Here are Springfield doctors willing to do marijuana certifications – Springfield News-Leader

Correction: An earlier version of this report misidentified June 4 on the Amendment 2 calendar. It is the date when Missouri will issue application forms for marijuana business licenses.

In Missouri this year, July 4 will carry extra significance.

Under Amendment 2, that’s the first day state officials can begin accepting applications from patients who want medical marijuana ID cards. Those are the cards that will let qualifying patients through the doors of Missouri dispensaries, expected to be open early next year. Patients can only get a card if they have one of the health conditions named in the amendment: cancer, glaucoma, HIV, PTSD and a number of others.

An internet-based application system is on track to be live for patients to use on July 4, state officials say. The state will start processing the applications July 5.

But there will be significant action between now and then.

On June 4, the state will issue license applications so that businesses wanting to run dispensaries, grow operations and other state-licensed cannabis businesses may legally operate next year.

Also in early June, for the first time, Missouri doctors will be able to write “physician certifications” for patients who want to get a medical marijuana card. Doctors interviewed for this story said they have been getting a lot of questions from everyday people about how to get a certification since Amendment 2 passed at the ballot box.

The certifications are a key component of Amendment 2. Missouri does not offer a way to legally access marijuana without getting an ID card — and getting a card requires a certification. Many doctors describe them as a note simply indicating, yes, this patient has cancer; yes, this patient has PTSD.

The amendment rules say that the certifications “must be no more than 30 days old at the time an individual applies for a patient identification card,” according to a summary posted by the Missouri Department of Health and Senior Services, the department in charge of keeping the medical marijuana program on the quick timeline set forth by Amendment 2.

That means patients will be hitting up doctors 30 days before July 4.

Until now, for Missouri patients, medical marijuana has mostly been a matter of future plans. But starting in early June, it gets real, at least in terms of paperwork. (It may be spring 2020 before any marijuana is sold at a Missouri dispensary.)

They don’t teach this in medical school

Cannabis is not part of a traditional medical-school education, said doctors the News-Leader interviewed for this story. Some doctors admit they are less than familiar with its possible risks and benefits.

Because cannabis is listed alongside heroin and ecstasy on the federal government’s schedule of illegal drugs, there’s little scientific research on marijuana taking place inside the United States.

That means physicians in a state with a new medical marijuana law often have some pretty basic questions.

In mid-May, the News-Leader sat in on a phone call with Jim Blaine, a Greene County doctor with a long track record as an expert on public health and DWI issues. Blaine got Lyndall Fraker, the head of Missouri’s medical marijuana program, on the line from Fraker’s office in Jefferson City.

Early in the call, Blaine said his wife bought him a special issue of Time magazine devoted to medical marijuana, so that he could study up.

At another point in the conversation, Blaine asked Fraker, “Are doctors all as naïve as I am (about medical marijuana)?”

“Well, somewhat,” Fraker replied. “There are some that have studied the plant, the industry. I’ve heard some speak that have been very excited that they may have some options … There’s certainly a large element that don’t have, that are maybe naïve. They haven’t studied the products, the plants, all of the benefits or in many cases the non-benefits.”

Blaine also asked Fraker, “The marijuana that’s going to be dispensed here — is it all forms? Smoking, as well as oral?”

“Yes,” Fraker replied.

How the drug is to be administered (Capsules? Tinctures? Vaporization? Smokable bud?) is a recurring theme in Missouri doctors’ response to marijuana. There’s “not enough consensus” in the medical community on the best ways to do so, said Mimi Vo, a St. Louis physician who sits on the board of the Missouri Medical Cannabis Trade Association.

Vo said that when it became clear that three versions of medical marijuana law would go on Missouri’s November 2018 ballot, she began diving into education about cannabis and its health effects. She thinks its “a myth” that research doesn’t support cannabis treatment.

But she said her earliest learning about the health effects of cannabis came by listening to her patients. Some of her patients had used legal marijuana in states like Washington and Colorado in an attempt to manage their conditions.

“They were very forthcoming with me with what they had tried and what could help them,” Vo said.

Not every patient feels so comfortable. As Peter Grinspoon, a Harvard Medical School doctor, wrote in a blog post last year, many patients want to learn more about marijuana but feel embarrassed to bring it up with their doctor.

“This is in part because the medical community has been, as a whole, overly dismissive of this issue,” Grinspoon wrote.

What about Cox and Mercy?

Missouri’s medical marijuana amendment contains specific language protecting the right of patients to talk about marijuana as treatment with their doctors.

When ordinary people bring up cannabis treatment with primary care doctors or specialists at local large health systems, what will they hear?

That’s not entirely clear. Gil Mobley, a physician who has certified patients for marijuana in the state of Washington (and who plans to do so at his practice in Springfield), has said that large health systems are often reluctant to engage with cannabis as treatment. It’s controversial. In Washington state, it has exposed doctors to legal risk. It can endanger a hospital system’s relationship with the federal government, which funds health programs like Medicare.

When the News-Leader asked three big health systems in Springfield how they would handle medical marijuana, the answer wasn’t a straight-up no — but it wasn’t an enthusiastic yes, either.

Jim Rogers is vice president of adult primary care for all Mercy operations in Missouri, Oklahoma, Arkansas and Kansas.

“It’s up to the judgment of the provider, actually,” he told the News-Leader. “We’re not dispensing. We answer questions — first and foremost, Mercy does not have a provider-directed approach on this. It’s up to the provider to express their opinion. We absolutely want no noncompliance with the law. We don’t dispense. Mercy is not directing any of the providers. We still ask them to do what we’ve always asked them to do: use their skills, use their learnings, stay up-to-date on any medication or supplement and prescribe or advise accordingly.”

Rogers added, “We equate this a whole lot to a handicap-accessible parking sticker. We really don’t grant those.”

When someone needs an accessible parking sticker, Rogers explained, a doctor fills out a form that states, for example, that a patient uses a wheelchair, then hands it off to state government, which determines whether the patient actually ought to have a parking sticker.

Rogers believes medical marijuana certification will work the same way.

“We don’t dispense, we don’t prescribe (cannabis),” he said. “We actually are supposed to attest to and verify what medical condition the patient may have specifically. If they ask X, Y or Z, we’ll probably verify if that’s what they have.”

Other health systems provided statements through spokespeople, declining to make officials available to the News-Leader for interviews.

Burrell Behavioral Health said it “is committed to providing evidence-based psychiatric care. While medical cannabis is approved, via Amendment 2, for treatment of PTSD and debilitating psychiatric disorders, there is at this time no evidence-based study that points to marijuana as beneficial to the treatment of behavioral health issues, even though there may be some identified benefits for various other medical conditions. Burrell Behavioral Health does not at this time plan on requiring or encouraging its physicians to apply for certification.”

The News-Leader asked if Burrell would prohibit its psychiatrists from certifying patients for a medical marijuana health condition.

“We do not foresee a situation where we would prohibit a physician from seeking certification,” a spokesman said.

Burrell did not respond to a request for comment on studies with mixed results as to whether marijuana is helpful for PTSD. There is some evidence that marijuana helps people with PTSD and some that it does not. Study authors often call for more research because there have been few randomized, controlled trials.

CoxHealth said it has not made a decision on how it will handle medical marijuana certifications.

It has also kept education on the topic at arm’s length.

Vo, the St. Louis physician on the marijuana trade industry board, said Cox canceled an educational session on medical marijuana planned for May 17 where she was slated to appear, citing legal concerns. Lisa Roark, a Cassville-based physician, related a similar account of the cancellation in a separate interview with the News-Leader.

A spokeswoman for Cox said, “We were approached about hosting the event at CoxHealth, but decided to decline since a final decision has not been made regarding our policy on medical marijuana.”

Cox provided a more detailed description of its overall position on medical marijuana in a May 20 statement.

“The passage of Amendment 2 has prompted a variety of complex questions, many of which are still in the process of being discussed. The final regulations in Missouri will not be available until June, so we must wait until those are released before making definitive decisions regarding its stance on medical marijuana. There are many things that factor into these decisions, including the fact that under federal law, the use of marijuana for any purpose is still illegal. Ultimately, our top priority is ensuring that our patients receive safe and high-quality care, and regardless of our final decision, we are confident that patients will find ready resources for medical marijuana in the community that will facilitate ease of access consistent with the new state laws.”

Local doctors who will provide marijuana certifications

Lisa Roark expects her direct-care clinic in Cassville to be one of those “ready resources.” She plans to do certifications for patients who live with a qualifying disease. She likened them to the Department of Transportation physicals and other a-la-carte services already offered by her clinic, Roark Family Health. They will cost $100, just like those other physicals.

“Basically, the feedback I’ve gotten from patients is they’re having a really hard time finding physicians who will do them,” Roark told the News-Leader, “whether because they’re employed by the larger health systems and told not to, or their physician doesn’t feel like they have the education necessary to really counsel the patients.”

Roark said that “literally right after the election,” she began getting calls from patients located across southern Missouri. She recently added a new physician to her team to handle the increased demand.

She said many patients have established a relationship with her clinic to make sure they have correct documentation of their health problems before going to the state with a medical marijuana application. Her direct-care clinic operates outside the health insurance system. Patients pay on a monthly basis, the way they would for a gym membership or Netflix.

In Springfield, Elite Pain Management began taking its first medical marijuana patients in late May. In its first week of appointments, the clinic saw 30 patients who want medical marijuana cards, said Justin Hobbs, director of operations. Patients who came in before June will come back for a second visit once doctors can write a certification. It costs $200, $150 for yearly renewals.

Hobbs said diagnosis and a drug screen happen before Elite’s physicians will write a certification. Elite needs to see patients’ health records so Elite can verify that they have a qualifying diagnosis.

Patients have been referred to Elite through Facebook groups and website listings. A Springfield company that wants to win a state dispensary license, Wholesome Bud, has been referring patients to Elite as well.

Hobbs also said Elite placed rack cards in CBD shops, smoke shops, oncology and neurology practices, along with “all of these specialists that might have qualifying diagnoses.”

Shawn Stranckmeyer, a doctor who’s been at the clinic for two years, said Elite plans to certify patients for medical marijuana under Amendment 2’s provisions that pertain to pain management: for example, chronic medical conditions that cause “severe, persistent pain or persistent muscle spasms” and ones “normally treated with a prescription medication that could lead to physical or psychological dependence.”

But they won’t be handing out marijuana certifications right out of the gate, Stranckmeyer said. “Some of the patients are going to be chronic pain patients who have failed with other modalities of treatment.”

“If someone has one of those qualifying disorders, medical marijuana is not going to be the first reach for them,” he said. “It’s not first line for any of the disorders that are out there. We’ll do a pretty extensive review of their medical records, seeing what treatments have been done in the past.”

Cannabis clinics 

Many parts of Missouri will soon see “cannabis clinics” open up, if they don’t have them already. These clinics are specifically intended to connect patients with marijuana ID cards.

They’re somewhat controversial. David Yablonsky, a doctor based in Edwardsville, Illinois, who is licensed in Missouri, is another board member for the Missouri Medical Cannabis Trade Association. He said Missouri’s medical marijuana law is open to a very wide interpretation, in terms of who gets marijuana cards.

“The thing about Missouri, as compared to Illinois — Illinois still has a very specific sheet of (health) indications,” Yablonsky told the News-Leader.

“Missouri has a list of all these specific conditions, and then there’s a catchall: ‘and any other chronic condition,’” he said. “It’s everything and anything. So the possibility for profiteering and abusing the privilege will be there, maybe more robust than in other places.”

Yablonsky said, “What I don’t want to see happen is a clinic opens up and basically it’s ‘gimme 100 bucks in cash, and then you have your card.’ Man, I didn’t get a medical degree to do that.”

The owners of cannabis clinics don’t see their clinics that way.

“That’s not how we operate,” said Emily Branch, owner of The Green Clinics. “We’re not a rubber-stamp clinic.”

Like the physician and operations staff at Elite Pain Management in Springfield, Branch emphasized that The Green Clinics will thoroughly review medical documentation of patients’ health problems before doctors consider whether to write a certification.

“There are some bad actors that do what we do,” Branch said, “but there are also some incredibly respectable physicians who care about patients.”

Branch claims The Green Clinics is the first of its type in Missouri, with the most doctors, many of whom have decades of experience.

Based in Kansas City, The Green Clinics also has locations in St. Louis, St. Joseph, Butler, Versailles, Trenton and Poplar Bluff. She’s working on Springfield and Columbia locations, too. She said following Amendment 2’s passage, she expected to open eight locations over three years, “but it’s just an opportunity that keeps opening up.”

“We launched in February,” she told the News-Leader. “We started pre-approving, pre-certifying, seeing patients in February, so that we wouldn’t have such a mad rush in June.”

Branch anticipates putting on what she calls “patient clinics,” or pop-up patient drives. She said they’ll go out into a community without a fixed clinic and have an educational session, following-up with clinic hours at a secure location.

The Green Clinics has a detailed pricing schedule. Most people pay $299 for an evaluation. (“We don’t sell certifications, we sell evaluations,” Branch said.) Veterans pay $149, though veterans and others with a disability status are charged $49.

Another cannabis clinic, Medical Cannabis Outreach, espouses a similar “patients before profits” vibe and claims it will also thoroughly vet patients to ensure they have documented health problems matching Missouri’s law.

Its co-founder, Caprice Sweatt, said she is looking at setting up shop in Springfield, Joplin and Columbia along with existing locations across Illinois. She told the News-Leader that she was diagnosed with Crohn’s disease at 17, then placed on a number of heavy-duty prescriptions including Percocet.

As a young adult, the Illinois native moved to Colorado, where a friend persuaded her to try cannabis. Echoing many marijuana boosters who lack extensive scientific data on marijuana’s performance as a treatment, she cited her personal experience as the factor that convinced her that marijuana is medicine, and a legitimate alternative to opioids.

“I hadn’t felt that good in so long, and I was shocked,” she said.

Sweatt said her company has connected 35,000 Illinoisans with cannabis under that state’s laws. She said an information session at a suburban St. Louis library drew a “standing-room-only” crowd back in April.

“In Missouri (cannabis law), there are not the restrictions that Illinois have, so we believe our numbers will be a lot higher in Missouri,” Sweatt said. Like Branch, with The Green Clinics, Sweatt said she is eager to ensure that small-town patients have the same chance to access marijuana as big-city ones.

She also said, “We’re not just giving people cards so they can go buy cannabis.”

Medical Cannabis Outreach charges $300 for a consultation in Illinois. Sweatt said she had not yet firmed up a fee schedule for Missouri.

Another company, Green Health Docs, has several locations in Maryland and Ohio and entered the Missouri market through St. Louis and Kansas City. It just opened a Columbia clinic and is scouting locations in Springfield, with hopes to open a clinic here over the summer, said Randy Shaffer, national marketing manager.

“We’re going to bring patients in, get them certified and register them so they can get their cards as quickly as possible,” Shaffer said. Green Health wants plenty of patients’ medical records up front, too.

Every state with medical marijuana is different, Shaffer said. “We’re very excited about Missouri. We think Missouri is going to have a strong market, a more competitive market in terms of prices (for marijuana).”

Green Health Docs charges $250 for a consultation, with discounts for veterans. It does a 90-day follow-up call to check if patients have questions.

Doctors’ doubts

While polls show that majorities of Americans and Missourians support medical cannabis, the federal prohibition of research on the plant means that the U.S. medical community doesn’t have a scientific track record that shows when and whether marijuana can be used as an effective treatment.

“No university in the United States can get any funding to research it,” said Sweatt, the cannabis clinic owner from Illinois. “They want to. Tel Aviv, Israel — they have done massive research.”

Tied to this concern, doctors interviewed by the News-Leader had plenty of questions about how cannabis could be or should be used as a medicine.

Mobley, the Springfield doctor who certified patients in the state of Washington, said that testing for multiple routes of treatment — not looking at marijuana as a cure-all — is really important.

“Whatever the problem is,” he said, “we are so remiss if we don’t go down that road to ask what could be the underlying problem.”

Mobley gave the example of a patient wanting marijuana to deal with insomnia, a condition that could potentially be addressed by routing the patient through a sleep study and making sure they use a CPAP machine to treat sleep apnea.

HIV is one of the health conditions outlined by Missouri’s cannabis law. California AIDS activists were early champions of medical marijuana. But when asked about cannabis as a treatment for people living with HIV — which can be controlled to undetectable levels using medications first innovated in the ‘90s — Mobley paused and sighed.

“Just based on the presence of a diagnosis?” Mobley wondered aloud. “I’ll think about that. I think it would be inappropriate to subject a patient to a substance that is harmful in many ways without having a known benefit that you’re after. That’d be a violation of the Hippocratic Oath, wouldn’t it? Unless there was some evidence cannabis would stop multiplication of the virus.”

Other doctors wonder about the potency of today’s cannabis. At about 12 percent THC, it’s stronger than the weed that baby boomers and others experienced as young adults. Concentrates are often much stronger. Blaine, the longtime physician and public-health advocate, expressed this concern to the state medical marijuana director on their call.

Follow-up care is another question for doctors.

Roark, the direct-care physician in Cassville, said that it would be an “ideal” situation for her to agree to perform marijuana certifications and counseling only for patients she regularly sees as members of her family health clinic.

“However,” Roark said, “that would mean probably two-thirds of patients would have no access to a physician to do their certification, because if they’re not an independent physician, they’re probably not doing certifications — or not anytime soon.”

“To me, it’s more important that patients have access,” she said.

Follow News-Leader coverage of cannabis:

Springfield police seize record amount of marijuana — without really trying

Arkansas legal marijuana sales began two weeks ago. How’s that going?

Where do Springfield’s medical marijuana zoning rules stack up among Missouri cities?

Waynesville and Kennett are both seeking direct deals with marijuana companies

Can poor Missourians use medical pot and stay on welfare benefits? We’re still not sure.

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