Medical marijuana’s last taboo

It’s increasingly accepted as a remedy for adults with serious health issues. Now the question is: Should doctors recommend the substance to children?

By Christine S. Moyer

Seattle physician Leslie R. Walker, MD, has patients as young as 10 who request medical marijuana. They often want the drug to ease alleged chronic pain, curb insomnia or enhance their ability to focus.

Dr. Walker has never given in to patients’ demands for medical marijuana. But she’s among the doctors worried by the growing number of young people who are seeking the substance for so-called health reasons.

medical_marijuana1“What’s concerning is children are coming into the doctor now and saying, ‘My back hurts. Can you write me a recommendation for a medical marijuana card?’ ” said Dr. Walker, chief of Adolescent Medicine at Seattle Children’s Hospital.

She doesn’t believe in recommending the drug to youths, but there are some health professionals who do recommend the substance.

In Arizona, for instance, 29 people younger than 18 are active medical marijuana cardholders, according to the state’s Dept. of Health Services. Arizona is one of the few states that report online the ages of its cardholders.

Although that constitutes a small percentage of the more than 36,000 Arizona residents using cannabis for health reasons, some medical experts say this is just the beginning.

They worry that as more states approve medical marijuana laws and the concept of medicinal marijuana becomes more mainstream, an increasing number of youths will attain the drug for health purposes.

Eighteen states and Washington, D.C., permit doctors to recommend marijuana for certain conditions, which can include anorexia, cancer, Crohn’s disease, inflammatory bowel disease, migraines, seizures and severe pain, according to the Marijuana Policy Project. The Washington-based nonprofit is the nation’s largest marijuana policy reform organization.

Only Connecticut and Delaware prohibit the use of medical marijuana by youths younger than 18, according to the Marijuana Policy Project. Delaware’s policy, however, has not yet been enacted.

Eleven states have pending legislation legalizing medical marijuana, and two of those states — Illinois and New Hampshire — probably will enact the measure this year, said Paul Armentano, deputy director of NORML, a Washington-based lobbying organization working to legalize marijuana.

“The history of medicine is just filled with stories of therapies that appeared promising initially and later were found to have devastating consequences,” said Sharon Levy, MD, MPH, chair of the American Academy of Pediatrics Committee on Substance Abuse. “That’s what’s really frightening about this idea of medical marijuana” for young patients.

DID YOU KNOW:
18 states permit doctors to recommend medical marijuana; laws are pending in 11 other states to legalize it.

The key concern is there are limited data on how the drug impacts the developing brain. Health professionals also said youths could become addicted to cannabis; raise their risk for mental conditions, such as anxiety; and have motor vehicle crashes due to impaired driving.

Because the Drug Enforcement Agency classifies marijuana as a Schedule I drug, which means it has a high potential for abuse and no known medical benefits, the substance is not regulated by the Food and Drug Administration. As a result, doctors don’t have information on the contents of medical marijuana, and there are no dosing instructions.

The American Academy of Pediatrics doesn’t “recommend medical marijuana under any circumstances for children,” said Dr. Levy, director of the Adolescent Substance Abuse Program at Boston Children’s Hospital. The AAP’s Committee on Substance Abuse is developing a new policy statement for marijuana that will express its position more clearly, she said.

Complicating matters is the potential liability risk for doctors who recommend medical marijuana to a young patient who later develops a mental health problem or gets in a car crash, said Stuart Gitlow, MD, MPH. He is president of the American Society of Addiction Medicine and a member of the American Medical Association Council on Science and Public Health.

“Certainly there are arguments that the person would have gotten into a car crash” or developed a mental condition even if cannabis was not recommended, Dr. Gitlow said. “But given the known risks associated with the drug … the physician would have very little to stand on in trying” to defend himself.
Marijuana as medicine

There is growing support for medical marijuana in the public at large. Proponents, such as Armentano of NORML, highlight the drug’s therapeutic use in adults, including reducing chronic pain and decreasing spasms in people with multiple sclerosis.

NORML’s website references a study of 38 adults showing that both high and low doses of inhaled cannabis reduced neuropathic pain of diverse causes among people who were unresponsive to standard pain therapies. The findings were published June 9, 2008, in The Journal of Pain.

Because of marijuana’s lack of toxicity and no reported cases of lethal overdose, “cannabis as a therapeutic agent appears to be … in some cases a safer substance than many conventional pharmaceuticals,” Armentano said.

Although there are little data on how the drug affects people younger than 18, NORML supports doctors’ cautious recommendation of medical marijuana for children and teens who have a health condition that warrants use of the substance, he said.

“The reality right now is that doctors have the discretion to recommend a litany of approved pharmaceuticals to young people, [many of which] were never tested in research and development in young people,” he added.

Seattle adolescent medicine specialist Yolanda N. Evans, MD, MPH, agrees that the lack of data on many pediatric prescription drugs is troubling. That’s why she tries to identify nonmedical forms of treatment, such as exercise or massage for patients with chronic pain, rather than prescribing medication right away.

“I don’t think cannabis is the answer for pediatric patients,” said Dr. Evans, assistant professor of pediatrics at the University of Washington School of Medicine.

Medical marijuana use “is different for adults, because they don’t have the same risks that go along with the developing brain,” she said.

Researchers have found that the human brain continues to develop into the mid- to late 20s, which means exposure to neurotoxins during that period can permanently alter the brain’s structure and function.

A study of more than 1,000 people born in 1972 and 1973 found that persistent cannabis use, starting in adolescence and persisting for more than 20 years, was associated with neuropsychological decline. Cessation of cannabis didn’t fully restore neuropsychological functioning, said the study in the April 23, 2012, issue of Proceedings of the National Academy of Sciences.

Those findings were contested by a recent study published online Jan. 14 in the same journal. That study used simulation models to show that socioeconomic status might account for the downward IQ trend seen in the April 2012 PNAS study.

“The message inherent in these and in multiple supporting studies is … regular marijuana use in adolescence is known to be part of a cluster of behaviors that can produce enduring detrimental effects and alter the trajectory of a young person’s life — thwarting his or her potential,” said Nora D. Volkow, MD, director of the National Institute on Drug Abuse, in a statement.
Responding to patient requests

When patients request a recommendation for medical marijuana, Dr. Walker asks why they want it and inquires if they already use the drug. She said every patient who has asked for a recommendation either already was using the substance or didn’t have a condition that she thought warranted it.

In declining requests, she explains the dangers of marijuana use, which can include an increased risk of developing anxiety, depression and a brief psychotic reaction, according to NIDA.

Dr. Walker tells the individual, “I do not think that what you’re concerned with will be helped by marijuana.” She then tries to help the patient develop a treatment plan to address their health issue.

Patients, and sometimes their parents, get upset when she doesn’t fulfill the request for medical marijuana. But “I never had anyone scream and say, ‘I’ll never come back again,’ ” Dr. Walker said.

Where the situation gets particularly difficult for physicians is when they’re faced with extreme cases, such as children with cancer who are experiencing severe pain from the disease or from chemotherapy, said Dr. Gitlow, of the American Society of Addiction Medicine. Parents sometimes ask the doctor for a medical marijuana recommendation to try to ease the child’s suffering.

“My heart goes out to those parents,” he said. “But I don’t believe” medical marijuana is the answer.

In those situations, Dr. Levy, of Boston, encourages physicians to tell parents that even though marijuana could help their child’s nausea, it could be toxic to their brain and negatively affect them for life.

She said more research is needed into developing cannabinoids as pharmaceutical products. Cannabinoids are the components of marijuana that have shown medical benefits.

In 2009, the AMA adopted policy calling on the government to review the status of marijuana as a federal Schedule I controlled substance in an effort to facilitate clinical research on the use of medical marijuana. A Schedule II classification would allow the drug to be used for medical purposes, but it still would be tightly restricted. The AMA policy stresses that this should not be viewed as an endorsement of state-based medical cannabis programs, of the legalization of marijuana, or that scientific evidence on the therapeutic use of cannabis meets the current standards for prescription drug products.

“There are definitely [negative] effects of marijuana” on children and adolescents, Dr. Levy said. “The fact that they’ve been hard to describe doesn’t mean that they’re not there.”

Complete Article HERE!

End-of-life care: ‘Shortfall in NHS services’

By Nick Triggle

There is a shortage of specialist end-of-life care in England, causing unnecessary suffering, experts say.

ENDOFLIFEPeople dying with the most complex conditions, such as cancer, dementia and heart and liver failure often need support from a range of professionals.

But a report – produced by end-of-life doctors and nurses – said many were going without the help they needed.

As well as being an inefficient use of NHS money, this could be causing greater distress at death, they said.

Specialist end-of-life care requires teams of professionals, including doctors, nurses, social workers, psychologists and pharmacists to work together to help manage pain and disability in the final year of life and ensure patients are treated with dignity and compassion.

As well as helping to achieve as comfortable a death as possible, the support can also reduce costs to the NHS by keeping people out of hospital, said the report, produced by a host of specialist bodies including the Association of Palliative Medicine and Marie Curie Cancer Care.

‘Paralysis’
Not everyone who dies needs such help as some deaths are sudden or unexpected.

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Palliative care has the ability to save the NHS money and improve the care of patients”

Dr David Brooks
Association of Palliative Medicine
But the ageing population means there is a growing number of people with complex, long-term problems that need carefully managing at the end of life.

The report said it was estimated that between 160,000 to 170,000 people a year were currently receiving specialist end-of-life care.

The groups said this was a “significant” shortfall on the numbers who needed help. It said more than 350,000 people required some form of end-of-life care, the majority of whom would benefit from specialist care.

Dr David Brooks, vice-president of the Association of Palliative Medicine, said: “There is a shortfall in services that needs to be addressed. Palliative care has the ability to save the NHS money and improve the care of patients.”

It comes after there has been mounting concern about one part of end-of-life care, the Liverpool Care Pathway.

Complaints
At the end of last year there were suggestions the regime, which allows doctors to withdraw treatment in the last days of life, was being misused in places.

Relatives of dying patients had complained that their loved ones had been put on the pathway without consent.

Professionals working in the field had agreed to launch a review into how the system was working, but that was then put on hold when ministers said it should be done independently.

That review has yet to start, although the government is expected to announce details of it in the coming weeks.

Dr Brooks said the profession was keen to find out what had gone wrong, but he said the controversy and wait for the review had created a “bit of paralysis”.

“It is important we get this right and tackle what was happening, but there is a little frustration it is taking some time.”

Complete Article HERE!

End-of-life care, talks help folks die well

By Dr. Andrew Ordon

As doctors, we are taught that death is the enemy. We are here to stop it and if a patient dies, we have failed. That mentality has led to an alarming statistic. According to one study, 60 percent of your health care dollar is spent in the last 30 days of life. Wouldn’t those resources be better spent on prevention and defeating curable diseases earlier in life? Why do we try so hard at the very end? One reason is that we think we can defeat the disease and gift the patient with more time. But there are times when that is not a reality.

One obvious example is the terminally ill. People with Stage 4 cancer. That means they have a cancer which has spread from the local area to a distant location. Cancer starts out in one place, and if it is isolated there, it’s called Stage I. If it erupts from its local area but has not spread to lymph nodes it is Stage 2. If it has spread to nodes but has not spread beyond the region of origin, it is Stage 3. If it has traveled by lymph or through the blood stream to a distant organ, that’s Stage 4, which is as bad as it gets. This is when doctors tell you how long they think you have left.

In a study published in November in the Journal of Clinical Oncology, 1,231 patients with Stage 4 lung cancer were evaluated for their End of Life (EOL) experiences. They considered “aggressive” care to be things such as receiving chemotherapy in the last 14 days of life, ICU stays in the final 30 days and an acute-care hospital stay in their last 30 days.

Researchers found that patients who had EOL discussions before the final 30 days were more likely to receive appropriate hospice care than those who did not have EOL discussions.

The authors wrote: “Given the many arguments for less aggressive EOL care, earlier discussions have the potential to change the way EOL care is delivered for patients with advanced cancer and help to assure that care is consistent with patients’ preferences.”

I have overseen the hospice care of a relative and can tell you firsthand that it is far better than having no plan in place. Hospice nurses and doctors treat the family as much as the patient. But arranging for hospice care sounds a bit like giving up. It isn’t. It’s acceptance of the reality that we all make this journey. Hospice care is merciful and compassionate.

The time to discuss end-of-life care is before the end is near. It is possible to die well.

Complete Article HERE!

My church seeks to deny a compassionate death … a good death … to those crying out for it

A MINISTER of the Church of Scotland has broken ranks with the Kirk and spoken out in support of a new bill to legalise assisted dying – despite longstanding opposition from the Christian community.
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The Reverend Scott McKenna said the religious arguments put forward by opposing faith groups, including his own church, “do not stand up” and believes voluntary euthanasia can “sit comfortably” within Christian faith.

He delivered a powerful speech at a conference chaired by Independent MSP Margo MacDonald, who has launched a second bid to legalise voluntary euthanasia.

The Kirk and the Catholic Church have come out strongly against the reform. But research suggests more than 80% of the British public is in favour of change.

The event, held at the Royal Society of Edinburgh on World Dignity in Dying Day, also brought together Ludwig Minelli, founder of the Swiss suicide clinic Dignitas, international representatives from the Right to Die movement, and Jane Nicklinson, widow of the late Tony Nicklinson, who this year campaigned for the right to die.

McKenna, Kirk minister at Mayfield Salisbury in Edinburgh, said his views had been shaped by supporting families through the death of a relative suffering from a terminal illness.

“The Church says, ‘You must not kill, ‘You must not take human life’. ‘God has forbidden it’,” he said. “What is wrong with this argument? There is no such commandment.”

“In the Bible, David killed Goliath, David’s armies killed thousands. In the Book of Exodus, in the original language, Hebrew, the sixth commandment is ‘You must not kill unlawfully’. This is a staggering difference. In the Bible there are circumstances in which killing is legally and morally acceptable, such as in battle or executing a death sentence. I am not offering you an obscure interpretation of scripture. It is mainstream: the Church is wrong.”

He said the Church’s other main argument, that life is a gift from God and only God can choose the moment of death, was also “deeply flawed.”

He said: “We are told that we shouldn’t interfere with God’s plan by shortening human life. This is bad theology. It portrays God as brutal and less loving than we are to our pets. When the Church speaks of compassion, it means to ‘stand in someone else’s shoes’ – yet too often the church seem distant, cold and paternalistic. They know best and, based on a flawed theology, seek to deny a compassionate death, a good death, to those crying out for it.”

The minister has previously campaigned in support of gay clergy and same-sex marriage. He delivered a sermon on assisted dying at last Sunday’s service and said the response from the congregation was overwhelmingly positive.

He said: “Almost everyone is speaking from personal experience. They have been at the bedside of a relative. I know people who have gone into a hospice and the family members know they only have a day left. Once they are pumped full of drugs they lasted 14 days. Why is that good?”

McKenna also said his position was supported by some Catholic theologians.

“Anecdotally there are significant Roman Catholic theologians who are in favour but you won’t hear that from the hierarchy. The churches can continue to have their own view but they shouldn’t be allowed to impose it. I hope that compassion will triumph over religious dogma and the decision to die be seen not as suicide or life-defeating but as life-enhancing and an act of immense faith.”

In its consultation response on the issue of the right to die, the Church of Scotland said: “We believe that any legislation which endorses the deliberate ending of a human life undermines us as a society. The Catholic Church has said the legislation would “cross a moral boundary”.

Complete Article HERE!

End-of-life system is needed in Wisconsin

By Charles E. Cady, Joseph Hansen and Steve Hargarten

This is in response to the Oct. 17 Journal Sentinel article “End-of-life medical care initiative prompts worries about abuse.” The current status of advanced planning for end-of-life decisions is a system that is woefully lacking, and where tools exist, they are of limited utility.

Autonomy is a fundamental bioethical principle: Patients have the right to make decisions affecting their health care, including deciding on the level and type of care they want. The principle of autonomy is no more important than in end-of-life decisions.

These decisions should ultimately be made by the patient but clearly benefit from discussions with health care providers, family, religious leaders and others important in a patient’s life. These decisions should reflect the individual’s goals as guided by his or her personal values and beliefs.

The Wisconsin Medical Society’s Honoring Choices Wisconsin is in keeping with the importance of autonomy, and we fully support this. However, Physician’s Orders for Life Sustaining Treatment (POLST) also must be moved forward in Wisconsin.

As emergency medicine physicians, we have found that the current system of communicating end-of-life decisions is lacking. In practice, it is the opportunity for clear communication of a patient’s wishes at the end of life that is most challenging.

Wisconsin’s do-not-resuscitate (DNR) law is very limiting. While it is the only tool mandated to be recognized by paramedics and emergency physicians, its utility is minimal. The order is only active once a patient has lost his or her pulse (in other words, is already clinically dead) and only pertains to the withholding of CPR. It offers no assistance with regard to other care for a dying patient. Wisconsin advanced directives lack precision, are not orders that can be acted upon by a paramedic and can be very confusing in an emergency situation.

The power of attorney for health care (POAH) system is also imprecise. While this system is a very important component of end-of-life planning, it is limited in emergency situations. Following direction from POAHs is not permitted for paramedics. In an emergency situation, the POAH may also have a hard time remembering that decisions are to be based on the patient’s, not the POAH’s, wishes. Logistically, in an emergency, the POAH is often difficulty to contact.

Physician’s Orders for Life Sustaining Treatment are clear and concise orders that can (and should) be acted upon by emergency personnel. They have been successfully implemented legislatively in 15 states. They take the pressure away from a POAH to make decisions in an emergency and alleviate that sense of personal responsibility for death.

They eliminate the vagueness that is commonplace in current advance directives. They also provide for decisions about care before someone actually dies. Most important, they help plan for the last moments of a patient’s life when clarity in planning and comfort are paramount.

Along with our paramedic colleagues, we encounter patients at the end of life on a daily basis. We see that end-of-life planning is limited. When end-of-life wishes are clearly described, it is an honor to provide that care.

However, these situations are the exception rather then the rule. Consequently, our ability to follow a dying patient’s wishes is limited. The result is often prolonged, painful and futile efforts that may not be desired.

In order to avoid these painful situations and to promote discussion of end-of-life planning, we strongly support efforts to successfully implement POLST in Wisconsin.

Complete Article HERE!

Pot compound seen as tool against cancer

Marijuana, already shown to reduce pain and nausea in cancer patients, may be promising as a cancer-fighting agent against some of the most aggressive forms of the disease.

A growing body of early research shows a compound found in marijuana – one that does not produce the plant’s psychotropic high – seems to have the ability to “turn off” the activity of a gene responsible for metastasis in breast and other types of cancers.

Two scientists at San Francisco’s California Pacific Medical Center Research Institute first released data five years ago that showed how this compound – called cannabidiol – reduced the aggressiveness of human breast cancer cells in the lab.

Last year, they published a small study that showed it had a similar effect on mice. Now, the researchers are on the cusp of releasing data, also on animals, that expands upon these results, and hope to move forward as soon as possible with human clinical trials.

“The preclinical trial data is very strong, and there’s no toxicity. There’s really a lot of research to move ahead with and to get people excited,” said Sean McAllister, who along with scientist Pierre Desprez, has been studying the active molecules in marijuana – called cannabinoids – as potent inhibitors of metastatic disease for the past decade.

Like many scientific endeavors, connections made between disparate elements – in this case, a plant considered a controlled substance and abnormal cells dividing out of control – involved a high degree of serendipity. The two researchers were seemingly focused on unrelated areas, but found their discoveries pointing in the same direction.

Desprez, who moved to the Bay Area from France for postdoctoral research in the 1990s, was looking at human mammary gland cells and, in particular, the role of a protein called ID-1.

The ID-1 protein is important in embryonic development, after which it essentially turns off and stays off. But when Desprez manipulated cells in the lab to artificially maintain a high level of ID-1 to see if he could stop the secretion of milk, he discovered that these cells began to look and act like cancer cells.

“These cells started to behave really crazy,” Desprez said. “They started to migrate, invade other tissues, to behave like metastatic cells.”

Based on that discovery, he took a look at metastatic cancer cells – not just standard cancer cells, but those responsible for aggressively spreading the disease throughout the body. He found the vast majority tended to express high levels of ID-1, leading him to conclude that ID-1 must play an important role in causing the disease to spread.
Anticancer potential

Meanwhile, McAllister was focused on studying anabolic steroids in drug abuse. McAllister, who also made his way to CPMC from Virginia in the 1990s, became fascinated with the role non-psychotropic cannabidiol, or CBD, interacts with cancer.

Marijuana’s better known cannabinoid – delta-9 tetrahydrocannabinol, or THC – had already shown some anticancer properties in tumors, but the non-psychotropic cannabidiol had largely gone unstudied. McAllister initial research showed CBD had anticancer potential as well.

About eight years ago McAllister heard his colleague, Desprez, give an internal seminar about his work on ID-1, the manipulated protein cells that masquerade as cancer cells, and metastases. That produced an idea: How effective would cannabidiol be on targeting metastatic cancer cells?

The pair teamed up – Desprez with his apparently cancer-causing ID-1 and McAllister with his cancer-fighting CBD – deciding to concentrate their research on metastatic cells of a particularly aggressive form of breast cancer called “triple negative.” It is so named because this type of breast cancer lacks the three hormone receptors that some of the most successful therapies target. About 15 percent of breast cancers fall into this category, and these cells happen to have high levels of ID-1.

Complete Article HERE!