I, Dr. Neil M. Flynn, declare as follows:

1. I am a Professor of Clinical Medicine in the Division of Infectious Diseases of the Department of Internal Medicine at the University of California at Davis School of Medicine. I also serve as attending physician in the University Medical Center's AIDS and Related Disorders Clinic. I received my B.A. in bacteriology from the University of California at Los Angeles in 1970, graduated from the Ohio State University Medical School in 1973, and did my internship and residency in internal medicine at Loma Linda University Hospital from 1973-76. I completed a fellowship in infectious diseases at the University of California at Davis from 1976-78 and was awarded my Master of Public Health from the University of California, Berkeley, in 1994. I am licensed to practice medicine in the State of California.
2. I am a member in good standing of several professional societies including the American Public Health Association; Infectious Diseases Society of America; American College of Physicians; and the American Society for Microbiology. I am board certified in Internal Medicine and in Infectious Diseases.
3. In addition, I have served on numerous hospital and medical school committees at the University of California, Davis (UCD). Currently, I am the Chairperson for the UCD Human Subjects Review Committee, and a member of the Chancellor=s Committee on AIDS. Previously, I have served as a member of the Department of Internal Medicine Quality Assurance Committee, the Medical Director of the AIDS & Related Disorders Clinic, and Chair of the Infection Control Committee.
4. Among the awards I have received are the ACP Humanitarian Award (1995), Sacramento Regional Pride Award (1991), Lambda Community Award (1988), Kaiser Foundation Hospitals Award for Excellence in Teaching Clinical Sciences (1986), Outstanding Staff Award at UCD Medical Center (1982-83), and the Roessler Foundation Research Scholarship Award (1972-73). I have successfully sought hundreds of thousands of dollars in grant money to pursue research on HIV and AIDS since establishing the UCD Clinic in 1983.
5. The continuation of this research depends upon my ability to obtain future grants from both private and public sources. I am the principal author or co-author of numerous articles and book chapters in the area of infectious diseases. My writings have appeared in such journals as The New England Journal of Medicine, Journal of the American Medical Association, Western Journal of Medicine, Life Sciences, Annals of the New York Academy of Sciences, and Journal of Acquired Immune Deficiency Syndromes. I have also delivered numerous lectures at professional symposia, in this and other countries, including the Third through Tenth International Conferences on AIDS.
6. Through the University=s AIDS Clinic and the Center for AIDS Research, Education and Services (CARES), a private, non-profit clinic for treatment of HIV infection and disease, I participate in the care of approximately 1,500 AIDS patients. I am the primary physician for 200 AIDS patients.
7. Intractable nausea and wasting syndrome are frequent symptoms associated with AIDS and the treatment of AIDS. The nausea, which can last for days, weeks or months, is one of the most severe forms of discomfort or pain that the human being can experience. It destroys the quality of life of the patient, whose sole objective is to make it through the next hour, the next day. Racked by intense vomiting and queasiness, time for the patient seems to stand still. Wasting can take a similar psychological and physical toll.
8. For patients suffering intractable nausea and/or wasting, my first concern is to relieve these symptoms. If I fail to do so, the patient is increasingly likely to decide that life is simply intolerable. I have had patients whose nausea and/or wasting were so disabling that they preferred death. As a physician, I try my utmost to avoid this end result.
9. Fortunately, I often can relieve the patient=s acute suffering and, thereby, restore her quality of life to an acceptable level. My first line of therapy for acute nausea involves the use of Compazine or Reglan. Sometimes these traditional anti-emetics do not work, either because they fail to reduce the nausea and/or the patient does not tolerate them well. The drugs themselves have side effects, and can cause impairments in a patient=s fine and gross motor skills. As a result, patients sometimes move in a slow, stiffened manner. Their faces may appear frozen. And they can develop severe muscle contractions. Many of these side effects are similar to those experienced by patients treated with Thorazine and Haldol. I have also tried prescribing a newer drug called ondansetron which was developed specifically for the treatment of chemotherapy-induced nausea. The success of ondansetron varies greatly among patients. Lastly, benzodiazepines can be tried.
10. If I am unable to relieve the patient=s nausea with the above remedies, I next prescribe Marinol, a synthetic version of THC, one of the main active compounds found in marijuana. Marinol is also helpful in stimulating appetite in patients suffering from AIDS wasting, as are other drugs, Megace, anabolic steroids, and human growth hormone.
11. If Marinol does not provide adequate relief from nausea and/or wasting, I may suggest that the patient try a related remedy, marijuana. I firmly believe that medical marijuana is medically appropriate as a drug of last resort for a small number of seriously ill patients. Over 20 years of clinical experience persuade me of this fact. The anecdotal evidence is overwhelming. Almost every patient I have known to have tried marijuana achieved relief from symptoms with it. That success rate far surpasses that for Compazine. Accordingly, as with any other medication that I consider potentially beneficial to my patients, I must discuss the option of medical marijuana in detail when appropriate. Anything less is malpractice.
12. For those patients for whom I believe marijuana is an appropriate remedy, I discuss the various ways in which marijuana can be ingested. Smoking marijuana is the most direct, rapid, and accurate delivery of the drug. But smoking has the drawback of putting particulate matter in the patient=s lungs. This is of concern to me because studies show that AIDS patients who are heavy cigarette smokers shorten their life spans by about 2 years. It is not unreasonable to surmise that heavy marijuana smoking could lead to similar results. Nevertheless, smoking may be the most accurate way to deliver a number of drugs, including nicotine or marijuana. Furthermore, there are ways of reducing particulate intake, for example through the use of water pipes which tend to filter the smoke, and consumption of unadulterated marijuana.
13. I inform my patients that they may try eating marijuana. But this, too, is not without difficulties similar to those experienced by many patients who try Marinol. Eating marijuana (or ingesting a Marinol capsule) can cause unpredictable results because the absorption of the THC can either be rapid or delayed, depending on whether the patient ingests the marijuana on a full stomach. The same is true for drinking marijuana tea.
14. In my experience, the unpleasant side effects that some patients experience from marijuana, however it is ingested, are far less severe than the side effects experienced from Compazine and Reglan and similar drugs. Nor do I have to worry about harmful drug interactions with patients who use therapeutic doses of marijuana: to my knowledge, there are none. If a patient presents with both nausea and anxiety, I can prescribe Compazine and Valium. However, marijuana can effectively treat both conditions simultaneously. It is not at all clear to me that the combination of Compazine and Valium, both of which are toxic, the latter of which is addictive, is better than marijuana alone.
15. As the above approach illustrates, I begin treating my AIDS patients by listening to their complaints and concerns. For symptoms such as intractable nausea and wasting syndrome, I first prescribe those medications that are legal. If these medications do not work, or prove intolerable, I then discuss the option of medical marijuana, which appears near the bottom of my cascade of options. But because I consider marijuana a legitimate medical option at all, I stand squarely in the cross-hairs of the federal government=s official policy against medical marijuana and the doctors who recommend it. The government=s threats to sanction physicians who, in their best medical judgment, recommend marijuana to treat a seriously ill patient are threats against me.
16. AIDS medicine is my profession and my passion. I have dedicated myself to this disease since 1983 when I opened the Clinic at U.C. Davis. Thus, I am deeply concerned about civil and criminal sanctions that loom over me. I do not want my job to be taken away by some government official who has a different medical paradigm than I, many of my colleagues, or for that matter, the majority of California voters. If I lost my Schedule II license, my ability to provide care for people with AIDS -- 80% of my patients -- would be severely compromised. I write 30-50 narcotic prescriptions per month for my seriously ill patients. I would no longer be able to do so if my DEA license were revoked.
17. I feel compelled and coerced by the government threats to withhold information, recommendations, and advice to patients regarding the use of medical marijuana. This state of affairs is unacceptable in medicine. My patients come to me seeking relief from pain or suffering or the threat of death or disability. Their complex and severe illnesses are often complicated by difficult personal situations. The government=s threats inject yet another complication into the mix.
18. The threats erect a barrier between me and the patient. Yet the patient=s trust is essential if I am to provide the best medical care possible. If, in an attempt to protect me from government sanctions, patients refrain from discussing the fact that they find relief from marijuana, I lose an opportunity to suggest that they try Marinol (if they have not done so already). Marinol, which is legal and covered by health insurance, can save the patient considerable money and anxiety, if it works. Similarly, if patients do not inform me that they can only control their nausea with marijuana, I remain ignorant of the full extent of the side effects of their illness or medications and miss the chance to change patients= bothersome medications in order to lessen or eliminate the nausea for which they have resorted to marijuana.
19. More fundamentally, I need to know how much pain my patients suffer. If I don=t know this, I cannot perform my job effectively. If a patient, because of the government=s threats, fails to inform me that s/he uses marijuana for nausea or wasting, but the marijuana is not very effective (although perhaps more effective and less deleterious than prescription medications), perhaps the patient is not using potent enough marijuana. As a physician, it is my duty to inquire into this possibility, and, where appropriate, suggest trying a different type of marijuana.
20. Protease inhibitors, the newest and perhaps most effective drugs in the battle against AIDS, are beginning to lose their efficacy in some AIDS patients. When this happens, wasting syndrome, a potentially deadly process, begins. Body mass lost to wasting is difficult to regain. Therefore, it is preferable to stop wasting as early in the process as possible. To effectively treat wasting, I must know when wasting starts and at what pace it occurs. Thus, it is important to know if a patient is combating wasting with marijuana. Such behavior signals that I should consider prescribing other drugs, such as Megace or anabolic steroids. The government=s threats, however, hamper the free exchange of information and advice necessary to an accurate and comprehensive diagnosis of the patient=s condition.
21. The government=s threats have been the subject of discussion among my colleagues who provide care to AIDS patients in the greater Sacramento area. As a general policy, a group of physicians who treat approximately 1,200 AIDS patients decided to speak with their seriously ill patients about the benefits and drawbacks of medical marijuana, but not to record this information to protect the patient from government recrimination which could cause them far greater harm than the use of the drug itself. The policy also aimed to protect physicians and the institutions with which they are affiliated from government sanctions or liability. Such a policy -- don=t chart, just tell -- flies in the face of how doctors are trained, and is not necessarily in the patient=s best interest. If salient facts regarding the patient=s medical condition and treatment do not appear in the patient=s chart, a consulting physician or the patient=s next physician may be deprived of critical facts necessary to provide adequate care. Doctors need every bit of information available to treat their seriously ill patients.
22. The absence of information in a patient=s chart also robs doctors of the ability to scientifically study the efficacy of marijuana in the treatment of various symptoms. If only every fifth patient chart accurately reflects the fact that Compazine failed as an anti-nauseant and the patient successfully resorted to medical marijuana, while, in reality every third patient presented with this history, the medical landscape which scientists analyze is deeply distorted. What we cannot see we conclude to be nonexistent. Thus, the government=s calls for further research of marijuana are undermined by its concurrent threats against physicians which result in the suppression of the data on which such research depends. The failure to record medical history in patient charts risks perverting scientific attempts to assess the use and efficacy of marijuana.
23. Doctors neither want to overdramatize nor obfuscate what they learn from their patients. Doctors should be free to record the information they learn and their ideas as they arise. We frequently do not understand everything we see or hear the first time we see or hear it. In my patient charts I sometimes write APuzzling@ or "not clear" if I am unsure of the significance of what I am observing or being told. I then can follow up and try to discover its true significance.
24. Physicians often consult with one another and discuss our various options of treatment and talk anecdotally about our patients= therapies, including their use of marijuana. We try to find the most effective, least toxic medications for our patients. When faced with a choice of equivalency, we opt for the least toxic treatment. When one medication is more toxic than another, but is also more effective, we discuss this fact with patients, and they pick the preferred course of action. Medicine is a constant process of adjustment. When advising a patient, I do not simply have my next move in mind, I have my next three or four moves in mind. I develop a sequence of options, in case my next move doesn=t work. AIf this hasn=t worked in 2-3 days,@ I tell the patient, Awe=ll try something else.@
25. Two of my colleagues have told me that they feel so constrained by the government threats that they will not talk with their seriously ill patients about marijuana until the issue is resolved legally.
26. The government=s policy and threats make criminals out of people who are suffering from life-threatening illnesses. This stigmatization is unnecessary. The government permits doctors to prescribe narcotics, such as morphine, for the relief of pain. To single out doctors who recommend or patients who use medical marijuana -- a substance almost certainly less addictive than many narcotics, not to mention alcohol and nicotine -- is irrational. Benzodiazapines and barbiturates are more addictive, and far more dangerous than marijuana with respect to their ability to induce death due from overdose.
27. The federal government and the public have little to fear from physicians abusing their recommendations or prescriptions of marijuana. The vast majority of physicians dispense morphine or Valium, much more powerful drugs, without incident. It has traditionally been the province of state governments to curb abusive practices of physicians. In California, the Board of Medical Quality Assurance polices the state=s medical practitioners. If a physician administers drugs in an irresponsible manner, an investigation will ensue. If the abuse is egregious, the doctor=s license to practice will be revoked. There is no reason to believe that these same policing mechanisms would not be effective for marijuana.

I declare under penalty of perjury under the laws of the United States and the State of California that the foregoing is true and correct to the best of my knowledge.

Executed at Sacramento, California, this 13th day of February, 1997.

Neil M. Flynn, M.D.