Daniel

I never have met Dan’s mother but w have talked on the phone a good bit and by email. It was in one of those first written notes that she got my attention. I was riveted on her words.

“ Al, I gave the Marine Corps a fine young man, eager to serve his fellow Marines and his country and look what they gave me back”.

His mom has a full length cardboard cutout of her son in his full dress blues. It is a picture of the poster Marine, the one chosen to visually exemplify the rest. Sergeant stripes and combat action awards proudly worn. A newer cardboard cutout would show a demoted and fined corporal, racked by prescription drugs.

Pain drives his day from an explosion in Iraq. He is consumed by it. He’s a smart guy I judge from the many phone calls we have shared. He wants badly to work, to share his future life as an equal partner. His wife he credits with helping him adjust to living with PTS(d) and dealing with the non supportive KY facility. They were married in July of 2011 in simple ceremony and with his black Labrador Retriever work together toward their goals.

When the State of Oregon first opened their cannabis door for approved patients 70% of those initially applying wanted cannabis for pain. Trauma pain, arthritis, phantom pain, joint pain such as fibromyalgia, rheumatism, more. Now it hovers near 80%.

His physical pain is in his back. It will be there for his life. The explosion also caused traumatic brain injury (TBI), and as has become increasingly known from studying the history of multiple traumas, Dan has been diagnosed with Post Traumatic Stress (PTS).

During the recovery period from his physical wounds he found cannabis, used cannabis and it helped him – a lot. He was an active duty Marine subject at any time to a urine test not because he was deficient or had a negative attitude, or that he was acting abnormally for the uptight group but because.

I do not know what else to write about this test on Dan. Just – because – that’s what our country does now. Clinics, test labs, technicians, trucking companies, governments, multiple levels of business, national and international now spend billions of years of labor and dollars checking urine to prove only that the person in question did or did not use some prohibited substance recently. Other than the money flowing through that spigot the whole activity is illogical but it sure does let the worker know he or she is owned, controlled. Pretty close to military life.

He was doing well. Sure he hurt but it was bearable and he had hope- then- that prescription drugs and physical therapy and his youth would bring him to a functioning level or better. A urine test was announced and he told the Marines to save some money because he smoked pot and it helped him. Please help me he said.

He was “written up” for using an illegal substance, fined and demoted. He was placed on chemical drugs all while at a wounded warrior battalion in NC. Here he turned into a chemically induced zombie. Anger, confusion, terror, unconsciousness became his norm. The wounded with him did what you would expect, they protected and watched their buddy closely. They know that world of terror, wanting, needing it all to just go away. They saw the signs. He attempted to shoot himself in the head. The Marines stated that there were no suicides or attempted suicides that year at that command. His mother in KY was called and she and her husband were on the road. They drove straight through the night. Dawn saw them and the Officer in Charge of the wounded arrive.

By noon Dan and his parents were gone from the Marine base, going home to KY. He was not discharged but placed in the care of his family.

Nothing is ever over when you hurt day and night, and the terror inhabits your head. It’s worse when your two tours in Iraq as a rifleman are dismissed as irrelevant to your emotional health by demoting you from earned rank and fining you as though you brought this nightmare upon yourself and you should pay for getting ordered to the wrong place at the wrong time.

Twenty years ago as a Vietnam Vet and combat counselor I lectured in meetings with health care professionals in Virginia where I was educating them about post traumatic stress. I stressed dropping the “D”.

“Please drop the D. I know it is a medical term but it is inappropriate, it’s insulting. These men and women are reacting normally to a completely abnormal set of traumatic experiences. Theirs is a normal reaction and you all must accept that as reality.” Call it a “response syndrome” to trauma. Change the medical terminology so that words “do no harm”.

I also found in those years it was normal for a Vet to use cannabis to calm him, to sleep, to eat, to give up hard drugs, to reduce or end alcohol use. Twenty years have passed and yesterday I spoke briefly with a man, now a senior law enforcement official in NC, who had in the past worked for 5 years in a VA hospital.

“It was everywhere in the hospital. We all knew what they were smoking and why. It was OK with everybody.”

It has not been OK for Dan. The VA hospital in Lexington, KY has refused to prescribe opiate based pain killers to him because of his past cannabis use as an active duty Marine and his continued use. The half dozen, non-opiate based chemicals they did try on him failed.

My call is that the VA system and the Marines failed Dan not the other way around.

It is flat unethical to deny pain medication for anybody let alone someone known to be a severely injured US warrior. That is what has been done without excuse. It’s the hospital policy to deny opiates to known drug addicts an ER MD told Dan two weeks ago. Addict?  It’s right here in your Marine record that you used cannabis and are therefore an addict. I cannot help you.

I co-founded a Veterans service organization, Veterans for Medical Cannabis Access for exactly the behavior exhibited by this VA facility. Behavior, aberrant, illogical and demonstratively damaging to another human being I always thought was worth worrying about. Urine testing for such action could be justified but is not in this case. The Commanding Officer who allows this type of judgment, actually a lack thereof to prevail needs the test not a “grunt” in pain.

I have a letter in my possession written by the Undersecretary for Health, Department of Veterans Affairs, dated July 06, 2010 addressed to my co founder of VMCA, in part it reads…

“This is a follow-up response to your letter requesting clarification of the Veterans Health Administration’s (VHA) policy regarding the practice of prescribing opioid therapy for pain management for Veterans who provide documentation of the use of medical marijuana in accordance with state law.” (State law is an important factor now in treatment for all Veterans regardless of duty period or medical problem. I call it treatment by geography. A completely new medical concept, never tried before in human history, being experimented with on the wounded.)

He continues, “If a Veteran obtains and uses medical marijuana in a manner consistent with state law, testing positive for marijuana would not preclude the Veteran from receiving opioids for pain management in a Department of Veterans Affairs (VA) facility.”

Dan did not in the Marines and does not obtain cannabis legally now in KY.  If KY were to allow cannabis used clinically Dan would be OK.

Who or what do you want to blame for this travesty?  The CO for being a bureaucrat instead of a doctor. Kentucky politicians for being feckless cowards. The ER physician for sending a man in pain out on the street. His case worker at the VA for being a lemming instead of a real advocate. The entire Congress of the United Sates for sending the youth off to war and then abandoning them because they smoked a joint? They all could be stand up humans but are not. Dan stood up and they could treat him as a role model instead they don’t treat him at all.

Dan did two tours in Iraq. He did them both with Larry. The first tour for them physically was a pass. Men died around them, the smell of rot filled their senses, doubt filled their soul, heat, boredom and sudden terror filled their days but they were physically OK. During the second tour the world as they knew it ended forever for Dan and Larry, Marines.

Each was blown up by an IED, what we called in Nam a mine, built out of unexploded bombs from aircraft, or scavenged containers, and scraps of wire and filled with nails and glass and metal pieces and exploded with stolen C4 or old ordinance buried until needed.

They were both returned to duty and continued to patrol as before, but this was before TBI and the resulting potential for PTS was considered a wound.  After returning to the US Dan was treated for PTS and cannabis use at a six week inpatient facility under Marine care.  Months later there was a “failed” urine test, cannabis use, at the VA hospital and without an explosion, instead a mendacious, illogical “policy”, a myth according to the Undersecretary, changed Dan’s life again and again for the worse. No pain control for a Marine in pain. “Support the Troops.” Picture all the yellow ribbons.

Larry was a California guy and returned to his home state after his discharge. He was and is treated in a VA hospital in that state. In California, its citizens voted to allow all residents to use cannabis therapeutically under medical supervision. The VA Undersecretary for Health as you have read has directed that opiate treatment be provided in VA facilities in “legal” states at the discretion and based on the judgment of the individual patients’ needs and the attending physician, NP or PA. Larry is registered cannabis patient and is treated for his pain with opiates. He is attending college.

On the phone Dan said to me, “Al, Larry and I were shot at by the same people. We shot at the same people. We got blown up by the same kind of bomb. The shrapnel I carry in me is the same shit that Larry carries in his body. Why won’t they help me?”

Riveting.                                              Al Byrne for Patients Out of Time

Blowing Off Blown Up Vets

(Al Byrne is a retired Naval officer who gave 24 years service to his country. He served as the Secretary-Treasurer and Chief Operating Officer of “Patients Out of Time” and has been certified by the DEA as a published expert on medical cannabis issues. He served on the Board of Directors of NORML from 1989 until 1994 while also serving as the US Representative for patient advocacy to the International Academy of Cannabis Medicine.)

I’m a therapeutic cannabis advocate so I am biased about the subject of cannabis. I’m a Veteran (1) and I’m biased about those folks as well. I write not of bias but of ignorance, not about doing a job but of not doing what is correct, injustice and collecting money, of yellow ribbons and black souls.

As a Vet who served in Vietnam, for a year of the 24 I wore the US uniform, I joined the VFW- Veterans of Foreign Wars.  As a member of the military that served over several periods of service that encompasses their regulations I joined the American Legion. So did my wife a Vietnam era US Navy Nurse. Ask any wounded survivor of that horror and they’ll tell you about the nurse they fell in love with during the surviving time.

Well I fell in love with my nurse but it wasn’t wounds that brought us together or maybe it was. An invisible wound. I did not bleed in Nam.

The VA determined in 1987 that I suffered from PTS and then hired me and other Nam Vets as peer counselors. We rode the back roads of Appalachia for 5 years looking for Vets, lonely and neglected for decades, paid for by the Agent Orange Class Assistance Program, funds from a law suit we took versus our own government and the chemical companies that poisoned us. We won, we spent the money wisely but don’t worry we’ll all be dead soon. End of one problem called Nam Vets.

Am I a cynic, yeah but not by birth or schooling, just life. Is there something wrong in Babylon on the Potomac?  Much. But I’m a cannabis expert and I’ll stay with this issue and the people who speak, as the Native Americans learned was a national game, with forked tongue. People who are blowing me and my brothers and sisters off after some of us got blown up.

That would be the VFW, “No one does more for Veterans” is their mantra and the American Legion also claiming “no one does as much for active duty military, veterans (sic), military retirees and their families as does the Legion.” A pissing contest for your money. The Legion is seeking a “catchy phrase” to market themselves better. Respond by April.

How about “one of two Veteran organizations that failed to live their creed.”

I’m a member, I’m an expert so I do the responsible, I call various offices and officers of the Legion and VFW. Can’t tell the difference as I wiggle through the labyrinth of staff who are not responsible for the non policy that I want to champion. It’s a complaint I want, a loud unceasing wail of displeasure to change stupid into an holistic action from these dwellers of Vet piety without Vet courage.

I should explain that all I want these self appointed ministers of all Vets to say is that the federal government policy of treating some Vets with PTS and TBI and a host of other Vet troubles with cannabis and denying that therapeutic protocol to me and others is wrong.

It’s illogical.

It’s unethical.

It’s crazy.

It’s wrong.

What do you people expect of me? How long must I be your target after being a target? Wounded Veteran medical treatment by geography? That’s Veterans Health Administration policy. I repeat-policy. (2). What the hell is going on?

I’ve had enough of mendacity, of pompous editors of Vet magazines, of political stupidity if not flat out cowardice. I’m appalled that US media seek out and codify dishonest and open flakes, all with zero medical or nursing knowledge as the wisdom we must have to refute the science of a multitude of countries concerning clinical cannabis uses.

Have you as citizens of the US had enough of folks and organizations that spit in the face of some Vets? I have. Is it 1970 all over again?

My  brothers and sisters blow their heads off every 80 minutes and the VFW and the American friggin Legion blow us off every day?

I know one thing after 70 years of life- you do not deserve us, you who propose to lead while you cower in power. Elected or appointed you need to get out of the way.

I will not resign from either group of weak  leaders. We’ve seen that ilk before and some of us lived long enough to see them die in disgrace.

I’d rather continue to be the voice of Vets opposed to these organized charlatans playing ostrich, and try to represent those who need medical cannabis to live and to live well.

So I am one Vet calling you guys out, whoever you are that claim leadership and hide like a Nam REMF. I’m saying that you suck bat shit from cave walls and I will repeat my mantra every chance I get until you remember who you were once and who you could be again.

I’m available to duel at your convenience.

Al Byrne, Lcdr, USN, ret.

            Www.VeteransforMedicalCannabis.org.

(1)   Please capitalize the words Vet or Veteran – they earned it.

 

“THE CURRENT MEDICAL MARIJUANA TREATMENT MODEL DOES NOT WORK”

“The future of MMJ treatment is dependent on several issues: physicians must establish legitimate, bona fide, physician/patient relationships, patients must have a method of determining the best medication for their unique symptoms, and clinical outcomes for ongoing treatment must be obtained to validate the field of medical marijuana. These are the three areas our company focuses on.” (C. Croan)

The anti-medical marijuana lobby is effective so let’s recognize how they are effectively undermining the medical marijuana industry:

 They have raised the issue of whether MMJ dr/pt relationships are valid, legitimate or even professional.
 The MMJ “evaluation” does not employ “MMJ care” it only uses “MMJ evaluation” in other words “care” or “treatment” is missing in the MMJ treatment model.
 Anti-mmj legislators have adroitly maneuvered MMJ physicians into performing evaluations only – with no follow up care. The MMJ docs thought they were winning a major point and they would cash in on evaluations. This robs the MMJ industry from obtaining positive clinical outcomes.
 Currently there is no vehicle to use aggregate data to indicate whether MMJ actually works as a treatment. “Pharma” trials do that but MMJ has entered the market essentially untested.

The current MMJ care model dooms the field.

In regard to physician/patient relationships the state legislators the author is familiar with intended only for a physician to perform the MMJ evaluation. It is clearly specified that a physician’s assistant or other professional may not perform the evaluation and have the doctor sign off – it’s flirting with disaster to operate against the legislative intent and administrative policy. We don’t need people in the field who cut corners. But they won’t be around long without licenses or clinics as we are seeing.

If a clinic takes your money for an evaluation…shouldn’t they reimburse your money if they dropped the ball about an aspect of their compliance and you were NOT provided a legitimate evaluation? Should you have received a refund from the clinic? This makes some clinics, or organizations look, pretty…mercenary.

Oh, and to the physician who related to the author, “Since PTSD is psychic pain I’m going to recommend that condition for MMJ because technically it’s chronic pain and PTSD isn’t authorized”. Bullshit, that’s dishonest.

Anyone cutting legal corners in the MMJ field is doing EVERYONE a disservice.

Failure to follow up in medicine is contradictory to the mainstream medical care model which is called “evidence based medicine”. After all – who would recommend a Schedule I substance and not follow up on the effect for treatment?

In every Medical Practice Act, in every state where MMJ is authorized, there lies the seed of one of the next regulations. Ever physician is actually required, now, to follow up with the patient about the medical intervention (the MMJ recommendation). Our prediction at Enigami is that legitimate follow up will be increasingly enforced by the regulatory agencies. At the time of this writing four states mandate follow up.

But what is it the regulatory agencies are going to require? Evidence based medicine. Wikipedia defines it like this: “Evidence based medicine aims to apply the best available evidence gained from the scientific method to clinical decision making.” In other words there needs to be some type of legitimate method to “follow up” or to monitor whether the medical intervention actually works. Okay, that’s just good medicine and good for the consumer.

Currently, in those states where there is no follow up care – we obtain no clinical evidence of whether MMJ actually is effective. Grrrrr.

The Colorado Medical Practice Act is pretty typical of the different States and partially relies on case law. Colorado’s Act quotes case law defining medical practice as not being a discrete single event. Yet in the MMJ care model it stops at a single event – evaluation. It’s true that in many areas of medicine consumers may go to a specialist who evaluates us and refers us on for ongoing needs – and therein is the key – MMJ evaluators have no viable follow up referrals because they don’t exist. How many primary care doctors will perform the follow up? There are a few MMJ doctors who perform minimal follow up and still more physicians who are concerned about the question of having a legitimate physician/patient relationship. Follow up care would go a long way to enhancing the MMJ care model. In fact performing follow up care, “evidence based medicine”, will help patients determine the best medication.

But there’s another great benefit to follow up care besides just practicing legitimate medicine. It can provide clinical outcomes which legitimize the entire field of medical marijuana. The “evaluation only model” was considered a win by physicians in legislation. So I say, “Congratulations, you’ve robbed the field of MMJ from establishing itself as legitimate by not being able to show hard research outcomes!”

Help is on the way though. Pioneering MMJ legislators are making legitimate follow up mandatory. It’ll be a short step to collecting those outcomes and being able to quote hard data instead of relying on anecdotal success stories. Instead of saying, “it MIGHT shrink tumors” we’ll get to say, “in an multi-year study involving 350,000 MMJ patients – those with such and such tumors showed reduction in size (etc.)”

The lack of a legitimate medical marijuana care model concerns us so here is what we did.

We created Enigami Systems, Inc., to uses outbound email inquiries (or other methods of media communication) to follow up and inquire about a client’s unique symptoms and how they are responding to a specific MMJ medication which we also track. The information, helps determine which medication is the best used to diminish, or contain, distressing symptoms. The outbound inquiries come from our online portal where the individual’s personal health record exists. We can monitor with whatever frequency is desired which makes a heckuva medical record but after all is said and done it beats the pants off of ANY mainstream medicine follow up.

Oh, our aggregate “outcomes” legitimize the MMJ field’s effectiveness

Medical Marijuana Is Becoming All About the Money …Less About the Care.

Let me share how I came to see the present medical marijuana business as “…all about the money”.

I’m a clinician and very interested in health information technology and how it may assist patients to improve care so I began to look at medical marijuana (MMJ) care with an eye to contributing to that care method. I also have to say I’m a sixties child and still full of that Love, Peace, and “people are basically good” approach to the world (thus my career as a caregiver).  I’m with a little IT company that helps patients track symptoms and the medical marijuana field seems to be an ideal place to help people in this regard. My company and I are unimportant to this article but where the field is going in respect to patients managing their treatment is important. My personal interests and background have helped me to frame an understanding of the cannabis care model. Here’s what we see…

In the medical marijuana field a patient has an evaluation (and if recommended) then purchases medication. In order to keep getting medication a person has to have an annual certification renewal. The docs get a buck, the dispensaries get a buck, and even the state gets a buck on the certification. So you got a condition and a medication – how is a patient supposed to manage treatment? Where’s that part of the care model fit in? Wasn’t someone supposed to have said something about that along the way?

In “mainstream medicine” an individual gets an evaluation (and if recommended) may get a medical intervention (like medication) but the patient will undergo some type of assessment of the interventions success later. If you’re in the medical field you would say, “that’s practicing real medicine”. That leaves it to reason that the cannabis care model is not considered legitimate medical practice by many. If you’ve been around medicine the last few decades you know that “evidence based medicine” (looking at the interventions results) is the norm and ethical practitioners ALWAYS assess their interventions. This makes MMJ look kind of, well funny.

In the medical marijuana care model there are three distinct, mutually exclusive, areas of involvement:

  • physicians manage evaluations
  • patients manage ongoing treatment or “follow up care”
  • dispensaries manage selling medication 

Why should patients needing help with multiple sclerosis, cancer, glaucoma,  pain management, or other illnesses be told, “we got ours…you’re on your own !”. Don’t the physicians and dispensaries feel any sense of partnership in the care model? Don’t the professionals owe it to the patient to get involved in the overall care model instead of concentrating solely on the profit side?

Should cannabis care be defined as more than the product, the physician, or the dispensary and more about the actual process of care? What sector is going to step up and help the sufferer find a way to manage treatment (right medication, right dose, right method of administration, strain, THC/CBD/CBN count, etc.). When you’re flopping around on a floor having a seizure or throwing your guts up these are a bit more important than just a recreational feature. You’re care is not a cookie cutter deal and you’re an individual with unique needs.

Why are these “mutually distinct groups” the care model for cannabis? Maybe it’s simply because the patients need for managing their care simply isn’t an area of interest to the other parties. Maybe it really is about the Almighty Dollar but maybe there’s more to it than that.

Physicians

Docs like to specialize – when they do they make more money. In MMJ this is very true. Is there anything wrong with wanting to operate in a specialty area of medicine? No. Is it a bad thing to be a diagnostician and not involved in subsequent care? No, again.  Do most cannabis physicians operate only in the MMJ field? Yes.

Regulatory authorities are struggling with the idea of treatment management and questioning whether it should be tied to the evaluating physician. This obligation hasn’t panned out because physicians in other areas of medicine are allowed to specialize in the same manner that cannabis physicians do. If physicians don’t help manage care are patients qualified to manage their own treatment? On a limited basis patients can manage their care but that’s not to say they don’t need meaningful consults from professionals like the cannabis physicians and “professionals” like the dispensary staffs are trying to be. Certainly no one expects a patient to travel too far into the “practicing medicine” area but to a limited degree patients can manage their well being reasonably well.

Is there a bit of trickery going on in the various state regulations when it comes to indicating the cannabis physicians should operate in a manner consistent with other areas of medicine and provide ongoing care? In my opinion I believe this may be the case because it takes us back to the “normal” way of practicing medicine “evidence based medical care” and I believe we’ll see a number of test cases where evaluating physicians are being prompted to provide ongoing care. (In some states follow up care is now mandated.) But this just takes us back to the “specializing in areas of medicine” paradigm and it’s really just an attempt to tie care to the evaluating physician. If a physician doesn’t really want to provide ongoing care he won’t.

If you want to know the answer to the question, “Does the doc really care about my well being?”…ask yourself this…did he REALLY steer you in the direction of specific, meaningful, and ongoing, care…or was it “try some acupuncture or yoga – and see you next year for the re-cert !”

But the docs aren’t the bad guys here. They’re just doing a job.

Dispensaries

Does your dispensary truly offer an array of ancillary services focused on your well being? Or, does the dispensary really just offer that one high dollar product? Check out Harborside Health Center in Oakland and see their commitment to their patients well being. They offer all kinds of ancillary services focused on patient’s well being. That’s a good model but it can be improved.

Dispensaries remind me of the plethora (yes, I actually used that word) of clothing boutiques which sprung up in the 1960’s (okay, I’m an old guy). Everyone just had to have a boutique, they were so cool, and so very hip. But most owners lost their businesses because they weren’t good business people – so perhaps we can forgive the dispensaries a bit because like the clothing boutiques they have a business to run and for many it’s new territory. For them the business is truly a bread and butter proposition and it’s not as if they took some kind of pledge to heal people or reduce people’s suffering.

A few months ago there were about 1285 dispensaries in Colorado now there are approximately 950. Do you think a few big money interests are getting together and forming chain dispensaries like in California? It’s just business folks.

And just trying to make a decent living doesn’t make you a bad guy either so the dispensaries are off the hook too.

Patients

Can consumers manage their care? Hasn’t that always been the bottom line reality anyway? Aren’t we forced to become our own advocates when we face our doctors in those 10-15 minute sessions? If you don’t speak up, you’re screwed. But where is the line for our competency as consumers?

Final rag, options for patients to manage their care will not appeal to businesses that are predominately concerned with helping people “score” legally. People who want to “get high” are NOT concerned about their well being or ongoing treatment. Businesses that wish to serve this type of customer will have no interest in legitimate treatment management options.  We all know the score on this issue.

So how do we create a workable cannabis care model?

Medical marijuana is a new, promising, and legitimate area of medicine. As a clinician I heartily believe it. As a human being I’m sold. It scared the pants off me to take a pipe and pot to my father in Texas when he was dying. Nauseated, and vomiting, the great man could have had some relief if only he could have gotten past the stigma and lit up. I was married to a wonderful woman who died of disabling asthma. I wish we’d known before the last year of her life that cannabis helped her breathe. She died when she was 44. They both deserved better medical options.

We need cannabis in the medical market and we need a decent model of care. We need the players to step up to the plate and do the right thing – get involved. Not because they have to, they don’t, but because it’s the right thing to do.

Ultimately it comes back to us, it’s our responsibility to look after ourselves. I hate to get all existential but you’re the one in charge – not just of your life but of your well being.

Now, go find the tools to take care of yourself. Look for good people to guide you. And along the way nag your doc and dispensary about helping you to manage your care. Try the guilt trip but remember to take your cash when you visit them.

Maybe Gordon Gecko was right, “It’s all about the money and the rest is conversation.”  

I hope not.

Enigami Blog 8-2-2012Copyright 2011 by Clifton D. Croan