11/28/18 Will Dolphin

This week on Century, we talk with William Dolphin and Michelle Newhart about marijuana and their new book, The Medicalization of Marijuana: Legitimacy, Stigma, and the Patient Experience.

Program: 
Century of Lies
Date: 
Wednesday, November 28, 2018
Guest: 
William Dolphin
Organization: 
Drug War Facts
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TRANSCRIPT

CENTURY OF LIES

NOVEMBER 28, 2018

DEAN BECKER: The failure of drug war is glaringly obvious to judges, cops, wardens, prosecutors, and millions more now calling for decriminalization, legalization, the end of prohibition. Let us investigate the Century Of Lies.

DOUG MCVAY: Hello, and welcome to Century of Lies. I'm your host Doug McVay, editor of DrugWarFacts.org.

This week on Century, we're going to hear from Michelle Newhart and William Dolphin. They're the authors of a new book, The Medicalization Of Marijuana: Legitimacy, Stigma, And The Patient Experience. It's just out from Routledge Press.

So, could you tell our listeners a little bit about yourselves first?

WILLIAM DOLPHIN: Sure. Well, so, I am William Dolphin, and I've been working on medical cannabis related issues since about 2001, 2002, first with Ed Rosenthal's federal trial in San Francisco, and then since then with a variety of patient advocacy organizations, including Americans for Safe Access. If you get the monthly newsletter from ASA, you know me because I'm the one who sends it out.

But, I'm also a teacher of writing at the University of Redlands, I've been at other places too, and Michelle and I have known each other for quite a long time around this, back in the Ed Rosenthal days.

MICHELLE NEWHART: Yes. And now we're married.

WILLIAM DOLPHIN: Now we're married, that's right, in part thanks to all this, I guess, yes.

MICHELLE NEWHART: And I'm Michelle Newhart, I have my PhD in sociology from the University of Colorado at Boulder, and prior to graduate school, I worked as an editor for Ed Rosenthal's publishing company for about eight years, doing research and writing about cannabis and medical cannabis since about 1999.

DOUG MCVAY: Now, Michelle, you write in the book, in the forward, you know, the preface, I guess, whatever it's called. Forward? Preface? You write in the book that marijuana chose you. Now, I think I know what you mean, but could you explain that for the listeners?

MICHELLE NEWHART: I guess what I meant by that is, it's the thing that found me, I didn't go looking for cannabis. I became a sociologist, and I ended working in cannabis initially with Ed because I literally cold answered an ad in the newspaper, and then when I left from working for Ed, I went to graduate school in Colorado thinking my days of working on cannabis were done, and lo and behold, everything blew up in Colorado while I was in graduate school, so I found myself working on that issue again.

DOUG MCVAY: Let's talk first about stigma, if that's all right, because, I mean, I talk about stigma on this show quite a lot. We talk about stigma a lot in drug policy reform and harm reduction in general, but, tell me about stigma in the context of the general social use of marijuana.

WILLIAM DOLPHIN: Well, stigma attaches to cannabis use, period. Right? And we see that in all aspects of it, and it doesn't matter where you are. At the point where you identify as a cannabis user, you're open to being stigmatized, and the point we make in the book is that the most consequential social construction of the twentieth century is cannabis.

Medical marijuana has driven a wedge into that, because it differentiates the use. Right? I mean, there's a sort of single story about what it means to be a marijuana user, and what marijuana is, and that's a drug of abuse that's only purpose is intoxication, in some problematic way. And of course medical cannabis use is entirely different, and that is the transition that it's going through.

But even with all of the many states that have enacted programs, and the growing body of research about it, and the growing public acceptance of it. As you know, Doug, the public opinion polls, 86 percent of Americans think you should have legal access if your doctor recommends it to you.

But nonetheless, people are super sensitive to being stereotyped around it, and that affects everything. That affects how they interact with their families, with their colleagues at work, and with their doctors.

MICHELLE NEWHART: Well, and as we know, that stigma is, in large part, by design. It was structured into how the laws work, and stigma and legitimacy can be seen as two ends of a pole of how we understand this issue.

And, it's also a behavioral stigma, so, like other behaviors, it's something that is in a moment and can be hidden or disclosed, and that makes it a special type of stigma, and so public identification becomes a very important part of understanding how that stigma works.

DOUG MCVAY: More specifically toward medical, now, I live in Portland, Oregon. That's the home of the National College of Naturopathic Medicine [sic: National University of Naturopathic Medicine, the name was changed in June 2016]. You don't have to live -- in fact we have more naturopaths in the state of Oregon and in this area than pretty much any other state in the country -- you don't have to live here though to know that alternative therapies and complimentary and alternative therapies have been growing in popularity for the past few decades.

In spite of the growing acceptance and use of complimentary and alternative therapies -- I prefer CAT to CAM, partly because I like cats, but also because when people think medicines they think drugs, and when people think acupuncture and the like, therapies might be a more inclusive word, so that's why, but in your book you refer to them as CAM -- but anyway, in spite of that growing acceptance and use of these complimentary and alternative therapies, there are still a lot of medical doctors who are, to say the least, skeptical.

So much so that a lot of people just lie to their doctors about their use of these therapies. Now, so, talk to me for a moment about the stigma around that, around the use of, generally, of complimentary and alternative therapies or medicines.

MICHELLE NEWHART: Well, when I decided to write about this, I was already writing about complimentary and alternative therapies, and thinking about how those were affected by the changes in the law that allowed nutritional supplements to market directly to consumers, and those laws changed in 1996, the same year that we got our first medical cannabis laws in California.

And, I started asking people when we did interviews about how they saw cannabis fitting with other complimentary and alternative medicines, and I expected people to see them as similar, but it was interesting that most medical cannabis patients didn't see them in the same category.

Yet, from the physician side, I think you're right, I think we've seen developments in integrative care since that, over the last couple of decades since that time, and we've certainly seen some changes in the language that's used around complimentary and alternative therapies.

But, even the latest study that just came out, Elin Kondrad and colleagues in 2018 interviewed primary care physicians and their patients about the various medical therapies that they used, including cannabis and differentiating whether it was medical cannabis use or not, and it was clear that about half of them who reported using medical cannabis did not tell their primary care physician that they were doing so.

So, even, you know -- you know, that's a very contemporary study, and still showing that there's communication problems between doctors and patients around things outside of biomedicine.

WILLIAM DOLPHIN: Well, and as you can imagine, you know, there's concern for what are called stereotype threats, just how people are going to categorize you based on disclosure. You know, it applies to all kinds of folks and no less doctors.

You know, doctors are authority figures. People are very concerned, and sociology would describe this in the context of other kinds of doctor-patient interactions as well, that people are trying to manage those relationships, and disclosing sensitive information that may lead to being treated like you're, you know, less of a person, or the wrong kind of person, may be hidden, for sure.

And, you know, the consequence of that, on the one hand may not seem like much, but one of the things that came out of that Kondrad study, it was a dual survey and both the doctors and the patients separately, was that the doctors identified that nineteen percent of their patients had conditions that they felt cannabis use might be contraindicated for.

So, not disclosing to the doctor what you're using it for can end up masking some more important problem that might be addressed through an alternative therapy than with cannabis use, so, you know, enabling solid communication between doctors and patients is important, and doctor education's the most important part of that.

So we're seeing more development of CME, continuing medical education credits, for doctors, but it focused on endocannaboid science and cannabinoid science, but there's still, to my knowledge, no medical school in the United States that's teaching.

DOUG MCVAY: Interesting. I'm intrigued, when you say that the patients didn't necessarily view -- did I get that right? You said that patients don't necessarily view medical cannabis, medical marijuana, I prefer marijuana, actually I call it weed myself, but never mind, that patients don't necessarily view that as a part of complementary and alternative? Or did I misunderstand?

WILLIAM DOLPHIN: Well, no, they do, they do see it that way, I mean, they see it as part of their medical regimen. All that the patients interviewed for this book are participating in a state program, and certainly viewed use through the lens of medicine.

Did they explicitly think of it as complementary and alternative medicine? No. And the classification of that comes more I think from the institutional medicine side, for instance the National Cancer Institute lists cannabis as a CAM, as a complementary and alternative medicine, so, that's more sort of the issue of the transition that it's undergoing, as it's gaining more institutional acceptance, and the institutions wouldn't matter if you're trying to figure out how to classify it and where to put it.

MICHELLE NEWHART: I expected patients who were interviewed to make that connection very readily. Many of them had disorders for which they'd been treated over a long period of time, they'd tried many pharmaceuticals, many of them had, and had tried various forms of complementary therapy.

But, when I asked them directly if they saw that connected to medical cannabis, they were ambivalent about that categorization.

DOUG MCVAY: You mentioned the patient interviews, you have quite a few in the book, and there's a theme around midlife patients. Tell me about cannabis use among these midlife patients. What kind of characteristics did you find in common?

MICHELLE NEWHART: Well, sure. Midlife was of interest because that is the largest growing population who signs up for medical cannabis patient programs, and the patterns of the majority were what you might expect. It was -- many had tried it in adolescence, and then as they took on more adult responsibilities, had kids, got more serious jobs and so forth, and moved into midlife, it had been a number of years since they had used cannabis. It kind of fell along the wayside somewhere in there.

And then, they tried it again through the medical lens in midlife, and so, that was a common trajectory that we saw. But there were also a minority who had never tried it, and there were a minority who had tried it in adolescence, liked it a lot, and continued using throughout adult life, on and off, or fairly consistently, across adult life.

So, we saw all three of those patterns. But by far, the most common one was trying it in adolescence, maybe using it for some time during adolescence, and then desisting use over adult life, and then deciding to try it again medically in midlife.

WILLIAM DOLPHIN: One of the interesting things that we found as well was that, you know, while they may have had a basis of experience as young people, the idea of using it medically tended to come from family and friends.

There was some type of intervention that was pretty commonly described, where basically these were folks who may have exhausted all the conventional medical remedies. This was medicine of last resort, and somebody came to them and said, hey, look, you know, I'm pretty sure, based on what I've heard, that this is going to work for you, sometimes very assertively, and convinced them to try it.

Once they did embark on using it medically, one of the things that's super interesting is the degree to which it matches the way folks use other medications. There is an existing body of literature that has examined, you know, through research methods, how folks use medicines, and it matches up pretty darned well, you know, and the term for it that we used it Min/Max Strategy.

So, trying to minimize the amount of medicine being used and the side effects of the medicine, and maximize the ability to function in their lives. And again, this is common with pharmaceuticals. Everybody knows that, you know, sometimes people follow exactly what the doctor directs with the medication, but a lot of times there's some experimentation in terms of dosage and frequency, because everybody's trying to get that sweet spot of being able to be as functional as possible, and that was true with cannabis as well.

MICHELLE NEWHART: It was also interesting because, we opened the book with two stories that we juxtaposed, one of Karen and one of Dale, and Karen was an example of that pattern we expect to see, where she was, you know, had used it in adolescence and then had children, and got married, had a job, you know, was like a PTA mom and active in her church, and all this kind of stuff.

And then she, actually, she came to it through her husband, who was in a car accident that left him with chronic pain issues, and she herself had migraines, and after his success with medical cannabis, she ended up trying and finding it successful for her migraine.

Then the other story about Dale is, he had been a, you know, kind of a juvenile delinquent who'd grown up using all kinds of recreational substances, including alcohol and cigarettes, and many different types of drugs across his adult life. But not very much cannabis, because that would get him caught on the drug test, and he needed to be able to pass drug tests for the type of work that he did.

So, the interesting thing is that neither one came to it thinking that cannabis was going to be legitimately medical, and so it was interesting to me that despite whatever recreational background the patient had, often they weren't really convinced of its medical efficacy until they experienced it themselves or saw somebody very close to them experience it in that way.

WILLIAM DOLPHIN: Yeah. They, I mean, really, it was such that regardless of experience, that single story, the stereotype about cannabis use and cannabis itself, was really powerful. And so even if there was a lot of direct experience, there was still deep skepticism about medical utility.

DOUG MCVAY: This is an interview with William Dolphin and Michelle Newhart, they're the authors of The Medicalization of Marijuana: Legitimacy, Stigma, and the Patient Experience. You're listening to Century of Lies, I'm your host Doug McVay.

Fifteen years ago, ten years ago, the number of people who used for chronic pain was used by -- you know, large number of people using medical cannabis for chronic and severe pain, and yet those numbers were being used by opponents to try and claim that medical marijuana wasn't -- was illegitimate because oh, pain, anybody can say.

Now, we have, in the context of an opioid overdose crisis, we have people I think starting to see pain relief and medical cannabis for pain relief as more than just legitimate, it's being seen as one way to relieve the overdose crisis. How has the perception of pain and the condition of pain, how do you think that's played into all this?

WILLIAM DOLPHIN: Well, I think you're exactly right, that there's growing awareness of the problems around treatment. Pain is the number one reason that people go to doctors for treatment, and it's the thing they're most likely to say they're dissatisfied with the treatment they're receiving.

And, you know, the US Pain Foundation estimates we've got a hundred million Americans with some kind of, you know, chronic pain syndrome. So, yeah, it's a significant problem, and opioids are in many respects, you know, a useful tool, but they come with severe side effects, and as long term treatments they're extremely problematic, as we've seen, you know, in the US, with the epidemic problem.

Now, another thing that's happening recently is that you have an increasing body of research about the combination therapies, that a little bit of cannabis goes a long way toward maximizing effective use of opioids. So, and many people report using it as a substitute, one for the other, as well.

But, we're understanding better the biology of how the synergism between those two drugs, classes of drugs really, work, but, you know, more importantly, you know, folks are recognizing that there's a different safety profile.

You know, there is no medicine with a better safety profile than cannabis, and so, I mean, I think the real challenge here is again moving it from a medicine of last resort to more of a frontline, first line sort of alternative, and, you know, we'll see about that. Again, it's, some of the doctors are generally skeptical about it, you know, patient experience is different.

MICHELLE NEWHART: Well, you bring up something that is very sociologically relevant, so, there were forty patients interviewed in the study, and ninety percent qualified under a pain condition, but, you know, the other conditions in Colorado can be more objective conditions, things like HIV or having a cancer diagnosis.

And patients such as Brett in our study, that, you know, I would qualify under the name of my condition if that were a condition that you could qualify under, but since it isn't listed as one of the qualifying conditions, many people qualify under pain, and conditions are not exclusive, so you can qualify under more than one condition, so it doesn't necessarily add up to one hundred percent. It wasn't everything else ten percent, but most had as their primary condition, pain.

WILLIAM DOLPHIN: Which can of course be a symptom of, you know, the other condition that you've got, that it's a good catch-all for a lot of folks in terms of qualifying, and of course, you know, medical cannabis laws, medical marijuana laws, are different than other types of medical practice because we generally trust doctors to make the determination about appropriate treatments, and when folks, you know, use drugs off-label, we don't usually get too concerned about it.

But, you know, with marijuana, we've got a situation where we list, it's like these are the only things that you can prescribe or recommend this for, and that's a little bit different.

MICHELLE NEWHART: One of the other aspects of that, too, and it plays -- it has to do with framing, so I think part of what you're bringing up is, you know, there's a period of time in which the media and the public presentation of this issue really was skeptical as well, and wondering if medical programs were simply a ruse for recreational users to find a legal way to use cannabis.

And I think we've seen some of that shift in terms of how it's being framed, with the opioid crisis, and it provides us a different way of understanding that, and may take some of that pressure away from that way of framing it.

But, I think pain is a subjective condition, and whether you're treating it with cannabis or opioids, I think it's problem area for doctor-patient relationships generally because it it subjective, and so this is, you know, reported also, if you look at other types of treatment for pain, it's concern, and part of the reason why, as William said, that cannabis provides a possible relief for the opioid crisis is its amazing safety profile, so there's more room for user error.

WILLIAM DOLPHIN: And from the transition point of view, the best clinical evidence is around pain. We have more clinical trials showing efficacy of cannabis for managing pain than for any other condition. So if you're an evidence based physician, as they mostly are and should be, that's what you have the most confidence in recommending for.

DOUG MCVAY: Again, folks, I'm speaking with Michelle Newhart and William Dolphin. Their new book is The Medicalization of Marijuana: Legitimacy, Stigma, and the Patient Experience.

What do you hope, when they read your book, what are you hoping will be the big takeaways?

WILLIAM DOLPHIN: Well, it depends on who you are, really.

DOUG MCVAY: That's fair.

WILLIAM DOLPHIN: Well, you know, we have tried to do several things at once with this, you know, that may be more or less successful depending on who you are, but, you know, first and foremost this is an academic study, and there's a concern for legitimacy around the science side of this. Behavioral science is neglected, looking at medical cannabis use.

There are certainly some studies that are out there, but there's been very little, most have looked at it, again, as a deviant behavior, not as a positive or therapeutic use, so, you know, kind of broadening the conversation on the academic side to say this is legitimate, and it's a legitimate subject of study.

And in fact, you know, we're twenty years into this social experiment of medical marijuana access. We really should take a look at what patients are actually doing, what they actually need, as we're making decisions about it.

So, you know, so an academic researcher can look at it and say, well, here's a really cool, qualitative study that's going to give you some insight into a particular population that's understudied.

If you're a policymaker, you should be able to look at it and say, I can make a much better set of decisions understanding what it is that people are actually doing and who these folks are.

And if you are a patient yourself, or you have a family member who you think might be helped my medical marijuana, in some sense, I hope that it provides a little bit of, if not a road map, at least something's that's a way of having a touchstone into, this is kind of what the experience is about. We organized the book in the order in which people encounter the issues, the decisions that they have to make, so there's a sense of I'm not in this alone.

And again, because this is a concealable behavior, and because of the stigma and stereotype, a lot of people hide it, or they hide their concerns. They don't know who to ask about it, and our hope is that this is a book that will help folks break down some of those barriers.

MICHELLE NEWHART: You know, at best, I hope that it offers them new ways to think about it and to frame the issue, so the overarching theme of the book is medicalization, an medicalization is a process that's been studied in sociology since the '70s. And also, our argument that, you know, marijuana's undergoing medicalization but that process is as of yet incomplete.

And since it is in progress and it's not necessarily a linear progress, there's no guarantee that it will be completed. But we can look at various things that are happening, socially and policy-wise, and think about how does that fit with this framing of understanding what's happening. And I think that's just one, I think we offer several other things of that type throughout the book, depending on which part you look at.

We talk about risks to patients, and we talk about stigma management. We talk about how patients form a thought community, and use similar strategies to manage stigma, and so, these just give a different place to hang your hat and think about the issue overall, and how different things fit within that.

DOUG MCVAY: That was my interview with Michelle Newhart and William Dolphin. They're the authors of a new book from Routledge Press, The Medicalization of Marijuana: Legitimacy, Stigma, and the Patient Experience.

And well, that's it for this week. I want to thank you for joining us. You have been listening to Century of Lies. We're a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I’m your host Doug McVay, editor of DrugWarFacts.org.

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We'll be back in a week with thirty more minutes of news and information about drug policy reform and the failed war on drugs. For now, for the Drug Truth Network, this is Doug McVay saying so long. So long!

For the Drug Truth Network, this is Doug McVay asking you to examine our policy of drug prohibition: the century of lies. Drug Truth Network programs archived at the James A. Baker III Institute for Public Policy.