Transitions by Stephen Dahmer
Family Doctor: A Journal of the New York State Academy of Family Physicians
My dedication to family medicine is rooted in responding to the needs of others while integrating a breadth of expertise. Life experiences, as well as professional experience, offer learning opportunities that we can apply to the myriad of situations challenging us when we care for others. My medical education has involved global travel studying phytopharmaceuticals in Palau, population health in New Zealand, and medical anthropology, ethnobotany and clinical medicine in Brazil. These experiences always led me back to the same main focus: direct patient care. Until very recently, I never thought I would do anything but direct patient care. However, after more than a decade of growing personal frustration with primary care, I experienced what is ubiquitous in our profession – a term I coined “The Hilfiker effect”.1-5, 40 With increasing peripheral demands, the obvious question resonated louder and louder: how much am I truly helping my patients?
Despite being open to a major change in my career, when Vireo Health of New York offered me the position of Chief Medical Officer, I struggled with making that decision. Vireo is one of five registered organizations awarded a license for growing, producing and dispensing medical cannabis in New York State following the enactment of the Compassionate Care Act. While my personal approach to medicine has always been considered integrative, assuming a full-time role as a “weed doc” carried far more professional risk.
I carefully thought through possible downsides: potential for patient harm, loss of my DEA license, federal imprisonment, decreased clinical acumen, career suicide, and the bias that comes when associating with an outlawed-cum-decriminalized industry. I also began to research medical cannabis, which opened up a world to me that did not exist in medical school or in any other area of my career. In society, there has been a dramatic shift in both attitudes and momentum regarding medical cannabis.14,16,17 I am specifically referring to medical cannabis – the use of cannabis, including constituents of cannabis, THC and other cannabinoids, as a physician-recommended form of medicine.
The 5,000 year history of the 36 million year old cannabis plant’s use as medicine is well documented.36-38 Attitudes toward cannabis have shifted following the discovery and growth of research exploring the endocannabinoid system and how cannabis chemical constituents influence multiple human physiological processes including appetite, regulation of mood and perception of pain.24-27,35 Any critic of medical cannabis will be quick to point out the lack of randomized controlled trials due in large part to its designation as a Schedule 1 substance.28
Despite this limitation, medical cannabis has been shown to relieve pain, muscle spasms and spasticity, as well as stimulate appetite and weight gain in patients with wasting syndromes. In addition, increasing evidence of the value of medical cannabis continues to build based on medium and large, doubleblind, randomized, placebo-controlled trials.18,19,29 One of cannabis’ greatest potential advantages as a medicine is its level of safety. There is no known case of a lethal overdose and on the basis of animal models, the ratio of lethal to effective dose is estimated as 40,000 to 1 – about 5,000 times more than is required for any effect. By comparison, the ratio is 10 to 1 for oral dextromethorphan and between 4 and 10 to 1 for ethanol.20 This is tremendously reassuring to any prescribing physician doing their best to remain true to their oath to do no harm.
Nonetheless, as with any novel therapeutic, vigilance is necessary. Numerous reports have suggested an association of cannabis smoking with an increased risk of heart attack, not to mention other serious possible harm such as addiction, adolescent cognitive dysfunction, and low birth weight.22,23,29 In addition to safety and efficacy, a top priority was direct patient feedback. During my interactions with patients in our Minnesota dispensaries, I spoke with the mothers of children with Dravet syndrome and other intractable epilepsies who had given up all hope. After initiation of cannabis therapies, I listened to stories of how their children made eye contact, wrote a note, or even played in Special Olympics games for the first time. In these interactions, I have been most impressed by the subtle ability of cannabis to treat illness, rather than a disease.39
A Gulf War veteran with debilitating muscle spasms significantly decreased his oxycontin use.6-10 One Crohn’s Disease patient had her first bowel movement in five years without using a laxative and another was able to drive to her parent’s house for first time without having to stop for the bathroom. And finally, there was the stage 4 breast cancer, hospice accepted “World’s Greatest Grandma” (written on her t-shirt) brought in via a three hour drive by her son looking for any alternative to the bottles of pills that make her “backed up and loopy”.
The most compelling stories are those that support improvement in the entire family’s quality of life. As physicians, we will all have our opinion, biases and recommendations regarding any new therapy. Before we jump to criticize any therapeutic falling outside FDA approval, we should also be honest about our current prescribing practices.33 Like many other previous therapeutics, medical cannabis defies easy dichotomies with conflicting information in both the media and the medical community. At this point, it is no longer a question of “if”, but rather “how”.31,32
A lack of FDA approval should be a red flag for further involvement, rather than an excuse to take it off our overflowing plates. Let us start the discussions on curbing adolescents’ access, developing standardized dosing levels and creating guidance for novice users, as well as ways to avoid unintentional poisoning.11 Let us insist on child-resistant packaging, limits on THC content, food-safety requirements, and required potency and contamination testing. Let us be the pioneers in promoting sound strategies to curb addiction, monitor potential side effects and drug interactions, and prevent falls in the elderly. And finally, let us also demand the exploration of the 400+ chemical compounds specific to cannabis, novel new forms of delivery, and the science required to confirm or disprove cannabis’ potential as medicine.
Ultimately, the deciding factor in accepting the position with Vireo was what I believed to be a unique possibility to offer our sickest patients a hope that did not exist before. I saw the possibility of providing a reputable and trusted medical product to replace what many were seeking on the black market in order to provide relief, making purchases of varying quality and composition.15 Finally, I saw a whole class of novel therapeutics with a unique advantage: a growing scientific evidence base of healing benefits and a proven safety record.34 After years of struggling with the practice of prescribing opiates, I hoped for the possibility of promoting alternative forms of effective pain relief.12
Despite a solid career practicing what I love, I decided to take a substantial risk and accepted the position with Vireo, as I determined it offered the strongest potential to utilize my gifts and training to alleviate suffering for the greatest number of people. Also, on a personal note, I wanted to forestall “the Hilfiker effect” from burning me out and making me cynical about our profession. I already miss not seeing patients on a daily basis. This void has quickly been replaced with intensive scientific research on cannabinoids, meetings with senators and city council members and advocates, creation of standard operating procedures for dispensaries, and intense involvement in the entire process of making a medication from seed to the patient’s hands. A priceless perk is the flexibility in my schedule and a work/family balance that has allowed me to accompany my wife during her prenatal visits and even be present to glue closed my two year-old daughter’s facial laceration when she fell down the stairs. These are experiences that I will carry with me forever.
To learn more about medical cannabis or to potentially recommend to qualifying patients, providers may register with the NYSDOH Medical Marijuana Program. Qualifying illness includes the following severe, debilitating or life threatening conditions: cancer, HIV infection or AIDS, amyotrophic lateral sclerosis (ALS), Parkinson’s disease, multiple sclerosis, spinal cord injury with spasticity, epilepsy, inflammatory bowel disease, neuropathy, and Huntington’s disease. The four-hour NYSDOH approved course Practitioner Education for the Medical Marijuana Program is now available online: https://www.health.ny.gov/regulations/medical_marijuana/ practitioner/
Stephen M. Dahmer, MD is a board-certified family doctor whose passion for health and healing has taken him around the globe. A fellow of the Arizona Center for Integrative Medicine, he has worked in divergent settings including Umbanda terreiros in the heart of Brazil’s second largest slum, Maori clinics in New Zealand, native healers on the Palauan Islands, and as a hospitalist to the Navajo (Dine) Tribe in Chinle, Arizona. Currently Chief Medical Officer for Vireo Health of New York, Dr. Dahmer is also Assistant Clinical Professor of Family Medicine and Community Health at the Icahn School of Medicine at Mount Sinai and continues to practice clinical medicine in New York City where he lives and resides with his family.