There are some more backroom deals going on that may or may not help patients. As a physician, I know why some insurance companies cover certain drugs while others are "off formulary" or are "third tier". Pharmaceutical companies and the managed care companies play Let's Make A Deal to see which drugs they will cover or not and then send out nice little letters to the patients informing them that their doctors are prescribing medications that are way too expensive for them. The patient then comes a callin' and we switch from one drug to another until the next round of deals occur and we start all over again. It is the medical version of the circle of life. Now, according to a NYT article, is a new spin to that circle. Merck is going to peg what they charge Cigna for their meds Januva and Janumet depending how well it brings down a patient's glycohemoglobin. Proctor and Gamble and Sanofi Aventis will do the same thing with their osteoporosis drug Actonel; this time reimbursing for any fractures that occur. This sounds all fine and dandy but I am not so sure. It is still backroom deal making and the patients are playing the guinea pigs. Are these same patients getting anything out of this other than Actonel and Januvia are now on formulary? Recent studies are also showing that too tight a diabetes regimen may not always be in the best interest for the patient. Now that Cigna will be spying hard on our charts, I wonder what their true interest will be - the HbA1C or the patient? I don't know the answer to these questions but I do know that everyone loves the "pay for performance" concept (except me) so expect more of these deals to happen soon.

Ok, I am going to toss a hand grenade in here and come right out and say that MJ should be legalized. In most states it is close to decriminalized. First offenses are treated about as seriously as traffic tickets.

Why did the Controlled Substances Act of 1970 exempt alcohol, tobacco and caffeine from the definition of addictive drugs without a medical purpose? Heroin, which is an excellent analgesic and cough suppressant, is illegal but these other addictive substances get a pass. How did that happen? Was this an act of Congress based on expert medical input? You know the answer - Prohibition was a disaster so don't even think about taking away smokes and coffee. Plus the huge lobbying efforts by the mfrs of these substances. Speaking of which, back in the 20th century when MJ was first being demonized, William Randolph Hearst ran a huge disinformation campaign against MJ to protect his financial interests. He was afraid hemp paper would kill his timber-based paper business. He also hated Mexicans because he lost 800,000 acres of timber land to Pancho Villa. Besides all that, lurid tales of crazed Mexicans sold papers. He used his vast media empire to accomplish these goals.

Go back and learn some history. They were passing out insane propaganda about the use of MJ. The attitudes toward MJ today are still highly influenced by the brainwashing the U.S. received in the early and mid 20th century.

The fact of the matter is that MJ makes the vast majority of people about as violent as does 5 mg of Haldol.

One can only conclude that the criminalization of MJ is a political and economic issue and not a health issue and that the implementation of the CSA of 1970 was a colossal monument to hypocrisy. The take home message is that a Schedule I drug is a dangerous substance that does not enjoy commercial support. There is absolutely no medical consistency to it. Nixon's own commission on MJ recommended legalization or at least decriminalization. Look it up and see who was on the commission. These were not radicals or political lightweights. Nixon didn't like the results so he ignored it.

Other than the potential hazard from the smoke, there isn't much of a physical health hazard. If it were legal the commercial products available would involve other routes than smoking (ingestion, nasal sprays, etc) so that is a non-issue. Addiction is far less with MJ than alcohol or tobacco. As far as the gateway drug issue is concerned, the only good predictor of street drug use in the 3rd decade of life is the onset of tobacco or alcohol use as a minor. See the JAMA study published in 2003.

As a pain specialist who does random drug testing on his patients I can tell you that MJ use is widely prevalent and that I have seen it in patients up to 73 years old. In fact, a lot of the relative number of positives I see has increased in retirees over the past 5 years or so. These are people with sternotomy scars, pacemakers, and hip replacements. Politically they are conservative (I treat a lot of former military and Dept of Defense veterans) and other than MJ use they are solid citizens. Little old ladies get together for Tuesday's poker night and pass around a doobie. When I ask them where they get it they say their adult children provide it.

If you legalize this relatively innocuous drug (compared to alcohol and tobacco) you undercut a major revenue source for the criminal psychopaths who now control the industry. California's state parks are being used to grow these crops. The irresponsible agricultural practices in these areas cause fertilizer and other chemical runoff that is killing off fish in the rivers and streams.

Speaking of industry, Forbes reported a few years ago that MJ is the 3rd largest Canadian export. Someone somewhere is using a lot of weed. It's time to take our heads out of the sand (and out of our asses).

I do not take the drug problem lightly. In a couple of weeks I will be testifying for the prosecution in a pill mill case - at no charge. I just think we need to sort this issue out and separate what really needs prohibition and what doesn't. Quite frankly, it is time that we wake up and realize that interdiction does not work. Paradoxically the more effective it is, the worse the problem gets because effective interdiction decreases supply without decreasing demand, so prices rise. Because of the higher risk and the higher reward, you pull in nastier players - people willing to take high risks for the higher profits. That means psychopaths who will kill at the drop of a hat like we now have in Mexico. We created those people just like we created Al Capone with Prohibition.

You could put a cop in every house in America and there would still be a drug problem. One can only wonder what might have happened over the past 100 years of increasing drug interdiction if addiction had been left to the doctors and not the politicians.

 

The government pays doctors in two different ways - Medicaid and Medicare. The first one reimburses so little that many physicians no longer see Medicaid patients lest they go bankrupt. Medicare, too, is starting to become shaky and many physicians are actually no longer seeing new Medicare patients or just opting out altogether. Medicare uses complex formulas to set the rates they pay doctors for each visit and they are not negotiable. Now, compare this to what the law firm that is dealing with bankruptcy of Lehman Brothers is asking to be paid. Weil, Gotshal and Manges LLP is claiming it worked more than 100,000 billable hours from September 15th and the end of January. The lead lawyer is asking for $950 an hour for the 795 hours he claims he worked during that time. That is over 50 hours a week for 15 weeks straight. The Federal bankruptcy judge is being asked to sign off on a $55 million bill for all of this and he probably won't bat an eye when he does. When I bill Medicare for a complete physical on an elderly patient...oh, wait a minute, they won't pay for complete physicals.....sorry. When I bill Medicare to do a "periodic review" on an elderly patient, I need extensive documentation as proof of the work that I have done. Turns out that the small glitch in this Lehman Brothers liquidation case is that there is "a fundamental flaw in the process by which advisers get paid because there are limited ways to verify a firm's charges". Well, I guess we just have to trust the attorneys here. I guarantee you are laughing at that last line, aren't you?