The University of Southern California’s Keck School of Medicine was first to offer students an introduction to cannabis. As reported in “Cannabis in the Curriculum” (O’Shaughnessy’s Spring 2004), 2nd year med student Rolando Tringale was the key organizer and pediatrician Claudia Jensen, MD, did the teaching.
Jensen was brave, honest, and committed to practicing medicine that was really evidence-based. Here’s an edited transcript of what she shared about her approach. It’s still very timely. —Fred Gardner
Route of Administration
I make a decision based on what their medical problem is, the duration of the effect that they need, the strength of the effect that they need, and the quality of the effect that they need. And then I advise them what to use based on what other patients have taught me. One of the biggest problems is that I’m not getting this information from scientific sources I’m trusting the patients. So this is a unique field of medicine, where the doctors are actually learning from the patients.
Instead of relying on data from placebo-controlled, double-blind clinical trials conducted in some far-off academic ivory tower, it’s from talking to the patients and finding out what they do and how does
So, it’s folk medicine with a trained listener. And the trained listener applies principles of science. Basically. I’m doing my own studies.
People with attention deficit hyperactivity disorder often have the greatest potential to be the most successful. They are the high achievers of the world, the movers and shakers. Or they are the drug
addicts breaking into your home and completely dysfunctional parasites on society. And sometimes cannabis is the difference. So that’s my favorite category of patients to work with. Those guys use more
marijuana than any other patient. They smoke more than the serious chronic pain patients. They literally need to keep their levels up the entire time that they’re awake. They sometimes have to smoke 8 to 10 grams a day.
As a physician, I tell them “Don’t smoke two ounces of weed a week. Get up in the morning, take a bong hit, eat a brownie. Four to six or eight hours later, eat another brownie.” I teach them how to feel their own rhythm.
I also teach them about the pharmacodynamics of the drug. How the inhaled version gives you higher peaks and shorter duration. I actually have a graph drawn out for them with colored markers which
shows my interpretation of how the drug is reaching its half-life. I chart its bioavailability. On one side it shows how peak blood levels and another length of time from the time they administer the
dose. Curves show difference between eating.
I try to explain the value of inhaling versus eating. If you’re going into a board meeting, you don’t want to smell like pot. So you use a tincture unless you’re already under the ffect of a brownie. If all you need to do is be focused and centered during the board meeting, and the rest of the time you don’t have to medicate, then you can use a glycerine based -and maybe when Sativex becomes legal- I talk to
them about different ways of medicating that will allow them to be more functional. And I talk to them about the differences between the indicas and the sativas, based on what I’ve learned from patients.
The Indicas seem to be better for pain, for insomnia and sleep onset and to calm their nerves. The Sativas seem to work better toelevate mood, to elevate energy levels. But I see a higher incidence of
patients who are nervous and have anxiety and rapid heart rate and also a high incidence of heartburn. So I talk to them about how to pay attention to what they’re using. I tell them, “don’t just buy any
street weed. Find out, what are you smoking? White widow? Chronic? Hindu Kush? Romulan? What are you using? Know the name of it and try to develop your own quality control standards because we can’t go to a textbook for that. So I teach them how to do their own experiments.
I actually have one patient who is in the PhD biochem program at UCLA. He’s going to get a lab book out and do his own clinical trials with different strains, testing half-life based on his own experience. I
teach them how to be their own scientist.
The vast majority of the higher functioning patients prefer that. The lower functioning patients don’t care, they’ll smoke anything. My practice is shifting more towards the higher level professional people who are functioning day to day using cannabis and just need to know how to use it better. There really should be a lab testing for cannabinoid content.
Dr. Jensen’s USC Talk —an Outline
Why is it important to evaluate and treat patients with cannabis?
A) Patient advocacy
1. Safety profile/Efficacy, quality of life.
2. Abandonment by healthcare providers. It’s important to evaluate and treat patients with cannabis because other physicians are afraid to.
3. Social ostracism and embarrassment. When a physician takes responsibility for advising a patient on this as a medication, it helps leigitamize for the patient that what they’re doing is okay. They should teach and educate their family and friends the truth so they can use this as medication without sneaking around in the back room.
4. Legal jeopardy. To help patients keep form having to be in trouble with the law for using medication legally in compliance with the law.
B) The patients need guidance.
1. No standard of care in the community. I get highly offended at the medical board trying to say what I did was wrong when they don’t have anybody at the Board with a clue about what we’re doing. This is cutting-edge medicine! This is an opportunity for physicians to gain education and wisdom.
2. The patient population —their medical issues are serious. There are neuropsychiatric sequellae to cannabis use, so it’s important for physicians to guide them through any problems.
C) It’s the law!
I put that slide up as a separate category by itself.
What are the disadvantages of treating with cannabis?
a) Legal jeopardy. Physician exposure. Requires courage to be a doctor who takes care of patients who
medicate with marijuana.
I tell them about being a focus of patient advocacy to remember that what you went into medicine for is to be an advocate for patients and that you have to have the courage to do that even if it’s not socially
B) The Medical Board of California. Even though their policy is to not investigate physicians without some specific reason, in fact, that does happen.
C) The Drug Enforcement Administration (skipped over some of this)
D) Social and professional ostracism. As a physician, on the one hand, I get referrals from all those local doctors —psychiatrists and family medicine and oncology doctors sending me patients because they don’t want to treat them. But on the other hand, I’m the ‘pot doc.’ There’s this unspoken attitude: ‘she’s not a real doctor, she takes care of cannabis patients.’
Many physicians who themselves use cannabis uncomfortable writing notes of approval because they don’t want to attract any attention to themselves. They don’t want to take the chance because somebody might come and say “Let’s test your urine.” There is a significant proportion of physicians who smoke pot surreptitiously. And they don’t see anybody to get a note, because they don’t want to be in anybody’s
database. So the whole thing boils down to patient advocacy and social ostracism. Physicians are afraid to come out of the closet. And it’s really a problem —it’s harmful to the patients.
Trusting your patient: This is the only field in medicine where you’re expected to distrust the patient. A patient can walk into a physician’s office and request and get a prescription of a bottle of insulin and a box full of needles —which can kill you.
Information vacuum. This is the only field of medicine where th patient routinely has more knowledge than the physician. As a scientist, that’s a bitter pill to swallow. I can’t go to a reference textbook. Where do you go for information on something that you’re not allowed to have information on.
Another disadvantage: lots of paperwork.
Patients require legal support, which occasionally means going to court.
a) To do a real, complete history and physical exam. No need to depend on a third-party payer. You can actually have the time to sit down and talk to your patient. For what they pay me ($250) I can spend an hour with them. I give discounts to disabled people and veterans, and extra discounts to Vietnam war veterans.
I’m being investigated on three cases. As far as I’m aware, there’s no allegation of wrongdoing. It’s actually in violation of their own policies and procedures. Which says very clearly that they are not
going to be investigating any physicians capriciously, that they’re only going to investigate when there’ a concern about physicians failing to comply with quality care and standard of care in the community. The bottom line is, there’s no allegation that I’ve done harm to these patients. The issue is that I wrote notes approving cannabis.
FG: Who filed complaints?
Dr. Jensen: One of them was a high school. I had an adolescent patient who was already using cannabis when he came to see me. He was at the bottom —one of those patients who was turning to drugs and alcohol and crime.He was in a gang and he was already involved in violent actions and on probation. When I interviewed him as a general pediatrics patient for a check-up and I routinely ask adolescents if they use drugs and alcohol. He confessed readily. Then I found out he was failing I school and that he’d always been a hyperactive kid with attention difficulties, et cetera. So I said to him “If you will work with me, we will find out if you have ADD, and if you do, I will give you my approval to use cannabis as a medication. But you’ll have to jump through hoops. And if you agree, I’ll work with you.”
He was ready to do it and we shook hands on it. I wrote him a list of things to do, including come back in a month.
In the meantime he went to school and told everybody that he could smoke pot. The school called my boss at a small community-based Hispanic clinic in a small town in Ventura County, the medical director of the clinic. She called me in and said “What were you thinking?” I explained and she said, “Oh, okay.” So then the school got pissed off at her, and they contacted the medical board.
FG: Was it the principal or a guidance counselor? Who dropped the dime?
Jensen: I’m not sure. But in the interim the boy who was 14 or 15, failed to follow through. So I got a phone call from his probation officer, who says “D. says it’s okay with you if he smokes pot.” I told the
probation officer my philosophy about that. And the probation officer said, “I can see your wisdom. Let me have him come back in and follow up with you. ” So the probation officer sent him back in to see me to be evaluated to use cannabis as a medication. Which I thought was the most awesome thing on planet earth!
So D. came in and I told him “You need to go to counseling, you need to get me a report card, etc. etc.” And I found out that indeed his grades had improved since I had talked to him about how to use cannabis more effectively. So I gave him a certificate good for one month, and told him to come back. But he failed to follow up, so I cut him off.
The other two I haven’t reviewed the charts but I think they’re both adult ADD cases. I can only think of three minors that I have treated with cannabis. One of the others was autistic and extremely violent
when he doesn’t use cannabis. The other was a kid who got kicked out of two junior high schools for violent behavior. He’s in the 9th grade and now has a 3.5 grade average.
The other two adults, I don’t know who turned me in on those.
The D. case, I was being investigated for four or five months before I was even contacted by the Medical Board, which I found very disturbing. I had this threat hanging over me. A Medical Board investigator
called my boss and asked them to provide them with a summary of care for the kid. My boss, who respects me and values my opinion, asked me to write the summary of care so I did. And I used the third-person, which is the correct way to write such a report. I got a message back that she wanted me to write it in the first person. Before I got around to it, I got a call from the Medical Director’s office saying I didn’t need to, the Board had said I didn’t need to. Subsequently they subpoenaed the records.
So I knew several months ago that I was under investigation, but I didn’t hear from the Board.
Then I received a phone call from one of the patients they’re investigating me on, and he was almost panicky. He said “I’m so sorry I don’t want to get you in any trouble, I didn’t know what I should
say to these people…” They went to his home! They interviewed him for an hour.
FG: In the Mikuriya case they didn’t interview a single patient, they just reviewed his records.
Well, my records are pretty thorough —hard to overcome!
Claudia Jensen died in 2008 at the age of 53. We ran a farewell from Dr. Tom O’Connell, who, like Jensen, did not conceal his willingness to approve cannabis use by adolescents with ADHD.