By Phillip Smith
On Wednesday, a group of 21 US senators and representatives sent a letter to the Department of Veterans Affairs calling on it to allow VA doctors to discuss and recommend marijuana as medicine in states where it is legal.
The bipartisan effort was led by Sens. Kirsten Gillibrand (D-NY), Steve Daines (R-MT), and Jeff Merkley (D-OR) and Reps. Earl Blumenauer (D-OR), Dina Titus (D-NY), and Dana Rohrabacher (R-CA). All represent medical marijuana states.
Under current VA policy, embodied in VHA Directive 2011-004, which expires Sunday, VA doctors are prohibited recommending marijuana as a treatment option even in legal states. This discourages patients and doctors from being honest with each other.
"According to the current directive, VA providers are prohibited from completing forms seeking recommendations or opinions regarding a veteran's participation in a state-sanctioned marijuana program. This policy disincentivizes doctors and patients from being honest with each other," the solons wrote. "Congress has taken initial steps to alleviate this conflict in law and we will continue to work toward this goal. However, you are in a position to make this change when the current VHA directive expires at the end of this month. We ask that you act to ensure that our veterans' access to care is not compromised and that doctors and patients are allowed to have honest discussions about treatment options."
If patients can't get a recommendation from their VA docs and thus can't access dispensaries, they would be tempted to go elsewhere for recommendations, to doctors "likely far less familiar with their symptoms and medical history," the solons wrote.
Noting that there has been a "sea change" in the legal framework around marijuana since the directive was issued in 2011, they asked that "upon the directive's expiration, any new directive remove barriers that would interfere with the doctor-patient relationship in states that have chosen to legalize marijuana for medical purposes."
But without a new directive, even though the old one is expiring, it will be the status quo at the VA, said Michael Krawitz, a US Air Force veteran and executive director of Veterans for Medical Cannabis Access. Krawitz participated in the process that led to the production and distribution of the directive.
"VA Directives remain in effect with full force even after expiration unless they are officially replaced or rescinded," he said. "Although I can understand that patients might not know that and might get uneasy about the expiring directive, but in practicality there should be no change in clinical practices caused by the expiration."
While VA patients could be spooked by the expiration, the status quo is unacceptable, said Dr. Sue Sisley, MD, in clinical psychiatry and internal medicine, who has two decades of experience treating veterans and who is set to do a pilot study on medical marijuana and PTSD for veterans.
"I've worked with veterans all over the country who are dealing with severe and chronic, debilitating medical problems," she said. "They just want the treatment that is going to help them the most, with the least side effects. I have seen firsthand the dramatic improvement so many veterans have had while taking cannabis. Not only have they experienced relief from problems such as PTSD, chronic pain, and migraines, but many of them have also been able to break their addiction to more dangerous drugs, such as opioids and benzodiazepines."
VA staff physician Deborah Gilman, MD, said current VA policy forces physicians to ignore the science if it conflicts with policy.
"Unlike private practice physicians, VA physicians are under a gag order regarding discussing marijuana with patients," she said. "In other settings, doctors can be honest about their medical opinions regarding treatment options, based on science. In the VA, an administrator can write policy that you can't disagree with without losing your job. Veterans are fearful of losing either their medical benefits or their access to health care if they acknowledge using marijuana. This causes a VA doctor to give you a medical opinion based on the VA regulation, not on the science. I knew many VA doctors whose professional opinion was that cannabis might help some of their patients, but they could never say so in their office or in public."
"There is nothing more sacred in healthcare than the doctor-patient relationship," said Sisley. "Right now we are seeing interference with that coveted relationship. No government policy should come between a doctor and their patients. The only people who should be making medical decisions for veterans are their physicians, not a bureaucrat and not a law enforcement official. These men and women have sacrificed so much for their country. It's only fair that they get the care that they deserve, and have access to the whole range of treatment options."
For Krawitz, it's about getting health care he and countless other vets deserve.
"I suffer from a combination of internal injuries and broken bones leading me to be a perfect candidate for cannabis as an adjunct pain treatment," he explained. "I need to be able to go in and see my VA doctor and have a honest conversation where my doctor feels free to gain knowledge now available through continuing medical education and relay that information to me in writing even if that is the very documentation is what I need to participate in a state medical marijuana program."
Now it's up to Veterans Affairs Secretary Robert McDonald. He's heard from Congress, he's heard from patients, he's heard from doctors and scientists. We'll see if he's listening.