If one just read the headlines, one would think that this poor dying patient was given a death sentence because of those evil drug laws. It’s being spun all over the internet, in Salon and in the news.

You have the dramatic dying patient

face and arms are hauntingly skeletal, but the fluid building up in his abdomen makes the 56-year-old musician look eight months pregnant.His liver, ravaged by hepatitis C, is failing. Without a new one, his doctors tell him, he will be dead in days.

Yada yada yada.

Actually, the AP Reporter did a good job, because if you actually read past the first two paragraphs, you find the doctor’s side of the story is there, and that there are some very good reasons to keep him off the tranplant list.

Let me talk about medical marijuana. There are probably substances in marijuana that would be valuable for our patients. But herbal medicines are risky. The dosage can vary from one batch to another, and it has a high incidence of sedation/confusion side effects.

This patient grows his own Marijuana because his doctor prescribed it to him, legally. He has “manufactured” so much of the weed he is in trouble with the cops.

His doctor is not a pain specialist, but only a Family physician with expertise in the state’s early HIV intervention program. He denies knowing that giving a person with a history of drug abuse an addictive substance that interferes with thinking might make doctors less likely to tranplant a patient.

Okay. Family docs don’t know everything..

Luckily for us, the AP reporter managed to get some information explaining why doctors might turn down such a patient for transplants. It’s routine reasons that any doc or nurse would know, but let me summarize it here.

First, the patient has end stage liver disease. Every doc has a couple of these in his practice. From the description, he already has complications: the fluid in the abodomen (ascites) suggests that he has low protein, because his liver can’t make protein. Usually this also means that he won’t heal as quickly, he will have clotting problems, and he may have portal hypertension with esophageal varices (blood backing up from the liver, leading to varicose veins in the tube leading to the stomach, which can cause massive bleeding).

In other words, he is a high risk patient.He has a high risk of dying from the surgery.
I’ve had two patients like this die while awaiting liver tranplant, one a child and the other a drug abuser who had been off all drugs for 2 years.

Which brings us to reason two: it’s hard to find a liver.

The child I mentioned above was transferred to a hospital that was planning to take a part of his father’s liver for transplant. But since removing part of a liver is very dangerous, it’s not something done very often from live patients. That means getting a liver from a dead person. Now it is true that a donor liver can go to two or three people, but it still means it’s a scarce resource.

Which brings us to number three: give the organ to the one who has the best chance of living.

Ironically, if one has hepatitis causing liver failure, there is a big chance that the new liver will get destroyed by the same virus. For those with hepatitis C, the chance of the new liver getting infected with hepatitis C is 90%. Some of these patients will die of severely progressive liver disease in the new liver.

Yet except for those with toxic liver failure, this is true for other diseases. So a person with hepatitis C is not eliminated from the transplant program, but it does mean that transplant is not always a cure.

Four: Patients with substance abuse and psychiatric problems are at high risk for tranplants.

To keep an organ alive post tranplant requires the ability to take medicines and to keep doctor’s appointments. So if you are schizophrenic, low IQ, spaced out on drugs, have dementia etc. it makes you high risk, since you might not be able to do all this. A good family might make up for your own mental disabilities, but often programs turn down those with major psychiatric disease or drug abuse problems.

Marijuana, has many sedative/memory/cognitive side effects. It also has a long half live, of several days (in contrast, alcohol is out of the system within hours). Since marijuana is removed from the body via the liver, in a person with a bad liver, they could stay high longer than a “normal” person.

Marijuana has been used anecdotally for peripheral neuropathy from Hepatitic C and to stop the side effects of the medicine used to treat the virus. Fine. But did his doctor try other medicine such as neurontin (gabapentin), which is metabolized via the kidney and would not stress the liver?

So here we have a person with a known history of drug abuse, who is taking medical marijuana. But is he taking a minimal dose, or is he abusing the “medicine” and appearing confused/sedated when the tranplant doctor sees him?

And most importantly: would he stop using it after a tranplant was done?

I have no problem with terminal patients smoking pot. I do have problems with  people who have a history of substance abuse using marijuana or even narcotic pain medicine for symptoms: because often they end up abusing the drugs.

That is why the doctors insisted that this person undergo detoxification and Drug rehabilitation treatment before his transplant.

Five: Marijuana has effects on the immune system. It makes one more likely to get infections, which is also a major cause of death in tranplant patients who usually have to take medicine that surpress the immune system. One European study showed that marijuana users with hepatitis C were more likely to get aggressive fibrosis (liver damage) probably from this immunsupression.

But marijuana has another problem: unlike tobacco, which is essentially baked, marijuana is a “natural” substance, and can carry germs, including aspergillosis, a fungus that can cause pneumonia in those with weakened immune systems.

So there you have it.

A guy who is at high risk to live through a transplant who is at high risk because of his insistance he wants to use (abuse?) medical marijuana. But the patient has abused drugs in the past (which he admits), and refuses to enter a drug treatment program to teach him coping mechanisms to live drug free.

Nevertheless, someone releases this as a sob story to the press to pressure the doctors to change their mind, and bump him to the head of the tranplant list. All those pro drug legalization types get involved in pressuring the transplant team. Even the Daily Kos is going around asking people to write letters to pressure the tranplant committee…

Summary: Because of this sociopathic manipulation of the press, he will very likely get a liver that otherwise would go to someone who plays by the rules, who very well may die.

And that, my friend, makes me very, very angry.


Nancy Reyes is a retired physician living in the rural Philippines. She writes medical essays to Hey Doc Xanga Blog.

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