Sunday, March 9, 2014
Two years ago, Sharon Gagne of Greenbush discovered she had two herniated disks in her neck. Her doctor told her surgery was not an option and instead encouraged physical therapy and prescribed a painkiller.
Dr. Dustin Sulak speaks with a reporter at his Falmouth practice. Sulak, who also has a practice in Hallowell, is one of the most sought after Maine doctors to write prescriptions for medical marijuana.
"I didn't like that," she said. "I know too many people who got hooked."
Gagne, 44, eventually asked about other options. Her doctor referred her to Dr. Dustin Sulak, a Hallowell osteopath who has become known throughout Maine for his willingness to certify patients for medical marijuana. Gagne's physician sent her medical records to Sulak, who then spoke twice on the phone with Gagne.
Without ever having met her face to face, Sulak certified Gagne as a medical marijuana patient. Now, whenever she feels pain, she smokes a little or nibbles a baked good fortified with cannabis.
Gagne's case illustrates the seeming ease with which Mainers with certain conditions can receive medical marijuana. Gradual changes to state law in the past three years have deregulated medical marijuana to the point that there is no way to know how many people are using it, how many doctors are certifying patients for it, and whether the number of users is growing.
Indeed, some doctors are actively recruiting patients. Sulak's practice recently placed an ad in a weekly newspaper offering a $50 discount to students for medical marijuana evaluations.
On Sept. 28, 2011, according to data collected by the state, 263 Maine doctors had certified a total of 2,833 patients. The next day, a law took effect that rendered Maine's medical marijuana reporting requirements optional. That means patients and doctors don't have to check in with the state. Police say the loosened system has made their jobs harder too, because they no longer have access to information that tells them whether someone caught with marijuana plants is growing it legitimately.
There also is no way to know how many patients are being treated for a diagnosis such as terminal cancer, which has been a permissible condition since medical marijuana became legal in Maine in 1999, or for something like intractable pain, which was added as a condition in 2009 as part of a broad expansion of the state's medical marijuana law.
Gordon Smith, executive director of the Maine Medical Association, said recent changes have made it nearly impossible to assess the program.
"Before, we had a handle on it; we could track progress," he said. "Now, we have nothing."
John Thiele, who oversees the medical marijuana program for the Department of Health and Human Services, conceded that the system is far less regulated than it was two or three years ago, but he said it seems to be working. To date, no complaints have been made to the two boards that licenses doctors and no penalties have been handed down for improper use, state officials said.
Thiele did say, however, that a small percentage of Maine doctors appear to be prescribing the majority of medical marijuana in the state.
"I'm not sure that's what the law intended," he said.
History in Maine
Medical marijuana has been legal in Maine since 1999, when more than 60 percent of voters approved a statewide citizens' initiative. The goal was to allow patients with certain debilitating conditions to grow and possess a small amount of medical marijuana for therapeutic use.
Some studies show that marijuana is safe and effective as a treatment for certain conditions. Other studies are not as conclusive. Last week a federal appeals court for the first time heard arguments about whether marijuana should be reclassified from a dangerous drug to a drug with potential medical benefits. That wouldn't necessarily lead to its legalization, but it would change public perception, advocates say.
Only a handful of states preceded Maine in legalizing marijuana for medical use. Now 19 states, including four in New England, allow it. Massachusetts could be next. Voters there will decide Nov. 6 on an initiative that would create a system similar to Maine's.
For the first decade, Maine's medical marijuana program ran smoothly but quietly, state officials said. The original list of diagnoses allowed under the law included cancer, HIV/AIDS, glaucoma, Crohn's disease, amyotrophic lateral sclerosis (Lou Gerhig's disease), hepatitis C and Alzheimer's. Only a few hundred patients were certified.
That changed in 2009 after Maine voters overwhelmingly approved an expansion of the original law to create nonprofit dispensaries throughout the state and allow certified caregivers to grow marijuana for other patients. The change also added a few more allowable conditions - seizure disorders, severe muscle spasms and intractable pain.
Intractable pain is difficult to define and hard to argue against. The state defines it as pain that has not responded to traditional treatment for at least six months.
The changes took time to implement, but within two years the medical marijuana program exploded, according to data provided by DHHS. In the first year after the law change, when the state required registration, the number of patients jumped from a few hundred to almost 3,000. All eight dispensaries created by the 2009 law have opened, and the most recent number of registered marijuana caregivers was just shy of 800.
Just as the state was beginning to get a handle on those growing numbers, though, the law changed again. Legislators last year approved a bill that created privacy restrictions. Now patients and doctors no longer have to register with the state.
Alysia Melnick, public policy analyst with the Maine Civil Liberties Union and the author of that law, said the goal was to protect patients from scrutiny by the public and doctors from scrutiny by federal authorities. "We didn't think that patients who are being treated for serious illnesses needed to have their names out there on a public list," she said. "No other types of medical treatment have lists."
But doctors are now protected at the same level as patients. The state now has no way of knowing whether a doctor is certifying one patient or a thousand.
Thiele said the confidentiality language insulates doctors from being flooded with patients who are looking specifically for medical marijuana.
However, Smith said the relaxed laws also have allowed for the creation of de facto medical marijuana specialists. If a patient's primary doctor is unwilling to certify, there is a short list of doctors who will.
Thousands of patients
Dr. Sulak, 32, who has practices in Hallowell and Falmouth, is perhaps the best known of Maine's cannabis specialists, and he's OK with that.
He speaks publicly and often about the benefits of medical marijuana. He employs three other "like-minded" practitioners. All are young. All are DOs -- osteopaths -- not MDs, which means they are trained to adopt a holistic approach to treating patients, as opposed to treating symptoms or performing surgeries. Many are trained in alternative forms of medicine. Sulak has studied acupuncture, hypnotism and Reiki, which aims to heal through the transfer of energy from the hands of the practitioner.
Asked whether he uses marijuana himself, either medicinally or recreationally, Sulak said, "I don't think the personal use question is relevant." But he did say "learning all I can about cannabis and the cannabinoid system of physiology has deepened my understanding of health and how to foster it."
Sulak said the expansion of conditions under which patients can be certified has increased his client base. He declined to say how many patients he treats with cannabis but said it was "thousands."
Many of his current patients are using cannabis to treat chronic pain. He said he would much rather see that than prescription narcotics.
"I'm always surprised by the number of people, young people, who are given opioids to treat chronic pain," he said. "They should be healthy, but they have already been down the road of Vicodin and OxyContin."
Sulak said the number of doctors in Maine who are certifying patients is low but growing.
"I think a lot of doctors are telling patients that it would violate their license (if they certify), but that's just something they can say," he said, adding that many doctors are prohibited from certifying patients because their employer does not allow it.
As more and more people become comfortable with cannabis as a form of treatment, he said, the stigma will wear off.
Count Catherine Lewis among the converted skeptics. She said medical marijuana was not in her "comfort zone" even a few years ago. Then, she saw how it worked. She saw her husband, who was seriously injured in a car accident 20 years ago, go from taking 17 prescriptions a day for pain and various side effects and still feeling lousy to using cannabis only and feeling great.
Lewis, now 44 and living in Manchester, was badly injured in the same accident. Like her husband, she took other medications over the years, often powerful narcotics. She hated them. She wondered whether medical marijuana would work for her, too.
Her pain specialist encouraged Lewis to consult with Sulak. He used Reiki and hypnotherapy first. Then they discussed Sulak's specialty.
Now, Lewis said she would recommend medical marijuana to anyone.
To become certified for medical marijuana, a patient needs to be diagnosed with one of the original conditions spelled out in the 1999 law. To certify someone for pain or severe nausea or seizures, a doctor must demonstrate and document that the patient has not responded to traditional treatment for at least six months.
Once those six months are up, and a patient's doctor is willing, little stands in the way. Doctors have full discretion to certify patients. There is no additional state oversight. The only barrier is that insurance doesn't cover medical marijuana. Sulak charges $300 for a first visit.
The other variable in certifying for medical marijuana is that pain is subjective. Doctors often cannot legitimately withhold treatment for pain. Some doctors prescribe painkillers; Sulak favors cannabis.
Brad Feuer, CEO of Sulak's practice, Integr8 Health, said he has seen and heard of practitioners who are certifying patients who don't have qualifying conditions.
"It upsets us because it gives the program a bad name," he said. "We take a lot of risk to provide this service."
The state has not fielded a single complaint against Sulak or any other medical marijuana practitioner. However, when told about Sulak's certification of Gagne without ever meeting her, Ken Albert, director of licensing and regulatory services for the Department of Health and Human Services, said that would raise a red flag. Albert said it's never good medical practice for a doctor to prescribe any medication without having a relationship with a patient.
Feuer said an exception was made for Gagne because she lived so far away (about 25 miles north of Bangor, in Greenbush). She still needed to meet the necessary requirements for medical marijuana certification.
"Not everyone that comes to us is certified," Feuer said. "We're not just giving it to anyone."
Feuer also argued that treating patients remotely is sometimes essential in a rural state like Maine. That no other doctor in Gagne's area was willing to certify her for medical marijuana is part of the problem, he said.
Sulak's practice recently placed an unusual advertisement in an alternative Portland weekly newspaper, offering $50 discounts to students who wanted to receive a medical marijuana evaluation. Asked about the ad, Sulak and Feuer paused before answering.
"That was just a test actually, to give them more of a discount," Feuer said, explaining that students are often on tight budgets and insurance does not cover medical marijuana. "But they would still have to have a qualifying condition."
Several state officials, when asked about the ad, said they hadn't seen it. Thiele said it sounded strange and likely would warrant a referral to the proper licensing board for an investigation.
Susan Strout, executive secretary of the Board of Osteopathic Licensure, said she could not offer opinions on specific practices.
Of course, many doctors refuse to get involved in medical marijuana.
Brian Pierce, a family physician in Rockport, has not certified any patients for medical marijuana and does not plan to do so. He said he's not convinced of its benefits.
"I have had patients who have run off to Portland or somewhere to get certified for medical marijuana and the certifying physician never requests that patient's records," he said. "The enthusiasm seems to exceed the evidence at this point. There are patients I know who have become certified who I'm not convinced should be using a hallucinogenic drug."
'Not reefer madness'
Cumberland County Sheriff Kevin Joyce said the relaxed laws have been problematic for his deputies. In several instances over the past year, his office has investigated marijuana-growing operations, only to find out later that they were certified. Having a database of certified users and growers would help, he said.
Joyce also said deputies see a lot of people who don't appear to need medical marijuana.
"There are some people we have dealt with in the past who have a history of using marijuana illegally and don't seem ill," he said. "Now they have a card saying they can use it legally."
Possession and distribution is still against federal law, but authorities have mostly looked the other way at the growing number of states that have legalized the drug for medicinal purposes. However, this year, dispensaries have been shuttered in California and Colorado because of violations. Maine's dispensaries are still new and tightly regulated.
Maine U.S. Attorney Thomas Delahanty said the state is not in danger of becoming California or Colorado, which have lax medical marijuana laws.
"There has been some monitoring of the program," he said.
Would it be easier if there were a database of doctors and patients?
"Of course," Delahanty replied.
Tony Pettigrew, regional spokesman for the U.S. Drug Enforcement Agency, declined to comment on Maine's medical marijuana program because it's not within the DEA's purview to assess it. The agency's position is that marijuana possession is against the law, he said.
Conflict between state and federal law created problems recently when the Maine State Housing Authority banned Section 8 housing clients from growing or using medical marijuana. Last week, the authority's board voted to suspend the ban for six months to gather more information and develop a clearer policy.
Last week, an appeals court in Washington, D.C., reviewed for the first time scientific evidence on the therapeutic value of marijuana. Supporters made their case that marijuana should be reclassified from dangerous drug to drug with potential medical benefits. The Justice Department argued that the drug is still widely abused. The three-judge panel is expected to rule in the coming weeks. Even if marijuana is reclassified, it would not be legalized.
Still, there has been a steady shift in states like Maine that continue to expand medical marijuana. Sulak is not the only doctor taking advantage of a deregulated industry.
Jeremy Spiegel opened a practice, Casco Bay Medical, in Portland this March. Since then, he has been seeing an increased number of medical marijuana patients. Most, he said, come to him because their own doctor will not certify them. Spiegel said he thinks it's actually better if certain practitioners act as specialists because it spares others doctors who are worried about being labeled "pot doctors."
Most doctors likely went through medical school and their residency without ever learning about medical marijuana as a form of treatment, Spiegel said.
If doctors want to learn about medical marijuana, Sulak said, they have to attend conferences, keep current on studies and observe patients.
But as more learn about its benefits, more might be willing to recommend it, Spiegel said.
"It's not a reefer madness mentality here," he said. "It really is more scientific."
Still, Maine's medical marijuana laws would change even more if some doctors get their way. Sulak and other advocates want to add conditions like post traumatic stress disorder.
And not everyone's happy about that. Gordon Smith, of the Maine Medical Association, said that if any more conditions are added, "you might as well just go ahead and legalize it."