D.C. COUNCIL APPROVES MEDICAL MARIJUANA, POSING CHALLENGES FOR DOCTORS

For doctors such as Pradeep Chopra, long accustomed to prescribing
carefully tested medications by the exact milligram, medical marijuana
presents a particular conundrum.

On Tuesday, the D.C. Council gave final approval to a bill
establishing a legal medical marijuana program. If Congress signs off,
District doctors -- like their counterparts in 14 states, including
Rhode Island, where Chopra works -- will be allowed to add pot to the
therapies they can recommend to certain patients, who will then eat
it, smoke it or vaporize it until they decide they are, well, high
enough.

The exact dosage and means of delivery -- as well as the sometimes
perplexing process of obtaining a drug that remains illegal under
federal law -- will be left largely up to the patient. And that,
Chopra said, upends the way doctors are used to dispensing medication,
giving the strait-laced medical establishment a whiff of the
freewheeling world of weed.

Even in states that allow for marijuana's medical use, doctors cannot
write prescriptions for it because of the drug's status as an illegal
substance. Physicians can only recommend it. And they have no control
over the quality of the drug their patients acquire.

"I worry about that," said Chopra, a pain medicine specialist. "That's
what's throwing a lot of [doctors] off."

The District's measure, like those elsewhere, specifies certain
conditions and illnesses that qualify for medical marijuana. A patient
who has HIV, glaucoma, multiple sclerosis, cancer or a chronic
debilitating condition will be able to receive a doctor's
recommendation to possess up to four ounces in a 30-day period.

Unlike in many states, the District law would not allow patients and
caregivers to grow their own marijuana, at least initially; an
advisory committee would later decide whether to permit cultivation.
Until then, patients could only acquire the drug illegally or from
five to eight government-regulated dispensaries.

The bill goes to Mayor Adrian M. Fenty (D), who is expected to sign it
and send it to Congress, which has 30 days to review the measure
before it becomes law.

In the District, physician reaction was mixed.

Internist Mahmoud Mustafa said a few of his sickest HIV patients
already smoke marijuana to ease pain and stimulate appetite. "I think
it'd be great," he said. "I don't have to worry about [my patients]
being arrested."

Hunter Groninger, medical director for palliative care at Washington
Hospital Center, said he would be uncomfortable recommending marijuana
because the medical community doesn't know enough about its benefits.

Because there are no uniform standards for medical marijuana, doctors
have to rely on the experience of other doctors and their own
judgment. That, they say, can lead to abuse.

In California, "quick-in, quick-out mills" that readily hand out
recommendations have proliferated, worrying advocates, including Frank
Lucido, a physician who spends half his time evaluating patients for
medical marijuana. The state, the first to legalize medical marijuana
14 years ago, allows for a wider range of conditions, including anxiety.

To guard against abuse, some doctors say they recommend marijuana only
after patients exhaust other remedies. Some doctors perform drug tests
as part of pre-screenings.

Under Michigan's law, all 200 of Sandro Cinti's HIV patients at his
University of Michigan clinic would qualify for marijuana. But in the
year since the law took effect there, he has signed off on just three
or four patients suffering extreme pain in their fingers and toes.

Cinti, an infectious disease specialist, said some patients have
acknowledged using marijuana all along for pain relief and weight
gain, smoking it two to five times daily. He counsels them about
adverse effects, including impaired mental state and lung disease.
"We're using it as a last resort in patients who have not had any
relief with anything else," he said.

If the experience of doctors from other states is any guide, some
District doctors might be slow to recommend the drug -- and some
patients reluctant to take it.

Chopra has approved the drug for five patients since Rhode Island's
program began four years ago, he said. He recently turned down a
request from a man in his 40s complaining of back pain. The man said
he had tried chiropractors and physical therapy, but Chopra found no
documented evidence. The patient then asked for a medical marijuana
recommendation. Chopra refused.

Some patients decline the drug, he said, for fear of sending the wrong
message. Last week, when he suggested pot to a patient after narcotics
and surgery had failed to ease excruciating head and facial pain, she
broke down in tears.

Her teenage son uses marijuana and she wants him to stop, she told
him. " 'How am I going to look if I start taking it?' " he recalled
her saying.

When Chopra suggested that another patient, Ellen Smith, 60, try
marijuana three years ago, she was reluctant, as was her primary-care
doctor. She is in constant pain from a rare degenerative disorder and
is allergic to most pain medication, so there were no other options.
She asked her four grown sons for help procuring the drug.

She now grows her own plants, grinds the buds to a powder that she
adds to heated olive oil and mixes with apple sauce. Two teaspoons,
strained, lets her sleep through the night.

"I don't look at this as pot: It's my lifeline," she
said.

Some doctors describe finding themselves acting as intermediaries in
families that have mixed feelings about marijuana use. Todd Handel, a
Rhode Island rehabilitation specialist, recalls recommending marijuana
to Chris Snow, 23, who has spina bifida and used the drug as a
teenager. Yes, he would get stoned, Snow said, but pot also made the
pain bearable. Only after consulting with Snow's mother and father --
a police sergeant -- did Handel recommend marijuana.

Snow, who lives with his parents, grows 12 plants -- the state's
maximum allowed -- in the basement. He uses a vaporizer that heats the
drug, releasing a mist that he inhales four breaths per session, two
to three times a day.

His father, who did not want to be identified, said he was conflicted
about his son's marijuana use initially, as was Snow's older brother,
also a police officer, who moved out of the house in protest. But the
father now supports the son because he is doing much better.

Still, Handel says he wishes he had more knowledge about marijuana and
more control over dosage. But, like his patients, he is figuring
things out as he goes along. "There isn't one dosage that works for
everybody," he said.