Reefer Madness

Last week, Delaware Governor Jack Markell put his signature to the state's first medical marijuana law. Of course, cancer is at the top of the laundry list of maladies that qualify patients for participation. I guess it's time to go shopping for a nice bong...

Kidding. For a state that trends to blue politically, Delaware is relatively socially conservative, and this is reflected in the fact that the law is substantially more restrictive than those currently in effect in, say, Colorado or California. Patients are not permitted to grow their own, and must obtain their smoke (a maximum of six ounces) from one of only three non-profit dispensaries (presumably one per county). Patients must have an on-going relationship with the prescribing MD; are supposed to have exhausted all the standard alternatives; and must obtain a state-issued ID card. It remains to be seen just how much of a problem there will be with people with nasty hangnails showing up at the dispensaries with ID cards and prescriptions, since there is an escape clause covering individuals with unspecified "chronic" and "debilitating" conditions. On the whole, it all sounds a lot more inconvenient than just driving to certain Wilmington neighborhoods on Friday night, but I guess that's partly the idea.

Huong asked me how interested I am in this. The answer is "Not Very", at least for now. I am not currently taking any kind of pain medication, not even any of the OTC varieties (OK, yes, I'm taking 81 mg aspirin, but that's for the heart, not for pain), and I'm hoping to avoid having to do so for as long as possible. The prescription opioids (e.g. Oxycontin) render me hopelessly constipated. I guess if it ever comes to the point where I'm pretty desperate then I'd consider smoking up. Actually, I'd prefer not to smoke it; I'd probably invest in a nice vaporizer.

Minus Aredia

The oncologist did not require much in the way of persuasion to call off the Aredia treatments for the time being, in honor of my recently discovered need for oral surgery. But he did question the need to order any CTX tests, indicating that it should only be necessary to wait a decent interval before proceeding. That was not the impression I had gained from what the endodontist had told me, so these two titans of medicine will consult, and presumably arrive at some kind of consensus on the subject.

This month, in addition to the usual blood tests (results as usual), I got a 24-hour urine test. This is really just looking for the same monoclonal proteins as the blood test, but is much more sensitive. It, too, failed to turn up anything. I also got a skeletal survey, which revealed little change since the last one I got, around a year ago. So everything is indicating stability at this point.

Recently it has seemed to me that the abdominal bloating has gotten worse, and I occasionally experience pains on the right side. Next week I am scheduled for an abdominal ultrasound, to check into this situation.

An Unexpected Complication

I seem to be specializing in Strange Maladies Of Indeterminate Origin. Last week, I visited my dentist for a routine cleaning and examination. I also got the annual full set of X-rays. The picture of one of the mandibular canines (tooth #27) caught the attention of the dentist, who forwarded it to an endodontist, who delivered a diagnosis of external root resorption. This is a poorly understood (especially by me) phenomenon, in which the tooth appears to be destroying itself from within, "apparently initiated by a peculiar inflammatory hyperplasia of the pulp", by one account. This could be an autoimmune disorder, but it is more commonly believed to be ultimately caused by trauma, where "trauma" is defined to include the wearing of orthodontic appliances -- which I did, back in the day. If the damage is not too advanced, the tooth can be rescued by means of a root canal; otherwise, it must be extracted and, nowadays, typically replaced by an implant. In my case, the endodontist would normally pass me off to an oral surgeon for extraction. But...

But I am receiving bisphosphonate therapy, to counteract the effects of the cancer on my spine. Normally, special cells called osteoclasts clean up old bone mass, making way for new bone created by the counterpart osteoblasts (a process known as "bone turnover"). Myeloma appears to overstimulate the osteoclasts, which begin to outperform the osteoblasts, creating many lytic lesions -- holes -- in the bone. This is obviously a Very Bad Thing, leading in my case to a greatly enhanced risk of spinal compression fractures. Bisphosphonates such as the one I am getting, Aredia, attempt to solve this problem by suppressing the osteoclasts, which is a mixed blessing, since bone turnover is as a result reduced everywhere, meaning that the bones are more brittle and are slower to heal than they should be. Apparently, this is especially a problem where surgical procedures performed on the jaw, such as a tooth extraction, are concerned, leading to a condition known as "bisphosphonate-related osteonecrosis of the jaw". The wounded jaw does not heal, and eventually the bone in the vicinity of the wound dies. This is another Very Bad Thing. So oral surgeons are understandably reluctant to perform extractions on patients receiving bisphosphonates.

The effect of bisphosphonates on bone turnover is typically gauged by a serum CTX test; patients getting bisphosphonates will show much lower than normal CTX numbers. A sufficiently lengthy drug holiday might return serum CTX to a range acceptable to an oral surgeon; a temporary root canal might be necessary to stave off disaster in the interim. The question is whether the oncologist can be persuaded to declare such a drug holiday. I was on track to continue receiving Aredia until at least the end of this year, for reasons of course completely unrelated to dentistry. My next visit with the oncologist should be much more interesting than usual, for this and certain other reasons, which I will discuss in due time.