Most Physicians Believed Pot Would Be Used by Terminally Ill Patients
to Relieve Pain

DOCTORS VIEW MEDICAL MARIJUANA WITH SKEPTICAL EYES

Plenty of Montana doctors supported the voter initiative that made
medical marijuana legal, but good luck finding one who supports what
is happening now.

Medical providers across the state are mystified and angered by the
way hundreds of Montanans have secured "green cards," or medical
marijuana cards, at mass clinics staffed by out-of-state doctors.

"I think it's being corrupted," said Dr. Jim Guyer, director of the
medical clinic at RiverStone Health in Billings. "What I see is
there's been a wedge developed and the door's open. The people coming
through the door are exploiting it. The people who are going to get
hurt are the people the law was intended for."

Guyer and others who voted for the 2004 Medical Marijuana Act
believed it would allow people suffering from terminal illnesses or a
handful of other debilitating diseases to ease their pain with marijuana.

"I didn't envision there would be marijuana stores on every corner of
Grand Avenue and these fairs at the Holiday Inn," said Dr. Deric
Weiss, an internist at Billings Clinic who chairs the hospital's
ethics committee. "Most of us envisioned it would be through your
personal physician and part of a comprehensive plan of care."

Some patients have asked their regular doctors for help in accessing
medical marijuana.

Under the Medical Marijuana Act, providers do not prescribe marijuana
but certify that a person has a medical condition that qualifies for
treatment with the drug. The state Department of Public Health and
Human Services issues licenses based on provider authorizations.

But many, if not the majority, of medical marijuana patients in
Montana have been authorized by physicians at traveling clinics set
up inside convention centers or hotel ballrooms.

The doctors' identities are kept secret, but it is clear that they
are not Montana residents. In a day, they see more than 100 patients
who have paid to be evaluated.

"We have reached the point in Montana where medical marijuana
certification is for sale with a physician's signature," Dr. Chris
Christensen said during a recent meeting of the Montana Board of
Medical Examiners in Bozeman.

Christensen, who runs a primary care clinic in Victor, said he has
certified at least 3,000 patients for medical marijuana. But all of
them received thorough assessments, and not everyone who asks for
Christensen's signature gets it.

"I don't want to be painted with the same brush as physicians who
sell their signatures," he said.

The medical board responded to concerns about mass clinics by issuing
a position paper on medical marijuana. The paper will allow the board
to discipline doctors whose care does not meet generally accepted standards.

It was clear that physicians who certify patients for medical
marijuana after brief consultations at mass clinics are practicing
below expected standards.

At most medical offices, providers spend 15 to 20 minutes with new
patients, require multiple visits before prescribing powerful
painkillers and follow up with patients after ordering any course of treatment.

"If you're treating diabetes, which is a chronic condition, you don't
see a patient once and say, 'Here's a medicine. Good luck with
that,'" said Dr. John Petrisko, an occupational health specialist at
Billings Clinic.

Doctors who authorize medical marijuana for chronic pain after a
quick visit and without seeing the patient again are not doing their
jobs, Petrisko and others said.

"What if there's another underlying cause that's not treated?" he
asked. "Do you have back pain because you strained your back at work
or do you have cancer?"

Members of the Board of Medical Examiners seemed to share the
skepticism expressed by many Montanans over the mushrooming number of
people with medical marijuana cards, but they were careful not to
take a position on the legitimacy of marijuana as medicine.

Doctors interviewed for this story said they would authorize a
patient for marijuana in the right circumstances but that those
circumstances are rare.

"I just can't see all these stores serving people with real medical
symptoms," Weiss said. "It's being abused."

Dr. Camden Kneeland, a pain specialist at the Montana Center for
Wellness and Pain Management in Kalispell, speculated that 3 percent
of current cardholders have valid medical problems that can be
treated with marijuana.

Kneeland and his colleagues authorize patients to use marijuana in
three specific situations - when a dying patient is in pain, when
other medications do not help patients with chronic nausea and
vomiting, and when a patient has cachexia, a wasting disease that
causes life-threatening weight-loss.

"I have not seen a single patient using medical marijuana for pain
who because of their use of medical marijuana has returned to work or
reduced their opioid need," Kneeland said. "Basically, reading
between the lines, they're smoking marijuana for all the same
reason's everybody else does - to get high. When you're high, you
don't care about pain."

Kneeland said marijuana can be psychologically addictive, which is
not the same as chemical dependency. A marijuana user who stops using
the drug will not experience physical withdrawals, Kneeland said, but
might struggle to stop because of a psychological addiction.

"People can be addicted to shopping even though there's no chemical
dependency there," he said.

Meanwhile, people who use marijuana for purely analgesic reasons
might have trouble controlling their pain because marijuana is not
regulated for quality or potency.

"I think there are valid uses for it," said Lee Ann Bradley, a
pharmacist in a Missoula pain clinic and president of the Montana
Board of Pharmacy. "I don't think you can control the potency.
There's no quality control. I don't think you can treat it the same
way as prescription drugs until it's regulated."

Few clinical studies examining the efficacy of marijuana as a
painkiller have been conducted in the United States, and doctors like
to have evidence that a therapy works - and works better than
existing medicine - before they recommend it.

A handful of studies conducted at the University of California's
Center for Medicinal Cannabis Research found some analgesic
properties to marijuana, but the results should not be taken as proof
that marijuana is an effective painkiller, said Dr. J. Hampton
Atkinson, a co-director of the center.

In one of the studies, HIV patients with nerve pain who smoked
marijuana cigarettes reported a significant reduction in pain, Atkinson said.

About half of the patients said their pain was reduced, compared with
15 percent of patients in a control group who smoked marijuana
cigarettes with the active ingredient removed.

The most pain relief occurred when moderate amounts of THC were in
the patients' systems.

"You don't need to be stoned and be out of it to experience
analgesia," Atkinson said.

But many of the study participants were on other painkillers, so it
is difficult to know whether the marijuana alone eased their pain.

"We've done the science. There seems to be something there," Atkinson
said. "It's up to policy makers to decide what to do with this data."