MEDICAL MARIJUANA ADDS CRIMP TO LIVER TRANSPLANT ELIGIBILITY

A new twist in a long-running debate within the transplant community:
Should people whose use of drugs or alcohol may have contributed to
liver problems be candidates for transplants? And if so, how long
should they be clean before becoming eligible for a new organ?

LOS ANGELES - Norman Smith, who has liver cancer, was placed on the
transplant list at Cedars-Sinai Medical Center last year.

But early this year, doctors removed him because he was using medical
marijuana and failed to show up for a drug test.

To get back on the list, Smith, 63, has to spend six months avoiding
medical marijuana, submitting to random drug tests and receiving
counseling. He is still undergoing chemotherapy and radiation for the
cancer, which recently returned after being in remission. Smith has
asked Cedars-Sinai to reconsider and reinstate him.

"It's frustrating," he said from his home in Playa del Rey. "I have
inoperable cancer. If I don't get a transplant, the candle's lit and
it's a short fuse."

Smith's case highlights a twist in a long-running debate within the
transplant community: Should people whose use of drugs or alcohol may
have contributed to liver problems be candidates for transplants? And
if so, how long should they be clean before becoming eligible for a new organ?

With the ubiquitous presence of medical marijuana, doctors say
patients like Smith who have prescriptions increasingly are showing
up at transplant centers seeking new livers. Statistics on such
requests aren't available, but experts agree the prescription
medical-marijuana cases are forcing doctors to revisit medical and
ethical questions surrounding drug use and transplantation.

There is no standard on transplants regarding the use of medical
marijuana or other drugs, according to the United Network for Organ
Sharing, which manages organ transplantation for the U.S.

Instead, transplant centers make their own decisions on which
patients are the best candidates for new organs, meaning policies
vary from center to center.

'Social' or 'medical'?

Livers are highly sought-after organs. More than 16,000 people are in
line for livers nationwide and the average wait is about 300 days,
according to the network.

"We have to do a prioritization, like you literally do on a
battlefield - who can die and who can survive, because we don't have
enough livers," said Dr. Goran Klintmalm, chief of the Baylor
Regional Transplant Institute and an expert in liver transplantation.
"As long as we have patients who die on the list waiting for organs
. is it right to give (to) patients who have a history of drug use?
You can discuss until the cows come home if it is social marijuana or
medical marijuana."

Transplant doctors said one of the main concerns is compliance with a
complicated regimen of post-transplant medications.

"If you are drunk or high or stoned, you are not going to take your
medicine," said Dr. Jeffrey Crippin, former president of the American
Society of Transplantation and medical director at Washington
University in St. Louis.

Cedars-Sinai spokeswoman Sally Stewart said federal law prevented her
from talking about Smith's case.

"Our concern is strictly for the health and safety of our patients," she said.

Prescriptions suspect

At Cedars-Sinai, if patients who need a transplant initially test
positive for marijuana, they can still be listed but must sign a
statement agreeing not to use the drug. Then, if they fail a random
drug test or don't show up for one, they are bumped from the list.

"There have to be guidelines in order to give people the best chance
at surviving a transplant," Stewart said.

UCLA Transplantation Services has an even stricter policy, requiring
six months of sobriety before a patient can be listed. Dr. Douglas
Farmer, a transplant surgeon and surgery professor at UCLA, said that
drug and alcohol use is a "huge issue" and that patients on medical
marijuana have also come to UCLA seeking transplants.

Farmer said, however, that many patients with medical-marijuana
prescriptions are not "legitimate," and transplant surgeons can't
risk wasting a precious organ on someone who is going to continue
abusing alcohol or drugs. "There are a significant number of people
who come in for liver transplants who have a substance-abuse history," he said.

Any delay in getting Smith a new liver could mean the "difference
between life and death," said Joe Elford, an attorney with the
medical marijuana advocacy group Americans for Safe Access, which is
representing Smith and considering a lawsuit against the hospital.

Smith's oncologist, Dr. Steven Miles, an attending physician at
Cedars, refilled the prescription for medical marijuana to manage his
patient's pain. Miles, who is in private practice, agreed that by
missing his drug test Smith raised concern about his patient's
post-transplant compliance with medical instructions.

Nevertheless, Miles said his patient will die without a new liver.
"Without a transplant, it is basically 100 percent fatal," he said.
"It's just a matter of time."

Smith, a former precious-metal trader, acknowledged that he didn't
follow the rules. He said he used medical marijuana after having
unrelated back surgery and weaning himself from prescription pain
pills. "I was in extreme pain and physical anguish," he said.

In April, he wrote a letter to the head of the liver transplant
program at Cedars, Steven Colquhoun, asking to be re-listed.

Smith, a recovered alcoholic, said he used marijuana recreationally
in the past before getting a prescription for medical marijuana. He
also has cirrhosis of the liver and previously had hepatitis C. Smith
said he stopped using marijuana in August and is attending Alcoholics
Anonymous meetings to satisfy his counseling requirement.

Smith is hopeful that he will get a transplant in time and that his
fight will raise awareness for others with medical-marijuana
prescriptions. "That's why I am going through this challenge, at the
very least to make it easier for the next guy," he said.