May 11, 2021

A doctor's case for medical marijuana | David Casarett

I would like to tell youabout the most embarrassing thing that has ever happened to me in my yearsof working as a palliative care physician.

This happened a couple of years ago.

I was asked as a consultantto see a woman in her 70s — retired English professorwho had pancreatic cancer.

I was asked to see her becauseshe had pain, nausea, vomiting .



When I went to see her, we talked about those symptoms and in the course of that consultation, she asked me whether I thoughtthat medical marijuana might help her.

I thought back to everything that I had learned in medical schoolabout medical marijuana, which didn't take very longbecause I had learned absolutely nothing.

And so I told her that as far as I knew, medical marijuanahad no benefits whatsoever.

And she smiled and nodded and reachedinto the handbag next to the bed, and pulled out a stack of about a dozenrandomized controlled trials showing that medicalmarijuana has benefits for symptoms like nauseaand pain and anxiety.

She handed me those articles and said, “Maybe you should read thesebefore offering an opinion .




” (Laughter) So I did.

That night I read all of those articlesand found a bunch more.

When I came to see her the next morning, I had to admit that it looks likethere is some evidence that marijuana can offer medical benefits and I suggested that if shereally was interested, she should try it.

You know what she said? This 73-year-old, retired English professor? She said, “I did try itabout six months ago.

It was amazing.

I've been using it every day since.

It's the best drug I've discovered.

I don't know why it took me 73 yearsto discover this stuff.

It's amazing.

” (Laughter) That was the moment at which I realized I needed to learn somethingabout medical marijuana because what I was prepared forin medical school bore no relationship to reality.

So I started reading more articles, I started talking to researchers, I started talking to doctors, and most importantly, I started listening to patients.

I ended up writing a bookbased on those conversations, and that book really revolvedaround three surprises — surprises to me, anyway.

One I already alluded to — that there really are some benefitsto medical marijuana.

Those benefits may not beas huge or as stunning as some of the most avid proponentsof medical marijuana would have us believe, but they are real.

Surprise number two: medical marijuana does have some risks.

Those risks may not beas huge and as scary as some of the opponents of medicalmarijuana would have us believe, but they are real risks, nonetheless.

But it was the third surprisethat was most .




And that is that a lotof the patients I talked with who've turned to medicalmarijuana for help, weren't turning to medical marijuanabecause of its benefits or the balance of risks and benefits, or because they thoughtit was a wonder drug, but because it gave themcontrol over their illness.

It let them manage their health in a way that was productive and efficient and effective and comfortable for them.

To show you what I mean, let me tell you about another patient.

Robin was in her early 40s when I met her.

She looked thoughlike she was in her late 60s.

She had suffered from rheumatoid arthritisfor the last 20 years, her hands were gnarled by arthritis, her spine was crooked, she had to relyon a wheelchair to get around.

She looked weak and frail, and I guess physically she probably was, but emotionally, cognitively, psychologically, she was among the toughestpeople I've ever met.

And when I sat down next to her in a medical marijuana dispensaryin Northern California to ask her about why she turnedto medical marijuana, what it did for her and how it helped her, she started out by telling me things that I had heardfrom many patients before.

It helped with her anxiety; it helped with her pain; when her pain was better, she slept better.

And I'd heard all that before.

But then she said somethingthat I'd never heard before, and that is that it gave hercontrol over her life and over her health.

She could use it when she wanted, in the way that she wanted, at the dose and frequencythat worked for her.

And if it didn't work for her, then she could make changes.

Everything was up to her.

The most important thing she said was she didn't needanybody else's permission — not a clinic appointment, not a doctor's prescription, not a pharmacist's order.

It was all up to her.

She was in control.

And if that seems like a little thingfor somebody with chronic illness, it's not — not at all.

When we face a chronic serious illness, whether it's rheumatoid arthritisor lupus or cancer or diabetes, or cirrhosis, we lose control.

And note what I said: “when, ” not “if.

” All of us at some point in our liveswill face a chronic serious illness that causes us to lose control.

We'll see our function decline, some of us will see our cognition decline, we'll be no longer ableto care for ourselves, to do the things that we want to do.

Our bodies will betray us, and in that process, we'll lose control.

And that's scary.

Not just scary — that's frightening, it's terrifying.

When I talk to my patients, my palliative care patients, many of whom are facing illnessesthat will end their lives, they have a lot of be frightened of — pain, nausea, vomiting, constipation, fatigue, their impending mortality.

But what scares themmore than anything else is this possibility that at some point, tomorrow or a month from now, they're going to losecontrol of their health, of their lives, of their healthcare, and they're going to becomedependent on others, and that's terrifying.

So it's no wonder reallythat patients like Robin, who I just told you about, who I met in that clinic, turn to medical marijuana to try to claw backsome semblance of control.

How do they do it though? How do these medicalmarijuana dispensaries — like the one where I met Robin — how do they give patients like Robinback the sort of control that they need? And how do they do it in a way that mainstreammedical hospitals and clinics, at least for Robin, weren't able to? What's their secret? So I decided to find out.

I went to a seedy clinicin Venice Beach in California and got a recommendation that would allow meto be a medical marijuana patient.

I got a letter of recommendationthat would let me buy medical marijuana.

I got that recommendation illegally, because I'm nota resident of California — I should note that.

I should also note, for the record, that I never used that letterof recommendation to make a purchase, and to all of you DEA agents out there — (Laughter) love the work that you're doing, keep it up.

(Laughter) Even though it didn't let memake a purchase though, that letter was pricelessbecause it let me be a patient.

It let me experiencewhat patients like Robin experience when they go to a medicalmarijuana dispensary.

And what I experienced — what they experience every day, hundreds of thousandsof people like Robin — was really amazing.

I walked into the clinic, and from the moment that I enteredmany of these clinics and dispensaries, I felt like that dispensary, that clinic, was there for me.

There were questionsat the outset about who I am, what kind of work I do, what my goals are in lookingfor a medical marijuana prescription, or product, what my goals are, what my preferences are, what my hopes are, how do I think, how do I hopethis might help me, what am I afraid of.

These are the sorts of questions that patients like Robinget asked all the time.

These are the sorts of questionsthat make me confident that the person I'm talking withreally has my best interests at heart and wants to get to know me.

The second thing I learnedin those clinics is the availability of education.

Education from the folksbehind the counter, but also educationfrom folks in the waiting room.

People I met were more than happy, as I was sitting next to them — people like Robin — to tell me about who they are, why they use medical marijuana, what helps them, how it helps them, and to give me advice and suggestions.

Those waiting rooms really area hive of interaction, advice and support.

And third, the folks behind the counter.

I was amazed at how willingthose people were to spend sometimes an hour or moretalking me through the nuances of this strain versus that strain, smoking versus vaporizing, edibles versus tinctures — all, remember, without memaking any purchase whatsoever.

Think about the last timeyou went to any hospital or clinic and the last time anybody spent an hourexplaining those sorts of things to you.

The fact that patients like Robinare going to these clinics, are going to these dispensaries and getting that sortof personalized attention and education and service, really should be a wake-up callto the healthcare system.

People like Robin are turning awayfrom mainstream medicine, turning to medical marijuana dispensaries because those dispensariesare giving them what they need.

If that's a wake-up callto the medical establishment, it's a wake-up call that manyof my colleagues are either not hearing or not wanting to hear.

When I talk to my colleagues, physicians in particular, about medical marijuana, they say, “Oh, we need more evidence.

We need more research into benefits, we need more evidence about risks.

” And you know what? They're right.

They're absolutely right.

We do need much more evidenceabout the benefits of medical marijuana.

We also need to ask the federal governmentto reschedule marijuana to Schedule II, or to deschedule it entirelyto make that research possible.

We also need more researchinto medical marijuana's risks.

Medical marijuana's risks — we know a lot aboutthe risks of recreational use, we know next to nothingabout the risks of medical marijuana.

So we absolutely do need research, but to say that we need research and not that we needto make any changes now is to miss the point entirely.

People like Robinaren't seeking out medical marijuana because they think it's a wonder drug, or because they thinkit's entirely risk-free.

They seek it out because the contextin which it's delivered and administered and used, gives them the sort of controlthey need over their lives.

And that's a wake-up callwe really need to pay attention to.

The good news though is thatthere are lessons we can learn today from those medical marijuana dispensaries.

And those are lessonswe really should learn.

These are often small, mom-and-pop operations run by people with no medical training.

And while it's embarrassing to think that many of these clinicsand dispensaries are providing services and support and meeting patients' needs in ways that billion-dollarhealthcare systems aren't — we should be embarrassed by that — but we can also learn from that.

And there are probablythree lessons at least that we can learnfrom those small dispensaries.

One: we need to find waysto give patients more control in small but important ways.

How to interact with healthcare providers, when to interactwith healthcare providers, how to use medicationsin ways that work for them.

In my own practice, I've gotten much morecreative and flexible in supporting my patientsin using drugs safely to manage their symptoms — with the emphasis on safely.

Many of the drugs I prescribeare drugs like opioids or benzodiazepines which can be dangerous if overused.

But here's the point.

They can be dangerous if they're overused, but they can also be ineffectiveif they're not used in a way that's consistent withwhat patients want and need.

So that flexibility, if it's delivered safely, can be extraordinarily valuablefor patients and their families.

That's number one.

Number two: education.

Huge opportunities to learn from some of the tricksof those medical marijuana dispensaries to provide more education that doesn't requirea lot of physician time necessarily, or any physician time, but opportunities to learnabout what medications we're using and why, prognoses, trajectories of illness, and most importantly, opportunities for patientsto learn from each other.

How can we replicate what goes on in those clinic and medicaldispensary waiting rooms? How patients learn from each other, how people share with each other.

And last but not least, putting patients first the waythose medical marijuana dispensaries do, making patients feellegitimately like what they want, what they need, is why, as healthcare providers, we're here.

Asking patients about their hopes, their fears, their goals and preferences.

As a palliative care provider, I ask all my patients what they'rehoping for and what they're afraid of.

But here's the thing.

Patients shouldn't have to waituntil they're chronically seriously ill, often near the end of life, they shouldn't have to waituntil they're seeing a physician like me before somebody asks them, “What are you hoping for?” “What are you afraid of?” That should be baked into the waythat healthcare is delivered.

We can do this — we really can.

Medical marijuana dispensariesand clinics all across the country are figuring this out.

They're figuring this out in ways that larger, more mainstreamhealth systems are years behind.

But we can learn from them, and we have to learn from them.

All we have to do is swallow our pride — put aside the thought for a minute that because we havelots of letters after our name, because we're experts, because we're chief medical officersof a large healthcare system, we know all there is to knowabout how to meet patients' needs.

We need to swallow our pride.

We need to go visita few medical marijuana dispensaries.

We need to figure out what they're doing.

We need to figure outwhy so many patients like Robin are leaving our mainstream medical clinics and going to these medicalmarijuana dispensaries instead.

We need to figure outwhat their tricks are, what their tools are, and we need to learn from them.

If we do, and I think we can, and I absolutely think we have to, we can guarantee all of our patientswill have a much better experience.

Thank you.


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