Category: Pain Control

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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!

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D.C.’s Marijuana Reform Rabbi

Jeffrey Kahn and his wife are set to open one of the first medical marijuana dispensaries in Washington, D.C.

Jeffrey Kahn, a Reform rabbi living in Washington, D.C., remembers several congregants who approached him over the years with the same dilemma: They’d heard that marijuana could relieve their nausea from chemotherapy or their pain from glaucoma or any one of a variety of other ailments, but they were unable to obtain the drug because it’s illegal.

The issue became personal when Kahn and his wife, nurse Stephanie Reifkind Kahn, watched her parents suffer and die—Jules Reifkind of multiple sclerosis in 2005 and Libby Reifkind of cancer in 2009. The Reifkinds’ doctors had recommended marijuana to ease their symptoms, but they lived in states where medical marijuana was illegal, making it nearly impossible for them to obtain the drug. Jules did use it a few times, probably getting it from a caregiver, his daughter remembers, and it reduced his pain and muscle spasms.

After the deaths of Jules and Libby Reifkind, the Kahns made it their mission to ease the suffering of others who might benefit from medical marijuana. For the past two years, they have been laying the groundwork for a legal dispensary for medical marijuana in Washington. Earlier this month, their efforts paid off: The D.C. Department of Health named four applicants eligible to register to operate such dispensaries—the first ones in the District—and the Kahns’ Takoma Wellness Center was one of them.

Dispensing marijuana may not be the usual path for a rabbi. But there is rabbinical support for the practice. And on a personal level, Kahn, 60, told me last week: “Our midlife quest for a new way to make a positive difference in people’s lives and a lifelong commitment to pushing the envelope to help others made this the obvious path to follow.”

***

College sweethearts who married 36 years ago during spring break from the University of Florida, the Kahns made aliyah in 2007. In Israel, he was involved in fundraising for Jewish organizations, after having spent more than 25 years with four different Reform congregations, including six years in Adelaide, the capital of South Australia.

But the economic downturn in 2008 made fundraising difficult, Kahn told me. Their older son, who’s also a Reform rabbi, had moved to Washington, D.C., where he now works for a Jewish social service organization. When they came for the bris of their grandson, now 3, they realized they didn’t want to live so far away from the baby. (Their younger son, who made aliyah at age 20, now serves as the Jewish Agency for Israel’s shaliach at his parents’ alma mater.) It was a homecoming of sorts for Stephanie Reifkind Kahn, who was born 57 years ago in Takoma Park, Md.—which borders the Takoma neighborhood in D.C. where they now live.

Medical marijuana was a hot-button issue in the nation’s capital when the Kahns moved here. Washington, D.C., voters had approved the legalization of medical marijuana more than 2-to-1 back in 1998, but Congress—granted ultimate authority over the city by the Constitution—blocked it with an amendment to the D.C. appropriations bill. In December 2009, though, Congress repealed the amendment, due in part to lobbying by former Georgia Republican Rep. Bob Barr, who had originally added it. The city issued regulations in July 2010 that said it would license up to five dispensaries and 10 cultivation centers; neighboring Maryland and Virginia have not yet legalized medical marijuana.

‘I think the rabbi is doing the Lord’s work’
With their sons’ blessings and, eventually, the support of their local Advisory Neighborhood Commission, the Kahns started paying rent a year and a half ago on a long-vacant, 1,300-square-foot former attorney’s office within steps of the Takoma Metro station. Their apartment is half a block away; their older son and his family, which now includes two grandsons, live two miles away.

The Kahns submitted 350 pages of documents to support their application. “We had this pretty strict review process,” said Mohammad Akhter, the physician who directs the D.C. Department of Health. “It’s very tightrope-walking. On the one hand we have a city law. On the other hand, we have law-enforcement officials, federal officials, who consider this not quite kosher.”

Applicants had to demonstrate that they “had the knowledge about what this business was all about,” Akhter said, and they needed to be able to provide adequate security and keep scrupulous records. (To avoid a conflict of interest, Akhter noted, he has never met the Kahns or any of the 16 other parties who applied to dispense medical marijuana in Washington.) “I think the rabbi is doing the Lord’s work,” said the Pakistani-born doctor, noting that Washington has high rates of diseases for which medical marijuana is approved, such as HIV/AIDS and cancer.

In August 2010, the Washington City Paper predicted that the first dispensaries might open in the spring of 2011. Akhter attributes the delay to the typically slow wheels of government and the desire to ensure that federal law-enforcement officials won’t shut down the dispensaries as soon as they open. “It’s a very lengthy process in terms of doing the review,” he said. “As a physician, I look at this as approving a new drug. We have done all the due diligence possible.”

Dispensing medical marijuana doesn’t pose any particular conflict for a rabbi, said Kahn: “As a medicine, there are no Jewish issues,” he told me. Just as sick Jews aren’t supposed to fast on Yom Kippur, he says, neither should they be expected to suffer because the federal government says marijuana has no medical benefit, especially given that 18 other Western countries that have legalized it for medical purposes—as well as 17 states plus D.C.—disagree.

The Union for Reform Judaism passed a resolution nearly nine years ago on “the medicinal use of marijuana.” “According to our tradition, a physician is obligated to heal the sick,” the resolution states. And, at least anecdotally, marijuana apparently “provides relief from symptoms, conditions, and treatment side effects of several serious illnesses.” For that reason, the resolution urges “congregations to advocate for the necessary changes in local, state, and federal law to permit the medicinal use of marijuana and ensure its accessibility for that purpose.”

It’s not just Reform rabbis, either. A number of rabbis across the spectrum of observance believe prescribing medical marijuana to relieve suffering is acceptable under Jewish law.

“Basically, Jewish teaching is extremely supportive,” said J. David Bleich, an Orthodox rabbi and professor of Talmud at Yeshiva University’s Rabbi Isaac Elchanan Theological Seminary and head of its postgraduate institute for the study of Talmudic jurisprudence and family law. “The beneficial purpose of marijuana seems to be countering the side effects of chemotherapy and other symptoms … and there’s no reason society shouldn’t take advantage of it.” Jurisdictions that approve and regulate medical marijuana, Bleich said, “certainly are to be lauded.”

The Kahns hope they’ll be able to serve their first patients by the beginning of December. For now, though, there is no marijuana to dispense, because in Washington, the dispensers of medical marijuana won’t be the ones growing it. In addition to approving four dispensaries out of 17 applicants, the health department approved six cultivators from among 28 applicants. (One of the six is a company co-owned by former talk-show host Montel Williams, a Maryland native who uses medical marijuana to treat his multiple sclerosis.) The cultivators still need to make structural changes to their facilities and haven’t yet started growing marijuana, Akhter says; once they begin, it will take 90 to 100 days before they will be able to supply the dispensaries.

No patients have yet been approved by the health department to receive medical marijuana, either, although many have expressed an interest, Akhter says. They must prove that they live in D.C. and receive a prescription from a doctor licensed to practice in the city. This process, too, will take time.

Once they open their doors, the Kahns’ have a business plan based on serving 500 patients their first year, although at best that’s a guesstimate. Their dispensary will serve patients by appointment only, making it less like a retail store and more like a doctor’s office, Kahn says. He and his wife also plan to partner with Takoma providers and refer patients to a wide array of complementary health services available in the laid-back neighborhood.

The Kahns hope that their dispensary will serve as a model for Congress to see that marijuana can safely be used to treat appropriate patients without ending up being diverted to people who aren’t ill. Kahn summed up his mission: “There’s no reason for people to be suffering and not getting the help they need.”

Complete Article HERE!

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Checklist approach to be tested in end-of-life care planning

Researchers from Harvard Medical School soon will begin testing a checklist-style approach to helping cancer patients get the kind of end-of-life care they want. The plans, detailed in June at a meeting of the International Society of Advance Care Planning and End of Life Care, are aimed at helping oncologists discuss end-of-life care issues with patients at an earlier stage in the disease process.

The trial of the serious illness communication checklist will involve 60 practicing oncologists and begin enrolling 450 patients in June. Data on patient and family satisfaction and treatment choices will be collected over three years, researchers said.

A wide body of research has found that patients who plan ahead are likelier to get the treatments they want as they near death. These patients tend to get less-aggressive care, earlier referral to hospice, are more satisfied with their care and see lower burdens placed on family members, experts say. Yet fewer than one in three Americans has a living will, and only half of U.S. patients with terminal illnesses have such directives documented in their medical records, according to the Agency for Healthcare Research and Quality.

Nearly 90% of patients with cancer have documented end-of-life care discussions with their physicians, said a study of about 2,200 patients in Los Angeles and Toronto published in the Feb. 7 Annals of Internal Medicine (ncbi.nlm.nih.gov/pubmed/22312140/). But most of the talks happened in the hospital less than five weeks before death and were with physicians other than the patient’s oncologist.

“I always think about this idea that it’s too early until it’s too late,” said Susan D. Block, MD, principal investigator of the serious illness communication checklist study. “In medicine, in general, these conversations take place way too late. There are lots of excuses on everybody’s side about that, but it needs to change.”

Oncologists participating in the trial will undergo a 2½-hour training session on how to use the checklist. They can have nurse practitioners join them for the training and help carry out the conversations with patients, which can take 25 to 40 minutes. The checklist asks patients who are estimated to have less than a year to live to discuss:

Their understanding of the prognosis.

  • How much information they want shared with loved ones.
  • Their goals of care, should their health seriously worsen.
  • Their biggest fears and what functional abilities they could not imagine living without.
  • How much medical intervention they are willing to undergo to gain more time.
  • How much they want family members to know about their priorities and wishes.

Talk focused on patient’s values
“We need to ask the right questions,” said Dr. Block, chair of the Dept. of Psychosocial Oncology and Palliative Care at Dana-Farber Cancer Institute in Boston. “Instead of focusing on procedures, we need to be focusing on goals, values, fears, quality of life, suffering and survival. Those are the things that matter to patients.”

The last step in the checklist is documentation, which integrates the patient’s answers — and any updates — into the electronic health record. The checklist has been piloted and fine-tuned during the last year, said Dr. Block, professor of psychiatry and medicine at Harvard Medical School. An abstract of her talk was published in the June issue of BMJ Supportive & Palliative Care (spcare.bmj.com/content/2/2/187.2.abstract).

Dr. Block was prompted to think about formulating the serious illness communication checklist by colleague Atul Gawande, MD, a professor of surgery at Harvard Medical School and author of The Checklist Manifesto: How to Get Things Right. Dr. Gawande, co-principal investigator of the study, had to overcome Dr. Block’s initial hesitation.

“I was very dubious,” she said in her presentation. “It seemed mechanical and reductionistic and cold to me, but I’ve warmed up to it. … I’m intrigued, in my mind, by this paradox — that something as routinized as a checklist could help with a conversation so deep and profound and complicated. It has some interesting potential, and we’re going to find out whether it works.”

Other presentations at the three-day conference focused on the challenges involved in advance care planning with racial and ethnic minorities, patients with disabilities and adolescents. Physicians, social workers, chaplains and other health professionals from Japan, Singapore, New Zealand, Australia and Canada presented information about end-of-life care planning initiatives in their countries.

Complete Article HERE!

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Burdening families with CPR decisions in the face of futility is cruel

by MONICA WILLIAMS-MURPHY, MD

Those who know and work with me have heard me state without hesitation that it’s morally wrong to do CPR on 90-year old great grandmas. So, it was with great relief that I read the “Do Not Offer CPR” option in a recent JAMA article urging a revision of our present approach to the use of CPR for those who are unarguably at the end of life.

This is a change from the present expectation of CPR no matter what, to a set of recommendations that incorporates the question of whether CPR “harms or helps” individuals. Finally, some sanity.

Medicine attempts to balance patient autonomy with the grand directive: “First, do no harm.” Recently, I have also discovered that as a doctor, it is also my job “to do no harm” to the families and surrogate decision makers of those in my care.

Last week, I learned that even asking families to make CPR or DNR decisions in the face of almost certain death creates unnecessary harm for them as well. In the following case, I created a decision-burden for a family that they neither wanted, needed, nor could handle—a decision-burden that would not change the outcome (death), yet would likely trouble them for the rest of their lives.

This case drove home to me another compelling reason why CPR should not be offered to those who are imminently dying: not only does the act of CPR harm the dying patient, the actual act of asking the families to make futile CPR vs DNR decisions harms them as well.

Mr. Gray was an 80-year old great-grandfather of 12. For years he had taken a blood thinner for his heart condition, without any complications, until 3 days before I saw him.

3 days prior, he had fallen and hit his head, developing a large bruise across his forehead. Despite his family’s urging, he had not gone to a doctor to get it checked out. Instead, he went about his daily activities, bothered only by a mild headache. This headache suddenly became severe on the 3rd day and he began to vomit. Immediately after vomiting, he became confused.

No more messing around, the family called 911. Mr. Gray was now too confused to argue or refuse a medical evaluation.

EMS loaded him up easily enough though, and told the family to follow them for what would be a short ride to the hospital. The ride was short enough, but something terrible happened during the transport-Mr. Gray fell unconscious and stopped breathing.

What ensued on arrival to my ER was high-end aggressive emergency care: he was intubated, placed on a ventilator, we placed multiple IVs, gave mannitol, ordered emergency plasma and ran with Mr. Gray to the Cat Scanner, all within minutes.

I tapped my foot impatiently awaiting the images of his brain to load up on the computer.

“Darn it,” I muttered when I saw the pictures confirming what I had already clinically diagnosed and begun treating. A large hematoma had developed on his brain. According to the radiologist there were already signs that his brain was herniating.

Just then, I got a call from the lab. Mr. Gray’s blood thinner levels were toxic. It would take hours to correct this before Mr. Gray could even go to surgery, and what Mr. Gray did not have was hours to wait. What he did have was a large, loving and very concerned family whom I had yet to talk to in detail.

I spoke with the neurosurgeon before I gathered this family. The specialists said that due to the blood thinner toxicity, the delay would most likely make the injury unsurvivable — meaning, we expected him to die.

I let out a long sigh and said, “Yeah, that’s what I thought.”

Hanging up the phone, I braced myself to talk to the family.

When I walked into the family waiting area it seemed to be standing room only. I asked those who could to take a seat. Sitting or standing, everyone leaned forward, anxiously, with expressions mixing dread with hope.

No matter how many times one has done this, these conversations are never easy. First, I gave the general explanation of what had occurred and how bad things looked for Mr. Gray. I explained that surgery to remove the hematoma could not be performed until the blood thinner problem was corrected and that this wait would most likely prove to be “too long” for him.

Tears began to flow. Children grabbed the hands of parents and siblings looked at each other in shock.

Next, I outlined all of the “doctor-driven” decisions that would be made and explained possible outcomes. If A happens then we can do B, but if C happens then B is not an option.

Then, finally, I laid the most serious decisions on them. How would Mr. Gray die, when his time comes? Would they allow natural death by withholding CPR? Would they request an attempt at CPR? Finally, would they consider withdrawing artificial life support measures.

Already grief-stricken, I watched their eyes glaze over in fear and pain as I gave them these final options and explained that eventually we would need to have a family decision on these choices (in the absence of a pre-selected decision maker to speak for Mr. Gray).
Looking around the room at heads hung low, there was deep silence. I stared at my feet, not looking at them in an attempt to give them space for thought.

But in that quiet moment, something shifted within me. I began to feel ashamed that I had even asked such questions at all. In that moment, I began to understand that the burden I had given them was too great and complex. I was asking them to participate in choosing his death, a task that they clearly did not want- something they obviously had never discussed. And, saddest of all, after pressuring them for an answer, this answer was not going to change the outcome for Mr. Gray-he was still probably going to die and all that they would have gained from this situation is a persistent guilt burden about whether they made the right choice or not.

Suddenly, it became so clear to me that this should not even be their burden at all. In that moment, I grew to understand that it was wrong to even ask families to make such decisions in futile circumstances – that should be my job. I should be the one who guides them through this time by saying, “CPR will not bring him back to who he was, it will not help him, it would only cause us to do further damage to his dying body. Because of this, we will not perform CPR on Mr. Gray when his heart stops, but we will care for him in every other way. We will make sure that he is comfortable and that you are with him. Now is your time to say, ‘Thank you, I love you, and good-bye.’”

I lifted my head. Looking around the room, I saw the strain on everyone’s faces and knew more than ever before that the way we practice end-of-life medicine must change.

Mr. Gray and his family, taught me first hand that it is cruel to burden families with CPR decisions in the face of futility. This type of decision-making should be built into medicine. It should be part of an end-of-life algorithm that is created and supported by the entire medical establishment for 3 reasons in addition to those cited in the JAMA article:

The maxim of “first, do no harm” should be extended to not just the patient, but also to the families of the dying patient in our care. We should not harm their emotional lives and consciences by asking them to make decisions about CPR that are ultimately futile. Such a burden is pointless and creates unnecessary suffering.

The Patient Self Determination Act of 1990 states that a patient or patient representative has the right to refuse or accept any medical procedures offered to them. This is the legislative back bone of modern concepts of patient autonomy. Presently, CPR is the default option and is therefore automatically offered by the medical system. But, as we learned from Mr. Gray and his family, there are times when this is inappropriate. I support the position of the JAMA article: “Physicians should not offer CPR to the patient who will die imminently or has no chance of surviving CPR to the point of leaving the hospital.” (Like Mr. Gray, whom we expected to die within 24 hours). Instead, we should spend our energies focusing the patient and families on creating comfort, peace, and closure with their remaining time together.

If the entire medical establishment agrees to create and adhere to guidelines outlining the exclusion criteria for CPR, like exclusion criteria for thrombolytics in stroke, then it cannot be argued that not offering CPR is a violation of patient autonomy. A patient or family cannot demand a procedure that is not offered when it is considered medically contraindicated.

In the end, it is we doctors who need to shoulder the burden of CPR decision making in futile situations. It is the burden for which we were trained, the years of experience caring for the dying, the hours of studying statistics and outcomes. We cannot in good conscience guide all other life-sustaining medical decisions then suddenly shift all death-determining medical decisions back to the family … it is a burden they are not equipped to bear and one they may never shed.

Complete Article HERE!

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Doctors hesitate to prolong their own lives to avoid pain

IT IS a common refrain from doctors doing the ward rounds in the intensive care unit of any major hospital: ”Please don’t ever let this happen to me.”

Most often the words are uttered at hand-over time when the day-shift doctors brief the evening-shift doctors at the foot of an elderly patient.

”He might be 80 years old, severe dementia, type two diabetes, previous strokes and a bit of renal failure, and now he’s fallen in the nursing home and suffered a head injury,” says Ken Hillman, professor of intensive care at the University of NSW, ”and the family wants him continued on life support hoping for a miracle.”
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There might be six specialists, eight junior doctors and when one finds the courage to say the words, ”We’ll all nod,” says Professor Hillman.

Professor Hillman believes many doctors would not put themselves through ”the same hell we often put other patients through”.

Professor Hillman is a speaker at a conference at NSW Parliament House next week on living well and dying well. The conference is organised by the non-profit organisation LifeCircle which helps people caring for loved ones at the end of their life. ”We support people having a good life right to the end with the conversations that will benefit the person dying and those they love,” said Brynnie Goodwill, the chief executive of LifeCircle.

With daily reports of miracle cures and medical breakthroughs, many people with advanced life-threatening cancers and other terminal illnesses pursue every possible treatment, no matter how gruelling, in the hope of extending life.

But do doctors choose the same path for themselves? The silence around doctors’ views was shattered earlier this year when Ken Murray, retired clinical assistant professor of family medicine at the University of Southern California, wrote in The Wall Street Journal that ”what’s unusual about [doctors] is not how much treatment they get … but how little.” He said doctors did not want to die any more than anyone else did. ”But they usually have talked about the limits of modern medicine with their families. They want to make sure that, when the time comes, no heroic measures are taken.”

Medical scepticism about life-saving interventions was revealed in a 1996 German poll where about half the specialists admitted they would not undergo the operations they recommended to their patients. A study last year, published in Archives of Internal Medicine, showed doctors often advised patients to opt for treatment they would not choose for themselves.

For example, asked to consider treatments for colon cancer, 38 per cent of doctors chose the option for themselves that had a low rate of side effects but higher risk of death (over an option with a high rate of side effects but lower risk of death). But only 24 per cent recommended this option for their patients.

Martin Tattersall, the professor of cancer medicine at the University of Sydney, said: ”I suspect very few doctors would opt for second or third line chemo therapy; my suspicion is that doctors are more likely to prescribe futile therapy than accept it. They’re aware of the statistics. The fact we’re not invincible is something doctors are reminded of every day of their practice and it probably slightly colours their attitude to fighting death as opposed to accepting it.”

Dr Rodney Syme, the author of A Good Death, said his father, a surgeon, when diagnosed with pancreatic cancer, refused surgery to relieve his jaundice even though he had performed the surgery on others many times. ”He didn’t believe there was enough merit in it,” Dr Syme said.

But Richard Chye, the director of palliative care at Sacred Heart, part of St Vincent’s Hospital, said doctors were distributed along the same spectrum as everyone else. ”I’ve known doctors to continue treatment right up until the end,” he said. ”It’s very much about their age group and attitude.”

Professor Hillman said 70 per cent of Australians said they wanted to die at home but 70 per cent died in hospitals.

Complete Article HERE!

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Massachusetts voters support medical marijuana and ‘death with dignity’ ballot initiatives

A majority of Massachusetts voters seem to be in favor of two controversial ballot initiatives that supporters say would ease the suffering of ill Massachusetts citizens.
Sixty percent of Bay State voters said they support allowing terminally ill people to legally obtain medication to end their lives, according to the latest survey from Western New England University Polling Institute in partnership with The Republican and MassLive.com.

Sixty-four percent of voters, meanwhile, backed legalizing the use of marijuana for medical purposes and 27 percent opposed the idea, according to the survey of 504 registered voters conducted from May 29 to 31.

Under state law, more than 68,000 certified voters must sign an initial petition to place an issue on the November ballot, with not more one-quarter of all the signatures coming from the same county. If the legislature does not take up the issue, an additional 11,000-plus signatures are needed by June 19th to put it on the ballot.

So as long as the initiatives fulfill the legal requirements, Massachusetts voters will have their say on the respective issues on election day.

“Polling on ballot questions is tricky because responses can be highly sensitive to question wording,” said Tim Vercellotti, associate professor of political science and director of the Polling Institute at Western New England University. “The actual questions that the voters see on the ballot tend to be longer and more complicated. Our questions attempt to get to the essence of each issue.”

The survey asked voters whether they supported or opposed “allowing people who are dying to legally obtain medication that they could use to end their lives,” according to Vercellotti.

Support for the “death with dignity” proposal outnumbered opposition by a margin of two to one in the Western New England University survey, with 60 percent of voters saying they support the idea, 29 percent opposing it and 11 percent saying they did not know or declining to provide a response.

John, a former high school teacher living in Holyoke who asked not to be identified by his last name, said his family’s experiences with cancer and other terminal illnesses shaped his support of the “death with dignity” option.

“I think it should be a matter of personal choice,” he said. “If someone is at the end of their life with a terminal illness and it may continue for six months or a year with terrible suffering and pain, why not give them the option? To me, it is freedom of choice.”

And although John identifies as Catholic, he said that he does not attend services and his religion holds no impact on his stance on the subject.
According to the data, opinions varied along party lines, with 67 percent of Democrats favoring the proposal, compared to 58 percent of independents and 53 percent of Republicans.

Support for the measure also varied by age, Vercellotti said.
While 61 percent of voters ages 18 to 49 and 72 percent of voters ages 50 to 64 support the idea, the same was true for only 46 percent of voters ages 65 and older.
Respondents who were 65 and older also were the most likely of any demographic group to say they were not sure or to decline to answer the question, with 20 percent choosing those options.

“I told them I didn’t know because I didn’t want to just give a quick answer. It’s a complicated issue,” said Robert Sandwald, a retired resident of Hopkinton, Mass. “I don’t want to give an answer I believe in. I’ll be thinking about it in case someone asks me in the future but I just don’t know how I feel about it.”
Views about the “death with dignity” proposal also varied by religion and religious observance.

Vercellotti said that although a majority of Catholic and Protestant voters said they support the proposal, their opinions tend to vary based on how often they attend religious services.

Fifty-two percent of all Catholic voters said they support the idea, 36 percent said they oppose it, and 12 percent said they did not know or declined to answer. But among Catholic voters who attend church at least once a week or almost every week, 52 percent opposed the “death with dignity” proposal and only 37 percent said they support it.
Deborah Greene, a 56-year-old Catholic from Milton who said she attends church services almost every week, opposes the “death with dignity” option.

“I’m against it because I just don’t think it’s right,” Greene said. “It is a religious conflict.”

Catholic voters who attend church less frequently – about once a month, seldom or never – backed the idea by more than a two-to-one margin, 62 percent to 25 percent.
Among all Protestant voters, 56 percent supported the proposal, and 28 percent were opposed. Opinion was much more narrowly divided among Protestant voters who attend services at least once a week or almost every week, with 42 percent opposed and 38 percent in favor.

“The results indicate that religious identity is not the only distinguishing factor when it comes to views on this issue,” Vercellotti said. “Responses varied not just by religious identity, but also by religious observance. When it comes to Catholics and Protestants, the more ‘churched’ you are, so to speak, the more likely you are to oppose the ‘death with dignity’ proposal.”

Voters from other religious backgrounds overwhelmingly supported the measure, with 76 percent in favor and 19 percent opposed. Voters who identified themselves as atheists or agnostic backed the idea by an almost nine-to-one margin.

On the topic of allowing people to obtain marijuana for medical purposes with the prescription of a licensed physician, the results varied by political affiliation, gender, age and education level.

If the proposed law legalizing medical marijuana appears on the ballot and is approved by a majority of voters on Nov. 6, then Massachusetts would join 16 other states in the U.S. by allowing such a treatment option, despite federal law which prohibits it.

The proposed law would allow a physician to prescribe a 60-day supply of marijuana to a patient with a “debilitating medical condition,” such as cancer, AIDS, Parkinson’s disease or a broad category that includes “other conditions.”

The law would also permit up to 35 nonprofit medical marijuana dispensaries or treatment centers across the state, including at least one in each county.
The idea of legalized medical marijuana in Massachusetts has stirred passionate conversation among the commonwealth’s citizens and legislators.

John, the former high school teacher in Holyoke, said he opposes medical marijuana primarily because of the possibility of it being a precursor to full legalization.
“When I was a teacher, I saw the destruction that marijuana caused in the lives of so many young people,” he said. “I’ve seen kids with a tremendous amount of potential just go down the tubes. And I know you can’t completely blame it on marijuana, but it was a contributing factor. I guess I’m opposed to this if it is opening the door to overall legalization.”

Greene, a devout Catholic, said she is open to the concept because of research on the issue.

“As I understand it, there are properties in marijuana that can ease the pain of cancer that come with certain developments in the disease,” Greene said. “So as I understand it, it would be beneficial under medical direction, so I’m open to that.”
When asked whether they would support or oppose legalizing the use of marijuana for medical purposes, 74 percent of Democrats and 62 percent of independents endorsed the measure, while Republican voters were almost evenly divided, with 47 percent opposed and 45 percent in favor.

More than two-thirds of female voters supported legalizing medical marijuana, while the same was true for 58 percent of male voters. Younger voters also responded more favorably than did senior citizens. Sixty-eight percent of voters ages 18 to 49 and 50 to 64 supported legalizing medical marijuana compared to 54 percent of voters age 65 and older.
Views also varied by education, with 68 percent of voters with college degrees endorsing the measure, compared to 61 percent of voters with some college or with a high school diploma or less.

The survey has a 4.4. percent margin of error.

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