Why kush doctoring makes me sick to my stomach

Contra Andrew Sullivan: the issue isn’t pot; it’s fraud.

Andrew Sullivan has the same snarky response as RBC commenter Ed Whitney to my statement that fraudulent kush doctoring makes me queasy:

So smoke some weed, dude. It’s great for nausea.

Ha. Ha.

Now, back to the argument. Sullivan adds:

If that is the worst that can happen – fee-for-service medicine capturing yet another simple medication – I’m not so downcast.

This misses my point entirely. The issue I’m concerned with isn’t “fee-for-service medicine,” nor is it cannabis usage. (I’d like to see the weed legally sold, without any need for a medical recommendation, which is why I’ve been working with the Washington State Liquor Control Board to make that so in Washington.)

The issue is the abuse of medical authority. When a physician says “X is good for this patient’s health,” or “Y is bad for this patient’s health,” that statement gets, and deserves, substantial deference from the legal system. Health is a primary value, and physicians are the accredited experts on what conduces to health.

To choose an example not at random: When a physician says that an abortion is indicated to protect the health of a pregnant woman, everyone but Sarah Palin wants that statement to carry great legal weight. (That includes those who think that the woman’s desire to terminate her pregnancy ought to be sufficient in its own right, without bothering about what the doctor thinks.)

When some physicians abuse their authority by making statements about health – for example, cannabis recommendations – without any basis beyond the customer’s willingness to tell a fairy-tale and pay a fee, they weaken the claim of medical authorities to deference from the legal system. If you think that health is a primary value and that its defense from state and private power requires a class of accredited experts, that should give you, as it does me, a queasy feeling that cannabis can’t settle.

Footnote And yes, I feel the same way about expert-witnessing. The expert should be there to Say the Thing that Is as the expert honesty sees it, not to help someone win the case. If your honest testimony is helpful enough so that a party to a lawsuit wants to pay you for your time, go right ahead. But what you say on the stand should be as bound by your professional scholarly ethics as what you write in a journal or say in your classroom. You’re working for a lawyer, but that doesn’t give you a lawyer’s license to say and do anything in the name of “zealous advocacy;” you’re not there as an advocate, but as a truth-teller.  If I ran a university, professors would lose tenure for offering b.s. expert testimony, just as they do for faking data in scholarly publications. And if I ran the court system, experts would work for the court rather than being hired guns for the two sides.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com

14 thoughts on “Why kush doctoring makes me sick to my stomach”

  1. I agree that, without any context, it’s cause for concern. However, I’m a bit puzzled as to why some of the fairly plausible circumstances described in the other post don’t provide sufficient context for you. For example, that doctors who are part of an HMO or other medical network are virtually forbidden to write such prescriptions and thus it’s falling to a small population of doctors without such constraints to fill the void. The need in some cases is quite real and obviously not in others. I don’t think that’s sufficient grounds to conclude or even suspect that their other medical needs are being neglected.

    OTOH, I probably would share your concern if we were talking about alcohol. But we’re talking about pot, so I can’t help but shrug.

    If by some tangle of weirdness it came to be that the only way to get cough surup was by getting a prescription from a doctor, I would be less concerned that doctors were “abusing their medical authority” by writing them en mass and more concerned that we’ve created this insane system that requires a doctor’s permission for such.

    Now if there’s evidence that these doctors are as cavalier in other areas of medical practice I would feel differently.

  2. Where “kush-doctoring” happens, it’s not a positive thing. I think the issue is a bit hazier than you’re seeing things, Mark. First, in how often it happens. Second, what it is — and is not.

    The numbers thing was hashed out pretty well in the previous thread. It does appear a few doctors may be overprescribing, or “kush-doctoring” if you will, if one simply looks at the numbers. I’m glad they don’t do aspirin, ibuprofen, or other toxic drugs. Fortunately, the benign nature of marijuana tends to prevent some of the imaged harms, which seem to presume access to something more toxic than pot to really be a threat, however often they see patients or for how long.

    Yeah, that’s not a good thing. But as with many things in professional practice that represent little chance of immediate harm, perhaps gentle persuasion from professional associations is the best thing. But that has been limited to some extent by marijuana’s legal status. Fixing that will, in itself as you’ve already mentioned, largely resolve the issue in most cases.

    As for the second issue, where a patient might forgo more appropriate or “standard” medical treatment for what turns out to be a serious medical condition and pop in for a med rec at the local pot shop instead, that can happen. In fact, that can happen with almost ANY doctor on a bad day, if they miss something. Let’s not even mention all those worker’s comp docs, where the patient is your boss, not you when you get hurt…No let’s…which is where I began my own 25+ year odyssey as a legit MMJ patient without a kush-doctor in sight. Misdiagnosed after what seemed a relatively minor accident, I suffered through an endless cycle of doctors with someone else’s interests than my own. After some legal issues two decades later, I was diagnosed with a relatively rare spinal condition for which, it turns out, MMJ is most likely the best anyone can do to manage the pain and side effects. Unfortunately, I live where the politicians are still trying to come to terms with the 20th century — and most of them are Dems. So I await the threat to my health that a kush-doctor might be…

    For those who live in states where they have the luxury of such anxieties, I strongly suspect that’s NOT the first medical care a person has sought when truly looking for medical relief through marijuana. Instead, they’re at the end of their rope with a shuddering behemoth of a medical system that pays little attention to many patients.

    Then there are all those “young, healthy looking men…” Seriously, if they didn’t go in looking for medical care, faked their way through, and got their rec, who cares? It’s safer than aspirin.

    Yes, I fully agree this needs fixed, ASAP, by outright legalization that is not some form of prohibition-lite. But don’t use it to pretend that marijuana doesn’t deserve respect as medicine. It does.

    And please quit beating this weird bongo drum. Every time a politicians hears something like this in states like mine, they add another barrier to actually having an effective MMJ law in my jurisdiction. Politicians are like chickens. They freak out when anyone runs through the henpen screaming their heads off — whether it’s really necessary or not.

    1. I think you’re still missing Mark’s point, because this:

      Fortunately, the benign nature of marijuana tends to prevent some of the imaged harms, which seem to presume access to something more toxic than pot to really be a threat, however often they see patients or for how long.

      Is utterly irrelevant to what he is saying. The harm he is describing has nothing AT ALL to do with whether marijuana is dangerous to the patient.

      1. J. Michael,
        Then I guess I do miss the point of why someone is so exercised about “kush-doctoring.” It sounds rather more like being upset at Lucy because she keeps charging Charlie Brown 5 cents for her counseling services.

        And “…abuse of medical authority”? That would certainly apply to the workers-comp docs my ex-employer kept sending me to, but that just doesn’t seem to have the sexy cachet of going all manic on something innocuous like someone recommending marijuana.

        How about all those doctors who believe their patients would benefit from medical marijuana, but who are restricted by their employer from recommending it? Maybe they’re not abusing their “medical authority” but their boss sure is.

        Then there is the good ol’ DEA. Their stubborn deathgrip of claimed ignorance about the medical benefits of marijuana may not be a direct “…abuse of medical authority” but it’s certainly an abuse that impacts the health of hundreds of thousands of people who would otherwise benefit from MMJ.

        If the bottom line is patient health, which I firmly believe it should be, then I’ll take the risk that someone not really qualified might — just possibly — get a hold of some MMJ. Beats the illegal market, if I should ever be so lucky as to have that option. I’d rather that a few people not “qualified” get something that they could probably get on the street anyway than deprive someone who might not have such an easy time getting blackmarket weed from easy access to the MMJ that they need.

        Until weed is just legal, that’s the best we can do in some place, so no big deal. Sad, but this issue says more about our corrupt political system than it does about the the supposed threat of healthcare delivered by alleged “kush-doctors.”

  3. Sadly, kush-doctorin may have a wider societal benefit-getting crappy doctors out of practicing “real” medicine.

    It is well-known that state physician boards are loath to punish and exile their own, even in cases where it is pretty clear gross malpractice. If we can get more of these bad physicians writing scripts for marajuana, the better.

  4. Let’s not overstate the importance of doctors when it comes to a person’s health. Most people’s health is far more dependent on their local grocers. Without food we all die real quick. Or where they chose to live, or how safe they drive. So for the most part, people chose their own health, and they can make really destructive choices without government permission already. The one area where an individual’s choice over their own health has been taken away is when it comes to drug consumption. Doctor’s hold the ability to issue permission slips and profit wildly from it. So if a doctor’s abuse of their permission slip authority merely results in the individual being returned the ability make their own health choices in that one area, then that’s not such a big deal.

  5. Here’s a case series of 139 patients accessing medical cannabis for chronic pain in Washington State that may help to settle your stomach:

    Characteristics of Patients with Chronic Pain Accessing Treatment with Medical Cannabis in Washington State
    Journal of Opioid Management 5.5, September/October 2009
    Sunil K. Aggarwal, PhD, MD Candidate, Gregory T. Carter, MD, MS, Mark D. Sullivan, MD, PhD, Craig ZumBrunnen, PhD, Richard Morrill, PhD, Jonathan D. Mayer, PhD
    http://cannabinergy.com/wp-content/uploads/2011/06/JOM_5-5-05.pdf

  6. re: “And yes, I feel the same way about expert-witnessing.”

    Anyone here read “Whores of the Court” by Margaret Hagen, Ph.D? A really excellent primer on court “experts”, specifically in the area of expert psychological testimony.

    re: “And if I ran the court system, experts would work for the court rather than being hired guns for the two sides.”

    The “court” (i.e. the government-hired, government-paid prosecutor/judge) already can trot out as many taxpayer-funded court “experts” as they please, now. What you’re proposing is that courts disallow and prohibit rebuttal of government “experts”, with defense “experts”. Juries (if those are allowed in this hypothetical system) may only hear the government-approved “expert” – who, being re-christened “the court” expert, is now much more impartial and even-handed (unswayed by their government paycheck – which is definitely *not* any kind of a vested interest in bolstering the government side of things, of course).

    re: “And if I ran the court system,…”

    With centralized planning diktats like that, who could argue? Nobody – at least not in such a court system with expert testimony that runs counter to “the court” (government), anyhow.

  7. To choose an example not at random: When a physician says that an abortion is indicated to protect the health of a pregnant woman, everyone but Sarah Palin wants that statement to carry great legal weight. (That includes those who think that the woman’s desire to terminate her pregnancy ought to be sufficient in its own right, without bothering about what the doctor thinks.)

    I think this is a great example but proves exactly the opposite to what you think it proves.

    For many years, the only way to get an abortion was to get a doctor or panel of doctors to sign off on medical necessity. Read Doe v. Bolton if you want an example of such a law.

    Now, it is true that as a result of such laws, doctors were placed in the position where they had to make false statements about medical necessity to ensure that women who needed an abortion should get one. But you know what? I just don’t think that was a big deal. The problem with the law was the medical necessity requirement (abortions should be elective), not the fact that doctors were using a bit of minor fraud to circumvent it.

    And that’s the issue with medical marijuana. If you are more concerned with doctors telling a little white lie than you are with either recreational drug users or serious medical users being denied something they want or need, you have the issue wrong. In an ideal world, we’d have a legal marijuana market, and then doctors wouldn’t have to lie. In the world we live in, doctors telling some lies prevents the greater evil of people being denied pleasure in their life due to the moral perversions of drug warriors.

  8. If you don’t mind my dealing with a side issue towards the end: “And if I ran the court system, experts would work for the court rather than being hired guns for the two sides.”

    I agree in principle. But think about how that works out now in practice. Coroners and Medical Examiners who in principle should represent ‘the thing that is’ in practice usually work for the prosecution. Including fabric experts and arson experts who often are little better than witch doctors. So my my question is, how would you implement this is a way that actually produced some approximation of the results you wanted? As opposed to it simply ending, in practice, banning defendants in criminal trials from having access to expert witness. Propose something that solves that problem and I’m seriously interested. (And, no, this is not snark. Our current system puts criminal defendants who are not wealthy at a serious disadvantage in such matters. So a solution that does not make things worse would be a real service.)

  9. A quibble: no, that’s not what I want. What I want is to have my privacy respected, such that no one in the government gets to *ask* me about my private medical decisions. People don’t get abortions for fun. If you have a problem with this, support access to free birth control and sex ed. (Birth control is too expensive.)

  10. Ah, but did Andrew Sullivan go on to denounce the slatternly practice patterns of licensed physicians who do not even attempt to take a history, examine a patient, put together a differential diagnosis of more than one possible condition, and fail to consider potentially serious conditions which can present to medical attention with the symptoms being reported by their patients?

    Did he go on to insist that boards of medical examiners have a duty to control grossly substandard medical practice the same way that other regulatory bodies have a responsibility to enforce building codes in the same communities? And was he attacked as a marijuana prohibitionist as a result?

    Mark seems to have had a visceral reaction to a situation calling for a cerebral response. I do get snarky when guts are substituted for brains. The right organ for the right job, says I.

    Visceral reactions are for things like child molestation, necrophilia, incest, and slave auctions. Republican policies toward the poor also qualify when accompanied by callous disregard for the vulnerable and defenseless. That is to say, the entire party platform as currently constituted warrants a “Yuck” response. Shoddy clinical practice masquerading as the practice of medicine warrants a “Gimme a break” response. If the kush docs are not adhering to minimal standards of patient care, go after their double-ohs. If their records show that they are asking pertinent questions, examining patients, and issuing marijuana cards after actually spending time with them, then leave them alone.

    So, Mark, if that gut reaction persists, try a little ginger ale. Make sure it still has some fizz. Stay on clear liquids for a day or so and see if you don’t feel much better.

  11. “…without any basis beyond the customer’s willingness to tell a fairy-tale and pay a fee,” is a weak argument because any such arrangement leaves the doctor legally vulnerable. Professionals who want to stay in business, and who stay in business, don’t do that. Also, the ‘pot doc’ myth isn’t receiving any support from primary sources. The best question in any such accusatorial frame of reference is ‘where are the bodies?’ Names? Dates? Places?

    But that would pose a difficulty, wouldn’t it? Naming a name is like revealing a commie in the State Department. How many were there? You tell us. But be advised that any such naming of the villain makes one vulnerable to a libel lawsuit. So that’s where primary information becomes essential. The secondary information, DEA talking points and propaganda about MMJ, is garbage.

    BTW, does any of your data include the fact that in CA medical marijuana recommendations are renewed every year? It still requires an office visit, but the needed medical records and adjunct prescriptions obtained from GPs and medical specialists are likely to be kept on an office LAN system, in order to make the renewal process go more quickly for the attending physician; less than 15-minutes, for example.

    1. Servetus, the same is true in WA, MMJ license must be renewed every year, at a cost ranging from $100 to $250, depending on the Dr. and on whether it is the first visit for the recommendation or subsequent visits.

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