The President’s Podium: The Business of Medical Marijuana

By Ronald Dunlap, M.D., President, Massachusetts Medical Society

It’s been one year since Massachusetts voters approved a ballot question DSC_0003 Dunlap 4x6 color 300 ppi_editedlegalizing the use of medical marijuana, adding the Commonwealth to a growing list of states allowing it to be used as “medicine.”

MMS had vigorously opposed the referendum, on the basis that the drug lacks the rigorous testing as other FDA-approved drugs; that claims for its effectiveness are not scientifically proven; that it poses health risks of toxins and cognitive impairment; and that a physician’s recommendation of any drug should be a medical decision made in the patient’s best interest based on scientific and clinical evidence and not by public vote. Voter approval notwithstanding, we still hold those positions.

Following the vote, the MMS House of Delegates adopted a revised policy, stating our desire to work with the Board of Registration in Medicine (BRM) and the Department of Public Health (DPH) in developing regulations that would address key issues of a medical marijuana program in the state. Among these issues were patient diagnosis, physician certification, implications for occupational safety and health, inclusion in the Prescription Monitoring Program, and adherence to established professional tenets of proper patient care.

That effort proved fruitful. When DPH issued its regulations, our reaction was positive, saying DPH had done a “thoughtful and responsible job overall” and that the regulations “have taken into account many of our concerns, especially those that call for physician judgment in determining what conditions may qualify and the inclusion of the Prescription Monitoring Program in certifying patients.”

We are now, however, seeing a troublesome sign: the emphasis on medical marijuana has turned from patient care to business opportunity. And it goes beyond the investment or ownership opportunities related to dispensaries.

Entrepreneurs and physicians alike have established internet companies offering to match patients with doctors who will certify their need for medical marijuana. These companies will provide consultations and certifications – for fees ranging from a low of around $50 to upwards of $200. “Renewal fees” may also be charged.

I have publicly raised concerns about such sites.  I told The Boston Globe in September such activity is “working around the edges” of the rules, and I elaborated with the Business Journal of Western Massachusetts in October, saying “people that I call internet opportunists are essentially getting a doctor or list of doctors they feel will certify patients, and simply inviting patients to pay them money as a finder’s fee.”

One of the key regulations, sanctioned by the BRM and adopted by DPH at the urging of MMS, was that a physician should have a “pre-existing and ongoing relationship with the patient as a treating physician” before a patient should receive certification.

The proliferation of what I call these “certification centers” is disturbing; it erodes, if not skirts entirely, the “ongoing relationship” regulation and has the potential for abuse.

The experience in Colorado, which approved medical marijuana in 2000, is instructive. A June 2013 report from the Colorado Office of the State Auditor found “evidence suggesting that some physicians may be making inappropriate recommendations.” Twelve physicians had certified half of the 108,000 registered patients, and one had registered more than 8,400.

Despite its legality, many unknowns remain about medical marijuana, including appropriate dosage and frequency of use for conditions, strength of the drug from various sources, and clinical effectiveness. The Massachusetts model does not include any provisions for dosage, administration, or other basic elements that would be contained in a prescription for another medication.

Further, we are uncertain of the liability issues and whether insurers will cover defense costs and judgments in cases involving certifications. The drug also remains prohibited by the federal government, raising more questions about physician licensing by the Drug Enforcement Administration, which, contrary to press reports, has firmly stated that it has not relaxed its policy on medical marijuana.

Each physician, after weighing the risks and reviewing a number of considerations, will make his or her own decision about certifying patients and whether it’s in the best interests of both patient and physician. Some are already doing so.  That is another of the many decisions to be made within the physician-patient relationship.

That the business of medical marijuana has taken hold is no surprise; it was inevitable and likely will always be there. But, as physicians, let’s do what we can to refocus the issue back where it belongs: on patient care and patient safety.

The President’s Podium appears regularly on the MMS Blog, offering Dr. Dunlap’s commentary on a range of issues in health and medicine.

  1. The best examples of leaders in my experience are those that set the example for others in their actions not in their words. If you have issues with how someone is doing a job poorly or over charging for a service – then site an example practice that does it in a way that is consistent with your viewpoint – if non-exist perhaps your standards are unrealistic in actual practice.

    In MA the voting block that favored medical cannabis was 63% – that means for most of us that approx 1/2 of all our patients see utility in medical cannabis. So instead of making the same tired arguments against it – would it not make more sense to look into the subject? I have not seen any CME programs developed for providers in MA – plenty of experts from CA, CO, WA, Canada, Isreal, Spain, UK or the Netherlands. MMS could have been teamed with – as could the good folks from the college downtown that starts with H. I suspect lack of involvement in this area of interest is a lack of ability to fully monetize the process for the parent organization. It is easier to say “We don’t know enough” – well as an organization put together a panel and study the subject – could be formed and findings published in 12 – 16 months. FYI Dr. Grinspon did this in 1967 – 68 – but feel free to repeat the exercise.

    I’m an Anesthesiologist – history shows that Boston is great at taking credit for others work “Ether Dome” indeed – Dr. Crawford Long 3 years out of Medical School used ether to remove a tumor from a patients neck – years before the “Ether Dome”. Where Dr. Long got the idea related to his medical school years where Long observed “traveling showmen who demonstrated hypnotism and sometimes the effects of nitrous oxide, or “laughing gas,” on the crowds”. – yes it was not in a controlled setting or by scientific method was this idea sparked – it was the recreational use of a substance by the public that prompted a leader – a forward thinking physician to apply what he observed to clinical practice – resulting in a discovery that changed the face of medicine. In Boston they were still strapping patients to the table and cutting as fast as they could years before Morton put on his show.

    So why are so many of my peers bent on repeating history? How the plant cannabis can benefit us is far from being known – embrace this point in history you will not have a chance to repeat it in your life time. Learn about it with a critical mind – don’t just base your opinion on information you have been fed by the media and the government for the last 60 years.

    About the FDA – Vioxx, Bextra and Iclusig. Aside from the last drug I would venture to say most of us wrote for the former drugs – yes you gave your patients potentially fatal medications that were withdrawn from the market – despite approval by the FDA – Iclusig “FAST-TRACK” approval pulled in 10 months on the market. Please reply with the deaths to date related solely to cannabis over the past 4000 years? While you are putting that list together – consider almost all of the drugs you provide to your patients are molecules that have only existed for 40 years at the most – yet you trust them more than cannabis?

    One final comment – MMS made sure “No certifying physician, physician co-worker or family member may have a financial relationship with a marijuana dispensary” Let’s apply that to all doctors in our state – to include investments involving anything medical – removal from medical device boards, no acceptance of funds from any pharma to support research that the physician could later be used to advance her/his career.
    I can’t wait to see consistency on this issue starting with the members of the taskforce that published Massachusetts Medical Marijuana Law: Considerations for Physicians.

    Full disclosure – I own and operate Delta 9 Medical Consulting – I teach patients and providers about cannabis. I am not perfect but at least I have taken the time to try and do the job correctly.

  2. Tris Dammin says:

    Disheartening to read the President’s Podium about the money changers in the medical temple. I guess I was just too nieve to envision what legalization of MM and it’s distorsion would engender.
    There are very few places where I see that MM being an appropirate alternative to conventional medical practice- one being the hospice and or palliative care patient in severe pain from bone metastases or other source. There is also data showing that patients suffering from the intractible nausea and vomiting of chemotherapy have found relief with marijuana. Both venues include a strong, binding physician-patient relationship in the clinical setting.

  3. Ted Bynum says:

    For many years, many aspects of ALL health care (not just medical marijuana) has shifted from patient care to “business opportunity.” Health care has become a commodity. (Yet, Eli Ginzberg demonstrated conclusively that health care is uniquely removed from market forces.)
    It is one of many compelling reasons that what is desperately needed is single payer (“Medicare for all”).

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