'IT'S NOT LIKE I'M ASKING FOR ANYTHING NEW. I JUST NEED MY MEDICINE.'
LIABILITY ISSUE CLOUDS ACCESS TO MEDICAL POT

The medical marijuana law passed by voters in 2009 was supposed to
create greater access to the drug for those suffering from a lengthy
list of illnesses. It replaced a 1999 law, also enacted at
referendum, that made it legal to possess marijuana as medicine but
offered no system for patients to obtain it.

More than a year after the vote, and two months after the new
registration system took effect, patients are still struggling to
find doctors willing to write medical certificates, as is now
required. And some patients are worse off than before.

One of them is Nicholas Stanley, 32, of Farmington, who was rendered
quadriplegic by spinal muscular atrophy, a condition brought on by a
congenital defect known as a tethered spinal cord. The problem
manifested itself during high school, and Stanley has had three
surgeries to correct it - but they only made the problem worse, he
said recently.

Since 2003, he has legally used marijuana to relieve his "constant
aches and pains," as well as anxiety and depression, under advice of
his long-time caregiver, Patricia Soderholm, who grew medicinal
marijuana for Stanley.

"I was prescribed opiates, but the side effects were much worse,"
Stanley said. "Now the only drug I take for pain is marijuana."

But when Soderholm attempted to navigate the new medical marijuana
system for him, she ran into a dead end. About 30 minutes before a
scheduled appointment with his primary care physician to obtain the
now-required medical certificate, as Stanley was being loaded into
the van he uses to attend medical appointments on a cold December
day, the doctor's office called and said they wouldn't be able to
provide the certificate. "It takes at least an hour to get him
ready," Soderholm noted.

The Franklin Community Health Network, affiliated with Franklin
Memorial Hospital, has decided that its physicians will not be
allowed to write marijuana certificates - even for patients they were
already treating, like Stanley - until "there is greater clarity from
the state on the issue," according to Jill Gray, community relations
manager. She confirmed this week that the policy remains in force.

Soderholm said she tried calling at least 15 physicians' offices
trying to find someone who would help, "and some of them were
incredibly rude," she said. "They said, 'Why would you try to get an
illegal drugUKP'"

Finally, she located a physician in Falmouth who would see Stanley,
but since insurance won't cover the visit, he will have to pay the
$150 charge out of pocket. "For someone living on a disability check,
that's hard," Soderholm said. "He's been saving for weeks so he can
make the visit."

Difficulty finding docs

It may be that few patients will have to undergo the same ordeal, but
Soderholm's attempts to find a provider points up one of the oddities
of the new law.

More than 100 providers have notified the state that they are willing
to write certificates, but their names are confidential. Unless they
are willing to announce themselves publicly - and only a few have -
it's difficult for patients to know who to call. Meanwhile, many
other medical providers have made it clear they will not write
certificates for marijuana.

Jennifer Smale, who with her husband, Tim, operates Remedy Compassion
Center in Auburn, a dispensary that expects to open in late spring,
said this identity issue is a dilemma even for some physicians who
write certificates. "They don't want to be known as marijuana docs," she said.

Catherine Cobb, who directs the state's Division of Licensing and
Regulatory Services, part of the Department of Health and Human
Services, says the 100-plus providers are well-distributed
geographically and should be able to handle patients registering with
the state - 600 so far, with another 300 applications pending. But
she conceded that linking up with a doctor, an essential step, may
not be easy, at least initially.

Once a certificate is obtained, patients may:

- - Grow their own marijuana, up to 10 plants;

- - Seek and pay for a caregiver to grow the marijuana for them under
the same terms, or;

- - Buy marijuana at a dispensary, at the rate of $300 to $400 per ounce.

No dispensaries are open yet. Auburn's, at 730 Center St., near the
Auburn Mall, may be the first. But caregivers can provide marijuana
now, if they can get certificates.

"The caregivers think the dispensaries may have an unfair advantage,
because (caregivers) can't grow plants until they have a patient with
a certificate, while the dispensaries can sell right away," Cobb
said. Growing a plant to maturity takes at least nine to 10 weeks.
But at the moment, that may be the less important delay.

Some docs can't write certificates, others won't

Gordon Smith, president of the Maine Medical Association, whose group
has sponsored a series of well-attended seminars for physicians
statewide on the new law, said MMA has tried to remain neutral on the
subject, "not encouraging or discouraging the writing of certificates."

Still, it's proving to be a bit of a stretch for many doctors. As
Smith points out, marijuana is not FDA-approved for any purpose, and
while research on its medical effects is common abroad, there are few
U.S. studies, in large part because the federal government long
rejected most research proposals.

Even doctors willing to write certificates say they know little about
effective dosing, and health professionals disinclined to participate
can find plenty of reasons not to.

Smith said the number of primary care physicians in the state - those
most likely to get requests for certificates - isn't known, although
there are 528 "practice sites," many of which have multiple physicians.

"There must be at least 1,500 doctors," he said, meaning that the 100
or so doctors currently signed up to write certificates, which can
include specialists, are a small minority.

Many practices are barred by federal law from participation. Doctors
at all Veterans Administration hospitals and clinics face this
prohibition, as well as rural clinics receiving direct federal
funding, such as the HealthReach Network that has sites in Strong,
Livermore Falls and Rangeley, and the DFD Russell Medical Centers in
Leeds, Monmouth and Turner.

Dr. Roy Miller, director of the Sheepscot Valley Health Center in
Coopers Mill, said his clinic gets 10 to 15 percent of its funding
from the federal government, and must comply with federal law in all
respects. "This is only one of a long list," he said. "We can't even
do a vasectomy without filing a federal report."

The only reason Maine's new law can operate without running afoul of
federal law, under which marijuana is illegal for any purpose, is a
directive from U.S. Attorney General Eric Holder, who issued guidance
shortly after the Obama administration took office in 2009.

Holder said that federal law would not be enforced in states where
marijuana has been legalized for designated purposes, but, as Gordon
Smith noted, that policy could change with a new administration.
Under George W. Bush, the Justice Department raided dispensaries in
California, the first state to make them legal.

Aside from the physician practices barred by federal law from writing
certificates, some providers have decided on their own not to do so.
In the Lewiston-Auburn area, the two major hospital groups have split
on the issue, with Central Maine Medical Center allowing its
affiliated physicians to write certificates, and St. Mary's Regional
Medical Center barring them.

CMMC yes, St. Mary's no

CMMC's pharmacy director, Philip Rioux, said that several hospital
committees considered the appropriateness of writing medical
certificates, and determined there was a "strong consensus" that
"patients may derive some benefit" from marijuana. He noted, however,
that the pharmacy itself is not involved, and, "We don't allow its
use on the campus," meaning that a patient using marijuana may not do
so while hospitalized.

Rioux, too, noted that "there is no standardized dosage" for the
drug, meaning that it's difficult to integrate with conventional
allopathic medicine.

Under CMMC's policy, any of the 68 providers in its network can write
certificates, but none are required to do so.

Reaching the opposite conclusion were the committees at St. Mary's
hospital. Dr. Ira Shapiro, the medical director, said that the 36
primary care providers there "will not be writing certificates."

He listed four reasons as contributing to the decision, including
that marijuana is not FDA-approved, and that research on it "has not
reached an evidence-based standard in long-term controlled trials."

Shapiro also cited the difficulty of offering a drug to patients who
"may already have a chemical dependence, including marijuana
dependence." Finally, he said there are indications that regular
marijuana use can "trigger or worsen" psychotic mental illnesses -
bipolar disorder and schizophrenia.

Asked whether the federal prohibition on marijuana research had made
it difficult to establish the drug's effectiveness, Shapiro said,
"We're not a research institution. If scientific evidence is
presented, we'll reconsider our policy."

Jennifer Radel, the hospital's community relations manager, said
later that St. Mary's policy, while communicated to all staff, had
not yet been put into written form.

'... Wrong way to make the system work'

Dr. Owen Pickus is among those who dispute the idea that marijuana
isn't safe and effective. Pickus, a cancer and AIDS specialist who
practices in Westbrook, is perhaps the best-known Maine doctor to
publicly endorse marijuana by writing certificates.

Trained as an osteopathic physician, he has taught at the University
of New England, the state's only medical school, for more than 20
years, and recently earned his law degree and opened a legal
practice. He also ran for the state Senate as a Republican last year,
losing to incumbent Democrat Nancy Sullivan.

Pickus said there's no question marijuana has benefited many patients
he's treated, though he also shares some of the concerns expressed by
other doctors. And he's frustrated that the FDA has never taken on
the questions of marijuana's safety and efficacy.

"That's the agency we depend on to test drugs and establish which
ones work," he said. "This should never have been left to the states.
It's the wrong way to make the system work."

Twenty years ago, Pickus chaired the first state medical marijuana
commission for then-Gov. John McKernan, who had made his name as a
young state representative by sponsoring the bill that decriminalized
marijuana possession. But after serving in Congress and then his
first term as governor, the political winds had shifted, and McKernan
never took up the commission's recommendations.

It was not until the first referendum vote a decade later - sponsored
and funded, like the second one, by an out-of-state organization -
that medical marijuana became legal.

Pickus decried what he called two "special-interest groups" - those
who see medical marijuana as a step toward full legalization, and
others who have tried to criminalize all uses - as not serving the
needs of those who can benefit from marijuana.

The dispensary system is far from ideal, in his view.

"Charging $400 an ounce for a drug that's not covered by insurance
can be a hardship," he said. "I have patients who have trouble
handling a co-pay."

But he doesn't spare his fellow physicians from criticism. "We've
really got to get our heads out of the sand and deal with this."
Although 13 states, from Alaska to Maine, have provisions for medical
marijuana, there's no visible push for a change in federal law at the moment.

Pickus is also skeptical of claims that marijuana use could unduly
harm patients' health. "Sure, there's the possibility of dependence,
but we over-prescribe opiates and OxyContin, and they're already a
common cause of death, just like alcohol use," he said. "To my
knowledge, no one has ever died from smoking marijuana."

'The first year is tough'

At Remedy Compassion Center, Jennifer Smale said the availability of
certificates should improve when all eight of the state-approved
dispensaries are operating, possibly by the end of this year, and
when caregivers and patients feel free of possible interference by
law enforcement.

"The first year is tough," she said. "After that, it seems to get a
lot better in all the states that have authorized dispensaries."

She noted that in Oregon, 40,000 patients are registered marijuana
users, and that in Colorado, some 1,200 physicians are participating
in the state system. Even states with recent laws are signing up
numerous patients - 2,500 in New Mexico, and 2,250 in Rhode Island,
whose original law dates only to 2006.

She believes that some doctors are still unduly suspicious of
marijuana as a drug. Some prospective dispensary customers have told
her they are prescribed opiates, but if their provider finds, through
drug testing, that they are also using marijuana, their treatment is
discontinued. "That's harsh," she said. "It's not easy to withdraw
from opium-based drugs."

Smale said that education is the biggest hope for eventual widespread
acceptance by the medical community. "Maine's system is going to work
very well," she said. "We'll see physicians becoming more
open-minded, particularly when they see how safe it is."

For Nicholas Stanley, that day can't come too soon.

"I didn't need a card when I started using marijuana, and now I can't
get one," he said. "It's been very confusing to figure out what to
do. Even though I've paid my fees and they say I'm approved, I can't
do it without a certificate."

He feels he never should have been put in this position. "It's not
like I'm asking for anything new. I just need my medicine."

Consent form aimed at liability issue

Possible misuse of marijuana by patients who can legally possess it
has been cited as one reason why providers should be cautious about
writing certificates. Dr. Owen Pickus, a Westbrook-based physician
who writes certificates, says "the OUI issue is a real one," and "no
one should be driving a car after smoking marijuana."

The state has offered one means of dealing with potential liability
issues by posting a "Consent to Treatment" form on the Department of
Health and Human Services website, which doctors can ask patients to
sign. It covers the lack of FDA approval, possible impurities and
contamination, and specifies that the patient is responsible for proper use.

For the form and further information, see the DHHS page:
www.maine.gov/dhhs/dlrs/