copyright: 2015 The New York Times Company
Contact: http://www.nytimes.com/ref/membercenter/help/lettertoeditor.html
Website: http://www.nytimes.com/
Details: http://www.mapinc.org/media/298
Author: David Casarett
Note: David Casarett is the director of hospice and palliative care 
at Penn Medicine and the author of "Stoned: A Doctor's Case for 
Medical Marijuana."

THE WEED DISPENSARY'S LESSONS FOR DOCTORS

THE first time you meet Robin, it's easy to be misled by her fragile 
appearance. She's in her 40s and painfully thin, and she grips her 
aluminum walker with hands that have been twisted by rheumatoid 
arthritis. But she's both tough and resourceful, and she doesn't give 
up easily.

I met Robin and many others like her at a California medical 
marijuana clinic where I was doing research for a book. She was one 
of almost a dozen patients seeking recommendation letters that would 
let them buy marijuana at designated dispensaries.

I asked how marijuana helped her.

"I can't live without it," she told me.

She said it helped her sleep, and it relieved the constant pain in 
her joints. But Robin was most eager to talk about how medical 
marijuana put her in charge. She can decide whether to use it, when 
to use it and how much she needs. She doesn't have to rely on a doctor.

"I'm in control," she said.

That simple declaration might be a rallying cry for proponents of 
medical marijuana, which is legal in 23 states and the District of 
Columbia. By some estimates, at least one million people in the 
United States are registered medical marijuana users. There are 
likely to be many more who obtain it without registering, and still 
more who obtain marijuana illegally.

In the past year I've talked to dozens of these patients in states 
where medical marijuana is legal, as well as in Colorado, Washington 
and Oregon, which allow recreational use. Many people with serious 
illnesses turn to medical marijuana because they're not getting the 
careful, comprehensive treatment they need for symptoms like pain or 
nausea or anxiety. That was certainly true for Robin, whose 
physicians didn't seem to have the time or the skills to help her.

As a palliative care physician, every day I see firsthand the 
suffering my patients have experienced, and the lengths to which 
they've gone to manage their symptoms and control their lives. They 
stockpile medications in case their pain increases. And some buy 
illegal drugs on the street because their physicians won't prescribe 
opioids. So is it any wonder that people like Robin with serious 
illnesses want to take matters into their own hands?

Yet it seems that many of my physician colleagues haven't considered 
the possibility that patients are turning to medical marijuana 
because the health care system has failed them. In general, their 
reaction to medical marijuana has been one of detached amusement, 
tinged with avuncular concern. And when they recognize the challenges 
that patients like Robin face, they point out that they don't have 
enough time in a typical 15-minute visit to deliver the kind of 
personalized care that Robin needed.

Fortunately, Robin's story offers solutions. I've identified at least 
three lessons the medical marijuana industry holds for our health 
care system. And none of them require doctors to spend any more time 
with patients.

First, we should give patients a chance to learn from one another. In 
marijuana clinics and dispensaries, I've seen as much advice and 
support offered by patients as I have by physicians. That's the 
beauty and attraction of websites like PatientsLikeMe, which has 
created communities of patients who support one another. Who better 
to offer advice about how to get your prescriptions filled on the 
weekends, or how to swallow those large pills, than someone who has 
already figured it out?

Second, if physicians can't spend more time with patients - and, in 
general, they can't - we should give patients more time with other 
office staff members. Robin didn't spend any more time with a doctor 
in that clinic than my patients spend with me. But she spent much 
more time with the marijuana clinic employees, none of whom had any 
formal medical training. They gave detailed answers to her questions 
about various marijuana strains, the unpredictable absorption of 
cannabinoids in edibles and even how to clean and maintain her 
vaporizer. That advice took time, but none of it required an extra 
minute with a physician.

Third, we should give patients more ability to manage their 
treatment. What Robin wanted was a chance to treat her symptoms in 
her own way, using strategies that worked for her. She wanted to try, 
and maybe fail, and try again. She wanted to be in charge.

Giving patients more control doesn't mean handing over a blank 
prescription pad. Patients can gain more control - safely - if they 
understand a drug's effects and duration, and if they have some 
leeway in when and how to use it. For instance, when I prescribe 
as-needed pain medication, I'll give my patients permission to figure 
out for themselves how much to take and when.

These suggestions aren't difficult, or expensive. Nor are they only 
for patients like Robin, or for physicians like me who care for 
seriously ill patients near the end of life. They're changes that any 
clinic could start making today. The medical marijuana industry has 
learned these lessons well, and our more mainstream health care 
system needs to catch up.
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MAP posted-by: Jay Bergstrom