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April 26, 2006

NORML Aftermath

This is the first entry since the ‘06 NORML Convention (San Francisco  from 4/20-4/22) ended. From now on, I intend to post more often and expect to have more time to do so,  because I will be spending less of it trying to  persuade 'organized reform’ to see the complex issues involved from my perspective. Since I know from experience that patients are far more likely to ‘get’ the things I'll be writing about, it makes a lot more sense to to focus my educational efforts on them through the blog.

Last week’s NORML meeting provided the last bits of evidence  needed to reach that conclusion. As is often the case, one item came from an unexpected source; the other came from a plan I’d hit on only after a last minute invitation to participate in a  panel on 'clincal use' of cannabis.

First the unexpected source: it was a brain-dead and ill-considered press release emanating (no other word suffices) from the FDA on Thursday, April 20, allegedly in response to a request from Rep. Mark Souder of Indiana. Whatever the truth of that claim, the timing  coincided with the first day of NORML; that some commentators apparently missed that obvious connection does not inspire much confidence in their abilities. As noted, the press release itself provided some key data; but in a completely negative way: it was simply florid propaganda echoing a former drug czar’s obvious attempt to spin the 1999 IOM report he'd requested— but then been disappointed by— because it (timidly) repudiated 2 key items of drug war dogma:  first, that “marijuana” has unique therapeutic value for at last some patients;  second there’s no compelling evidence to support that the idea that it leads people to try/use other drugs (“gateway” effect).

Thus the ballhooed 'report' was merely repetition ot a medically untrained general's opinion from seven years ago–– entirely without supporting evidence. What it actually demostrated how just how far the credibility of the FDA has fallen. That s commentators were oustspoken enough to recognize that fact and take them to task was encouraging; as was the simultaneous and unrelated concession by a hard core Right Wing SF journalist that pot has medical value.

As for the meeting itself; on Friday evening, I attended a hosted, but informal, dinner conclave of nominal ‘reform leaders’ where the main agenda item was to be medical marijuana framed in a context which had originally been ‘recreational’ versus ‘medical.’ Just before the dinner, I’d learned that ‘social’ had been substituted for 'recrational.’ No objection. I still don’t see the difference; but no objection. As for ‘medical’ I have always understood that to mean prescribed by someone with a medical license— as opposed to used on the person’s own judgement.

The point I wanted to make was that ‘medical’ has picked up so much baggage in the context of pot that there is no chance of any consensus ever emerging. In fact, anyone with much clincical experience in the practice of medicine will tell you that there is constant bickering and disagreement among physicians over the best treatment of certain conditions/problems/diseases. That’s the nature of the beast. Most clinical encounters begin with SYMPTOMS (patient complaints). The doctor then comes up with a working diagnosis and  has to decide how far to go in confirming it (ruling it ‘in’ or ‘out’). It’s a complicated algorythm which can vary with a host of factors; not the least of which is setting. For example, a GP who has known the patient for years is going to be a lot less worried when someone who has always exaggerated their physical symptoms complains of a new one— at least at first. On the other hand, an ER physician, who has never seen that patient before and won’t be able to conduct a follow-up,  might feel the need to order hundreds (or even thousands) of dollars worth of tests— mostly for his own protection against a possible law suit.

That’s one of the key reasons an ER is a bad place to go with minor or vague new complaints. The hardcore uninsured have no such billIng worries, and must be dissuaded by other means— such as long waiting periods in ERs. I’ve wandered off-topic, but I hope I've left you with a feeling for what the working MD gets paid to do: exercise clinical judgement. Now, I'm off across the Bay to exercise some clinical judgement of my own. The next entry will why I think the FDA fiasco may point toward a key strategy change that 'reform' should adopt; I will also describe more adventures at NORML '06.

Doctor Tom

Posted by tjeffo at April 26, 2006 11:14 PM


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