Dr. Mikuriya's Observations

10 YEARS OF LEGALIZED MEDICAL MARIJUANA IN CALIFORNIA

Tod Mikuriya, MD (Berkeley), was the first California doctor to
monitor patients' use of cannabis systematically. In the early 1990s
his interviews with members of the San Francisco Cannabis Buyers Club
documented Dennis Peron's observation that people were
self-medicating for an extremely wide range of problems.

The broad range of applications confirmed what Mikuriya had learned
from his study of the pre-prohibition medical literature on cannabis,
and so when Prop 215 was being drafted, he urged that it apply not
only to people with a list of named conditions, but to those treating
" ... any other illness for which marijuana provides relief."

No sooner had Prop 215 passed than top California law enforcement
agents colluded with Clinton Administration officials and
Prohibitionist strategists from the private sector to plan its
disimplementation. On Dec. 30, 1996, Drug Czar Barry McCaffrey,
Attorney General Janet Reno, Health & Human Services Secretary Donna
Shalala, and the director of the National Institute of Drug Abuse,
Alan Leshner, held a press conference to threaten California doctors
with loss of their licenses, i.e., their livelihoods, if they
approved marijuana use by their patients. McCaffrey stood alongside a
large chart headed "Dr. Tod Mikuriya's, (215 Medical Advisor) Medical
Uses of Marijuana." Twenty-six conditions were listed in two columns.
("Migranes" was misspelled.) "This isn't medicine, this is a Cheech
and Chong show," he said. Reno said prosecutors would focus on
doctors who were "egregious" in approving marijuana use by patients.

Dr. Mikuriya watched the press conference on CNN at his home in the
Berkeley Hills. "As doctors become more fearful," he says. "I'll
obviously get more and more patients who are using cannabis or are
considering it. Will that make it seem that there's something
'egregious' about my practice? You bet it will!"

From the Attorney General's office in Sacramento a memo went out
from Senior Deputy AG John Gordnier to district attorneys in all 58
counties asking them to forward any cases involving Mikuriya. In due
course, on the basis of complaints from sheriffs, cops, and DAs,
Mikuriya was investigated by the medical board and found to have
committed "extreme departures from standard practice." He was placed
on probation and ordered to pay $75,000 for his own prosecution.

Over the years the number of cannabis specialists among California
doctors has risen slowly but steadily. In 2000 Mikuriya organized a
group, now known as the Society of Cannabis Clinicians, to share data
for research purposes. More than 20 doctors have become involved with
the SCC. Collectively they have approved cannabis use by an estimated
350,000 patients. This summer, with the 10th anniversary of Prop
215's passage approaching, I surveyed the SCC doctors get their basic
findings. Here are Dr. Mikuriya's responses to the survey he inspired.

Approvals issued to date: 8,684. Previously self-medicating: )99%
Category of use: Analgesic/immunomodulator 41%
Antispasmodic/anticonvulsant 29% Antidepresssant/Anxiolytic 27% Harm
reduction substitute: 4%

Results reported are dependent on the conditions and symptoms being
treated. The primary benefit is control without toxicity for chronic
pain and a wide array of chronic conditions. Control represents
freedom from fear and oppression. Control -or lack thereof-is a major
element in self-esteem.

With exertion of control, with freedom from fear of incapacity,
quality of life is improved. The ability to abort an incapacitating
attack of migraine, asthma, anxiety, or depression empowers.

Relief from the burden of criminality through medical protection
enhances a salutary self-perception.

Alteration in the perception of and reaction to pain and muscle
spasticity is a unique property of cannabis therapy.

Patient reports are diverse yet contain common elements. 100% report
that cannabis is safe and effective. Return for follow-up and renewal
of recommendation and approval confirms safety and efficacy.

Cannabis seems to work by promoting homeostasis in various systems of
the body. Its salient effects are multiple and concurrent. They include-

o Restoration of normal functioning of the gastrointestinal tract
with normalization of peristalsis and restoration of appetite.

o Normalizing circadian rhythm, which relieves insomnia. Sleep is
therapeutic in itself and synergistically helps with pain control.

o Easement of pain, depression, and anxiety. Cannabis as an
anxiolytic and antidepressant modulates emotional reactivity and is
especially useful in treating post-traumatic stress disorders.

Patients treated for ADHD: 92 Patients using cannabis as a substitute
for alcohol: 683. The slow poisoning by alcohol with its sickening
effects on the body, psyche, and family can be relieved by cannabis.

Medications no longer needed? Opioids, sedatives, NSAIDS
(non-steroidal anti-inflammatories), and SSRI anti-depressants are
commonly used in smaller amounts or discontinued. These are all drugs
with serious adverse effects. Opioids and sedatives produce
depression, demotivation, and diminished mobility. Weight gain and
diminished functionality are common effects. Cognitive and emotional
impairment and depression are comorbid conditions. Opioids adversely
effect vegetative functioning with constipation, dyspepsia, and
gastric irritation. Pruritus is also an issue for some. Circadian
rhythms are disrupted with sleep disorders and chronic sedation
caused by these agents. Dependence and withdrawal symptoms are more
serious than with sedatives.

Opioids are undoubtedly the analgesic of choice in treating acute
pain. For chronic pain, however, I recommend the protocol proposed by
a doctor named Fronmueller2 to the Ohio Medical Society in 1859:
primary use of cannabis, resorting to opiates for episodic worsening
of the condition. Efficacy is maximized, tolerance and adverse
effects are minimized. (Neither cannabis nor human physiology has
changed since 1859.)

NSAIDs can be particularly insidious for those who do not immediately
react with gastric irritation and discontinue the drug. Chronic
irritation with bleeding may produce serious morbidity. Most often,
the dyspepsia produced is suppressed with antacids or other
medications. Many patients tolerate acute intermittent use but not
chronic use. SSRIs, if tolerated, coexist without adverse interaction
with cannabis. Some SSRI users say cannabis is synergistic in that it
treats side effects of jitteriness or gastrointestinal problems.

Many patients report pressure exerted by the Veterans Administration,
HMOs such as Kaiser Permanente, and workers' compensation program
contractors to remain on pharmaceutical regimens. A significant
number describe their prescribed drugs as ineffectual and having
undesirable effects. "Mainstream" doctors frequently respond to
reports of adverse effects by prescribing additional drugs. Instead
of negating the problem, they often complicate it. Prevailing
practice standards encourage polypharmacy -the use of multiple drugs,
usually five or more.

Out of the ordinary conditions? While all pain reflects localized
immunologic activity secondary to trauma or injury, the following
atraumatic autoimmune disorders comprise a group of interest: Crohn's
disease Atrophie blanche, Melorheostosis, Porphyria, Thallasemia,
Sickle cell anemia, Amyloidosis Mastocytosis, Lupus, Scleroderma,
Eosinophilia myalgia syndrome. These are all clearly of autoimmune
etiology, difficult to treat. Specific metabolic errors such as
amyloidosis and certain anemias warrant further study and may
elucidate the underlying mechanisms of the illnesses and the
therapeutic effects of cannabis. Multiple sclerosis with its range of
severity varies in therapeutic response to cannabis.

Demographics: male patients, 72; female, 28%. Women are more likely
than men to use cannabis for psychotherapeutic purposes (32% to 18%).
Men are more likely to use for harm reduction (4% to 1%). A roughly
bell-shaped curve describes the age of my patients. 0-18 years, 1%;
19-30, 19%; 31-45, 36%; 45-60, 37%; older than 61, 7%.

Additional Observations:

Proactive structuralism works. Meaning: people can create something
and by doing so, set a precedent.

Medical cannabis users are typically treating chronic illnesses -not
rapidly debilitating acute illnesses.

The cash economy works better than the bureaucratic alternative. Word
of mouth builds a movement.

The private sector is handling marijuana distribution because the
government has defaulted.

Cannabis was once on the market and regulated, then it was removed
from the market and nearly forgotten.

Not all that we've learned in the past 10 years is new.

Once upon a time the California Compassionate Use Act of 1996 became
the law of the state. We had the mistaken belief that civil servants,
sworn to uphold the law, would set about implementing the new section
of the Health & Safety Code. Hardly... Twenty California doctors have
been investigated by the Medical Board for approving cannabis use by
their patients. Limited immunity from prosecution for physicians was
either proclaimed invalid or, more commonly, evaded by the Board and
the Attorney General. They dissimulate, pretending that it is not the
physician's approval of marijuana at issue, but his or her standard
of practice. They then hold cannabis consultants to a standard that
most HMO doctors violate constantly.

The fix is in. The state criminal justice entities share information
and operate in concert with the DEA. There has been a total end run
around the injunctive protection of the Conant ruling. [In Conant, a
federal court enjoined the government from threatening doctors who
discuss cannabis as a treatment option with patients.] General media
indifference enables this RICO under color of authority and the
continuing defiance of the will of Californians who spoke ten years ago.

This is counterbalanced by the rewards of helping patients with
serious chronic aliments who have adverse experience utilizing
so-called main stream medicines.