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Living with incurable cancer, after a third relapse of Hodgkin's lymphoma, 39-year-old Lalanya Blue McGraw credits the daily use of medical marijuana for allowing her to make the most of what may be borrowed time.

"I've been considered terminal for a long time. The cancer is still there, even after all the chemo and two bone marrow transplants. When it gets worse, I can go into a clinical trial with a chemo drug that has not yet been approved in Canada. But until then, I have defied the odds," says the Vancouver resident, a former jazz singer whose voice has been affected by the disease.

"I think, I believe, it's the cannabis that is slowing the cancer down. That's my perspective anyway. It's the only thing I'm on."

When McGraw first asked an oncologist at the BC Cancer Agency in 2002 to prescribe marijuana to treat some of the effects of her cancer, he was reluctant. He didn't object to her using it, but balked at dealing with the Health Canada paperwork required when prescribing any one of four products that can be obtained through the federal Medical Marijuana Access Regulations, she says.

In 2001, Health Canada delegated the responsibility for prescribing marijuana to doctors, who must fill out one of two forms attesting to the fact their patients fit certain criteria. The first form asks doctors to confirm their patient has a cancer or degenerative neuromuscular condition that might benefit from marijuana. If doctors don't feel they can attest to that, they must fill out an alternate, longer form that can take 20 minutes to complete.

After her last relapse a few years ago, McGraw joined the Compassion Club, which has a simple form with check boxes. She had a new family doctor who had moved from Ontario and McGraw said she didn't hesitate to sign the form.

"I just printed off the Internet form and took it into her. She was very familiar with it and giggled as she checked off the boxes."

The Compassion Club form takes only a minute to complete and doctors don't have to do much more than declare that the patient reports their symptoms are helped by cannabis.

Unlike the federal forms, it does not protect patients from prosecution for possession but, as an article in the B.C. Medical Journal said: "Practically ... police are usually reluctant to prosecute a patient who has a physician endorsement for possession of marijuana."

McGraw buys marijuana from the club dispensary in various forms -most often in a $15 tincture vial from which she extracts drops that she places on her tongue. It calms her mood, alleviates any nausea and helps her sleep. Although she sometimes smokes it in the dried form, she says it can make her feel "too goofy."

She also buys an olive oil infused with cannabis, "but that's mostly when I want to put it in brownies to spoil myself on my birthday," she says.

McGraw was calm throughout the interview, despite facing several questions about her own mortality. That sense of calm broke, however, when she was asked about her first experiences with the Compassion Club. She got teary as she recalled being fast-tracked during her orientation process because of her incurable form of cancer.

"It is an exceptionally supportive environment at the Compassion Club. I remember on my first visit, a guy with crutches came over to me and whispered in my ear to say 'everyone is very friendly in here.' And they are. It has definitely become a family for me. I don't have the people I've met there over for dinner or anything, but in the waiting room there is a passive, friendly vibe. No one tries to upstage anyone else when it comes to medical problems. Everyone is respectful and compassionate."

DOCTORS RESPOND

Thousands of doctors in B.C. have prescribed marijuana over the past several years to their patients even though their advocacy and regulatory bodies aren't convinced on the scientific evidence.

Dr. Pippa Hawley is one of them.

Although she agrees with the College of Physicians and Surgeons of B.C. and the Canadian Medical Association -which both contend the lack of credible information makes prescribing marijuana potentially dangerous because of unknown risks, benefits, complications and drug interactions -Hawley is one of several specialists at the BC Cancer Agency who prescribes medicinal marijuana.

"I don't set myself up as a marijuana prescriber. I'm a physician and if marijuana, or one of its derivatives, is an appropriate management strategy for a particular patient then I have no problem facilitating access to it, either by prescribing it or filling in the forms for them to take to the Compassion Club. But that doesn't make me an enthusiast," says the internal medicine specialist who started the Pain and Symptom Management/ Palliative Care program at the BC Cancer Agency.

Hawley was surprised to hear that, according to the most recent Health Canada information, 1,773 B.C. doctors have helped 3,627 patients get permission to legally possess marijuana.

That figure is the highest in Canada, more even than Ontario where 1,693 doctors signed authorizations for 3,427 patients. Even Quebec, which like Ontario has a far greater population than B.C., has only 306 doctors prescribing marijuana.

While 1,773 B.C. doctors have filled out the official forms to authorize patient use of "medicinal" marijuana, the Compassion Club, the oldest medical marijuana dispensary in Canada, says many more doctors have signed off on the club's less onerous -albeit quasi-legal -form.

It says 3,400 B.C. doctors, including medical doctors, naturopaths and traditional Chinese medicine practitioners, have referred patients there in the past 14 years.

The Compassion Club says it has about 4,000 members for a total of 6,500 since it opened its doors in 1997.

While patients and marijuana advocates have complained over the years about the lack of enthusiasm on the part of doctors, Hawley says she knows of no colleagues withholding access to medicinal marijuana.

"Not that I think they are fantastic products. There may be doctors who aren't keen on marijuana, but I don't think anyone would deny a patient access if it was medically justifiable," she says.

"With all symptom control there is a degree of trial and error because everyone is different, but particular pain syndromes that can respond well to marijuana are the ones where there is neuropathic nerve pain or if there are a lot of muscle spasms.

"And it is not well documented, but people who have difficulty with anxiety, especially if they have been recreational users of marijuana in the past, may be those ones who tend to do well," she says.

Since marijuana is known to sometimes carry side effects, Hawley says doctors have to be aware of that.

"It can make people paranoid. That's why we have to be careful about being too liberal with it. People who have already been recreational users tend to know their threshold."

The oral (pill) form is good for treating nausea and poor appetite, but when pain and anxiety are the main complaints, then a spray inside the mouth can be prescribed.

The Health Canada form allows patients to possess dried marijuana for smoking; they also can grow it themselves or buy it from authorized growers. Hawley said some patients prefer she fill out the Health Canada form instead of the Compassion Club form, but she has to warn them that it can take weeks or months for processing by the government so "forget it for people at the end of their life; they are better off going to the Compassion Club or some other dispensary."

Those who favour -about one in three patients -going the Health Canada route are patients who tell her they feel more secure knowing they have the full legal, Health Canada designation, especially if they have a history of any drug infractions, she says.

Hawley says she wouldn't be surprised to hear that family doctors sometimes encounter patients who ask for the authorizations just because the marijuana is so much cheaper when bought from the Compassion Club rather than from dealers on the street.

"There may be some patients who are faking something. But if someone has a genuine pain problem and they are reasonable people who have not behaved dysfunctionally, have not been aggressive or abused previous prescriptions, have been polite and pleasant, then I think very few doctors would have problems filling out the forms."

She says a third to a half of cancer patients report that medical marijuana provides symptom relief.

"I give people fairly low expectations when I first prescribe and I am more receptive to prescribing if they have tried other stuff [like methadone] but not responded."

Some patients hate the "spacey" side-effect of marijuana because they don't like feeling different, while others find it to be a pleasurable effect.

OPINION DIVIDED

Getting any kind of agreement on the pros, cons, risks and benefits of marijuana is seemingly impossible.

The Canadian Medical Association's position statement on medical marijuana has evolved over time.

Initially, it "vigorously" opposed making physicians part of the supply chain because of the lack of evidence. More recently, it has stated it accepts that physicians who feel qualified to recommend medical marijuana to their patients do so in accordance with Health Canada regulations, which ask doctors to attest to a diagnosis and the failure of conventional therapies.

It has encouraged government to fund research on safety, dosing and delivery systems.

And it has endorsed compulsory education and licensing programs for doctors who do prescribe.

The doctors' legal defence agency, the Canadian Medical Protective Association, has told its members that anyone who is uncomfortable with the Health Canada regulations should refrain from prescribing the drug to patients.

In B.C., the College of Physicians and Surgeons has a position statement that says the lack of good evidence on smoked marijuana's medicinal use makes it "difficult and possibly dangerous for physicians to prescribe," especially because of uncertainty about interactions with other drugs.

Doctors could be "the subject of accusations or suggestions of negligence, including liability if a prescribed drug [like marijuana] produces unforeseen or unidentified negative effects."

Like the CMA, the college says only doctors who are familiar with the pharmacology of marijuana should prescribe it.

A medical literature search on marijuana will turn up anywhere from 12,000 to 15,000 articles and studies. But Dr. Robbert Vroom, senior deputy registrar of the college, says there is a "minuscule" number with "real science" methodology.

If the evidence was clear, then doctors across Canada would be uniformly prescribing, he says.

Instead, B.C. now has the highest number of doctors prescribing -"seven times more per capita than Quebec" -a situation he attributes to the "lack of robust evidence-based guidelines as well as a spillover of the highly prevalent use of recreational marijuana in B.C."

Vroom, a former emergency room doctor at Surrey Memorial Hospital, said he doesn't doubt that some patients experience benefits when they use marijuana.

He said they may well be the same kinds of people who turn to "the comfort and pleasure of a substance they enjoyed in the past, be it tobacco, wine or Scotch."

"I maintain that medical marijuana is a substance of unknown composition, potency, or dose administered by smoke inhalation, foisted on the medical profession for us to gate-keep," said Vroom, in a recent letter in the BC Medical Journal.

He was rebutting a letter from Philippe Lucas and Rielle Capler, co-founders of the advocacy organization Canadians for Safe Access, who contend that "the fact that cannabis has an excellent reputation as a recreational drug in no way negates the evidence of the efficacy and relative safety of its medical use."