A doctor's case for medical marijuana | David Casarett

I would like to tell you about the most embarrassing thing

that has ever happened to me in my years of working as a palliative care physician.

This happened a couple of years ago.

I was asked as a consultant to see a woman in her 70s --

retired English professor who had pancreatic cancer.

I was asked to see her because she had pain, nausea, vomiting ...

When I went to see her, we talked about those symptoms

and in the course of that consultation,

she asked me whether I thought that medical marijuana might help her.

I thought back to everything

that I had learned in medical school about medical marijuana,

which didn't take very long because I had learned absolutely nothing.

And so I told her that as far as I knew,

medical marijuana had no benefits whatsoever.

And she smiled and nodded and reached into the handbag next to the bed,

and pulled out a stack of about a dozen randomized controlled trials

showing that medical marijuana has benefits

for symptoms like nausea and pain and anxiety.

She handed me those articles and said,

"Maybe you should read these before offering an opinion ...

doctor."

(Laughter)

So I did.

That night I read all of those articles and found a bunch more.

When I came to see her the next morning,

I had to admit that it looks like there is some evidence

that marijuana can offer medical benefits

and I suggested that if she really was interested,

she should try it.

You know what she said?

This 73-year-old, retired English professor?

She said, "I did try it about six months ago.

It was amazing.

I've been using it every day since.

It's the best drug I've discovered.

I don't know why it took me 73 years to discover this stuff. It's amazing."

(Laughter)

That was the moment at which I realized

I needed to learn something about medical marijuana

because what I was prepared for in medical school

bore no relationship to reality.

So I started reading more articles, I started talking to researchers,

I started talking to doctors,

and most importantly, I started listening to patients.

I ended up writing a book based on those conversations,

and that book really revolved around three surprises --

surprises to me, anyway.

One I already alluded to --

that there really are some benefits to medical marijuana.

Those benefits may not be as huge or as stunning

as some of the most avid proponents of medical marijuana

would have us believe,

but they are real.

Surprise number two:

medical marijuana does have some risks.

Those risks may not be as huge and as scary

as some of the opponents of medical marijuana would have us believe,

but they are real risks, nonetheless.

But it was the third surprise that was most ...

surprising.

And that is that a lot of the patients I talked with

who've turned to medical marijuana for help,

weren't turning to medical marijuana because of its benefits

or the balance of risks and benefits,

or because they thought it was a wonder drug,

but because it gave them control over their illness.

It let them manage their health

in a way that was productive and efficient

and effective and comfortable for them.

To show you what I mean, let me tell you about another patient.

Robin was in her early 40s when I met her.

She looked though like she was in her late 60s.

She had suffered from rheumatoid arthritis for the last 20 years,

her hands were gnarled by arthritis,

her spine was crooked,

she had to rely on a wheelchair to get around.

She looked weak and frail,

and I guess physically she probably was,

but emotionally, cognitively, psychologically,

she was among the toughest people I've ever met.

And when I sat down next to her

in a medical marijuana dispensary in Northern California

to ask her about why she turned to medical marijuana,

what it did for her and how it helped her,

she started out by telling me things

that I had heard from many patients before.

It helped with her anxiety;

it helped with her pain;

when her pain was better, she slept better.

And I'd heard all that before.

But then she said something that I'd never heard before,

and that is that it gave her control over her life

and over her health.

She could use it when she wanted,

in the way that she wanted,

at the dose and frequency that worked for her.

And if it didn't work for her, then she could make changes.

Everything was up to her.

The most important thing she said

was she didn't need anybody else's permission --

not a clinic appointment, not a doctor's prescription,

not a pharmacist's order.

It was all up to her.

She was in control.

And if that seems like a little thing for somebody with chronic illness,

it's not -- not at all.

When we face a chronic serious illness,

whether it's rheumatoid arthritis or lupus or cancer or diabetes,

or cirrhosis,

we lose control.

And note what I said: "when," not "if."

All of us at some point in our lives will face a chronic serious illness

that causes us to lose control.

We'll see our function decline, some of us will see our cognition decline,

we'll be no longer able to care for ourselves,

to do the things that we want to do.

Our bodies will betray us,

and in that process, we'll lose control.

And that's scary.

Not just scary -- that's frightening,

it's terrifying.

When I talk to my patients, my palliative care patients,

many of whom are facing illnesses that will end their lives,

they have a lot of be frightened of --

pain, nausea, vomiting, constipation, fatigue,

their impending mortality.

But what scares them more than anything else

is this possibility that at some point,

tomorrow or a month from now,

they're going to lose control of their health,

of their lives,

of their healthcare,

and they're going to become dependent on others,

and that's terrifying.

So it's no wonder really that patients like Robin,

who I just told you about,

who I met in that clinic,

turn to medical marijuana

to try to claw back some semblance of control.

How do they do it though?

How do these medical marijuana dispensaries --

like the one where I met Robin --

how do they give patients like Robin back the sort of control that they need?

And how do they do it

in a way that mainstream medical hospitals and clinics,

at least for Robin, weren't able to?

What's their secret?

So I decided to find out.

I went to a seedy clinic in Venice Beach in California

and got a recommendation

that would allow me to be a medical marijuana patient.

I got a letter of recommendation that would let me buy medical marijuana.

I got that recommendation illegally,

because I'm not a resident of California --

I should note that.

I should also note, for the record,

that I never used that letter of recommendation to make a purchase,

and to all of you DEA agents out there --

(Laughter)

love the work that you're doing,

keep it up.

(Laughter)

Even though it didn't let me make a purchase though,

that letter was priceless because it let me be a patient.

It let me experience what patients like Robin experience

when they go to a medical marijuana dispensary.

And what I experienced --

what they experience every day,

hundreds of thousands of people like Robin --

was really amazing.

I walked into the clinic,

and from the moment that I entered many of these clinics and dispensaries,

I felt like that dispensary, that clinic,

was there for me.

There were questions at the outset about who I am,

what kind of work I do,

what my goals are in looking for a medical marijuana prescription,

or product,

what my goals are, what my preferences are,

what my hopes are,

how do I think, how do I hope this might help me,

what am I afraid of.

These are the sorts of questions

that patients like Robin get asked all the time.

These are the sorts of questions that make me confident

that the person I'm talking with really has my best interests at heart

and wants to get to know me.

The second thing I learned in those clinics

is the availability of education.

Education from the folks behind the counter,

but also education from folks in the waiting room.

People I met were more than happy, as I was sitting next to them --

people like Robin --

to tell me about who they are, why they use medical marijuana,

what helps them, how it helps them,

and to give me advice and suggestions.

Those waiting rooms really are a hive of interaction, advice and support.

And third, the folks behind the counter.

I was amazed at how willing those people were

to spend sometimes an hour or more talking me through the nuances

of this strain versus that strain,

smoking versus vaporizing,

edibles versus tinctures --

all, remember, without me making any purchase whatsoever.

Think about the last time you went to any hospital or clinic

and the last time anybody spent an hour explaining those sorts of things to you.

The fact that patients like Robin are going to these clinics,

are going to these dispensaries

and getting that sort of personalized attention

and education and service,

really should be a wake-up call to the healthcare system.

People like Robin are turning away from mainstream medicine,

turning to medical marijuana dispensaries

because those dispensaries are giving them what they need.

If that's a wake-up call to the medical establishment,

it's a wake-up call that many of my colleagues are either not hearing

or not wanting to hear.

When I talk to my colleagues, physicians in particular,

about medical marijuana,

they say, "Oh, we need more evidence.

We need more research into benefits, we need more evidence about risks."

And you know what? They're right.

They're absolutely right.

We do need much more evidence about the benefits of medical marijuana.

We also need to ask the federal government to reschedule marijuana to Schedule II,

or to deschedule it entirely to make that research possible.

We also need more research into medical marijuana's risks.

Medical marijuana's risks --

we know a lot about the risks of recreational use,

we know next to nothing about the risks of medical marijuana.

So we absolutely do need research,

but to say that we need research

and not that we need to make any changes now

is to miss the point entirely.

People like Robin aren't seeking out medical marijuana

because they think it's a wonder drug,

or because they think it's entirely risk-free.

They seek it out because the context in which it's delivered and administered

and used,

gives them the sort of control they need over their lives.

And that's a wake-up call we really need to pay attention to.

The good news though is that there are lessons we can learn today

from those medical marijuana dispensaries.

And those are lessons we really should learn.

These are often small, mom-and-pop operations

run by people with no medical training.

And while it's embarrassing to think

that many of these clinics and dispensaries are providing services

and support and meeting patients' needs

in ways that billion-dollar healthcare systems aren't --

we should be embarrassed by that --

but we can also learn from that.

And there are probably three lessons at least

that we can learn from those small dispensaries.

One: we need to find ways to give patients more control

in small but important ways.

How to interact with healthcare providers,

when to interact with healthcare providers,

how to use medications in ways that work for them.

In my own practice,

I've gotten much more creative and flexible

in supporting my patients in using drugs safely

to manage their symptoms --

with the emphasis on safely.

Many of the drugs I prescribe are drugs like opioids or benzodiazepines

which can be dangerous if overused.

But here's the point.

They can be dangerous if they're overused,

but they can also be ineffective if they're not used in a way

that's consistent with what patients want and need.

So that flexibility, if it's delivered safely,

can be extraordinarily valuable for patients and their families.

That's number one.

Number two: education.

Huge opportunities

to learn from some of the tricks of those medical marijuana dispensaries

to provide more education

that doesn't require a lot of physician time necessarily,

or any physician time,

but opportunities to learn about what medications we're using

and why,

prognoses, trajectories of illness,

and most importantly,

opportunities for patients to learn from each other.

How can we replicate what goes on

in those clinic and medical dispensary waiting rooms?

How patients learn from each other, how people share with each other.

And last but not least,

putting patients first the way those medical marijuana dispensaries do,

making patients feel legitimately like what they want,

what they need,

is why, as healthcare providers,

we're here.

Asking patients about their hopes, their fears, their goals and preferences.

As a palliative care provider,

I ask all my patients what they're hoping for and what they're afraid of.

But here's the thing.

Patients shouldn't have to wait until they're chronically seriously ill,

often near the end of life,

they shouldn't have to wait until they're seeing a physician like me

before somebody asks them,

"What are you hoping for?"

"What are you afraid of?"

That should be baked into the way that healthcare is delivered.

We can do this --

we really can.

Medical marijuana dispensaries and clinics all across the country

are figuring this out.

They're figuring this out

in ways that larger, more mainstream health systems are years behind.

But we can learn from them,

and we have to learn from them.

All we have to do is swallow our pride --

put aside the thought for a minute

that because we have lots of letters after our name,

because we're experts,

because we're chief medical officers of a large healthcare system,

we know all there is to know about how to meet patients' needs.

We need to swallow our pride.

We need to go visit a few medical marijuana dispensaries.

We need to figure out what they're doing.

We need to figure out why so many patients like Robin

are leaving our mainstream medical clinics

and going to these medical marijuana dispensaries instead.

We need to figure out what their tricks are,

what their tools are,

and we need to learn from them.

If we do,

and I think we can, and I absolutely think we have to,

we can guarantee all of our patients will have a much better experience.

Thank you.

(Applause)