Medical Cannabis in the Empire State: It's Right and It's Respectable

Granting New York physicians, PAs and NPs the authority to certify appropriate patients with debilitating conditions to use marijuana medicinally is the right thing to do.. Here's why I, as a resident physician, think so.

Some 15 percent of all physicians in the United States make their way to New York -- more than any other state -- to complete residency training, the multi-year mostly hospital-based training doctors complete after graduating medical school. Two years ago, I became one of them in the field of Physical Medicine and Rehabilitation, a medical specialty that focuses on restoring or maximizing function and improving quality of life for patients with pain and chronic or temporary disability. While I am not yet able to function as a fully independent practitioner, I came to New York with a significant amount of clinical experience, published research, and scholarship under my belt on the medical uses of cannabis-marijuana, a result of the dual degree MD/Ph.D. route I took in medical school which gave me the opportunity to design and conduct independent research with human subjects. Given that the state legislature is again considering bills to make New York the 19th state in the country to formally allow medicinal use of cannabis, I'd like to share some of my experiences studying and working within a medical marijuana health system and how I have been received as a medical resident in the Empire State.

First, a bit about my qualifications. "The medical geography of cannabinoid botanicals in Washington State: Access, delivery, and distress" was the title of my PhD dissertation that I wrote as a National Science Foundation Graduate Research Fellow as part of the National Institutes of Health (NIH)-supported Medical Scientist Training Program at the University of Washington. It involved a two-armed study of 176 chronically ill patients with qualifying conditions using cannabis under medical authorization. Subjects enrolled in the study under the protections of federally-issued Certificates of Confidentiality, utilized for the first time for this class of subjects. They collectively had 374 years of state-authorized medical marijuana use. Using medical records review, surveys, interviews, observation, and critical literature review, I documented patient health-related quality of life, varieties of chronic pain syndromes being managed, levels of psychosocial and legal distress, and other indicators, and made comparisons to previously studied populations. Nearly all sections of this research have now been published in peer-reviewed medical journals as a series of 6 articles (with the final one 'in press'), which I am pleased to say have received some recognition in the academic and medical community in the form of citation in journal articles and one textbook. Moreover, the American Academy of Physical Medicine and Rehabilitation has invited me to speak on a panel on cannabis and pain at their 75th anniversary annual assembly this year and the American Academy of Hospice and Palliative Medicine gave me a poster award this year for my poster on cannabinergic pain medicine.

In addition to such research and study, I have worked to change outmoded federal laws which restrict medical use and human research with cannabis. As a medical student delegate, I brought the issue of medical cannabis policy reform to my state medical association and to the American Medical Association (AMA) in the form of a resolution, which led to the commissioning of a report. I served as an external reviewer on that 2009 AMA report which 1) acknowledged the gold-standard (that is, randomized, double-blinded, placebo-controlled) clinical trials evidence base and mechanistic rationale supporting the medical efficacy of cannabis for pain, symptom control in multiple sclerosis, and wasting syndromes and 2) concluded by urging the federal government to review of its classification of marijuana as a Schedule I drug. This is an ill-fitting categorization reserved for drugs/substances which have no currently accepted medical use in treatment in the United States and no acceptable level of safety for use under medical supervision. This position was ultimately adopted by the AMA House of Delegates in November 2009, but there has as yet been no change in the federal classification of marijuana. Hence there is a pressing need for state governments to pick up the slack and protect the health and well-being of their populations by allowing cannabis to be legally used medicinally.

Stigma is the foremost issue to address within medical and other professional circles which impedes clear thinking and advancement of cannabis therapeutics. Stigma fuels lack of knowledge, maintains illegality, and leads to medical neglect. At the large academic medical center in New York City I train at, I see numerous opportunities in which patients presenting with difficult-to-manage pain syndromes, abnormally increased muscle tone, and movement disorders could be counseled about the potential benefits medicinal use of cannabis, a very safe herbal cannabinoid botanical drug, could afford them. The fact of the matter is that medicinal use of cannabis is a 'hot' and 'cutting edge' area in medicine, in part due to the entirely novel molecular signalling system that was discovered as a result of research conducted to understand how cannabis interacts with the human body. This system is a master-regulator for mood, appetite, memory, muscle tone, pain perception, inflammation, and many other functions, and its discovery is truly Nobel-prize worthy and will lead to many medical breakthroughs. But the power of over seven decades of marijuana prohibition enforcement with tens of millions of arrests and draconian sentences meted out can chill and stifle even the wonders of medical discovery and advancement. But thankfully the chill is beginning to thaw as rationality and compassion slowly prevail over ignorance and prejudice.

Physicians' engagement in health justice advocacy is in line with the AMA's long-standing principles of medical ethics which call on physicians to work to change laws which are contrary to the best interests of patients. In the hopes of encouraging others, I wish to demonstrate through my own matching and standing in a well-ranked New York residency program that my interest in medical marijuana which I openly wrote about in my application and discussed in admission interviews was not a liability, but rather an asset. This was especially so given that the program I joined is open to complementary and alternative medicine and had even featured on their list of important articles in the field a review on the role of cannabis in the management of neurological disorders. In my personal statement, which was part of my application to join residency, I wrote:

In my research, I studied patients with marked dysfunction and disability secondary to, for example, multiple sclerosis or major traumas, who used cannabinoid botanicals under medical supervision to ease pain and other symptoms. In getting to know these chronically ill patients in their own home and community environments, I began to see improving quality of life and maintaining as much function as possible as valuable medical care goals in and of themselves which mattered most to the hundreds of patients I studied.

Chronic pain is a pandemic that holds back individuals, families, and often whole communities from their full potential. With inadequate pain management, careers fade away and lives fall apart. Some become and remain non-functional for life while others deteriorate due to medication toxicity, accumulated over years. One area that holds great promise for pain relief is cannabinoid medicine, which has advanced at a dizzying pace in recent years. In the peer-reviewed literature, there are now over 16,000 articles on the chemistry and pharmacology of cannabinoids and cannabinoid botanicals, and over 2,000 on the endogenous cannabinoid, or endocannabinoid, signaling system. The endocannabinoid system has become an important therapeutic target as it has been found to modulate pain, mood, appetite, inflammation, muscle relaxation, and memory, amongst other vital functions. Its presence helps to explain why cannabinoid-based approaches have been shown to relieve pain in virtually every experimental model. For example, the mechanism of analgesia of cannabinoid botanicals is centered at their activity at cannabinoid receptors, the most abundant G-protein coupled receptors in the brain, also expressed on peripheral nociceptors, spinal interneurons, immune cells, and other tissues. Having familiarized myself with this literature through independent study, mentorship, conferencing and journal club attendance, I chose to devote a significant portion of my doctoral research towards helping bridge the current translational gap between research findings and clinical applications of cannabinoid medicines. I have brought these and other research findings to the attention of national medical societies and policymakers.

cannabinoid medicine...could bring advances to rehabilitation, not only in pain management, but also neuroprotection, stroke recovery, and disease modification

I have also been invited for a clinical fellowship in Hospice and Palliative Medicine at the National Institutes of Health (NIH) Clinical Center, indicating that even leading clinicians and researchers at America's largest hospital dedicated to clinical research are comfortable with accepting a fellow who studies patients treated with medical cannabis. Surely New York is ready to move beyond stigma and do what's right and respectable.

Disclaimer: The views expressed here are my own and not those of my employer or any organization I am affiliated with.