Why medical marijuana is off to a slow start in MN

Medical marijuana sold in MN will be smoke-free
Only smoke-free medical marijuana, sold as pills, oils or tinctures, will be available for qualifying patients Tuesday, May 5, 2015 at Minnesota Medical Solutions in Otsego, Minn.
Jennifer Simonson | MPR News

Jessica Blake has been battling a potentially deadly brain tumor for months. The former Esko high school teacher lives in Duluth, where her parents have moved in to help care for her.

It's been tough lately. Blake can't keep most medicine down, and the conventional drug she got from her doctor didn't work.

"It actually gave me hallucinations," she recalled. "It was terrifying. I don't ever want to experience that again." The hallucinations went on for two days.

"When Jessica said that was two lost days, that's very difficult," said her mother, Kathleen Blake. "Because she is not sure how much time she has."

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Jessica Blake and her parents want to try easing her symptoms with medical marijuana. But her doctor in Duluth won't put her on the registry of patients approved for the drug.

"He has been unable to prescribe it, because Essentia Health has not solidified their policy," Blake said. "So even though I qualify, I haven't been able to use the system."

Rick Blake, Jessica Blake and Kathleen Blake
Rick Blake, Jessica Blake and Kathleen Blake in Duluth, Minn. Rick and Kathleen's daughter Jessica has an inoperable brain tumor and what to try easing her symptoms with medical marijuana.
Derek Montgomery for MPR News

Essentia says it can't discuss individual cases, and won't say whether it has certified anyone for the program. Blake's parents say they're hoping a nurse practitioner from their hometown, Grand Rapids, will help get their daughter through the approval process.

Only 183 people are registered for Minnesota's medical cannabis program, which began dispensing the drug July 1. That's far below the state's projection of 5,000 patients. Officials are wondering about demand, but some patients say they can't get doctors to certify them.

Sarah Wellington suffers from MS
Sarah Wellington suffers from multiple sclerosis and is a patient representative on the state's medical cannabis task force.
Tim Nelson | MPR News

Doctors must be registered and authorized before they can certify patients. So far, fewer than 300 practitioners have received such authorization. No list of those doctors' names is publicly available.

There are anecdotal reports about other patients who, like Blake, are finding it difficult and expensive to get approval for medical marijuana despite last year's law making it legal.

Sarah Wellington, a St. Paul middle school teacher with multiple sclerosis, is among the small number of Minnesotans taking medical marijuana. She's also a patient representative on the state's medical cannabis committee. Her regular doctor wouldn't put her on the cannabis registry, so she got certified by another provider at a pain management program. She said the marijuana is helping her.

"The doctor was extremely professional and it was treated as just a regular doctor's appointment," she said. "It was a very thorough job. You know, all the things that are done at a doctor's appointment were done. Really impressive.

"But I am not the norm. At all. This is not what's happening with people. This was a ton of work to get to this point and a ton of money." Critics are calling it the "doc block." The state only requires that health care providers confirm patients suffer from one of nine qualifying conditions to get access to marijuana in pill or oil form. Doctors don't prescribe the drug or even approve its use. Licensed pharmacists actually recommend and dispense the drug.

That lack of a doctor's formal prescription puts a legal firewall between cannabis and doctors in Minnesota, and that's what made medical cannabis possible in Minnesota. But many health professionals concede they're still hesitant.

Dr. Ilo Leppik
Dr. Ilo Leppik is a physician and director of the Epilepsy Research and Education Program with the University of Minnesota's College of Pharmacy.
Tim Nelson | MPR News

Ilo Leppik is among them. He's one of the doctors at MINCEP, an epilepsy specialty care practice with about 5,000 patients. He's also a professor at the University of Minnesota's College of Pharmacy and on the board of the Epilepsy Foundation of Minnesota.

He said doctors worry about the psychoactive effects of marijuana.

Epilepsy patients are thought to benefit most from a compound called CBD — which doesn't get users high. Doctors like Leppik say the compound that does make users high, THC, could have unwanted effects, particularly for children and adolescents.

But under Minnesota law, doctors have no control over what marijuana their patients are getting.

"The Epilepsy Foundation of Minnesota has written a letter saying that we would request our epilepsy patients only get the high CBD-containing product," Leppik said. "But the pharmacist is at liberty to give to the patient whatever they think may be appropriate."

Leppik has certified a handful of patients. Even though he and his colleagues are not writing actual prescriptions for marijuana, Leppik said, they still feel responsible for their patients' care.

"In modern medicine today, we want to know how much is in each pill," Leppik said. "We want to know, is it safe? Is it going to be effective? ... We have such limited data, we just don't know. For example, in epilepsy, we're guessing."

But for Dr. Stuart Bloom, an oncologist with Minnesota Oncology who specializes in breast cancer, cannabis is a reasonable treatment for some of his patients as they battle life-threatening diseases.

Bloom was one of the early adopters of the program. He's so far approved six patients to get cannabis.

"It seems to me that this whole thing was approved reluctantly and with all these filters," he said. "With all these filters it makes it more difficult to take care of patients."

The Minnesota model is not followed everywhere. In Colorado, more than 100,000 patients are enrolled on the medical marijuana registry. More than a quarter million have applied since the state made medical marijuana legal in 2000. Recreational use became legal in 2012.

Under a system like Colorado's, marijuana is "not medical by any stretch of the imagination," said Dr. Charles Reznikoff, an addiction specialist at Hennepin County Medical Center and a member of Minnesota's medical cannabis advisory committee. He said Minnesota law is more stringent and holds doctors to a higher standard.

"Some doctor who doesn't even know you, and who will never see you again, is allowed to rubber-stamp a cannabis prescription," he said. "Which really means you get to smoke marijuana in the form of joints. That's what's happening in other states.

"And what Minnesota said is, if we're going to have medical cannabis, let's treat it medically. Let's have your doctor, who knows you and understands you and will be following you, understand the treatment and how it fits into the bigger picture of your medical illnesses."

Health providers in Minnesota tend to be connected to large networks, which often take a long time to make changes, particularly about topics as controversial as marijuana. Some big health care providers, like Mayo, won't even discuss their cannabis policy publicly. Allina Health has told doctors to certify patients only when all other avenues have been exhausted or in end-of-life cases. HealthPartners is leaving the decision to doctors.

Dave Thorson, a doctor with Entira Family Clinics and incoming president of the Minnesota Medical Association, attributes the slow pace to the state's methodical, evidence-based medical culture. Doctors have a long list of concerns, he said, even beyond the unknowns about what patients are getting.

For example, he said, there is little research on known potential side effects, like unmasking schizophrenia in adolescents.

"If I am going to put you on a cholesterol medication, I can talk to you about the fact that this is what the intent of the cholesterol medication is," Thorson said. "And these are what the potential risks of taking the medication are, and this is how we're going to monitor you for these risks. I can't do that with medical marijuana, because we don't have studies to tell me what the risks are."

Thorson said there are legal questions about whether doctors could be held liable for authorizing use of a non-FDA drug and how marijuana might fit into existing malpractice law and insurance.

And there are longstanding concerns about misuse and diversion of medical marijuana. Thorson has already been approached by new patients who don't have a qualifying condition, but want to be certified to buy medical cannabis anyway. Thorson said doctors are acutely aware of prescription opiate abuse and don't want to help create another such crisis.

And yet other doctors say they wonder whether the low numbers actually reflect weak demand.

Art Wineman, a HealthPartners doctor and head of the family medicine department, said treatment prospects may be overblown. He said some doctors who treat glaucoma and Crohn's disease are skeptical that marijuana helps patients, and think they have good reason not to enroll in Minnesota's program.

Wineman questioned the state's projection that 5,000 people would want it. He said that number may be a ceiling, not a floor.

"They had to do their best estimate," he said. "I frankly don't know how they could have figured that out. They could have gone to see how many patients in the state seem to have these specific conditions. Part of what's happening in Minnesota is we're being very cautious with how we're doing it, as opposed to other states, where they pretty much throw it open to any condition. Here, it's very specific conditions that are somewhat limited."

The state may add another key condition — intractable pain — to its list next year, potentially expanding the patient base. But Wineman is on the committee weighing that option, and said it's not clear Minnesota wants to add another qualifying condition to the cannabis list.

He put the chances of such an addition at about 50-50, a reflection of the medical community's ambivalence about legal marijuana.

MPR News reporter Riham Feshir contributed to this report.