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Md. medical cannabis industry hailed, but room for improvement seen

FILE- In this March 22, 2019 file photo, marijuana buds are seen in prescription bottles after being sorted at Compassionate Care Foundation’s medical marijuana dispensary in Egg Harbor Township, N.J. Most of the nearly 700 different groups that filed 2,163 marijuana business applications in Missouri are not from the state. Some Missourians are concerned that ownership of the industry will disproportionately go to firms outside Missouri. (AP Photo/Julio Cortez, File)

FILE- In this March 22, 2019 file photo, marijuana buds are seen in prescription bottles after being sorted at Compassionate Care Foundation’s medical marijuana dispensary in Egg Harbor Township, N.J. Most of the nearly 700 different groups that filed 2,163 marijuana business applications in Missouri are not from the state. Some Missourians are concerned that ownership of the industry will disproportionately go to firms outside Missouri. (AP Photo/Julio Cortez, File)

Doctors, patients and those who work in Maryland’s medical cannabis industry say they are happy with the program’s development since its 2017 rollout – relieved that people can now access cannabis in a legal and safe fashion to help them cope with a range of illnesses and conditions, including chronic pain.

Some in the industry nevertheless say there is room for improvement in how cannabis is prescribed and how cannabis patients are monitored. They point to the often-loose relationship between the health care practitioners who approve individuals to receive medical cannabis and those individuals, who often visit the practitioner only once. Others in the industry point to the influence of a recreational marijuana culture on the medical cannabis industry.

‘Cannabis brought my life back’

Maryland medical cannabis patient Linda Biggs was deemed permanently disabled after a 2012 car crash left her in debilitating pain.

“I didn’t think I would ever have my life back,” she said in an interview.

Though she said she had never used marijuana before the crash, Biggs said that she eventually was willing to try it to see if it helped relieve the continuing pain.

“It’s total magic,” she said.

“Cannabis brought my life back,” Biggs said. “I’ve tried stopping and I go right back to where I was.”

Today, Biggs uses a concentrated form of cannabis called Rick Simpson Oil, or RSO. She uses it in the form of suppositories she makes at home.

Biggs settled on the delivery system after trying a variety of methods, including one that involved absorbing cannabis through her navel.

In fact, Biggs says that one of the biggest problems with medical cannabis is that patients must find what works for them via trial and error. Because of a lack of research, and the fact that people react differently to the various methods of consuming cannabis, it can take time to figure out what method works best for a particular condition.

Who is prescribing?

In Maryland, four groups of health care providers can recommend patients for medical cannabis: physicians, nurse practitioners, dentists and podiatrists.

whats-to-comeWhile these health care providers can recommend cannabis to a patient, which allows the patient to obtain a medical cannabis card, the providers do not actually prescribe medical cannabis. Also, providers are not required to give patients advice on which specific strains of cannabis to consume, how much to consume or how to consume it – whether via smoking or vaping or through tinctures, salves, dermal patches or other modes of delivery.

Through October, a little more than 1,000 Maryland medical providers were certified to recommend medical cannabis.

With around 90,000 medical cannabis patients in the state, the ratio of one provider for every 900 patients is “solid,” said Gene Ransom, CEO of MedChi, Maryland’s medical society.

Providers – who must have an active, unrestricted license in good standing and who must be registered to prescribe controlled substances in Maryland — can recommend medical cannabis for a patient with cachexia, anorexia, wasting syndrome, chronic or severe pain, severe nausea, seizures, severe or persistent muscle spasms, glaucoma and post-traumatic stress disorder (PTSD), as well as for additional chronic, severe disorders that have not responded to other treatment.

Leigh Vinocur, a physician for more than 30 years who has spent much of her career in the emergency department at the University of Maryland Medical Center, began learning about cannabis after she met a researcher who was studying endocannabinoid levels in stressed rats. (Endocannabinoids are neurotransmitters made by the body that help regulate mood and appetite, among other things.)

That meeting started Vinocur’s interest in cannabis as an alternative to traditional pharmaceuticals. Because medical cannabis was not legal at the time in Maryland, Vinocur undertook her own education, traveling to learn from doctors in California, Maine and elsewhere.

“I had to do a lot of the studying and training on my own,” she said.

Today, Vinocur’s practice is made up of mostly older patients who come to her for a recommendation for a medical cannabis card. Many are referred by oncologists. Others find her through word of mouth.

A strong believer in cannabis as medicine, Vinocur nevertheless said she worried that too many providers are recommending cannabis to patients simply because they want the additional business – not because they believe cannabis would be necessarily helpful for their patients.

“There are a lot of providers that are just basically … hiring people under them and they are churning out these (cannabis) certifications,” she said. “That’s not how it needs to be done if (cannabis) needs to be treated as medicine.”

Ransom does not think this is a widespread problem in Maryland.

“My impression has been … that most (providers), regardless of whether they are physicians or non-physicians, they are complying with the law and they are not just giving out recommendations willy-nilly,” he said. “There’s a big liability risk if you’re not doing this right.”

But Ransom said some of his members are concerned about practitioners recommending cannabis for conditions they do not treat.

“I have heard concerns like, for example, how does a dentist write a marijuana recommendation for glaucoma?” Ransom said.

Opioid alternative

Health care providers say they believe that the conditions covered by the Maryland medical cannabis statute are indeed conditions that respond to cannabis. But some would like to see another condition added: opioid use disorder. They would also like cannabis to replace opioids in some cases of pain management.

Many medical cannabis patients have chronic pain that is often treated with opioids. But given the devastation of the opioid crisis, patients have become skeptical of drugs with a strong potential for addiction, doctors say.

“People don’t want to take opioids,” Vinocur said.

The Maryland Medical Cannabis Commission is split on the issue of adding opioid use disorder as a condition that can be treated with medical cannabis.

“I have a fair number of physicians who said that they believed (cannabis) is a good way to reduce opioid use,” MedCHI’s Ransom said.

Scientific rigor

Vinocur takes a scientific approach with her patients. She prefers to recommend cannabis tinctures and says she does not like to recommend smoking.

With tinctures, she can recommend that patients start at a certain dosage and work their way up if necessary.

Most of her patients are older people who deal with chronic pain and appreciate this approach, she said.

“They are the ones that have relationships with physicians and want (medical cannabis) a little more legitimized,” she said.

But physicians are not the only people who help patients with cannabis decisions. It is generally a cannabis dispensary employee who helps a patient find appropriate cannabis products.

Melissa Beatty, a pharmacist for more than 20 years, became disillusioned with the world of traditional pharmaceuticals and the “need to just run for a pill” and turned toward natural healing. When a former boss started a cannabis dispensary, she was asked to come on as the clinical director.

Beatty is now enrolled in the inaugural class at the University of Maryland, Baltimore’s medical cannabis master’s program.

At the dispensary, Beatty says, she comes across a range of people, from those who seek to get off pharmaceutical medicines to others who “just want to get high.”

“One of the main reason (patients) come in is they don’t want to take all the pills they are taking,” Beatty said.

Just a beginning

Given cannabis’ illegal status for years – the federal government still considers it a Schedule I drug — little meaningful research has been done, Vinocur emphasizes. So determining what strains or delivery methods work well for which conditions is a matter of trial and error, or guesswork, she said.

Patients are encouraged to use journals to log their experiences with different strains and products to learn what works best for them.

Ransom thinks more scientific studies would be helpful – “non-industry-supported but truly independent clinical research and studies with what was going on around this medicine and what it was actually doing.”

Physicians would also like to be able to know and track what forms of cannabis their patients are taking. As is, the only state-mandated interaction between medical provider and cannabis patient is when a provider recommends cannabis, enabling a person to obtain a medical cannabis card.

After that, doctors and other providers have no idea what kind – or how much – cannabis their patients are taking.

Physicians say more information would help them make better clinical decisions and could help prevent the diversion of medical cannabis to people who are not patients.

“If you have some patient buying 72 vape pens, it might be worth having a conversation with them about diversion,” Ransom said. “If it’s really going to be medical, we need to treat it like medical.”