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Medical marijuana leaving doctors, patients in limbo



Tuesday, April 29, 2014
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.

Follow @caingazette //

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.



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.”



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.

Follow @caingazette //

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.



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.”