ASA in the News

By Sasha Goldstein for Seven Days

"There's always the concern that, if there's not a specific statute or guideline [granting protections], then the risk [of discrimination] remains," said David Mangone, legislative counsel at Americans for Safe Access, a Washington, D.C.-based organization that advocates for access to medical cannabis. The group recently graded every state's medical marijuana program and gave Vermont's a zero out of five for its organ transplant protections.

At the University of Vermont Medical Center, the only hospital in the state where kidney transplants are performed, potential recipients undergo a rigorous screening to get a shot at the life-changing operation. Among the factors that Dr. Carlos Marroquin, the chief of transplant surgery, considers is whether a patient uses marijuana, including medical cannabis.

"Because of the risks of infections, the unknown risk of cancer, because of the unknown effects on blood vessels, we try to select out for a healthy lifestyle, and so we strongly encourage patients against smoking marijuana," Marroquin said. "I think it's a risk."

Legislation under consideration in the Vermont House would take at least some of the decision making out of the hands of physicians such as Marroquin. The proposal would prohibit medical providers from disqualifying a patient "from any needed medical procedure or treatment, including organ and tissue transplants" solely because the patient uses marijuana for medical reasons.

The proposal is meant to protect patients on the medical marijuana registry, which was created when Vermont legalized cannabis for medical use in 2004. The initial medical marijuana program "was already such a sea change that not every consideration really had been teased out or contemplated," said Senate President Pro Tempore Tim Ashe (D/P-Chittenden).

In the years since, Vermont's medical marijuana program has grown to include more than 5,600 patients. Legislators have approved pot dispensaries and expanded the list of conditions the drug can treat to include debilitating illnesses such as Parkinson's disease. Protections for organ transplant recipients just hadn't come up, according to Ashe.

That is, until Caroline Tassey, a nurse practitioner with a private practice who also works part time in the UVM Medical Center's transplant program, proposed the legislative fix earlier this year. She cited a meeting in which, she said, Marroquin stated that he would not so much as evaluate a medical marijuana patient for a transplant unless he or she had stopped using cannabis for six months. She worries the surgeon's stance has become an unwritten policy.

Tassey has worked in the hospital's kidney disease program since 2001; Marroquin joined as transplant surgeon in 2014. "We have had a number of surgeons, before the current surgeon, and using marijuana had never been an issue in terms of not transplanting people," Tassey said.

When asked if he had refused to evaluate medical marijuana users, Marroquin denied it and said, "We evaluate all patients on a case-by-case basis, which we always do." Health and lifestyle factors, such as whether the patient is a cigarette smoker or obese, are considered, according to the surgeon.

"We don't have a strict policy on marijuana — we don't have a policy on marijuana at all," he said. "We encourage people not to [use marijuana] because of the risks we've identified and the unknown risks. It's someone's well-being. If someone wants to come forward and improve their life [with a kidney transplant], why would you do something that imposes an unknown risk to your overall well-being?"

It's unclear whether any Vermont patients have been passed over for a transplant because of marijuana use, medical or otherwise. When asked if he'd transplant an organ into a medical marijuana user, Marroquin said it depends.

"We evaluate the reasons why they're on [medical marijuana]," he said. "If there are substantial systemic manifestations of another disease that causes them to have to be on medical marijuana, maybe they're not fit for transplant."

Screening potential transplant recipients is particularly important because too many patients are vying for too few kidneys. Vermont's kidney waiting list is 65 patients long, according to U.S. Department of Health and Human Services data. Surgeons in the state have yet to transplant a kidney this year, but they performed 21 transplants in 2017 and 24 the year before.

Approximately 330 Vermonters underwent kidney dialysis treatment in 2016, according to data from the End-Stage Renal Disease Network Program. Some of those patients consider kidney transplant as an option, Tassey said.

"A transplant is not a cure [for kidney disease]," she said. "It's another illness — it's simply a better illness. People live longer with the transplant, and the quality of their lives is better."

It's unclear how many dialysis patients are also medical marijuana users. But dialysis, which requires three four-hour sessions each week, can cause nausea and loss of appetite, two things medical cannabis can help, according to Tassey.

"I think if there's any research out there that most people agree on, that would be the research," she said, noting that physicians have long prescribed Dronabinol to stimulate appetite. The drug is a synthetic form of the cannabis derivative tetrahydracannabinol (THC).

In the Vermont Senate, Ashe added the transplant protections as an amendment to S.216, a measure that addresses oversight of the state's medical marijuana program. The full Senate approved the bill in March.

"We have a legal system of medical marijuana, and it would just not be right or fair to tell someone who's legally accessing marijuana for a medical condition that, solely because they're obeying the law, they're going to get ditched or dropped from a list for a potentially life-saving procedure," Ashe said.

The bill is before the House Human Services Committee, which is scheduled to take it up on Thursday, April 26.

"I'm walking into this entire bill with an entirely open mind, because that's what the legislative process is all about," said Rep. Ann Pugh (D-South Burlington), the committee chair. "I had no idea it was an issue until that aspect of the bill was brought to my attention ... The question, though, is, how big of an issue is it? Does it lend itself to a legislative fix?"

While the bill was in the Senate, the Vermont Medical Society provided the lone voice of dissent. In written testimony, the group, of which Marroquin is a member, argued that physicians "should not be legally prohibited from weighing certain factors that may impact the appropriateness of a treatment or organ and tissue transplants."

Ashe disagreed with the medical society's assessment.

"What we were saying is that medical professionals should always be making the decision, and it should be based on the medical facts, not just because someone's on the list," Ashe said. "If there's nothing problematic with marijuana use, for instance, it would be strange to tell someone that they're going to be punished for legal behavior. We recognize that medical professionals should be making the decision, and what we've done doesn't actually depart from that."

Some other states already have addressed the issue. New Hampshire's 2013 medical cannabis law requires that medical providers consider the drug as they would any legally prescribed medication.

The topic can be sensitive. When asked about the policy at Dartmouth-Hitchcock medical center, which treats many Vermonters, spokesman Michael Barwell flatly refused to answer. "We choose not to respond to your query," Barwell said.

In Maine, a patient who was skipped for a transplant because he used cannabis helped get a similar law passed last year. It allows medical users in need of a transplant to ingest marijuana but not to smoke or vape it.

The issue is cropping up across the country as cannabis use gains mainstream acceptance, medically and recreationally. About 30 states have a comprehensive medical cannabis program, according to the National Conference of State Legislatures, and approximately a dozen have protections in place for potential organ transplant recipients.

"There's always the concern that, if there's not a specific statute or guideline [granting protections], then the risk [of discrimination] remains," said David Mangone, legislative counsel at Americans for Safe Access, a Washington, D.C.-based organization that advocates for access to medical cannabis. The group recently graded every state's medical marijuana program and gave Vermont's a zero out of five for its organ transplant protections.

Mangone acknowledged that there is no medical consensus on marijuana use by potential organ transplant recipients. The U.S. Drug Enforcement Administration has stunted study for decades by classifying cannabis a Schedule 1 drug, meaning the feds don't believe it offers any medical benefit.

"Most physicians in academic medical centers really [rely] on research and rigorous trials and studies," said Isabelle Sargeant, who is president of the Vermont Kidney Association and spent years as the UVM Medical Center's director of renal and transplant services. "And the jury is still out ... They still don't know how [marijuana] works or why it works, so that's the problem."

The policy at Maine Medical Center, the only hospital in that state where kidney transplants are performed, specifically prohibits smoking or vaping the drug because of the risk of sinopulmonary aspergillosis, a fungal infection of the lungs that can be fatal, especially in patients whose immune systems are suppressed by anti-rejection drugs. Two transplant recipients in Maine who smoked marijuana died of that infection.

UVM Medical Center's Marroquin said he has similar concerns and worries about "downstream ramifications" that marijuana could cause by interacting with the myriad drugs kidney transplant patients must take.

"The topic is not one that lends itself to a straightforward answer," said Dr. David Klassen, the chief medical officer at the United Network for Organ Sharing, a nationwide organ procurement and transplant network based in Virginia. "There are risks, and obviously there are benefits for medical marijuana use, as well, so I think potential recipients and transplant physicians need to sort of weigh the risks and the benefits as they try to resolve these issues."

Sargeant has retired as a full-time medical professional but still covers shifts each summer at the UVM Medical Center's nephrology office, where she's gotten to know Marroquin.

While Sargeant said she sees merit in the legislation — "both sides can work with that" — she also understands Marroquin's concern about cannabis use.

"When you think about it, to be a transplant surgeon, you have to be very passionate and rule-based because, again, you're dealing with a very precious resource," Sargeant said. "So he's quite strong. When he feels, 'This is the right course,' he sticks to his guns."