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Washington struggles with use of medical marijuana

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When Elliott Cain lived in California, staff at a marijuana dispensary there recommended a mild brand of marijuana that they said was effective at treating anxiety.

Cain, who had a doctor’s authorization to use marijuana as medicine, found it did just that, tamping down his anxiety without zonking him out.

But when he moved to Washington, medical marijuana was no longer an option. The only legal drugs he could access were prescription medicines that interfered with his sleep.

Cain wanted to know why it is legal to use medical marijuana to treat anxiety in California, but not OK in Washington where patients with other conditions such as cancer and HIV have had legal access to pot for more than a decade.

Cain posed his question to a special state panel that evaluates requests to add medical conditions to the list of those that can be treated with marijuana. The panel’s answer: There is no rigorous scientific evidence that marijuana is effective in treating anxiety.

But the answer also has as much to do with politics as science. Despite more than a decade of experience with marijuana as medicine, Washington’s relationship with cannabis and the community seeking to expand its use remains a troubled one.

For years, patients have complained that ambiguities in the state’s 1998 medical- marijuana law have made obtaining and possessing cannabis difficult, even scary. And while at least one state lawmaker is proposing to make it easier and safer for patients to obtain cannabis, no one has yet proposed a better way for the state board to decide which illnesses can legally be treated with marijuana.

In California, doctors can recommend pot for any debilitating illness for which it provides relief. Other states, including Washington, allow marijuana to be used as medicine only for specific medical conditions. Those conditions typically include diseases such as cancer and HIV, and other “terminal or debilitating” illnesses.

The state Medical Quality Assurance Commission has added only four medical conditions since 1999. To be added, new conditions must be approved by that board in consultation with the state’s Board of Osteopathic Medicine and Surgery.

For that to happen, someone has to petition the commission to add a specific condition, such as post-traumatic stress disorder. Members from each board schedule a joint hearing, review scientific literature, invite expert testimony, and take public testimony. A condition can be added only if a majority of the medical commission approve.

On paper, the process is a model of objectivity. But in reality, the board’s decisions are as political as they are scientific, a symptom of the lack of clinical studies involving pot. Even some of the people who serve on the medical-marijuana panel are exasperated with the process.

“It should be done in a different manner,” said Dr. Catherine Hunter, a Covington gynecologist who served on two panels that evaluated two medical-marijuana petitions despite what she said was her lack of expertise on the subject. “Medical decisions shouldn’t be made in a political arena,” she said.

The boards’ main responsibility is to establish and enforce licensing qualifications and police medical professionals.

Donn Moyer, spokesman for the state Department of Health under which both boards operate, said board members generally feel they lack the expertise to evaluate claims of efficacy, and because they’re making recommendations on a drug that is still illegal in America.

“It appears to me they’re uncomfortable in the role of deciding whether someone should have an illegal drug,” he said. “It’s an awkward place for people to be.”

Most of the evidence presented to the panel members comes in the form of anecdotes from patients or family members who say it helps them or their loved ones lead more normal, productive lives. Panel members have decried the lack of rigorous studies, even as they recognize that the drug’s illegal status has made it difficult to conduct the type of clinical trials that would provide more conclusive evidence of efficacy.

Without a large body of evidence, authorities in the 15 states and the District of Columbia that have approved medical marijuana tend to hew to a conservative line, lest they open the doors to more widespread use, said Allen St. Pierre, executive director of NORML (National Organization for the Reform of Marijuana Laws).

“It’s intellectual dishonesty,” St. Pierre said. “Their fear is of having these catchall diseases where so many people would potentially qualify. They’ve winnowed it down to fairly specific ones, and are rue to see the types of disease types where anyone can make the claim.” They tend to steer away from issues involving pain and mental health.

People hoping to gain legal access to cannabis by expanding the list of conditions in Washington state are in for an uphill climb against a medical establishment that has yet to embrace the concept of pot as medicine.

The executive director of the Washington Osteopathic Medical Association, for example, lodged objections to a patient’s request to add depression, social phobia and bipolar disorder to the list of approved conditions in November 2009.

The director, quoting a psychiatrist, wrote in an e-mail to the board that the request was “just a ploy for marijuana addicts to use more marijuana.”

Dr. George Heye, a medical consultant for the state Health Department, said the prevalence of depression and anxiety, and the availability of other effective treatments definitely comes into play when the commission makes decisions.

“The law requires hearings, and you have to make decisions on your best judgment: Is it safe or too risky?” Heye explained. “Depression is very common, and it is a backdoor way of thinking it would be legalized. But the whole issue of legalization is not part of the discussion.”

Heye said most decisions come down to competing opinions, and the opinions of medical people tend to carry greater weight because they represent a broader patient experience.

“I guess it depends on what the expert says, what other people in the panel happen to know or what they heard from people in the audience or people offering testimony at the hearing,” said Heye.

Heye acknowledged problems with the process, calling it “piecemeal.” But, he said, “The law was written, and we have to live with it. ”

Although the hearing process seems open-ended on paper, in practice it can seem more like theater where the outcome has all but been decided.

For example, when the board held a hearing to consider depression, anxiety and bipolar disorder in December 2009, they invited as their only expert witness Dr. Andrew Saxon, a well-regarded psychiatrist whose experience consists largely of treating and studying people with addictions.

Saxon serves as director of the Addictions Treatment Center at VA Puget Sound Health Care System and of the University of Washington’s addiction psychiatry residency program.

Saxon was recommended to the commission by Dr. Mick Oreskovich, who at the time ran a rehabilitation program for physicians and who expressed a dim view of the proponents in an e-mail to the commission. He wrote, “I find the attitude of those who propose the expanding use of marijuana to treat an increasing number of disorders to be cavalier, irresponsible and dangerous.”

Saxon was of like mind. When the commission asked him to serve as its expert at the hearing to add depression, bipolar disorder and anxiety to the list, he replied in an e-mail that he thought adding those conditions was “a horribly bad idea.”

In his testimony before the commission, he said there was no evidence that marijuana was effective in treating those mental conditions, and some evidence that it could be harmful. He suggested that the patients who told the commission that marijuana improved their lives could be drug addicts.

In an e-mail to Heye after the hearing, Saxon wrote, “I have no idea, of course, what the people who testified looked like, but their descriptions of their own lives did not make a good advertisement for the use of marijuana to treat mental illness. In fact, it was rather heartbreaking, and their plight made it very difficult for me emotionally to play the villain.”

Saxon reiterated that view in an interview Wednesday, saying, “I really don’t believe the state should be supporting the idea that marijuana is helpful for those conditions where there is no evidence.”

Saxon said his clinical experience treating people with addictions, and the informal review he did of scientific literature made him an appropriate person to serve as expert witness at the hearing. He said he was gratified that the commission’s decision to deny marijuana as a treatment for those conditions mirrored his own views.

It was the second time the commission rejected bipolar disorder and anxiety and the third time since 2000 that it voted against adding depression to the list. “I don’t know what the best process is,” Saxon said. “I can understand why the population wants to get its concerns addressed, but at some point, the state has to have the authority to make responsible decisions. It’s a matter of philosophy where you want to draw that line.”

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