The medical marijuana law passed by voters in 2009 was supposed to create greater access to the drug for those suffering from a lengthy list of illnesses. It replaced a 1999 law, also enacted at referendum, that made it legal to possess marijuana as medicine but offered no system for patients to obtain it.
More than a year after the vote, and two months after the new registration system took effect, patients are still struggling to find doctors willing to write medical certificates, as is now required. And some patients are worse off than before.
One of them is Nickolas Stanley, 32, of Farmington, who was rendered quadriplegic by spinal muscular atrophy, a condition brought on by a congenital defect known as a tethered spinal cord. The problem manifested itself during high school, and Stanley has had three surgeries to correct it — but they only made the problem worse, he said recently.
Since 2003, he has legally used marijuana to relieve his “constant aches and pains,” as well as anxiety and depression, under advice of his long-time caregiver, Patricia Soderholm, who grew medicinal marijuana for Stanley.
“I was prescribed opiates, but the side effects were much worse,” Stanley said. “Now the only drug I take for pain is marijuana.”
But when Soderholm attempted to navigate the new medical marijuana system for him, she ran into a dead end. About 30 minutes before a scheduled appointment with his primary care physician to obtain the now-required medical certificate, as Stanley was being loaded into the van he uses to attend medical appointments on a cold December day, the doctor’s office called and said they wouldn’t be able to provide the certificate. “It takes at least an hour to get him ready,” Soderholm noted.
The Franklin Community Health Network, affiliated with Franklin Memorial Hospital, has decided that its physicians will not be allowed to write marijuana certificates — even for patients they were already treating, like Stanley — until “there is greater clarity from the state on the issue,” according to Jill Gray, community relations manager. She confirmed this week that the policy remains in force.
Soderholm said she tried calling at least 15 physicians’ offices trying to find someone who would help, “and some of them were incredibly rude,” she said. “They said, ‘Why would you try to get an illegal drug?’”
Finally, she located a physician in Falmouth who would see Stanley, but since insurance won’t cover the visit, he will have to pay the $150 charge out of pocket. “For someone living on a disability check, that’s hard,” Soderholm said. “He’s been saving for weeks so he can make the visit.”
Difficulty finding docs
It may be that few patients will have to undergo the same ordeal, but Soderholm’s attempts to find a provider points up one of the oddities of the new law.
More than 100 providers have notified the state that they are willing to write certificates, but their names are confidential. Unless they are willing to announce themselves publicly — and only a few have — it’s difficult for patients to know who to call. Meanwhile, many other medical providers have made it clear they will not write certificates for marijuana.
Jennifer Smale, who with her husband, Tim, operates Remedy Compassion Center in Auburn, a dispensary that expects to open in late spring, said this identity issue is a dilemma even for some physicians who write certificates. “They don’t want to be known as marijuana docs,” she said.
Catherine Cobb, who directs the state’s Division of Licensing and Regulatory Services, part of the Department of Health and Human Services, says the 100-plus providers are well-distributed geographically and should be able to handle patients registering with the state — 600 so far, with another 300 applications pending. But she conceded that linking up with a doctor, an essential step, may not be easy, at least initially.
Once a certificate is obtained, patients may:
— Grow their own marijuana, up to 10 plants;
— Seek and pay for a caregiver to grow the marijuana for them under the same terms, or;
— Buy marijuana at a dispensary, at the rate of $300 to $400 per ounce.
No dispensaries are open yet. Auburn’s, at 730 Center St., near the Auburn Mall, may be the first. But caregivers can provide marijuana now, if they can get certificates.
“The caregivers think the dispensaries may have an unfair advantage, because (caregivers) can’t grow plants until they have a patient with a certificate, while the dispensaries can sell right away,” Cobb said. Growing a plant to maturity takes at least nine to 10 weeks. But at the moment, that may be the less important delay.
Some docs can't write certificates, others won't
Gordon Smith, president of the Maine Medical Association, whose group has sponsored a series of well-attended seminars for physicians statewide on the new law, said MMA has tried to remain neutral on the subject, “not encouraging or discouraging the writing of certificates.”
Still, it’s proving to be a bit of a stretch for many doctors. As Smith points out, marijuana is not FDA-approved for any purpose, and while research on its medical effects is common abroad, there are few U.S. studies, in large part because the federal government long rejected most research proposals.
Even doctors willing to write certificates say they know little about effective dosing, and health professionals disinclined to participate can find plenty of reasons not to.
Smith said the number of primary care physicians in the state — those most likely to get requests for certificates — isn’t known, although there are 528 “practice sites,” many of which have multiple physicians.
“There must be at least 1,500 doctors,” he said, meaning that the 100 or so doctors currently signed up to write certificates, which can include specialists, are a small minority.
Many practices are barred by federal law from participation. Doctors at all Veterans Administration hospitals and clinics face this prohibition, as well as rural clinics receiving direct federal funding, such as the HealthReach Network that has sites in Strong, Livermore Falls and Rangeley, and the DFD Russell Medical Centers in Leeds, Monmouth and Turner.
Dr. Roy Miller, director of the Sheepscot Valley Health Center in Coopers Mill, said his clinic gets 10 to 15 percent of its funding from the federal government, and must comply with federal law in all respects. “This is only one of a long list,” he said. “We can’t even do a vasectomy without filing a federal report.”
The only reason Maine’s new law can operate without running afoul of federal law, under which marijuana is illegal for any purpose, is a directive from U.S. Attorney General Eric Holder, who issued guidance shortly after the Obama administration took office in 2009.
Holder said that federal law would not be enforced in states where marijuana has been legalized for designated purposes, but, as Gordon Smith noted, that policy could change with a new administration. Under George W. Bush, the Justice Department raided dispensaries in California, the first state to make them legal.
Aside from the physician practices barred by federal law from writing certificates, some providers have decided on their own not to do so. In the Lewiston-Auburn area, the two major hospital groups have split on the issue, with Central Maine Medical Center allowing its affiliated physicians to write certificates, and St. Mary’s Regional Medical Center barring them.
CMMC yes, St. Mary's no
CMMC’s pharmacy director, Philip Rioux, said that several hospital committees considered the appropriateness of writing medical certificates, and determined there was a “strong consensus” that “patients may derive some benefit” from marijuana. He noted, however, that the pharmacy itself is not involved, and, “We don’t allow its use on the campus,” meaning that a patient using marijuana may not do so while hospitalized.
Rioux, too, noted that “there is no standardized dosage” for the drug, meaning that it’s difficult to integrate with conventional allopathic medicine.
Under CMMC's policy, any of the 68 providers in its network can write certificates, but none are required to do so.
Reaching the opposite conclusion were the committees at St. Mary’s hospital. Dr. Ira Shapiro, the medical director, said that the 36 primary care providers there “will not be writing certificates.”
He listed four reasons as contributing to the decision, including that marijuana is not FDA-approved, and that research on it “has not reached an evidence-based standard in long-term controlled trials.”
Shapiro also cited the difficulty of offering a drug to patients who “may already have a chemical dependence, including marijuana dependence.” Finally, he said there are indications that regular marijuana use can “trigger or worsen” psychotic mental illnesses — bipolar disorder and schizophrenia.
Asked whether the federal prohibition on marijuana research had made it difficult to establish the drug’s effectiveness, Shapiro said, “We’re not a research institution. If scientific evidence is presented, we’ll reconsider our policy.”
Jennifer Radel, the hospital’s community relations manager, said later that St. Mary’s policy, while communicated to all staff, had not yet been put into written form.
'... Wrong way to make the system work'
Dr. Owen Pickus is among those who dispute the idea that marijuana isn’t safe and effective. Pickus, a cancer and AIDS specialist who practices in Westbrook, is perhaps the best-known Maine doctor to publicly endorse marijuana by writing certificates.
Trained as an osteopathic physician, he has taught at the University of New England, the state’s only medical school, for more than 20 years, and recently earned his law degree and opened a legal practice. He also ran for the state Senate as a Republican last year, losing to incumbent Democrat Nancy Sullivan.
Pickus said there’s no question marijuana has benefited many patients he’s treated, though he also shares some of the concerns expressed by other doctors. And he’s frustrated that the FDA has never taken on the questions of marijuana’s safety and efficacy.
“That’s the agency we depend on to test drugs and establish which ones work,” he said. “This should never have been left to the states. It’s the wrong way to make the system work.”
Twenty years ago, Pickus chaired the first state medical marijuana commission for then-Gov. John McKernan, who had made his name as a young state representative by sponsoring the bill that decriminalized marijuana possession. But after serving in Congress and then his first term as governor, the political winds had shifted, and McKernan never took up the commission’s recommendations.
It was not until the first referendum vote a decade later — sponsored and funded, like the second one, by an out-of-state organization — that medical marijuana became legal.
Pickus decried what he called two “special-interest groups” — those who see medical marijuana as a step toward full legalization, and others who have tried to criminalize all uses — as not serving the needs of those who can benefit from marijuana.
The dispensary system is far from ideal, in his view.
“Charging $400 an ounce for a drug that’s not covered by insurance can be a hardship,” he said. “I have patients who have trouble handling a co-pay.”
But he doesn’t spare his fellow physicians from criticism. “We’ve really got to get our heads out of the sand and deal with this.” Although 13 states, from Alaska to Maine, have provisions for medical marijuana, there’s no visible push for a change in federal law at the moment.
Pickus is also skeptical of claims that marijuana use could unduly harm patients’ health. “Sure, there’s the possibility of dependence, but we over-prescribe opiates and OxyContin, and they’re already a common cause of death, just like alcohol use,” he said. “To my knowledge, no one has ever died from smoking marijuana.”
'The first year is tough'
At Remedy Compassion Center, Jennifer Smale said the availability of certificates should improve when all eight of the state-approved dispensaries are operating, possibly by the end of this year, and when caregivers and patients feel free of possible interference by law enforcement.
“The first year is tough,” she said. “After that, it seems to get a lot better in all the states that have authorized dispensaries.”
She noted that in Oregon, 40,000 patients are registered marijuana users, and that in Colorado, some 1,200 physicians are participating in the state system. Even states with recent laws are signing up numerous patients — 2,500 in New Mexico, and 2,250 in Rhode Island, whose original law dates only to 2006.
She believes that some doctors are still unduly suspicious of marijuana as a drug. Some prospective dispensary customers have told her they are prescribed opiates, but if their provider finds, through drug testing, that they are also using marijuana, their treatment is discontinued. “That’s harsh,” she said. “It’s not easy to withdraw from opium-based drugs.”
Smale said that education is the biggest hope for eventual widespread acceptance by the medical community. “Maine’s system is going to work very well,” she said. “We’ll see physicians becoming more open-minded, particularly when they see how safe it is.”
For Nickolas Stanley, that day can’t come too soon.
“I didn’t need a card when I started using marijuana, and now I can’t get one,” he said. “It’s been very confusing to figure out what to do. Even though I’ve paid my fees and they say I’m approved, I can’t do it without a certificate.”
He feels he never should have been put in this position. “It’s not like I’m asking for anything new. I just need my medicine.”
Consent form aimed at liability issue
Possible misuse of marijuana by patients who can legally possess it has been cited as one reason why providers should be cautious about writing certificates. Dr. Owen Pickus, a Westbrook-based physician who writes certificates, says “the OUI issue is a real one,” and “no one should be driving a car after smoking marijuana.”
The state has offered one means of dealing with potential liability issues by posting a “Consent to Treatment” form on the Department of Health and Human Services website, which doctors can ask patients to sign. It covers the lack of FDA approval, possible impurities and contamination, and specifies that the patient is responsible for proper use.
For the form and further information, see the DHHS page: www.maine.gov/dhhs/dlrs/