November 10, 2003
Medscape Neurology & Neurosurgery 5(2), 2003
October's Supreme Court decision not to reconsider an appellate court ruling on medical marijuana is a small step in the direction of improving society's attitude about the necessity of moving outside the box when it comes to pain relief. The underpinnings of the lawsuit began about 30 years ago with the Controlled Substances Act of 1970. This legislation placed all drugs, including illicit drugs, into the now familiar 5 "schedules" or categories, based on factors including safety, potential for addiction, and availability. Marijuana was categorized as a "Schedule I" drug -- among other substances with a high potential for abuse and no accepted medicinal use in the United States -- simply illegal. (It's useful to note that up until 1937, a healthy number of legal medications contained marijuana, but by 1970, those medicinal uses were all but forgotten.) Since then, efforts to make marijuana available by prescription as a Schedule II drug have met with intense resistance from and litigation by and against the Drug Enforcement Administration (DEA).
Citizens in 9 states have voted to remove state-level criminal penalties for seriously ill people who possess or grow marijuana. However, as a federal institution, the DEA apparently can override the states and assign its own criminal penalties for possession and use of marijuana. In California, the DEA went a step further, seeking to penalize docs who advised patients about the potential medical benefits of smoking pot, under the provisions of the state's compassionate-use statute. Thus, doctors who mentioned marijuana as a potential strategy to relieve pain and nausea or stimulate the appetite were threatened with losing their federal drug licenses. The US Court of Appeals for the Ninth Circuit upheld the doctors' right to discuss marijuana with their patients. And the Supreme Court declined to hear the DEA appeal, essentially endorsing the state's right to oversee this issue.
Why smoke marijuana when there are so many other options for patients with severe pain, including an FDA-approved drug (dronabinol) that contains the chemical equivalent of the active ingredient in the marijuana plant? Well, since you ask, sometimes the marijuana plant works better and faster. Advocates say that twice as much of the chemical is absorbed twice as fast when the plant is smoked, compared with swallowing the pill. Sometimes patients who need it can't keep a pill down -- they can't really abide the idea of swallowing anything. Furthermore, the drug comes with side effects and potential drug interactions that some patients can't tolerate.
This issue is not only about marijuana and it's not only about a small number of people with AIDS- and cancer-related pain. It's also about elders with arthritis, people with the painful spasticity of multiple sclerosis, paraplegics, and diabetics with neuropathies, among others. And it's about the demonization of those who need unconventional strategies in sometimes unconventional doses and combinations, and the criminalization of physicians who want to help them achieve relief and comfort with those strategies.
In a call-in radio show a few days after Rush Limbaugh announced that he is addicted to oxycontin, pain management specialists and numerous callers noted that some patients with chronic pain require huge amounts of pain medications. They aren't addicted to the drugs; they have severe pain that requires bigger-than-average relief. Yet only the experts in pain management seem to know that this isn't addiction. To the world at large, including many of the physicians doing the prescribing, if you need more drugs than they prescribe, this kind of drug-seeking behavior means you must be addicted. And those who do prescribe higher doses or more frequent dosing fear that they themselves will be investigated and lose their licenses, or worse.
Maybe Limbaugh wasn't receiving the appropriate regimen for his pain, or his prescription didn't allow him to take it as often as he needed. Maybe he was embarrassed to ask for more medication, given his and others' very public statements about addiction, etc, so he resorted to getting his oxycontin by going around the system. Maybe he believed that was his only option. Now, I'm no fan of Rush Limbaugh, and I'm not in favor of decriminalizing substance abuse across the board. I am in favor of those with pain receiving relief without being made to feel like they're bad or weak when they need more than they're offered to become pain-free.
This current climate of fear ends up helping no one. Physicians and
policymakers should reevaluate both regulations and prescribing practices
so that patients experiencing acute or chronic pain get the relief they
Copyright © 2003, Medscape