Doctor's duel on medical use of marijuana

By Paul Monies
Oklahoma Watch

A contingent of medical associations have come out against an Oklahoma ballot initiative that would legalize medical marijuana, saying State Question 788 is full of loopholes and would exacerbate drug abuse in the state.

But the voices of individual doctors have been more muted. Many prefer their medical association or other groups to make the arguments for or against the proposal, which will be decided in Tuesday’s primary election. Others are taking a wait-and-see attitude and may be more vocal should the question pass.

Oklahoma Watch talked to two doctors with differing viewpoints on legalizing marijuana for medicinal use.

Dr. Art Rousseau is an Oklahoma City psychiatrist who believes Oklahoma’s proposal could endanger patient safety and open doctors up to professional and legal problems.

Dr. Barry Gordon is a former emergency-room physician from Ohio who is now chief medical officer at a medical marijuana clinic in Florida; he believes patient education is key to the success of medical marijuana and patients should be given all options for treatment.

Florida Law vs. SQ 788:

There are differences between Florida’s marijuana law and Oklahoma’s initiative.

Florida lawmakers first passed medical marijuana in 2014 for the terminally ill. Voters expanded that under a constitutional amendment in 2016 to include more than a dozen medical conditions. The smokable form of marijuana is not allowed, nor can patients grow their own. Patients can get medical marijuana in pill form, sublingual tincture oils, sprays or vaporization products. A circuit court recently ruled Florida’s ban on smoking medical marijuana was unconstitutional, although that decision is being appealed. Almost 124,000 Floridians are on the medical marijuana use registry.

Oklahoma’s SQ 788 does not limit medical marijuana to any specific medical conditions. After consulting with a doctor, patients would be certified to use medical marijuana for up to two years. Backers of the initiative said it is an initial framework and could be limited in scope by legislative changes or administrative rules. (The Oklahoma State Department of Health, which would regulate medical marijuana if SQ 788 passes, recently released draft emergency rules.)

Oklahoma allows for use of cannabidiol oil, or CBD, which comes from the cannabis plant, with a doctor’s authorization. But the oil is limited to a small amount of THC, the psychoactive ingredient in marijuana.

Gordon and a fellow Ohioan, Patrick Deluca, started Compassionate Cannabis Clinic in Venice, Fla., in late 2016. The clinic now has more than 2,400 patients. Their average age is 55, with about one-third who had never used marijuana before, Gordon said.

“I never promise 100 percent results to anybody, because that would be like a snake-oil salesman,” Gordon said. “But I love giving the 100 percent safety profile of cannabis: Nobody has ever died from my stuff, and nobody ever will. That doesn’t mean there’s not any degree of abuse potential with it, but surely in comparison with alcohol, opiates and many other substances out there in society, I feel extremely comfortable with what’s going on.”

Gordon said patients in Florida can get their marijuana with varying mixes of THC and CBD, depending on what the doctor might recommend.

“Sometimes people come in and get an education, but they want to continue to use the CBD products with no THC,” Gordon said. He added, “Research your THC and CBD ratio. Medicinal cannabis is fascinating because on the street, all you’re going to get is THC. When I graduated high school in 1974, it was a 5-percent (THC) product. Twenty minutes from here, you can buy it on the street with 20 percent THC, so it is much stronger and that’s what freaks out the prohibitionists. The only way the citizens of Oklahoma can get safe, clean, purified, strain-specific, and CBD and THC ratio-specific product is through the medicinal program. That’s the difference between recreational and medicinal.”

Rousseau, who treats patients at his Oklahoma City practice for behavioral and mental disorders and addiction, said too much is unknown about the effects of medical marijuana for its use in a controlled medical setting.

“To refer to this state question as medical marijuana is a total misnomer,” Rousseau said. “It is not a medical bill, although it is trying to come across as one. Basically, this would legalize marijuana for the population of the state of Oklahoma.”

Rousseau said marijuana’s classification as a federal Schedule I drug, the highest category for abuse potential, has limited medical research into its therapeutic effects. The Oklahoma State Medical Association and the American Medical Association have called for its reclassification as a  Schedule II drug, which would open up more research and grants.

“Marijuana may have some possible, potential medical benefits,” Rousseau said. “I’m not denying that’s a possibility, and we’re getting hints that it may in some specific diagnoses. But we do not have enough research and background for me to define utilizing marijuana as a treatment modality for my patients.”

A Question of Control:

Rousseau said when he writes a prescription for patient, he knows their medication history and how different drugs might interact based on dosage and frequency. If the medications are controlled substances, they must be logged in the state’s prescription monitoring program. That prevents “doctor shopping”, where patients seek out doctors for multiple prescriptions of the same medication.

“I have control,” Rousseau said. “I have a way of knowing what other things the patient may be taking. Because of the way the system is set up, I have to keep refilling this medication or have the patient come in to get another scrip so I can see how well it’s going.”

Under SQ 788, a doctor just has to certify that a patient is eligible for medical marijuana, Rousseau said. Nothing would be entered in the prescription monitoring program and other doctors wouldn’t know a patient’s medical marijuana use unless the patient told them. He’s skeptical of the medical advice and economic motivations of employees at medical marijuana dispensaries.

“You’re going to go to a non-medical person, maybe a high school graduate, who’s standing behind a counter and whose primary purpose is to sell you a product,” Rousseau said. “You’re going to go in and say, ‘I have depression and anxiety. How much should I use of this? Should I smoke it, should I eat it?’ This non-medical person is now taking control of the chemical, the dose, the frequency.”

Gordon, the Florida doctor, said while he understands that loss of control, patient education and empowerment is the key. More than 1,300 physicians in Florida have been certified to recommend medical marijuana, but the vast majority of the state’s doctors are reluctant to get involved. Some have restrictions from hospital systems and fear they could lose their privileges to practice at a particular hospital.

“They don’t teach you anything about the endocannabinoid system in med school,” Gordon said, referring to an internal body system that interacts with naturally produced compounds. “Every single patient that comes to us wants less of the manufactured pharmaceuticals.”

Gordon said he gets referrals from other doctors because they know he is recommending treatment appropriately, with education, advocacy and respect for the patient.

“Doctors need to teach,” Gordon said. “If you don’t enjoy spending 15 minutes to a half hour with a patient and teach them about medicinal cannabis, you’re not going to do this. You need to give up control of the medicine to the patient.

“Doctors are used to dosing, right?” he added. “Like 10 milligrams three times a day. Not with cannabis; cannabis is opposite. There’s too much variability and where your patients are coming from, be it a vet guy (longer-term patient) versus a grandma who’s never had a whiff. We don’t really talk dose. We like to give our patients control. It’s safety, plus control, equals relief.”

For Rousseau, though, the risks are just too high for doctors and patients under the Oklahoma proposal.

“Do I want to be involved in this? No,” Rousseau said. “I will not be judgmental. If they want to set the law up that says you want a license to carry marijuana, then go do it. Don’t involve the medical community in this. If this passes and I have patients come in and say, ‘Will you certify me?’ and I say no, I may lose patients. And certainly you can find a doctor who will do it.”

Oklahoma Watch is a nonprofit, nonpartisan media organization that produces in-depth and investigative journalism on a range of public-policy issues facing the state. For more Oklahoma Watch content, go to www.oklahomawatch.org (link is external).
All rights reserved, The Gayly 6/26/2018 @ 5:24 p.m. CST.