Time and Money Ill-spent on Medical Marijuana

This blog post can also be viewed where it was first published in the Denver Post on April 8, 2012: http://www.denverpost.com/opinion/ci_20335024/guest-commentary-time-money-and-medical-marijuana

I know of no one who is neutral on the issue of medical marijuana. Some claim that it is a myth. They do not believe there is anything medicinal about the use of marijuana, or if there is, it is nothing that can't be replicated by pills or shots, which are much safer and much less damaging to society. 

People may feel better, because they get intoxicated, or "high," but it does nothing positive for their medical conditions. In fact, smoking marijuana causes harm to the lungs and may lead to lung cancer. How can that be medicinal? This is the official position of the U.S. Government. In July, 2011, the U. S. Drug Enforcement Agency denied a petition to reclassify marijuana from a Schedule I controlled substance (like heroin) to a lesser schedule. In their response they stated, "Marijuana has no currently accepted medical use in treatment in the United States."

Others claim marijuana is a magic potion that is being withheld from patients who are in severe pain and distress. Not only does it combat the pain, nausea and vomiting, poor appetite, intraocular pressure, muscle spasms and seizures of those conditions for which it has been "approved" in the Colorado Constitution, it also helps those with asthma, atherosclerosis, bipolar disease, Crohn's disease, diabetes, anxiety, hepatitis, hypertension, opiod dependence, arthritis, depression, Tourette's syndrome and post-traumatic stress disorder.

They believe it is a travesty of justice that an influential but small-minded group of puritanical government officials can keep it from those who are suffering with these debilitating conditions.

I believe that medical marijuana is at best a misalliance, and at worst is an oxymoronic name used in the manipulation of voters by the political, economic and social proponents of the legalization of marijuana. By playing on the humane sympathies of the Colorado electorate for those who are obviously debilitated by their conditions, and by claiming a medical benefit that is questionable at best, the proponents were able to weave together a constitutional amendment that aligns marijuana and medicine in a relationship that is truly a shotgun wedding. 

Nothing about the way marijuana has been studied, produced, distributed or used in any way resembles the normal pathway of an approved medication. Research on the medical benefits of marijuana is scarce, and reported studies usually include questionable methods and small populations; there is no standardization of dosage or regulation of "prescribed" amount; the "medication" is not obtained at a pharmacy with a licensed health care provider's prescription, but is grown at home or "handed out" at a dispensary to those whose names have been registered based on a physician's certification that they have a qualifying debilitating condition; and instead of taking a prescribed dosage at a prescribed periodicity, the users self-medicate to their own level of symptom relief on their own time schedule.

I believe that the time, money, and emotions that have been spent trying to wedge marijuana into a medical model have been ill-spent. There are already FDA-approved medications available that are chemically identical to the active ingredient in marijuana that have gone through the approved medical pathway to legitimacy. For numerous reasons, though, (time to response, level of response, inability to control level of response, etc.) most qualifying "patients" prefer smoking the plant to taking the medication. 

But smoking the plant, even for the relief of symptoms, falls outside of most physicians' acceptable range of appropriate medical modalities. No respectable doctor would encourage patients to start smoking cigarettes, even though there are some scientifically proven benefits, (very few, and not worth the risk), and most doctors in Colorado are reticent to encourage patients to start smoking marijuana. There's something about that "first, do no harm" mantra that seems to get wired into our DNA somewhere in our years of training.

There are clearly some individuals who deserve and get comfort from smoking marijuana. For the most part, they are those who are described in the constitutional amendment we approved in 2000. They are so severely debilitated that they require a caregiver for most of their daily needs, and they have found no relief in the available treatments or prescription medications. Most of them have diagnoses that can be objectively validated. If asked on a ballot to once again approve the use of marijuana for the relief of their symptoms, I would be sorely tempted to vote "yes." 

But the roller coaster ride on which we as a state have been, mostly for the past four years, with zealots on both sides of the issue doing their best to manipulate the legal and medical systems in their favor, and the fact that currently 94 percent of the registered medical marijuana users have been certified with only the diagnosis of "severe pain," the one qualifying condition that cannot be objectively validated, has finally made me nauseated. 

It is time for decisions about the use and legalization of marijuana to once again be made by the whole community, based on the political, economic and societal arguments for and against it, instead of continuing to hide the issue behind the white coats of medicine.

What do I do for a living? I fight Poop!

I have felt Clark Kent’s pain.
When my children were young, they and their playmates would often ask me what I did at work all day. Each time I answered, I would feel a twinge of guilt and pain as I hid my true identity from them. “I go to meetings,” I would say. Better for them to think I was a mild-mannered, somewhat cowardly bureaucrat than for them to know the terrible truth.

I fight poop.

As hard as it may be to believe in this scientific day and age, we are surrounded by poop and poop-wielding fiends and foods. There is chicken poop on egg shells and in cookie dough; cow poop in ground beef and on lettuce, broccoli and alfalfa sprouts; and sometimes, there is even human poop in our hamburgers, salads or water. My job, when I’m not in meetings, is to find and destroy that poop before it is eaten or drunk by our citizens, and for sure before it reaches me.

Superman had Lex Luthor and General Zod. I, too, have enemies. Some of my enemies dump their sewage directly into our streams and rivers. Some build their septic tanks with inferior materials, or site them too close to wells or springs. Some forget to wash their hands after pooping, or don’t believe they need to take the time to wash them thoroughly. Little do they realize that they are the most likely victims of their own crimes.

Like Superman, I, too, have special powers (granted by the Colorado Legislature, the Jefferson County Board of Commissioners and the Jefferson County Board of Health). I can require builders and homeowners to use approved materials when building and repairing onsite wastewater (septic) treatment systems (OWTS). I can require well-drillers and landowners to keep their wells and their septic systems far away from each other, and I can require that these systems be inspected as to their installation and operational status before being transferred to a new homeowner. And I have a legion of inspectors (two) on my team who make sure these requirements are being followed.

I also have an army of restaurant inspectors (six) working with me who make sure that the almost 2,000 food establishment owners in Jefferson County are keeping their employees under surveillance to guarantee that they are washing their hands with hot soapy water before handling food and after using the rest room; that they are keeping raw meat, poultry, seafood and their juices away from ready-to-eat foods; and that they are heating and freezing potential poop-carrying foods by cooking them at the proper temperatures and refrigerating foods promptly at adequately low temperatures.

But my greatest weapon is education.

As you can see from the size of my army of inspectors, there is no way that I can guarantee that all septic systems are sited and built correctly, or that all food establishments are on guard every minute of every day watching out for the poop-carrying employee who forget to wash his or her hands. So we spend a great deal of time educating builders, well-drillers, homeowners, school children, food establishment managers and food handlers about the dangers of poop, the devious ways it sneaks onto our hands and into our guts, and the steps that must be taken to defeat it before it spreads. We also teach about and recommend immunizations, like the hepatitis A vaccine, so that the poop that might sneak through our defenses is less dangerous to us.

However, just like Superman, my special powers are not limitless. Poop is my kryptonite. I can’t get into every kitchen and rest room in the county to make sure our recommendations are being followed and that poop is being destroyed before it gets loose. I can’t make the general public or food-handlers get immunized against hepatitis A. I can’t inspect the food that is coming into the county to make sure it has been properly grown and cleaned. And I can’t make you wash your hands.
The life of a super-hero can be very lonely and discouraging (I’ll bet), and every time I think about the challenges and obstacles that are out there fighting back against our efforts to keep the citizens of and visitors to Jefferson County from getting sick I find myself using the worst swear word known to public health professionals –   “Poop!”

Life as a Meerkat - By Mark B. Johnson, MD, MPH

When I was in college I had the good fortune of living in Tanzania, East Africa, for a year. While there, I was occasionally asked to “guide” visitors through some of the world-famous national parks and game reserves in that area, including Serengeti, Lake Manyara, Amboseli (actually in Kenya) and the Ngorongoro Crater. Having the opportunity to observe the many varieties and species of animals in their natural habitat was an experience I will always treasure!
Serengeti National Park is famous for its vast plains covered with herds of migrating grassland antelopes, including wildebeests (gnus), hartebeests and various gazelle species. Several times while observing these animals we saw lions attack and kill one or two of the young or straggling members of the herds. What fascinated me at the time was how other antelope would watch curiously from a fairly close distance or nonchalantly graze near the kill site while the lions finished off their recently deceased colleagues. They seemed to sense that in this game of chance they were now safe.
I was reminded of this later when I lived in Los Angeles. The daily commute to work on the L.A. freeway system was also a community game of chance. We would all drive as fast as we could, sensing that sooner or later someone would get into a crash and we’d all have to stop and probably be late to our appointments. Then we’d curiously crawl empathetically around the crash site and speed off again on our important business, thankful, for the moment that we were safe.
With a highly probable impending disaster, no individual antelope or Angelino ever seemed to feel that they were going to be the next victim. There was no need to change behavior. After all, what are the odds of getting killed when there are thousands of other wildebeests around or 10 million other crazy drivers on the freeway?
It seems that we’ve built risk denial into many of our cultural rituals and even base public policy on it. For example, we know that there are individuals among us who cannot tolerate the use of alcohol, but we bet that it won’t be us or one of our family members, and therefore we joke about how much college students drink, glorify the use and abuse of alcohol on television and in the movies, and set policies around its sale and distribution that we know won’t really keep it away from the kids. Similar arguments could be made for such things as cigarettes, handguns, marijuana use, unprotected sexual activity and the use of bicycle or motorcycle helmets. We curiously, and perhaps empathetically, watch as the young or the stragglers are destroyed, but quickly speed off again on our important business as soon as we can.
But there are animals on the African savannah that live differently, meerkats. Everybody loves meerkats. They are cute, cuddly-looking and very friendly, sociable animals. They’ve starred in at least two of their own movies (Meerkat Madness (2001) and The Meerkats (2008)), and have had their own television series on the Animal Planet network (Meerkat Manor and Meerkat Manor: the Next Generation (2005 – 2008)). Timon, one of the heroes in Walt Disney’s The Lion King movies, is a meerkat.
One of the most distinctive characteristics of meerkats, however, is their custom of assigning sentinels for their colonies. While the other meerkats are busy playing, exploring, hunting and gathering around the colony’s den, one or more of the adult meerkats stand at attention and scour the landscape for danger. When something unknown or threatening appears, they loudly signal the others to seek the safety of the colony’s shelter.
On June 15, 2009, in a speech at the annual meeting of the American Medical Association, President Barack Obama appealed to the physicians of this nation to join him in safeguarding the community by acting as medical sentinels. Part of his speech was directed at those of us in preventive medicine and public health: “Building a health care system that promotes prevention rather than just managing diseases will require all of us to do our parts. It will take doctors telling us what risk factors we should avoid and what preventive measures we should pursue…. Our federal government also has to step up its efforts to advance the cause of healthy living. Five of the costliest illnesses and conditions – cancer, cardiovascular disease, diabetes, lung disease, and strokes – can be prevented, and yet only a fraction of every health care dollar goes to prevention or public health. That’s starting to change with an investment we’re making in prevention and wellness programs that can help us avoid diseases that harm our health and the health of our economy.”

As I read the transcript of this speech, my mind went back to the meerkat sentinels on the Serengeti plains. They instinctively worked to prevent the injury and death of the members of their community. It’s funny, though – I don’t recall ever hearing anyone refer to those watchful lookouts as “do-gooders” or advocates of “nanny government.”

Building Health Care a Foundation

Health depends more on what you eat and drink, where you live, whether or not you have a job, how often you wash your hands, whether or not you smoke, how far you got in school, and where the factory next door dumps its waste than it does on high tech surgical procedures or the newest pharmaceutical drugs.

This is where public health fits in. Public health is the foundation of health care. As the Institute of Medicine has said, “The mission of public health is to fulfill society’s interest in assuring conditions in which people can be healthy.”

So how do the “conditions in which people can be healthy” relate to health care reform?

Let me give an example.

Let’s say two children are born on the same day, but in different communities. One is born to a mother who has carefully watched her diet throughout pregnancy and has abstained from alcohol and smoking. She lives in a village with pristine water and unpolluted air. The sewage and garbage in her village are transported far from town, where they are carefully processed and recycled. As she grows, her mother carefully teaches her about health and personal hygiene, and makes sure there is always plenty of nutritious food, soap and toothpaste in the house.

The second child is born a bit premature and is small for his age, due to his mother’s inadequate diet and heavy smoking throughout her pregnancy. He grows slowly because of his frequent coughs and bouts of gastrointestinal disease, and because he shares his limited nutrition with the hookworms he has acquired from running barefoot in the village. The water he drinks is questionable, and the air in his home is polluted from the coal-powered stove on which his mother cooks the meager fare which she is able to find in the marketplace. Outside, the stench is almost palpable from the garbage on the streets and the cracked and leaking sewage pipes. His mother knows little about hygiene, and is too busy with her other babies to teach him what she does know.

This exaggerated picture does have a message: It makes a big difference how much effort and the level of resources your community puts into assuring healthy conditions for you and your family. In fact, Dr. Herman Biggs, the Commissioner of Health for New York City in the late 1800s claimed, “Public health is purchasable. Within natural limitations a community can determine its own death rate.”

Now, if these two families came to buy health insurance from you, which would you prefer to insure? Before either child has even entered the “health care system,” you already know which one is going to have the highest health care costs. One has grown up in a community with a rock solid foundation of public health, and the other is attempting to survive in a community that is falling apart.

The choice is ours. “Within natural limitations, (we) can determine (our) own death rate.”

Treating STD's . . . A community Concern

I met your daughter’s boyfriend last night. Seems to have a good head on his shoulders. He says he wants to get into college on a football scholarship and plans on becoming an engineer. Nice kid. Good family. Bright future.

I felt bad I couldn’t do more for him, but you know how it is. With all the budget cuts lately, we really can’t afford to just give away medications in our sexually transmitted disease (STD) clinics. I’m sure he’ll come up with the funds somehow.

Seems funny now how things used to be. We used to get state and federal funds to treat kids like this. It had something to do with the old-fashioned concept that communicable diseases somehow impact the whole community. In fact, we were forbidden by the state legislature to charge for these services if the person couldn’t pay. How naïve we all were!

What a waste of money, trying to control things like syphilis, gonorrhea, tuberculosis, hepatitis and AIDS. Of course, we didn’t have things like HDTV plasma screen televisions to spend our tax rebates on in those days. I guess we could afford to be a bit more community minded back then.

But I wouldn’t worry too much if I were you. Like I said, your daughter’s boyfriend seems like a really nice kid. And I’m sure that “Just say, ‘No!’” lecture you gave her really sank in. It would be a real stretch to imagine she might be in that group of women (74%) who say they had sex before they turned 19. Besides, I’m sure he’ll come up with the money for the medications somewhere.