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Steve Bryson
Dec 14, 2009

When your client uses medical marijuana

There has been some controversy developing in our field, and I wonder if any one else has been seeing it. It involves the recent change in the Federal guidelines about the enforcement of marijuana laws that differ from state laws. For those of you who don't know, the current Administration has directed the Justice Department not to interfere with states' medical marijuana laws, thus opening up availability of marijuana to patient use through primary provider prescription and the development of legal dispensaries.

Currently 13 states have medical marijuana laws, and 15 others are considering such legislation. Until the recent Federal directive, the growth of this health care intervention has been minimal, as the prescriber, dispensary, and patient all risked Federal interdiction. But since the directive, there has been a virtual explosion of prescribers, despensaries and patients. One might think that a relatively conservative state like my home state of Montana would be far from this, but a medical marijuana law passed with a significant majority (62%). Nonetheless, the recent change from the Feds has caused a divisiveness: there are those who adamantly decry this as a tragic development, while others are quietly supporting it and still others are capitalizing on it.

From a clinical standpoint, there is ample evidence that medical marijuana can be of great help to a variety of serious maladies. There is also ample evidence that marijuana is not the demon it was once considered, yet is not the innocuous substance pro-recreational use advocates make it out to be.

I would like to present several potential situations regarding patients who might have been prescribed medical marijuana since the Federal change. It would seem that at times it is a very legitimate and helpful prescription, allowing (for example) cancer patients to eat and gain weight while undergoing chemotherapy. I believe most of us would not see this type of usage as controversial. Next, there is the patient with a neurological disorder whose medical marijuana use can help a great deal by relieving muscle spasms, again probably not too controversial. But then there is the young person with Irritable Bowel Syndrome (IBS) who uses medical marijuana. In this case I have to wondered if his/her "beneficial use" is actually that s/he has become dependent on marijuana and has fewer "IBS symptoms" after using marijuana because s/he has developed a dependence on the substance to alleviate emotionally-sourced physical symptoms of a primary chemical dependence. Is this a "beneficial use"? I am uncertain.

Perhaps, the most troubling is a young teen with short duration anorexia who was prescribed medical marijuana a few weeks before counseling. One cannot deny that her preprandial usage, carefully monitored by her mother, could allow her to have an appetite at mealtime. She does not use recreationally and recovers well. Her refeeding period was remarkably uncomplicated, her weight gain is without the anxiety usually experienced during recovery, and this young cowgirl from a conservative Christian family no longer uses medical marijuana, nor recreational drugs of any kind. And while I see the promise in this intervention, I sruggle with the notion of recommending marijuana to young people with developing minds and bodies. Nonetheless, anorexia is a potentially fatal, or at least potentially chronic disorder, destructive to both the patient and her family. One might say: let's get some research to tell us of the potential risks and benefits of medical marijuana in the treatment of anorexia. Most university settings would be hesitant to expose young people to this, and the Human Subjects review committee would be even more liability shy.

In my last blog, I noted the glacial pace with the which the treatment community changes: it took 60 years for physicians to accept what British sailors long knew-that eating limes prevented scurvy. Am I being a traditionalist, stuck in dogma? Or am I being cautious, gauging each case individually?

I know that numerous studies have found that most providers view pain in a way that reflects their own experiences with pain: stoic providers tend to expect stoicism in their patients while other providers are just the opposite. Further, those of us with addiction treatment backgrounds are acutely aware of the ravages of addictions, and are loath to open the door to a new substance with abuse potential. But we also are knowledgeable enough to realize that a person who uses large doses of narcotics for chronic pain relief are benefitting when monitored therapeutic use of marijuana reduces or eliminates narcotic use.

I have no firm answers. But it is inevitable that this issue will confront us as more states pass such laws and more people are prescibed medical marijuana. I do know that I must check my prejudices at the door to my office. I am just beginning to realize how far my preconcieved notions carry me, and I see this as an opportunity to grow both personally and professionally.

What do you think?

Steve Bryson is a counselor in private practice in Whitefish, Montana and a registered nurse. He works with adolescents and adults, couples and families and has a special interest in eating disorders.

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