The Colorado Department of Public Health and Environment's Board of Health has had a rough few months navigating the issue of medical marijuana.
In July, the board determined that a caregiver only had to provide a patient with marijuana to earn that label. Then, in November, the board voted to strike language to this effect in an emergency action, only to have Denver District Court Judge Larry Naves nix the switch. Afterward, the board postponed a meeting at which members were scheduled to try and figure out what to do next.
Now, however, the department is taking the initiative regarding the handful of physicians who've authorized the vast majority of the state's medical marijuana patients -- fifteen who've accounted for 73 percent of the state's nearly 16,000 total, with a third of them okaying nearly half that amount.
Ned Calonge, the state's chief medical officer, speaks plainly about such docs. "I don't believe these physicians are practicing within the community standard of medical care," he says.
Calonge offers an example from numerous anecdotes he's heard.
"You might walk in to a dispensary, and they give you a pre-completed form. You check off chronic pain. They might do a blood-pressure check, and then a physician looks at you, asks you a couple of questions, signs your form and your application is complete. And that's not appropriate medical care. That's substandard.
"Let's just lay it out. There's no other setting in medicine where this can occur -- where you can walk in off the street, see a physician who's never seen you before, have him or her diagnose you with a chronic condition without ever examining you, document this chronic debilitating condition, refer you to a pharmacy that he or she may have an interest in or gets a kickback from, give you a psychoactive substance, and when you walk out the door, you'll never see that doctor again.
"If it was any other substance -- if it was dilaudid, say -- that doctor would be arrested and his or her license would be taken away. That's substandard care. But we have report after report that this is exactly what's happening, and the public-health department can't sanction substandard care. One of my obligations as a licensed doctor in the state of Colorado is that if I have concerns about substandard care being delivered by another physician, I have a duty under my license to report it -- and not reporting it is grounds for disciplinary action."
A strong argument. But many patients believe that they must work with dispensaries and physicians like these because more mainstream doctors are not open to the possibility that medical marijuana may help them and therefore refuse to prescribe it. Calonge acknowledges that this is a legitimate issue.
"Medical care is delivered within kind of a set model -- what we call the medical standard of care," he says. "And I think most physicians, most mainstream physicians, tend to use the traditional medical model as their first line of approach. We usually prescribe medications that are very carefully regulated by the FDA in their manufacture, purity, the amount of medication, the dose, the potency, the activity. All of that is carefully regulated, so we know what blood levels we do, how it's going to interact with other medication. And, of course, other medicines don't come with their own carbon monoxide poisoning. So we're likely to try those therapies first and consider medical marijuana for a chronic, debilitating condition for those for whom we're not making an impact."
According to Calonge, he's actively encouraged physicians to take this latter course.
"I've had several doctors call me as this [medical marijuana issue] has gotten more interesting and say, 'I have patients, one or two, three or four, who I think might benefit from this' -- maybe a chronic pain patient or a cancer patient or a patient with another condition for which the physician has tried the traditional methods and they're not working. Or the medications have so many side effects that the quality of life for the patients isn't very good. And they'll say, 'I'd like to try this. Do you think this is a bad thing?'"
His response? "I'll tell them that I think this is what the constitutional amendment was written to provide. And when patients get medical marijuana in this kind of setting, doctors are able to bring them back and say, 'Did it work?' So I'd like to use this opportunity to raise awareness among physicians and let them know it's okay -- that no one will ever come after them and no one will ever know they prescribed it, at least from us. That way, we can make sure patients who really need this therapeutic approach have access to it."
Another option for getting around what Calonge describes as "the issue about, what if my doctor is old and crotchety and isn't going to do it"? Integrated care clinics.
"Let's say I'm a chronic pain patient, or I have one of the other conditions on the list," Calonge begins. "I can go to a clinic where I'm brought in as a legitimate patient, and I have this full assessment, and they say, 'Medical marijuana might be useful to you, but we want to figure that out through an exam and reviewing your past records. We want to come up with a pain treatment that's tailored specifically for you -- and that might include medical marijuana.'
In Calonge's view, such an approach "would establish a legitimate doctor-patient relationship that would meet the standard of care. The doctor could prescribe a treatment, then bring a patient back to see if he needs to add something to it. To me, that's the answer to the question, 'What if my doctor just won't do it?' I've heard from doctors who are interested in setting up that kind of clinic model, and I believe in working with the governor's office, we've suggested legislative wording that would allow that model to work and meet the standard of care to which all physicians should aspire. And a doctor in that situation might have 200 patients, or 1,000 patients, on the registry, because that's all he or she does. But they're not sitting in a dispensary. They're in a real, bona fide medical clinic setting."
By legitimizing the medical marijuana system, Calonge is hopeful that "more doctors will think about where medical marijuana fits in their overall armamentarium, and we'll see appropriate use rise as we hopefully reduce fraud and abuse."
And he believes there's plenty of both.
"We have to deal with this issue of economic ties to dispensaries," he stresses. "That's actually a question of federal law. As a doctor, I can't own a pharmacy, I can't sell drugs that I make, I can't get a kickback. That's all illegal. So you have to sever the economic ties between the documentation of the recommendation to get medical marijuana and the economics associated with selling it to patients. Those have to be separated, because that's just unethical. You can't do that for any other pharmaceutical."
As for criticism of the Board of Health within the medical marijuana community, Calonge thinks the perception is "we don't like this program and we want to get rid of it. But it would be nice to have people hear that we understand there are people for whom medical marijuana might be helpful. The people voted for that and put it in the constitution, so what we at the health department want to do is make sure we administer the program and make sure the people who are going to benefit from it from a health standpoint will do just that.
"That's a true medical marijuana program and not a backdoor entry to fraud and abuse and potential legalization of marijuana," he goes on. "Now, I'm not giving you an opinion about whether that should or shouldn't happen. But I am telling you that shouldn't be done through the public health system."
Look below to read the health department's news release about prolific prescribers.
Medical Marijuana Registry Data Shows Cause for Concern
DENVER -- The latest data from the Medical Marijuana Registry maintained by the Colorado Department of Public Health and Environment shows that as of Dec. 15 a total of 820 licensed physicians had authorized medical marijuana for 15,800 patients. Of those 820 physicians, just 15 accounted for 73 percent of total patients, and just five have authorized 49 percent of all recommendations.
"These figures are representative of the concerns we have about whether some physicians really have a bona fide physician-patient relationship, as required in the Constitution, with those for whom they are authorizing the use of marijuana," said Chief Medical Officer Ned Calonge. "Working with the Governor's office, we have crafted statutory language changes that would, among other things, clarify what constitutes a bona fide physician-patient relationship."
The department is asking legislators crafting medical marijuana related bills to include the following subjects to help address issues of fraud and abuse:
• define a bona fide physician-patient relationship that includes an on-going relationship, a complete assessment of a patient's medical history and follow up care
• ensure a physician recommending medical marijuana is in good standing and has not had his/her federal drug enforcement administration registration revoked or suspended
• prohibit physicians from receiving remuneration from a primary care giver or dispensary
On average, the 805 physicians with the lowest number of medical marijuana authorizations have approved just over five patients per doctor, while the 15 physicians with the most authorizations for medical marijuana have approved an average of 760 patients per doctor. These dramatic differences raise concerns about the medical care being provided to these patients.
According to Calonge, these data are all the more reason to make statutory language changes that will better assure that the appropriate patients are participating in the medical marijuana program, with assessment and treatment that meets the medical standard of care in the community and assures the health outcomes intended by those voting in favor of the original constitutional amendment.
"Many of these requirements parallel federal laws designed to provide protection from economic conflicts of interest that may arise when a physician stands to benefit directly from the sale of a medication or service that he or she prescribes," said Calonge.
The latest estimate from the Colorado Department of Public Health and Environment is that approximately 29,000 to 30,000 individuals now have submitted the necessary applications/authorization to be included on the state's medical marijuana registry. An exact count is not available at this time due to the high volume of mailed applications being received by the registry each day.
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