June 22, 2018
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Marijuana meds: Should docs have pot-prescribing freedom? Other states say no

Tom Groening | BDN
Tom Groening | BDN
Betsy Foster uses marijuana at the Medical Marijuana Caregivers of Maine trade show. Foster has a prescription for the drug.
By Robert Long, BDN Staff

AUGUSTA, Maine — The new Maine Legislature likely will consider a bill that would free patients seeking medical marijuana from the requirement that they be diagnosed with at least one of a list of “debilitating medical conditions” defined in the law.

Rep. Mark Dion, D-Portland, plans to submit the legislation, the latest proposed modification to the medical marijuana law first approved by Maine voters in 1999. If the bill passes, Maine will become the first state to leave discretion for recommending medical marijuana exclusively to physicians.

Advocates for the change contend that giving physicians greater latitude in determining whether patients would benefit from using medical marijuana, regardless of whether their diagnosis fits the specific criteria now set in the law, would extend protections to Mainers who want to comply with the law and ensure that doctors and patients, not lawmakers and bureaucrats, control treatment decisions.

“Right now patients who could benefit from protections of the law are either forced to go into the black market or be less than honest with their doctor about other qualifying conditions,” said Alysia Melnick of the American Civil Liberties Union of Maine.

A key element of the change would be to allow physicians to recommend medical marijuana for behavioral and mental health conditions, including post-traumatic stress disorder experienced by veterans returning from war and others who have experienced trauma.

The Maine Medical Association opposes the proposed changes, according to Gordon Smith, the association’s executive vice president. Smith described the list of qualifying conditions now in the law as “liberal” because many simply reflect a symptom such as vomiting, nausea or pain.

The Maine Medical Association does not support adding mental health conditions to the list of qualifying conditions, although the association would be open to adding PTSD and other potentially debilitating conditions as now allowed by law, he said.

Eighteen states and the District of Columbia have enacted laws that deal with medical marijuana. All include a list of conditions for which medical marijuana can be recommended. The most common, which also appear on Maine’s list, are seizures, glaucoma, multiple sclerosis, nausea, HIV/AIDS, cancer, hepatitis C, Lou Gehrig’s disease, Crohn’s disease and intractable pain, which Maine defines as lasting at least six months.

No states list mental health disorders specifically, but many allow treatment for additional conditions subject to government approval.

In states that post data about the number of diagnoses that qualify for medical marijuana treatment, “severe pain” far outnumbers any other. The Colorado Center for Public Health and Environment reports that, as of Sept. 30, “severe pain accounts for 94 percent of all reported conditions.” Oregon’s Medical Marijuana program listed 55,400 “severe pain” qualifying diagnoses, 40,000 more than the next most prevalent condition.

Of 39,022 qualifying conditions reported as of Aug. 16 in Arizona, 27,878 were for chronic pain. The next most-common diagnoses are muscle spasms (3,957), nausea (2,654) and hepatitis C (1,233).

Melnick argues that marijuana offers a less addictive alternative to potentially addictive pharmaceutical painkillers.

“People have told us that they have gotten off prescription drugs by using marijuana,” she said.

Smith counters that marijuana is not regulated by the U.S. Food and Drug Administration, so physicians can’t be sure about its purity, toxicity and interaction with other medications.

Most states, including Maine, require that a physician recommending medical marijuana be either a medical doctor or doctor of osteopathy. Maine stipulates that the physician hold a valid Drug Enforcement Agency license to prescribe drugs.

Many states require that the recommendation come from an “attending physician.” Oregon’s law is representative of most. It states, “You must have an established patient/physician relationship with your ‘attending physician.’ Naturopaths, chiropractors and nurse practitioners cannot sign the documentation.”

Washington and Arizona also allow practitioners licensed in “naturopathic medicine” to certify patients for medical marijuana use. In Arizona, more than half of the medical marijuana certifications come from naturopathic practitioners.

Maine differs from many states in that its law does not contain language requiring that the recommending physician have a history of caring for the patient. Maine law states that medical marijuana can be recommended “only in the course of a bona fide physician-patient relationship after the physician has completed a full assessment of the qualifying patient’s medical history.”

Vermont takes it one step further by mandating a “bona fide health care provider-patient relationship” of at least six months. Connecticut’s new law, which took effect Oct. 1, requires a physician to initiate the application for each patient’s medical marijuana certification.

Dr. Dustin Sulak, a DO affiliated with Integr8 Health LLC, which is “highly recommended” by the Compassionate Caregivers of Maine for medical marijuana consultations, said Maine’s current law inhibits primary care physicians from recommending treatment with medical marijuana.

“A lot of the conditions that are indicated in Maine right now are things that need to be diagnosed by a specialist,” he said.

Sulak said he typically spends an hour with each new patient referred to him for medical marijuana consultations.

“We absolutely do a physical exam,” he said. “We review medical records, history and provide education about how to use it. We go a step beyond and take an integrated and holistic look at all aspects of their lives.”

Integr8 Health LLC’s Falmouth clinic does have a “telemedicine option” for disabled patients or those who live far away, but “we require a recent physical from their primary care physician,” he said.

Most states don’t differentiate between oversight of physicians who recommend medical marijuana versus other care.

“We treat medical marijuana recommendations like any other controlled substance,” said Jennifer Simoes of the California Board of Medical Licensure. “We don’t treat marijuana differently or separately monitor physicians who recommend marijuana.”

Fourteen states mandate that patients register with a government agency.. Maine amended its law in 2011 to make patient registration voluntary and to “expunge all information in the records of the state’s medical use of marijuana program indicating a patient’s specific medical condition.” The changes make it difficult to determine how many Mainers now use medicinal marijuana in consultation with their physicians.

An Aug. 5 report in the Boston Globe said the state’s voluntary patient registry includes about 2,700 names. Paul McCarrier, legislative liaison for Medical Marijuana Caregivers of Maine, estimates the number of Mainers using medical marijuana in consultation with their physicians to be somewhere between 4,000 and 6,000.

While Smith of the Maine Medical Association argues that switching to voluntary patient registration prevents the medical community from having reliable data on the extent of medical marijuana use in Maine, the conditions for which it is being recommended and the effectiveness of treatment, McCarrier says voluntary registration protects patients’ confidentiality and shields them from retaliation.

“One of the reasons we got rid of the registry is that we have numerous veterans who use marijuana for their conditions,” he said. “With a database, they could face retribution from the Veterans Administration.”

The next step to “safeguard the private relationship between patients and doctors,” Melnick said, would be to eliminate the list of qualifying conditions.

“If their condition is not part of the list, then they have to petition the Legislature or a board that hasn’t been established yet to add their condition,” she said.

“The public really needs to know that patients are out of time,” McCarrier said. “This is what the people want and this is what the doctors want.”

Smith disagrees, noting that many doctors don’t have time to research whether marijuana could be beneficial to a particular patient’s condition.

“We think we ought to see how the law goes and leave it alone for now,” he said. “We would not object to adding conditions and diseases as long as there’s science to show that marijuana would be beneficial to those conditions.”

Robert Long is a political analyst for the BDN.

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