Is marijuana good medicine?

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By Laura Finaldi

It’s been about four years since Massachusetts residents voted to legalize marijuana for medical use, but the state’s health care community as a whole is far from a consensus on how or even if it should be used.

State records show that the number of Massachusetts physicians registered to certify patients for the use of medical marijuana has increased steadily over time, but also that a concentrated number of physicians are the ones handing out the certifications. Just 19 of the registered doctors in Massachusetts issued over three-fourths of the approximately 65,000 unique patient certifications given through Aug. 22.While some doctors have registered with the state to certify medical marijuana themselves, many doctors and large health care systems aren’t ready to get on board just yet. Some are unsure of marijuana’s medicinal value, saying the science isn’t there to back up the claims. Others are afraid that providing a certification for use of a substance that is still illegal under federal law could lead to liability issues.

But medical cannabis advocates and doctors said that its use has been transformative for those suffering from everything from chronic pain to HIV or cancer, and that pushback from those who oppose it is contributing to a stigma felt by patients who just want some relief.

The Massachusetts Medical Society opposed the medical marijuana ballot question before Massachusetts residents voted to legalize it in 2012. The society’s president, Dr. James Gessner, said there is a lack of consensus on medical marijuana because there isn’t enough scientific evidence supporting the claim that marijuana is safe and effective medicine.

“Doctors like to take care of their patients. And they like to use proven therapies and follow best practices, but there isn’t any data about marijuana. There aren’t good studies on its clinical effectiveness,” Gessner said.

Differing approaches

According to the Massachusetts Medical Society, the 2002 federal appeals court decision of Conant v. Walters set the precedent for the role of physicians in the business of medical marijuana. The decision said under the first amendment, physicians have the right to discuss medical marijuana with their patients, but that doesn’t mean they can help them obtain medical cannabis.

That’s why doctors have to issue written certifications of potential patient benefits for marijuana, instead of prescriptions. Physicians issuing certifications have to have a full license with an established place of business in-state, complete two hours of continuing medical education credits on the proper use of medical marijuana, and utilize the state prescription monitoring program, among other things.

State records show that the number of doctors registered with the state to provide certifications has grown steadily. Six doctors were certified as of October 2014; by the following July, 99 doctors were in the system. The most recent count included 167 registered physicians as of August 2016.

Two of the state’s top marijuana doctors by number of certifications recently had their licenses suspended for allegedly improperly certifying patients for use of medical marijuana.

That example contributes to a concern within the medical community -- that some medical marijuana doctors see issuing certifications as a business opportunity, rather than as a way to treat patients, Gessner said. A certification appointment can cost about $200.

Pushback for doctors and patients?

But doctors involved with certifying patients and patient advocates disagree. Pressure from the state and from the so-called “medical establishment” led the state’s top cannabis certifying physician, Dr. Jill Griffin, to shut down her Northampton practice last month. In a letter that has since been taken down from her website, Griffin, who certified 6,997 patients as of Aug. 22, said although her interest was only in helping her patients feel better, it had gotten to the point where she was afraid she would lose her ability to practice medicine.

“Although I know, as a matter of my experience and training, that I have done nothing wrong in caring for you, the risk of losing my medical license is a peril I can no longer endure,” Griffin wrote in the letter.

That same pressure is felt by patients who use medical cannabis, said Nichole Snow, executive director of the Massachusetts Patient Advocacy Alliance. Although medical marijuana is legal, there is a stigma around using it, she said. Even patients who are certified sometimes get pushback from law enforcement or child protective services, she said.

“[Patients] might experience further harassment or inappropriate commentary, even though it’s their choice and it’s legal,” she said.

Though Griffin felt pressure from the state and ultimately decided to close her practice, other medical offices specializing in medicinal marijuana certifications reported different experiences. At Canna Care Docs, which has eight locations in Massachusetts including one in Worcester, doctors issue certifications for patients with chronic pain or seizure disorders, among other things. Kevin Kafka, the company’s managing director, said Canna Care Docs has no issues with the state’s oversight of the program.

“We believe we provide a vital service to patients in need in a way that is both convenient and professional. We also have the expertise in cannabis therapy that other clinicians don’t necessarily have,” Kafka said in an email.

That’s a sentiment shared by Brad Feuer, CEO of Integr8 Health, which is based in Maine and bills itself as the leading medical marijuana doctor group in Massachusetts; it has an office in Burlington. Feuer said doctors at Integr8 see themselves as specialists in cannabinoid medicine, which makes them well-positioned to provide consultations to patients.

As their name implies, Integr8 is focused not just on medical marijuana, but also on other integrative ways to improve health, such as diet and exercise changes as well as pain and inflammation therapy. Patients who do come in wanting a certification usually meet with a doctor for an hour, Feuer said.

“We require medical records, we require follow up visits, we require ongoing consultations, we require an ongoing relationship,” he said. “We kind of live by trying to set these standards in the industry.”

Health systems

Larger health care systems have taken varying approaches to medical marijuana. UMass Memorial Health Care in Worcester, Central Massachusetts’ largest health system, allows its physicians to issue certifications.

“Since the questions surrounding this issue are complex, we recommend that our physicians who are considering certifying one or more of their patients familiarize themselves with the law before proceeding,” UMass Memorial spokesman Anthony Berry said in a statement.

At Saint Vincent Hospital in Worcester and MetroWest Medical Center in Framingham and Natick, hospital employed doctors do not certify medical marijuana, according to Erica Noonan, a spokeswoman for Tenet Health, the hospitals’ parent company.

The same rings true at Harrington HealthCare System in Southbridge. Over 50 percent of Harrington’s income comes from government sources, so there’s a fear that money could go away if the federal law that makes marijuana illegal was enforced, said chief medical officer Dr. Arthur Russo. The Obama administration has indicated that it won’t pursue legal action in any state where medical marijuana is legalized, according to the Massachusetts Medical Society.

But Russo said one of his biggest concerns is that unlike with other medicines, there aren’t known therapeutic levels or doses of marijuana for doctors to go by when issuing certifications.

Since medical marijuana is classified as a Schedule 1 drug by the U.S. Drug Enforcement Administration, doing research on its medical effectiveness up until this point has been difficult. But in August, the D.E.A. said it planned to expand the number of registered marijuana manufacturers that can grow and distribute the plant for F.D.A.-approved research. The idea is to facilitate research concerning marijuana and its components, according to the D.E.A.

Snow from the Patient Advocacy Alliance said her group sees marijuana as an alternative medicine, and so in that sense it shouldn’t have to go the traditional, F.D.A. approval route that other medicines have to complete.

“To say we don’t have enough research, that’s all language we would like to forget, because it’s never going to go that route. Its an alternative medicine, we have to treat it that way,” she said.