Ned Calonge on leaving as CO's chief medical officer & the "distraction" of medical marijuana
Dr. Ned Calonge, the Chief Medical Officer of the Colorado Department of Public Health and Environment, is leaving his post in November to serve as president of The Colorado Trust. Below, Calonge talks in detail about the decision to rejoin the private sector, his goals at the Trust, and his CDPHE tenure, with a focus on medical marijuana -- a topic that's taken more time than he'd like.
In Calonge's words, MMJ "has been a pretty significant distraction from what I would consider higher-priority public health issues" of the sort he'll be able to tackle in his new position with the Trust, which he's worked with on and off since shortly after it was formed in 1985.
"Its mission is to improve the health of the people of Colorado," Calonge says, "and it currently has a ten-year mission to ensure access to health care for everybody in the state."
The Trust provides grants to worthy recipients, although Calonge prefers to think of these bestowals as "strategic investments that help us move to policies and programs that will help us achieve our vision."
The Trust has a sizable pool from which to draw -- "somewhere around $20 million a year to help nonprofits or government agencies or academic institutions move the state forward. For example, look at health-care reform. One of the big opportunities for the Trust is to figure out how strategic investments can help achieve the objective of federal health-care reforms, which is to get access to health-care insurance for everyone. I think that moves us a long way forward to health care for everyone. And we'll be looking at whether health-care exchanges can help."
One of the appeals of the Trust presidency for Calonge is "a greater agility and a greater ability to make quicker decisions" than he can at present. "I may now be able to do things that both the politics and the machine of state government really prohibited in the past."
At the same time, he hopes to put his bureaucratic experience to a positive use. "I actually think that was one of the factors the trustees considered when they made their selection," he notes. "As an insider, I've worked for both a Republican and a Democratic administration, I've worked with the joint budget committee and the general assembly. And that knowledge will hopefully come in handy when we think of the best places to leverage the funds we have to make a difference."
Before he can do so, however, he's got some other things on his agenda.
"I've asked permission to work half-time through September and October and then go full time with the Trust in November," he says. "There were a few issues I wanted to see if I could conclude before I left."
Prominent among them, he adds, are "a few rule-making hearings in front of the board of health regarding medical marijuana and our implementation of Senate Bill 109," which attempts to clarify the relationship between MMJ patients and doctors, " and HB 1284," the main medical-marijuana regulatory measure.
According to him, "I thought it would only be fair, and help get some closure for me, too, as we tried to put policies together to make the program more medical."
For Calonge, the "medical" part of medical marijuana has gotten lost at times during the debate over MMJ. During an interview with Westword last December headlined "Colorado's Chief Medical Officer Charges Some Medical Marijuana Doctors With Substandard Care," he decried physicians who recommended cannabis to patients without incorporating it into an overall treatment regimen, or even arranging followup visits to make sure the stuff worked as hoped.
Such concerns had a major influence on SB 109 -- but they also earned Calonge the antipathy of many medical marijuana advocates, whose loud protests made it more difficult for him to deal with other aspects of his job, he says.
"I've kept my eye on things like H1N1 and the food-borne outbreaks we've had this summer -- and it's taken more diligence than in the past because of the distraction associated with medical marijuana."
This frustration didn't prompt his departure from the CDPHE -- a prospect debated in the recent Joel Warner piece "Did Medical Marijuana Smoke Out Colorado Chief Medical Officer Ned Calonge?" He characterizes this theory as "simply ludicrous. If that was true, I wouldn't be hanging around to get through the next two rulings.
"This has a lot of moving parts, and it's my job to help the physicians of the state know how to do it right -- to not get into trouble, and to make sure patients who really need access to this as a medical therapy can actually navigate through the system."
This approach has brought him into conflict with some marijuana boosters, who he divides into two categories.
"One group of people think marijuana should just be legalized and decriminalized," he says. "And those advocates mix in with what I'd call more medically minded marijuana folks -- people with conditions where there's at least some scientific evidence that marijuana will benefit them.
"If you look at it from the side of, 'What do I think about using the medical marijuana program as a backdoor to legalization or to broaden recreational use?,' I would say I'm a stanch opponent. But if you turn towards the question of, 'What are the uses of marijuana where it would make the most difference in patient care?,' I see potential benefits."
With that in mind, he says he'd like to see more doctors consider medical marijuana as a treatment option -- "because that actually increases the chances that a patient who's really going to benefit from it has access to someone who's going to consider it and potentially recommend it when other things aren't working, or if they think other things might work better. That way, we adopt more of a medical model, which I see as more the intent of Amendment 20," which legalized medical marijuana in Colorado.
After all, he goes on, "if we keep it to a few physicians whose only service is to provide recommendations, and who don't provide followup on the use of marijuana in terms of the rest of the patient's therapy, I think that's the wrong model. It actually creates a system for misuse, abuse and actual harm to patients, because no one's watching. It'd be like proscribing a very powerful medication with potential for abuse and then never seeing the patient again. And that's not good medical care.
"My hope is that by having more physicians understand how to do it right, which isn't difficult if you treat it like real medicine, it will expand the base of those providing it and patients who won't have to segregate their care."
In the meantime, though, "we have our own problem," Calonge concedes -- that being the delays involved in processing applications for medical marijuana cards.
Right now, there's controversy within the medical marijuana community about Governor Bill Ritter's plan to use $9 million in MMJ fees to help offset a budget shortfall. Advocates like the Cannabis Therapy Institute's Laura Kriho find it unconscionable to shift these funds at a time when tens of thousands of applications remain unprocessed. Calonge's take?
"We went to the general assembly, because we felt we needed to find an answer for that," he says. "It was a processing issue where we needed more people, and we had the money. And the joint budget committee approved it, and we're hiring people and actually using other state agencies for help -- agencies that had the capacity, and we could pay them to take on the extra work.
"We've really pulled out all the stops to try to work through this backlog. I know it'll still seem slow, but I'm hoping that within some period of time, people will get their cards and we'll get through the backlog and then start processing new applications."
Some of Calonge's critics believe the CDPHE isn't really all that enthusiastic about tackling this task, because of his doubts about whether all the applications are on the up and up. But he denies that.
"Regardless of what concerns I might have about the potential legitimacy of all the applications, not processing them in accordance with the state constitution isn't good, and it's something we're concerned about and are trying to work through as quickly as we can. And I will tell you, I just don't think we ever would have dreamed that we would have had this surge in applications.
"Even Oregon, the state on which our constitutional amendment was modeled, only has something like 20,000 people in its registry, total. We kept thinking, this can't continue to increase, and it can't be sustained at this level, but it did. That's the risk you run in trying to predict the future. My apologies for having the backlog don't go very far, but this is an area of concern, and we're dedicated to working through it as quickly as possible."
In contrast, Calonge doesn't express regret about arguing against the inclusion of post-traumatic stress disorder as a condition treatable by medical marijuana -- a position that prompted protests from MMJ advocates in June and a PTSD petition submitted by Sensible Colorado's Brian Vicente in July.
Before PTSD or any other medical condition gets the MMJ nod, Calonge wants to see more than anecdotal evidence. But he insists that he's not automatically opposed to any addition to the treatable-conditions list.
"We have a medical marijuana advisory committee we're using as our stakeholder group to discuss rules in front of the board of health," he says, referencing a group that got off to a rocky start when appointee Ken Weaver turned out to be a plane-stealing ex-con who resigned after his shadowy past was made public. "And we're talking about the petition process. We're really trying to set some evidentiary standards for adding a condition.
"If the FDA approves a new drug, even an over-the-counter drug, they have four phases of study -- and by the time you get to phase three, clinical trials in humans, you're looking at thousands of patients. And that's to get any drug approved for use, much less something that's in the Schedule 1 category."
Marijuana is listed as a Schedule 1 drug at a federal level, meaning the U.S. government doesn't recognize any approved medical use for it.
Does Calonge propose using FDA standards before supplementing Colorado's list? No. "If we did that, we'd never approve another condition -- and, to be honest, none of the ones in the constitution would be approved, either, because none of them have that robust evidence to prove that they're beneficial. So we tried to look at another standard -- at least one randomized trial on humans that shows it works. That's a really low standard, but one we think should at least elevate a condition to consideration either in front of the advisory board or the board of health."
Tourette syndrome may be the first condition to be evaluated in this way, Calonge says, "because there was a randomized trial of 24 individuals in Germany, and it showed some modest efficacy in terms of reducing tics. The size of the study is really minuscule, because of the 24 people in the trial, only seventeen of them finished. But it's the first petition where I've received any evidence of efficacy in humans -- and we're not going to add a condition on the basis of rat studies. There's no country in the world that approves medication on the basis of animal studies only. We need to have at least some shred of evidence from a good study that it's actually going to help humans -- do more good than harm."
That isn't the case with Hepatitis C, he maintains. "A petition was brought forward for that, but there are no fewer than three studies that demonstrate marijuana use speeds liver problems for patients with Hepatitis C. It clearly does more harm than good. And using that kind of model is the approach we're going to take."
For now, anyhow. Come November, however, Calonge will make his move to the Colorado Trust -- and medical marijuana will become a problem for someone else at the CDPHE...
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