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August 6, 2011

"How Many Medical Marijuana Patients Are Fakers? Does It Matter?"

The questions in the title of this post come from the headline of this interesting new piece over at Reason.com posted by Jacob Sullum.  Here are excerpts:

A recent survey of 1,746 patients at nine medical marijuana evaluation clinics in California indicates that "the patient population has evolved from mostly HIV/AIDS and cancer patients to a significantly more diverse array."  University of California at Santa Cruz sociologist Craig Reinarman and his colleagues, who report their results in the Journal of Psychoactive Studies, say "this trend toward increasing therapeutic uses is bringing marijuana back to the position it held in the U.S. Pharmacopeia prior to its prohibition in 1937."

Reinarman et al. found that "relief of pain, spasms, headache, and anxiety, as well as to improve sleep and relaxation, were the most common reasons patients cited for using medical marijuana." The top three reasons physicians gave for recommending marijuana were "back/spine/neck pain" (31 percent), "sleep disorders" (16 percent), and "anxiety/depression" (13 percent).  Although those may sound like easy-to-fake symptoms, four-fifths of the patients reported trying other, doctor-prescribed medications (most commonly opioids) before marijuana.  They could have been malingering then too, of course, and it may be easier to get a recommendation for marijuana than it is to get a prescription for Vicodin or Valium.  But on the whole, it does not look like allowing the medical use of marijuana has fundamentally changed the nature of the doctor-patient relationship.  Doctors do, after all, commonly prescribe psychoactive pharmaceuticals to treat not only pain but also sleep disorders, anxiety, and depression — all with the government's blessing.  If some people find that marijuana works better for these purposes, there is no rational reason to prevent them from using it....

The authors are keenly aware of the widepread impression that a large portion of California's medical marijuana patients are using phony or exaggerated ailments as an excuse to get high.  They note that it is hard to measure the extent of such "diversion" and that the phenomenon is not limited to marijuana.  More fundamentally, they suggest that the distinction between medical and nonmedical use of drugs is becoming increasingly difficult to draw....

If you believe the government has no business drawing or policing this line, it is hard to get worked up about people who fake their way to a medical marijuana recommendation. But as I argued back in 1993, reformers could pay a price if all the talk about relieving the suffering of cancer and AIDS patients is perceived as a cover for recreational use. Politicians in other states commonly cite the California example as a reason to block medical use or restrict it to a short list of conditions.  Then again, the perception that California's current law encourages dishonesty (much as the medical and religious exceptions to alcohol prohibition did) may strengthen support for outright legalization, which last fall attracted support from 46 percent of California voters.

UPDATE:  This new item from the paper Haaretz in Israel provides an interesting international perspective on these issues. The piece is headlined "Israeli government approves guidelines for medical marijuana," and here are the specifics:

The Israeli government approved on Sunday arrangements and supervision regarding the supply of cannabis for medical and research purposes.  A statement from Prime Minister Benjamin Netanyahu's media adviser said "the Health Ministry will -- in coordination with the Israel Police and the Israel Anti-Drug Authority -- oversee the foregoing and will also be responsible for supplies from imports and local cultivation."

Of approximately 6,000 Israelis currently being treated with medical cannabis (aka medical marijuana), most suffer from chronic pain and terminal illnesses.  The therapeutic potential of cannabis has been known for many years and is recognized by the Health Ministry.

But many patients -- such as sexual assault victims suffering from post-traumatic stress disorder (PTSD), who have been recommended psychiatric treatment with medical cannabis -- encounter bureaucratic obstacles.

August 6, 2011 at 11:16 AM | Permalink


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No one conversant with pot culture (I went to Stanford in the 1970's) believed the numerous assurances of its backers that the "medical" marijuana program would be administered under the regulations established for it. For those who did believe those assurances, the snickering question now will be, "You mean you were stupid enough to be taken in by THAT?"

Medical marijuana has always been the stalking horse for wholesale legalization. Since legalization doesn't sell to a majority (see Prop 19 and virtually every poll), it has to be smuggled in through the back door. Hence "medical" marijuana without, it now gets revealed, any very pressing need for the "medical" part.

Far out.

It's like other parts of the Lefty agenda: If you can't sell it by telling the truth about what you actually want, then -- obviously -- avoid telling the truth! This is a page right out of the book of death penalty abolitionism, which -- unable to get majority support stated for what it is -- seeks to get implemented anyway by calling itself a temporary "moratorium."

There was never intended to be anything "temporary" about the "temporary" moratorium, an there was never intended to by anything very "medical" about "medical" marijuana.

Posted by: Bill Otis | Aug 6, 2011 12:03:20 PM

Out of curiosity, what other medical diagnosis includes a prescription to SMOKE anything? If marijuana usage is supposed to be a medical benefit, then have it go through the normal FDA approval process and standardize a method of ingestion or inhaling into the body for its intended medical effect. If in fact marijuana DOES have a significant health benefit, then it would be incumbent upon the government to allow for such research to establish a medical threshold for the integration of marijuana into prescription protocols.

Bill is exactly right: The intent of the current method of legalization of medical marijuana is really meant to establish a gateway into legalizing drugs as a whole. Whether one agrees with drug legalization or not, once sees similar steps taken from the OTHER direction BY the government in the form of sex offender laws, which are really the canary in the mine for the war on American individual liberties.

Posted by: Eric Knight | Aug 6, 2011 12:46:16 PM

What? People are using pot to get high and not to cure cancer? We should immediately shut down the medical marijuana program in California. Because. . . well, there's got to be a reason around here somewhere. If not, let's make one up.

If we've learned one thing from 40 years of combating marijuana use, we should have learned by now that people will use it even if it's illegal. So we have a choice: people can buy it from producers who want to operate openly and lawfully, who are subject to supervision and regulation, and who pay taxes. Or they can buy it from the Gulf Cartel or Zetas. For some reason, a lot of people in America would prefer that drugs come from--and that the money goes to--murderous thugs rather than deluded hippies. I'll never understand that. It's like the idiots who oppose HPV vaccines, or condoms, or allowing heroin users access to Naloxone. They seem to feel that if people are going to do something that they don't like, it is better that they do it in a way that is as dangerous and harmful as possible. They can't tell the difference between permission and promotion.

Posted by: Anonymous | Aug 6, 2011 3:28:34 PM

Anonymous --

I guess you missed my main point: MM was sold to the public on the theory that desperately ill people needed access to cannabis, and that they would get it under tightly controlled conditions. A number of people, me included, said at the time that this was pure hokum, and that MM was the cat's paw of unbridled legalization and essentially unlimited use. We were derided as a bunch of Puritan nay-sayers.

It now turns out, as this UC Santa Cruz study shows, that we were right. MM is used primarily to get blasted.

So here are two thoughts. First, tell the truth about what you're doing and don't use people in actual medical distress as window dressing for unlimited availability for the get-blasted crowd. Second, if MM were indeed such a good idea, why was there a need to lie about what was really going to happen with it?

Posted by: Bill Otis | Aug 6, 2011 3:47:23 PM

You miss the wisdom and legitimacy, Bill, of a legalization plan that stresses at first responsible and needy users rather than just thrill seekers. Despite lots of rhetoric about liberty, most folks favor status quo restrictions on liberty and justify this view by stressing the harms of extreme thrill seekers. Thus, it makes sense and seems sound to stress those in need rather than thrill seekers to get a move off the status quo started.

I would wager few who favor med marij would oppose legalization, but I also suspect those fearful of legalization can be okay with med mall. Thus, one seeking to build toward complete legalization would be foolish not to start a movement by taking the low hanging fruit of med mall.

You should recognize that that who favor restriction on liberty such as on sex offenders or via LWOP for three strikes often play this game the other way by stressing the worst offenders as a gateway to broad restriction on lots of offenders.

Posted by: Doug B. | Aug 6, 2011 8:12:27 PM

Doug, great point. This is *always* done in the other direction -- witness the Heritage Foundation report that was released the other day about SORNA compliance; it starts out with an attention-grabbing, horrifying description of a sex offense against a young child. I didn't see anything in there about all of the minor offenders who've been clean for decades who get swept up in sex offender registration programs.

Incidentally, I am a non-faker potential med mal patient. I have a condition that has been causing pain for a couple years. I've taken prescriptions, various therapies, but they only help to a certain extent. I don't know if pot would help, but my condition is one of the ones often listed often listed as being treatable with pot, and I'd be happy to try it if it were available in my State. Can't be worse for my liver than the relatively high doses of pharmeceuticals I've been on at various times.

I don't see why I should have to risk lung cancer, etc., though. Seems like there should be a way to get the dose prescribed without smoking. Maybe the dispensaries should carry boxes of Betty Crocker and brownie recipes.

Posted by: Anon | Aug 6, 2011 8:42:22 PM

Doug --

Bait and switch is dishonest, and does not become less so because it gets used by more than one faction.

MM was distinctly NOT sold to the public as the first step in recreational use. Indeed, most of its sponsors took pains to DENY that they were paving the way for such use. The pitch instead was that it was to be used only for its medicinal value, and only then for people in serious need for whom standard medications were of no use. In addition, so we were told, it was going to be tightly regulated to insure that these limited medical goals were the only ones getting served.

As the UC study shows, it was all baloney. If one wishes to go after "low hanging fruit," fine, but don't say that's all you're seeking and then, once permission is granted on that basis, turn around and grab the whole tree.

The principled way to expand on MM is, say, to have it for a few years as the carefully regulated and restricted regimen it was loudly promised to be. Legalization proponents could then return to the voters saying, "Look, it's worked so far. There have been tax revenues and people have been helped. The controls we promised have been enforced. Now we ask you to try one more step, allowing recreational use for persons over 21 and limited to possession of X amount."

It's just astoundingly cynical for MM proponents to have gone into such detail about the measures they planned to take to screen out fakers, and now say, as the article does, well, if there are fakers, "does it even matter?"

If fakers weren't going to matter, the voters should have been told that up front. Instead they were told the opposite. If a private businessman tried a stunt like that, he'd go to jail for fraud.

Posted by: Bill Otis | Aug 6, 2011 11:28:06 PM

going to have to give bill this one! That is exactly what should have happened. it would have shown the public could control itself. it would have shown any health benefits for those taking it. It would also have provided research time for science to study it something they ARE NOT getting now with the fed's blanket bans.

Posted by: rodsmith | Aug 7, 2011 1:11:51 AM

Bill misrepresents the MM debate - shocking! Most of the folks pushing MM in California were fairly up front that they'd prefer legalization but that, for the reasons Doug mentions, they were going after MM.

And it's ironic to lecture others on the "principled way" of advocacy when Bill constantly pulls exactly the bait and switch Doug mentions: "stressing the worst offenders as a gateway to broad restriction on lots of offenders. What's good for the goose ...

As for Rod's comment, the current situation still shows all those things, gives research opportunities, etc.. If that's your concern, Sullum's question stands: Does it matter?

Posted by: Gritsforbreakfast | Aug 7, 2011 8:57:34 AM

Notice how cleverly Grits sneaks his way past the main point. He says, "Most of the folks pushing MM in California were fairly up front that they'd prefer legalization but that, for the reasons Doug mentions, they were going after MM."

I'll assume arguendo the debatable (and undocumented) proposition that "most of the folks" pushing MM said "they'd prefer" legalization.

Grits's deception lies in very quietly conflating what medical marijuana advocates said they PREFERRED with what they told the voters their initiative WOULD ACTUALLY DO. If and when MM advocates acknowledged their persoanl preference for broader legalization, their VERY NEXT LINE was inevitably something like this: "But while that's what I want, it's not what I asking you do to, and that's not what the MM proposal will accomplish. I'm only asking you voters to approve marijuana for a much more limited purpose. You should vote for MM because, whatever you might think of legalization generally, surely, out of normal human compassion, you should allow it to a very small class of desperately ill people. And you'll see that, in our MM initiative, there are careful safeguards and regulations to insure that it's only those people who'll be able to get it. Fakers will be screened out."

Grits wants to drop down the memory hole this absolutely crucial component of the 1996 California campaign for medical marijuana. And he wants to do this while accusing OTHERS of deception.


Posted by: Bill Otis | Aug 7, 2011 10:10:40 AM

Bill, I think you here now complain about a sales pitch that is common to all liberty/vice advocates. The tobacco companies, the alcohol industries, the gaming/gambling houses and the gun makers all assert that they only want responsible users involved with their products, but then they only self-regulate enough to keep govt/voters off their backs. Whether in terms of liberty or in terms of money, these industries all profit from trying to convince the general public that they will avoid/restrict the harms/access of extreme thrill seekers.

You may be troubled by the bait and switch, but it is not clearly different in the MM arena than in these other areas. When you start assailing the beer companies for having pretty/skinny people in their ads, the gaming industry for showing people winning, the gun lobby for stressing responsible uses of AK 47s when they lobby, then you attacks on the MM folks will also make sense. Until then, you seem like you are just picking a status quo liberty/vice up to a higher standard.

Posted by: Doug B. | Aug 7, 2011 10:04:12 PM

Doug --

"When you start assailing the beer companies for having pretty/skinny people in their ads, the gaming industry for showing people winning, the gun lobby for stressing responsible uses of AK 47s when they lobby, then you attacks on the MM folks will also make sense. Until then, you seem like you are just picking a status quo liberty/vice up to a higher standard."

Ha! When SL&P starts publishing ads about beer, casinos, and gun manufacturers, then, absolutely, I'll start responding to them. When, as now, it publishes pieces about California's MM program, and particularly about the rampant disregard of what we were promised by its sponsors would be its careful regulation, I of course respond to THAT. It's my exercise in staying on topic.

You note that various private businesses do the bait-and-switch when selling their wares. This is true, but irrelevant here for two reasons.

First, the fact that A, B, and C are dishonest and sleazy in making their pitches hardly excuses D for doing the same thing. Nor does it make the behavior of A, B, and C -- or D -- anything other than dishonest and sleazy. In addition, every parent, including I'm quite sure you, knows how to react when he hears the excuse, "Oh c'mon, EVERYBODY does it." In my house when I was growing up, the "everybody does it" toss-off for bad behavior was a fast route to getting grounded. "Everybody does it" is no more than a confession impersonating an excuse.

Second, even to the extent that sort of excuse may be relatively acceptable in the sphere of private merchandising, it is thoroughly UNacceptable in deciding watershed issues of governmental policy.

The medical marijuana initiative represented a major change in law. The change involved balancing the dangers of withholding potentially important medical aid versus the dangers that were thought likely if pot became available beyond what medical necessity would dictate.

It was for exactly this reason that the MM sponsors stressed there would be strong safeguards against seepage into the general population. They were well aware that the voters weren't going to go along with wholesale legalization (an insight borne out just last year when the Prop 19 lost decisively, even though overall attitudes toward marijuana had eased since the MM referendum 15 years earlier). Indeed, given the vastly different outcomes between the MM initiatiative (55% acceptance) and Prop 19's general legalization initiative (54% rejection), it's no exaggeration to suggest that the MM initiative's definitive promise of no seepage into the general population was THE key to its passage.

The upshot is that there is little to no chance the voters would have gone along with MM if its backers had said -- with the UC Santa Cruz article -- "Hey, if there are fakers, so what?" The backers knew they had to promise the opposite, and they did.

To say that it just doesn't matter if the voters got spun on this promise is astounding, and its embrace of a destructive cynicism mind-boggling. Is this the way we should make public policy?

And one final point, now that you have me thinking about beer. Beer ads use skinny women, but they don't say point-blank, "If you drink our beer, you're going to be skinny." The MM sponsors DID say point-blank, "If you adopt our initiative, access to pot will be restricted to medical necessity." If that is not any longer to the case, what we have here is not a deceptive commercial but a pretty direct lie.

Posted by: Bill Otis | Aug 8, 2011 12:11:37 AM

One way of putting it more succinctly is to say we've heard all we need to when MM backers brag that their campaign had all the seriousness and honesty of beer commercials.

Posted by: Bill Otis | Aug 8, 2011 10:59:41 AM

Here's the way I look at it, if it helps ONE PERSON feel better, just one, it has medicinal properties and should not be classified as a schedule 1 narcotic! It should be between doctor and patient if it will help or not! It should not have anything to do with the government...LOOK AT WHAT THEY HAVE DONE TO THE UNITED STATES LATELY! Maybe we should all just smoke a joint and relax a little...especially after all that the government has put us through this past month or so! It's a wonder we don't all have PTSD! Bottom line is, it helps some people...that should be enough...No one can tell those people that it doesn't help them when they are the ones that are getting the relief from it! Legalize it already!

Posted by: momma | Aug 8, 2011 11:27:37 AM

Oh, and by the way, Kudos to Israel...way to make a decision that will benefit the whole country, all at once! WOW, What a concept!

Posted by: momma | Aug 8, 2011 11:29:54 AM

momma --

"Here's the way I look at it, if it helps ONE PERSON feel better, just one, it has medicinal properties..."

Under that theory, gin has "medicinal properties," as does sniffing glue and mainlining heroin.

Should those also go unrestricted ?

Posted by: Bill Otis | Aug 8, 2011 12:12:46 PM

Am I missing something in this article? From the abstract and the Reason article it sounds like the finding is that doctors are prescribing marijuana for a broader range of ailments than a couple years ago. While five years ago marijuana might have been prescribed solely for cancer patients with nausea from chemotherapy, now they prescribe it for many more disorders. I do not see any evidence in this article to support the claim that there is an epidemic of patients and doctors abusing the system to deliver marijuana to those who have no medical need for it.

The Reason article mentions the perception that patients are gaming the system to get marijuana, but it offers no numbers. The Journal abstract mentions nothing about abusing the system. My reading is this shows doctors using marijuana prescriptions to treat disorders instead of Valium, Prozac or other prescription medications. There are patients who abuse the system to get prescription marijuana, but there is no reason based on this article to believe that number is greater than the number of patients who abuse the system to get Valium. I doubt anyone would argue that we should ban Valium because it is addictive and people lie to get it.

Further, if marijuana is as good or better at treating a disorder as another prescription why not use it? Marijuana is less addictive than Valium or Oxycontin. I would rather risk a patient becoming addicted to marijuana than Oxy. A patient addicted to marijuana presents a far smaller danger to the public than a patient with undiagnosed Bipolar disorder prescribed an SSRI.

I did not pay the $54 for the full Journal article, so I concede there may be hard numbers on marijuana abuse in the article. I welcome education from anyone who read the full article.

Posted by: Paul | Aug 8, 2011 1:34:14 PM

Paul, Finally someone without an ax to grind! How refreshing.

Posted by: Tim | Aug 8, 2011 3:09:22 PM

Two quick responses, Bill.

1. You seem to assert that the express or implied "promise of no seepage" among 1995 MM advocates is the key issue/concern/problem here. But I suspect some (many? most?) 1995 MM advocates truly hoped for no seepage to pot thrill seekers (especially at the outset and even now). Moreover, because the potential for fakers was known/discussed back in 1995, one could arguably contend voters accepted this risk (just like they seem to accept the risk of senting the innocent to death when they favor the death penalty). Further, the reality that some (many? most?) MM advocates NOW are not troubled by seepage may itself be the (reasonable) result of their discovery (1) that lots of people beyond the seriously ill now benefit from easy access to pot, and (2) there is little or no evidence of serious harm that comes from easy access to pot. (And, of course, if seepage is such a problem in the view of voters, they (or their reps) can and should just revise the law accordingly. Since they haven't, I suggest relatively few find evidence of seepage to be a big issue/concern/problem here.)

2. You say that "we've heard all we need to when MM backers brag that their campaign had all the seriousness and honesty of beer commercials." There is true insight here, largely because I think most pot reformers merely want pot to be treated the same way as beer: legal and regulated (and providing the basis for a huge LEGAL economy and for community education programs so we enhance the benefits of legal pot access, while seeking to reduce its harms).

In the end, we return to my main policy view: there seems to be much more (economic and social) harms than benefits that come from treating pot like heroin, rather than like beer, for legal and regulatory purposes. To the extent you disagree --- i.e., you think the cost/benefit calculus runs the other way --- please advice (and provide data if you have any).

Posted by: Doug B. | Aug 8, 2011 5:15:28 PM

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