Physicians and marijuana: Q & A with Larry Wolk, MD
Kate Alfano, CMS contributing writer
Larry Wolk, MD, is the executive director and chief medical officer of the Colorado Department of Public Health and Environment. Previously, he served as chief executive officer of the Colorado Regional Health Information Organization (CORHIO), Colorado’s nonprofit, state-designated health information exchange. Wolk is a practicing pediatrician. He is the founder and executive director of Rocky Mountain Youth Clinics and served nearly five years as president and chief operating officer at Correctional Healthcare Companies. Wolk has served as the senior medical director for both Blue Cross/Blue Shield of Colorado and Prudential Healthcare of Colorado, and held regional and national roles as senior health care executive at CIGNA HealthCare.
Colorado Medicine (CM): Can you provide background on the issue of marijuana and medical practice?
Larry Wolk (LW): There are three tiers of physician involvement in marijuana: legalized marijuana, medical marijuana under the standard dose, and medical marijuana at excessive amounts.
As of Jan. 1, anyone can go to a store and buy as much as one ounce for recreational use and have no more than one ounce on their person at any particular time. With that tier, physicians have a responsibility as do we as the public health department to make sure that the general public is educated on the benefits and the detriments of marijuana to one’s health, with the focus on youth, pregnant women and folks for whom we know that either primary or secondary exposure to marijuana – like secondhand smoke – could be detrimental.
For the second tier, the constitution says that the standard medicinal dose is two ounces or six plants, which is double the amount you’re allowed to have if you’re a non-medical or recreational user. In that regard the physician has to recommend it for the patient – they don’t prescribe it – and they have to attest to the condition for which the medical marijuana is being used. There are eight constitutionally allowed conditions: cachexia, cancer, glaucoma, HIV/AIDS, muscle spasms, seizures, severe pain and severe nausea, with 94 percent being recommended for pain.
The third tier is the one I’m most concerned about. It requires a physician’s recommendation, the same as the second tier. But in the 10 years of this program it has been largely unregulated because, in my opinion, it’s a bit of the tail wagging the dog. I think the dispensaries have created products that require more than two ounces or six plants and have collaborated with physicians to justify under the term “medical necessity” recommending these rather large and excessive amounts for patients.
In a state of 5.5 million, we have about 120,000 patients who are in our registry. Of those, we have about 3,000 requests a month for these increased amounts. I’ve seen recommendations as high as 99 plants or 33 ounces for things like pain, or to make a special oil, ointment or spray. There’s no science, there’s no peer-reviewed literature, there are no studies to support this excessive amount or this excessive use. You have a number of physicians in the state who are passively complicit in allowing for excessive amounts of marijuana to be recommended without any academic, scientific or medical knowledge to support that use.
CM: What are you doing to address this third tier?
LW: First, we’re optimistic that we’ll get spending authority from the state to release $7 million so we can have researchers study medical marijuana – both effectiveness and safety – so we can establish whether these increased doses are warranted. Second, we’re tightening up our role with regard to how we enter a patient’s plant and ounce count into the registry by almost blanketly stating that we’re not going to enter anything more than two ounces or six plants. Because even though a physician might recommend it, without an established community standard for medical necessity, I’m not going to put my name on letting a child get the equivalent of 99 plants and 33 ounces.
CM: What do you see as the role of CMS?
LW: I think the medical society should help aggregate the evidence-based information about marijuana. It’s easy to get drawn into the popular media when you see a child whose parents say has been miraculously cured of his seizures by marijuana. But the Epilepsy Foundation and the American Academy of Pediatrics have come out in support of our position, which is to say we don’t have any evidence to base any support for this and it could be toxic. Not only that, but what we do know about marijuana with or without THC is it can be addictive and it can impact the developing brain of a child or adolescent. So at least in the area related to kids, we could be creating a problem that’s as bad if not worse than the problem we’re trying to treat.
I empathize with the parents and the medical community because we’re asking for medical necessity information where medical necessity information doesn’t exist yet. We’re backing folks into a corner to say they’re going to have to deal with two ounces and six plants because there’s really nothing that you can provide us to date that would meet the community standard for medical necessity.
CM: What message do you have for physicians?
LW: This is a bit of a warning. I am now charged with the health and safety of the population. For those physicians who are recommending excessive amounts for a large number of patients, especially in association with single dispensaries and outside of their trained field of expertise, I’m referring those physicians for investigation by the board of medical examiners because there’s a possibility that they’re not practicing within the community standard that applies to the general practice of medicine.
The majority of the recommendations for excessive amounts are coming from only a handful of physicians. For example, in the month of October 2013 we had almost 3,000 applications with recommendations for increased or excessive amounts. Of those 3,000, about 80 physicians made those recommendations. Of the 80 physicians, 10 of the physicians accounted for 2,000 of the 3,000 recommendations. And of those, two physicians accounted for 1,000 of those recommendations.
CM: Is this a legal or ethical issue?
LW: Ethically, it applies to the general practice of medicine’s community standard. There shouldn’t be anything unique about marijuana that we wouldn’t apply to any other medication, therapy or procedure. We have an obligation as physicians to educate our patients as to what’s evidence-based. On the flip side, patients have the right, independent of their physicians, to now gain access to one ounce of marijuana as long as they’re over 21, and physicians have the right, per the constitution, to recommend medical marijuana at the constitutionally dictated dose of two ounces if the patient suffers from any one of those eight conditions. All I’m asking is that we apply that same standard to medical marijuana, not any different or stricter standard.
Legally, medical marijuana is an affirmative defense, meaning that you have to prove that you have an excess number of plants or ounces because of a medical condition. If you have the standard amount, the physician’s recommendation and a registry card, then you’re okay. But if you have the card and the physician’s recommendation and an excessive amount when the registry says you are only allowed the standard amount, there would likely be legal implications for both the physician and the patient if they can’t demonstrate medical necessity for the increased or excessive amounts. Physicians recommending medical marijuana should consider these things when making dosage recommendations that exceed two ounces or six plants.
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