Medical Marijuana: Certifying Physicians Must Study Regulations, Science of Treatment

Vital Signs: Summer 2013

Twelve years ago, Taunton pediatrician Eric Ruby, M.D., received devastating news. His son, Ethan, had been hit by a car while on a crosswalk and sustained a spinal cord injury that left him paralyzed from his chest down.

“Putting him back together after all of this was a nine-month ordeal in which he spent six weeks in intensive care, six weeks at rehab and another six months really learning how to cope with it,” Dr. Ruby said.

Eric Ruby, MD
Eric Ruby, MD

For paraplegics like Ethan Ruby, learning to function using a wheelchair was the easy part, he said. More difficult challenges included coping with bladder and bowel problems, skin breakdown, pneumonia risk, and severe central neuropathic pain.

The pain was excruciating, said Dr. Ruby, often reaching a six or seven on a pain scale of ten. Narcotics resulted in unacceptable side effects and alternative therapies were ineffective.

Eventually, with a friend, Ethan discovered that smoking marijuana brought his pain level down to a two or three, and told his father about his experience.

“As a father and part of the establishment, it was very difficult to see him suffer and not be able to help him within traditional means,” Dr. Ruby said. Because of the profound impact marijuana had on his quality of life, Ethan ultimately moved to Colorado, which established a medical marijuana registry in 2000.

“So when this [regulation] came to Massachusetts, I said, ‘Wow, I can get my son and my grandchildren back,’” Ruby said. “So I’m very much a proponent of it. When people ask why I’m so passionate about it, I say, ‘My son is 2,000 miles away; I’m passionate about it.’ It’s very personal.”

Regulatory Uncertainty Ahead

The Massachusetts Public Health Council approved final medical marijuana regulations in May; however, it’s unclear how the program will unfold in the Commonwealth.

Political controversy aside, Bill Ryder, legislative and regulatory counsel for the MMS, outlined several potential areas of concern.

For starters, he said, physicians need to recognize that certifying a patient to use medical marijuana is an entirely different process than writing a traditional prescription.

“What they are doing is they are certifying that patients have the particular condition or disease that might benefit [from marijuana] within the particular framework of the rules,” Ryder said. “In that context, the physician has very little control over what the patient actually does after that point.”

The DPH then registers the patient, who next goes to a dispensary to purchase the medication. It’s the dispensary staff — not the physician — who determines what strength and form of the drug to sell to the patient.

“Regardless of what the physician says to the patient, the only control that the physician has is the timeframe in which they certify a patient,” he said. “It’s not at all like a prescription where you’re saying, ‘here’s a seven-day supply of antibiotic, take it twice a day and call me back.’ There’s none of that. That’s a very different experience and that’s a little bit hard to reconcile,” Ryder said.

Family and addiction physician, James Broadhurst, M.D., has spoken publicly about marijuana’s risks, and urged physicians who want to participate in certifying patients to be thorough in their understanding of the regulations as well as their patients’ needs.

“The regulations speak to the fact that the basis for a recommendation or certification of marijuana is not purely and simply the making of a diagnosis, but also of documenting the debilitating nature of the condition right now as the indication for marijuana treatment,” he said. “And that would also require, in my opinion, the review of previous treatments to assure that conventional medical therapies, legal alternatives and complementary therapies have all been investigated and tried from a therapeutic perspective before a decision is made to add marijuana to the therapeutic mixture.”

Steep Learning Curve

Another issue raised by both proponents and skeptics of medical marijuana is that physicians currently receive no clinical training in the effects of marijuana on individuals with certain conditions. While the regulations will require physicians to take two hours of CME about marijuana treatment beginning in July 2014, some physicians have criticized the DPH’s educational requirement as being too cumbersome. Dr. Broadhurst said those hours of training should be viewed as a minimum.

James Broadhurst, MD
James Broadhurst, MD

“The education for physicians to understand the risks and benefits of recommending a crude plant mixture as a therapeutic agent — particularly one where the risks of both side effects and addiction are so well documented — is important,” said Dr. Broadhurst. “I believe that physicians who are interested in this area will spend many, many more hours of study in order to provide recommendations and certifications that are appropriate and professionally handled.”

One physician who has taken it upon himself to study the science of cannabis in depth is anesthesiologist Harold Altvater, M.D., owner and operator of Methuen-based Delta 9 Medical Consulting, a company that evaluates patients for medical-marijuana certification.

"There’s a significant amount of catching up to do to even consider recommending it for your patients,” he said. “I think physicians need to separate the political and legal arguments from the scientific and the therapeutic stances. If you’re able to look at it from a scientific point of view, it’s easier to see how it could potentially benefit your patients.”

Liability Concerns

Before certifying patients, physicians should have a very clear understanding of what constitutes a bona fide physician-patient relationship under the regulations, Ryder said.

The definition, as it appears in the state’s regulations, is as follows:

A relationship between a certifying physician, acting in the usual course of his or her professional practice, and a patient in which the physician has conducted a clinical visit, completed and documented a full assessment of the patient’s medical history and current medical condition, has explained the potential benefits and risks of marijuana use, and has a role in the ongoing care and treatment of the patient.

In addition to ensuring that your relationship with a medical-marijuana patient meets these criteria, Ryder cautioned that state regulatory agencies, including the DPH and Board of Medicine, will have access to a centralized database of which physicians write certifications and for whom.

“Physicians should familiarize themselves with basic elements of what’s a legitimate patient relationship, in which the physician has a significant role in the ongoing care of the patient, [and write certificates] for a small number of appropriate patients,” Ryder said.

Ryder also suggested that physicians, particularly those in group practices, talk to their medical liability carriers about how they intend to cover issues related to medical marijuana certification. “There will be conflicts within individual groups with people who want to do it and those who don’t. They should develop a policy within their individual practices before it becomes a crisis issue,” he said.

See related Vital Signs story, “Law and Ethics: Medical Marijuana and Workplace Law.”

— Debra Beaulieu

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