At a recent reception, I was engaged in a conversation regarding how proposals to expand the prescriptive authority of physicians to solve certain public safety and social problems would not be practical, prudent and productive. A young physician succinctly summarized the discussion by stating, "I am off to the bar to get a glass of 'medical merlot.'"
The prudence of legalizing or decriminalizing marijuana as a recreational substance is a legitimate public policy debate. Tasking physicians with the responsibility to determine whether a substance with few -- and often vague -- medical applications is being sought for medical, recreational, dependency, diversion or commercial resale would require physicians to make difficult, "non-medical," public safety determinations for which they are not trained.
There are no such things as "medical marijuana," "medical merlot" or "medical tobacco"; they are myths or aberrations. For centuries individuals have been using these and other substances, including plants such as hogwort and figwort/foxglove, for medical purposes.
For a substance to be responsibly and competently prescribed/dispensed by a modern medical professional there must be an identification of the "active ingredients" (in the above cases croton oil and digitalis) as well as adequate knowledge of the medication's safety, efficacy, dose-response relationship, side-effects, etc. A medical professional prescribing/dispensing marijuana is acting at a responsibility/competency level equivalent to suggesting a cardiac failure patient try some figwort/foxglove. Although cannabis may have medicinal applications in its current, usually prescribed, "non-pharmaceutical" form, physicians would be asked to prescribe a "weed" without defined pharmaceutical parameters.
At its November 2013 House of Delegates meeting, the American Medical Association recognized and addressed the ineffectiveness, inequity and negative consequences of the current criminal justice system approach and penalties, e.g., incarceration, that govern personal possession of marijuana. They urged it be replaced with a "public health" approach that stresses such activities as expanded research, enhanced education regarding the harmful health effects of cannabis, increased and improved treatment of abusers and removal of discriminatory hiring practice.
However, the AMA continues to recognize cannabis as a dangerous drug constituting a serious public health concern and opposes its legalization at this time.
Pseudoephedrine is a defined pharmaceutical with legitimate medical applications that raises similar concerns. Symptoms and signs justifying its medical use are general and often vague. Physicians primarily would be asked to perform a law enforcement observation and interrogation function for which they have not been trained or equipped, assessing the probability that one might divert the drug to illicit (production of methamphetamine) use.
Without access to a registry of known diverters -- and aware a diverter might use a surrogate -- other than possibly unproven stereotyping (e.g., tattoos and piercings), there is little in the way of "medical" criteria to deny the diverter (or surrogate) such requested medications.
Such requirements would burden legitimate patients and physicians with the additional unnecessary hassle and expense of a doctor's visit, potentially decreasing the ability of patients to obtain illness relief in a timely and affordable manner and reducing the physician's ability to care for sicker patients. Actions in the past limiting or restricting the availability of certain medications, have led to the use of less effective, more harmful and more costly substances.
Illicit pseudoephedrine diversion and methamphetamine production is a serious public health and safety issue that calls for a public health and safety, not medical, strategy.
Physicians should be tasked with continuing to work with law enforcement, public safety, public health, pharmacy and other community agencies to develop and implement improved public health strategies to reduce diversion, as well as the use and abuse, of marijuana and other harmful substances.
Proposed expansion of prescriptive requirements for "medical marijuana," "medical merlot" or pseudoephedrine products will not help such development and implementation.Felsen, of Great Cacapon, is a public health physician.