It’s been more than a year since Massachusetts became the 18th state to legalize the dispensing of marijuana for people with medical conditions. However, the referendum question voters approved authorizing medicinal marijuana dispensaries gave only a loose framework for what would become the dispensary business. Now physicians Island-wide are now beginning to grapple with the moral, legal, and ethical implications of recommending a substance, legal in Massachusetts but illegal federally, for medicinal purposes.
State law allows doctors to recommend up to 10 ounces of marijuana as a 60-day supply after determining that a patient has a “debilitating condition.” which may include intractable pain, nausea, impaired strength or ability, extending to such an extent that one or more of a patient’s major life activities is substantially limited.
Physicians who choose to certify patients for marijuana use must have an active Massachusetts licence, at least one established place they practice, register as a certifying physician with the Department of Public Health (DPH,) and take a two-hour online certification course.
As the DPH continues to fine tune the rules and regulations before the opening of the first registered marijuana dispensary (RMD, several Island health care professionals have expressed varying opinions concerning their participation.
Not medical treatment
Dr. Charles Silberstein, a psychiatrist based at Martha’s Vineyard Hospital, said he is strongly opposed to the idea of marijuana being used for medicinal purposes. “It’s hard for me to see this as medical treatment,” he said. “One reason is that this is something that’s poorly regulated. There is not good medical monitoring of dosage, side effects, or the effects of marijuana, like other medications.”
Dr. Silberstein also noted the long-term effects of marijuana, particularly in people who are prone to anxiety and psychotic disorders.
“Every single patient who I have seen in the last ten years who had a psychotic disorder, developed it after using marijuana heavily,” Dr. Silberstein said. “It doesn’t mean that most people who use marijuana will develop psychotic disorders, but some will, and it’s really a huge tragedy in a series of lives of people that I’ve worked with.”
In addition, Dr. Silberstein said the cognitive risks in adolescents are cause for great concern. “The bigger concerns for me are it’s going to increase access to marijuana both for the general population but particularly for adolescents,” he said. “Because no doubt, marijuana will be shared, and it sends the message to adolescents that marijuana is something that’s safe and reasonable to use, when in fact, for the developing brain, it can be dangerous and a gateway towards other drugs.”
Veteran physician says no
Henry Nieder, a longtime primary care doctor at Martha’s Vineyard Hospital, also opposes marijuana for medicinal use.
In his op-ed essay in this week’s print edition of The Times, called “Medicinal marijuana, mostly a fiction,” Dr. Nieder writes:
“I suggest we try to be the last county in Massachusetts to have a dispensary. See what happens elsewhere first. If Dukes County must have a dispensary, it should have only one. We should discourage the establishment of any medical office whose primary purpose would be to prescribe medical marijuana.”
Mr. Nieder also addresses the legal issue patients could face if caught taking a controlled substance. “Unfortunately marijuana is not legal in Massachusetts. Possession of less than an ounce is now a civil offense, on par with a parking ticket, in this state. But those who use marijuana in greater quantities risk arrest and a felony charge. It is also still a criminal offense to cultivate or distribute the drug.”
Dr. Nieder says he will not get certified to recommend marijuana use to patients.
A place for pot
Hyannis-based ear, nose and throat doctor Edward Caldwell, who regularly sees patients at Martha’s Vineyard Hospital, says that while medicinal marijuana is not for everyone, it does have a place, and serve a purpose.
“I think that it’s going to have a limited role,” he said. “Traditional physicians have been slow to adapt to it, but I think there’s certain patients who are going to benefit, particularly chronically ill patients.”
In particular, Dr. Caldwell noted its efficacy for patients undergoing chemotherapy who don’t respond to more traditional forms of treatment.
“To a limited extent, because of the nature of what I do as an ear, nose and throat physician, less of these are chronic pain patients,” he said. “But I do have some head and neck cancer patients who have tried it, and it’s been successful. But it’s not for everybody.”
Dr. Caldwell, who is building an office in West Tisbury, said he plans to become certified to prescribe marijuana, when the time comes.
“I think, like anything new, it’s going to take a while for it to be integrated into their own practices,” he said. “Everybody’s different, and it’s nice to have that alternative.”
Carol Forgione, nurse practitioner and clinical director at Vineyard Medical Services in Vineyard Haven, said she sees both sides of the medical marijuana argument.
“The problem from my perspective is that there is the option for abuse,” Ms. Forgione said. “And the question of how do we screen people properly, how do we deal with the demands? And then there’s the issue of federal approval.”
Without the blessing of the U.S. Food and Drug Administration (FDA), marijuana is still considered to be an illegal, schedule I drug along with cocaine, heroin, hallucinogens, inhalants, painkillers, tranquilizers and stimulants. Schedule I drugs, by legal definition, have no medical use and a high potential for abuse.
“A lot of us have worked very hard for a long time to get where we are, and we don’t want to lose that,” Ms. Forgione said. “I think there is a place for medical marijuana; the problem is we’re not sure how that place is going to look.”
On one issue Ms. Forgione was not ambiguous – smoking marijuana exposes the user to harmful carcinogens. “I’m certainly opposed to anybody smoking anything,” she said. “I don’t think there’s been many studies to show the side effects of long-term smoking, and there must be other ways of administering this.”
A learning experience
One commonality for physicians The Times spoke with, is the lack of awareness and education including the short-term and long-term effects of using marijuana for medicinal purposes.
“When I was in medical school, and I learned how to treat patients with cancer, it (marijuana) wasn’t exactly something that was around,” Dr. Ellen McMahon, who practices geriatric medicine said.
Dr. McMahon said that while she’s not opposed to recommending marijuana to certain patients and can see instances where it would be beneficial, she hesitates because of the lack of awareness surrounding the drug.
“I wouldn’t be against recommending. I can see how there would be instances, like cancer or anorexia related to cancer, or patients in severe pain who would benefit from its use,” Dr. McMahon said. “But it’s unclear what the benefits are going to be.”
Like many physicians, Dr. McMahon is uncertain of the medicinal benefits.
“There’s a lot of confusion. I’ve had a lot of people, both old and young, who have asked for prescriptions for different reasons,” she said. “So one way or another, we will be dealing with this very soon.”
Britain Nicholson, chief medical officer at Massachusetts General Hospital, who also has ties to the Martha’s Vineyard Hospital, is currently in the process of getting his staff up to speed in preparation of the first state-approved dispensary.
“We’re in the process of coming up with common prescription practices,” Dr. Nicholson told The Times. “We want to make sure we have a consistent approach.”
Through the use of an online medical training website called healthstream.com, Dr. Nicholson said he is now in the process of compiling a list of criteria as well as other guidelines and materials as they pertain to recommending marijuana for medicinal use. The list will be made available to physicians to use in the coming months. “We can’t anticipate every particular situation, but this should help as a guide and we’re encouraging physicians to utilize that,” he said.
As far as the response from physicians in the face of prescribing the drug for medical use, Dr. Nicholson said he sees the benefits in treating oncology patients suffering from nausea as well as glaucoma. “I think it’s a very effective way to treat certain symptoms in patients,” he said. “But I think the general response so far has been that we just don’t know that much about it.”
Ancient history & marijuana milestones
Cannabis has a long and varied history that dates as far back as 2700 B.C.
Historians have found that cannabis and hemp was used for everything from making rope, paper and clothing to a potent herbal Chinese tea.
Marijuana has since been prescribed for everything from glaucoma and arthritis to HIV and epilepsy.
It didn’t take long before the popularity of medicinal marijuana spread throughout Asia, the Middle East, and parts of Africa, but it wasn’t until the late 18th century that marijuana use took hold in the United States.
In 1996, California was the first state to legalize marijuana for medicinal use with proposition 215 which allows for the sale and medical use of marijuana for patients with AIDS, cancer, and other serious and painful diseases.
Today, 20 states across the U.S. have approved marijuana for medicinal purposes.
According to a 2012 report by the National Survey on Drug Use and Health, marijuana was found to be the most commonly used illicit drug in the United States, with an estimated 18.9 million users nationwide. That figure is on the rise.