Pubdate: Mon, 28 Apr 2014
Source: Daily Hampshire Gazette (MA)
Copyright: 2014 Daily Hampshire Gazette
Contact:  http://www.gazettenet.com/home/
Details: http://www.mapinc.org/media/106
Author: Chad Cain

MEDICAL MARIJUANA IS LEGAL HERE, BUT MANY DOCS DON'T WANT TO PRESCRIBE IT

This is part one of a two-part series on the legalization of medical 
marijuana. Publication was delayed of a Florence resident's 
experience with finding help from medical marijuana in the face of a 
fatal diagnosis after the man died Monday.

Medical marijuana may be legal in Massachusetts, but local patients 
seeking the drug to treat serious medical conditions may have trouble 
getting it, because few area doctors are willing to approve it for 
their patients.

One of the Valley's largest physician groups has adopted a policy 
forbidding doctors from certifying patients as eligible to acquire 
cannabis - a required step for a patient to obtain it - and several 
other medical groups are considering going that route. Many other 
individual doctors remain reticent about recommending marijuana as a 
treatment option.

The docs say they harbor concerns about conflicts between state and 
federal laws regarding marijuana, and believe there is not enough 
hard science proving the value of medical marijuana.

Medical marijuana Catch-22

As opening day for dispensaries across the state approaches - one 
planned for Northampton is on track for its approval this spring, 
with plans to open in September - the medical marijuana terrain 
remains full of Catch-22s that create complications for both patients 
and their doctors. Some examples:

∎ Marijuana is legal in Massachusetts and 20 states for 
medicinal purposes, but use and possession are still against federal law.

∎ Most doctors are wary of recommending medical marijuana due 
to what they say is inadequate research surrounding its 
effectiveness, yet the federal government forbids Food and Drug 
Administration-led studies because cannabis is against federal law.

∎ A rise in "certification centers" that deal only with 
patients seeking marijuana is drawing criticism from the mainstream 
medical community, yet the centers are opening to fill a void left by 
primary care doctors staying on the sidelines.

∎ Many doctors say marijuana can be an effective tool, yet they 
won't approve it and instead refer patients to the only doctor in the 
region who does so. Yet she says she will soon be too busy to take on 
new patients.

Nearly everyone involved acknowledges medical marijuana is a work in 
progress as procedures and protocols are developed to meet the new 
law. Doctors are a key link - or, in this case, missing link - in this process.

Certification required

Under state law, doctors sign a certificate for medical marijuana. 
Patients take that certificate to the Department of Public Health, 
where they register as a medical marijuana user. Doctors do not 
actually prescribe the drug, or determine the strength and form of 
the drug patients will take. Patients will able to get marijuana at 
dispensaries when they open, but in the meantime, certification 
allows them to grow the plant themselves or acquire cannabis through 
a personal caregiver, who must register with the state.

Dr. Jeffrey Zesiger believes marijuana can help patients, but like 
many colleagues, he won't certify for marijuana. He refers patients 
to Dr. Jill Griffin, who for the last year has issued medical 
marijuana certificates out of her small Florence office called 
Northampton Medical Marijuana.

"It's very early in our understanding about what marijuana's going to 
be helpful for," said Zesiger, a palliative care physician at Cooley 
Dickinson Hospital. "So we're going to do it anecdotally, case by 
case. That's the way I've approached it."

Griffin is a full-fledged believer in the effectiveness of medical 
marijuana for patients who are dealing with serious illnesses 
including cancer, AIDS and Parkinson's, or suffering from anxiety. 
She sees both young and old patients, but says few are on the hunt 
for a legal way to get high for fun. Most use small doses of 
cannabis, with some smoking it and others using hand-held vaporizers.

"Initially, I would say no to patients," Griffin said. "But after I 
wrote it for a few people and they did well, it was just a logical 
progression for me. Almost every day people say, 'This is a huge 
thing you're doing.' It doesn't feel like it. It just feels like I'm 
practicing medicine and trying to help people."

But the vast majority of doctors are treading carefully in uncharted 
waters amid equally important fears. They lament being thrust into 
the middle of a political hot potato without clear guidance about how 
and when to approve the use of a non-traditional medical treatment.

"The law is taking a half-step toward legalization," said Joel 
Feinman, president of Valley Medical Group, a Greenfield company that 
operates family practice offices throughout the Valley. "Colorado 
(and Washington state) went to the full step and said it's now legal 
to a set amount. That seems clearer."

Kevin Fisher, executive director of New England Treatment Access 
Inc., which plans to operate Hampshire County's only medical 
marijuana dispensary at 118 Conz St. in Northampton, says doctors who 
don't explore the use of marijuana for cancer and other debilitating 
diseases are doing a disservice to their patients.

"I'm not saying cannabis solves everything that's wrong in the world, 
but patients should not have to compromise if they are faced with a 
life-threatening disease," Fisher said.

As for doctors' concerns about the federal law, he says:

"I understand the reticence, but the bottom line is, we haven't seen 
physicians who are responsibly recommending cannabis in the course of 
their practice see any negative administrative or legal impacts."

Baystate policy

Baystate Medical Practices, which includes 10 offices throughout the 
Valley, has adopted a written policy that forbids doctors and staff 
from certifying patients as eligible and in need of cannabis. Other 
medical groups, including those affiliated with Cooley Dickinson 
Hospital and Valley Medical Group, are in the early discussion 
stages, officials said.

The Baystate policy, issued by Dr. Glenn Alli in late March, does not 
apply to the entire Baystate Health System. The hospital and 
speciality departments are discussing what, if any, policy they will 
adopt, said Alli, the interim vice president and medical director of 
Community Primary Care.

Alli said a recent survey found that nine of the 10 medical directors 
under Baystate Medical's umbrella support the policy. The survey also 
asked for opinions on the effectiveness and risks of cannabis as a 
medical treatment.

"The directors felt the risk exceeded the benefits and did not think 
at this point in time it was a risk they want to take," Alli said.

Many other large physician practices across the state have announced 
that their organizations will not certify medical marijuana use for 
patients. And the Massachusetts League of Community Health Centers 
advises its 36 federally funded facilities that they could be at 
legal and financial risk if they certify patients to use marijuana, 
said Kerin O'Toole, public affairs director. There are community 
health centers in Huntington and Worthington, Greenfield, Orange, 
Turners Falls, Holyoke and Springfield.

"It really is an unsettled area of law," O'Toole said. "Health care 
centers also need to work with their own boards to develop their own policies."

Scientific evidence

Alli said one driving force behind the qualms doctors have is a lack 
of research surrounding the effectiveness of the drug. Marijuana has 
yet to be studied by the Food and Drug Administration and its 
long-term effects are unknown, he said.

"The scientific evidence for the effectiveness of cannabis is very 
limited and there is very little safety," Alli said.

Some doctors prescribe Marinol, an FDA-approved drug for treating 
headaches, nausea and vomiting. The drug includes THC, a chemical 
found in marijuana, but there is debate about whether the drug is as 
effective as marijuana.

Zesiger says it could be years before those studies are complete to a 
level that doctors feel comfortable certifying marijuana for 
patients. Studies are complicated because the plant has multiple 
compounds in it, and prohibited because the FDA cannot study illegal drugs.

"The federal government is still very strict about not studying 
marijuana," Zesiger said. "If they would let people study it and 
start to figure out what are the compounds ... that would be very interesting."

The Massachusetts Medical Society, the largest doctor organization in 
the state, warns that the state regulations for marijuana contain no 
provisions for dosage, administering the drug, or other details 
included for prescriptions for meds that have undergone the rigors of 
clinical trials.

"Claims for its effectiveness have not been scientifically proven," 
Dr. Ronald Dunlap, the society's president, said in a statement 
earlier this year. "It poses health risks of toxins and cognitive 
impairment, the last condition being especially risky for young patients."

Fisher counters that there have been more than 20,000 published 
studies that show cannabis is an effective treatment. One of the 
world's most renowned marijuana researchers, Israeli professor 
Raphael Mechoulam, is expected to visit Massachusetts in the coming 
months to talk about his decades of medical marijuana research.

And, Fisher said, unlike many FDA-approved drugs that have killed 
thousands of people, consumption of marijuana has never killed a patient.

Griffin shared many of her colleagues' concerns until she took 
numerous continuing medical education courses, studied the drug's 
effectiveness on her own and analyzed studies, many originating from 
Europe, about marijuana and its effectiveness in treating patients. 
She said she avoids research by groups known to support cannabis, 
instead focusing on studies that analyze the basic science behind marijuana.

Legal jeopardy

Contradictions between federal and state laws trouble doctors and 
health care administrators. Despite a Massachusetts law passed by 
voters in November 2012 that legalized marijuana for medicinal 
purposes, marijuana remains a "Schedule 1" drug under federal law. 
Schedule I drugs are considered to have a high potential for abuse 
and to have "no currently accepted medical use in treatment in the 
United States."

Alli said the federal Drug Enforcement Administration is "pretty 
clear" that state law offers no protection from prosecution or other 
punishment, such as loss of federal funding, for doctors or physician 
groups that certify marijuana for patients, which "raises a real 
dilemma" for doctors.

But, he noted, Baystate officials understand the situation is fluid, 
which is why they will re-evaluate the policy in six months.

"Our policy is a conservative initiative approved during this very 
unsure time as to what this conflict of federal and state law means," 
Alli said.

In practice

Many doctors don't shy away from sending patients to Northampton 
Medical Marijuana when it seems warranted.

Zesiger has referred a few patients to Griffin, as have other doctors 
under the Cooley Dickinson umbrella. He anticipates more will do so 
as patients seek it out. Griffin confirms this is happening, with 
many patients coming in with a prescription that simply says, "Please 
see Jill Griffin for marijuana."

Even without a dispensary open, Griffin has already certified 1,200 
patients in the last year to grow or buy the drug from a "personal 
caregiver," which is an adult over 21 who helps a patient use medical 
marijuana.

She said the number continues to rise, so much so that Northampton 
Medical Marijuana may soon be too busy to take on new patients.

Alli acknowledged that some patients will feel strongly about medical 
marijuana and seek out other physicians who will certify, but he 
anticipates these patients will retain their Baystate doctor for 
primary care. In those cases, doctors will encourage patients to let 
them know if they are taking marijuana, which is important 
information they'll need to treat patients.

"The policy is not intended to be a judgment on the patient who does 
want medical marijuana," Alli said. "It's not a restriction on the 
patient in any way. We can't restrict, nor do we want to."

Griffin said she serves as a cannabis consulting physician and does 
not take over as a primary care doctor, though she does have her own 
patients she sees as part of a house-call practice. As a consultant, 
she meets with patients for an initial one-hour visit, studies their 
medical records and determines whether they meet the criteria under 
the state rules to use medical marijuana. State law says that 
patients must have a debilitating medical condition that interferes 
with one or more major life activity.

Griffin said many are screened out before they step in the door, 
particularly if they don't have adequate medical records to show the 
treatment is medically necessary. Evaluations cost $200 for an 
initial visit, $100 for an annual renewal and $50 for a mid-year 
visit, fees that are not covered by insurance.

The law requires that doctors who certify patients have a "bona fide 
physician-patient relationship," including seeing patients in the 
office, assessing medical history, explaining the benefits and risks 
of marijuana, and being involved in ongoing care.

The Massachusetts Medical Society is raising a red flag about what it 
calls the growth of "certification centers" that deal only with 
patients seeking marijuana. There are more than a dozen such offices statewide.

"They appear to sidestep the DPH regulation of an 'ongoing 
physician-patient relationship' in the general course of medical 
practice as a requirement for certification," Dunlap said.

Yet these practices are flourishing in part because so many 
physicians are reluctant to certify patients who want to use marijuana.

"Someone is going to fill this void for patients who seek this 
therapy," Fisher said. "Is that how we would prefer things to work? No."

Griffin admits she is uncertain whether her practice fits the state's 
definition of a physician-patient relationship.

"It's a tough call," she said. "It's what I worry about when I go to 
bed at night. I try to practice good medicine. I take good notes and 
do what I would normally do in any medical practice and hope that it stands up."
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MAP posted-by: Jay Bergstrom