Missouri made medical marijuana legal, but most doctors don't want any part of it

November 12, 2018 by Andy Marso, The Kansas City Star

Joshua Mammen, a Kansas City area cancer surgeon, has a plan for when patients ask him for medical marijuana. He'll discuss the symptoms they want to treat. And then he will propose alternatives.

Voters may have overwhelmingly approved medical marijuana by constitutional amendment last week. But all the state's major physician groups—including the Kansas City Medical Society, of which Mammen is president—opposed every marijuana measure on the ballot.

Now the amendment's passage makes doctors the gatekeepers of legal marijuana in Missouri, a role most of them didn't want. And if other states are any indication, a small minority of doctors will be willing to recommend medical marijuana, and those who do may have booming businesses.

Most doctors don't think of marijuana as medicine, at least not in its raw plant form.

The medical groups say that although certain parts of the cannabis plant have legitimate medical uses, medical marijuana programs like Missouri's provide access to products that aren't sold in standard dosages or purities.

Essentially, patients don't know what they're getting, so it's impossible for doctors to measure the risks against the benefits. The marijuana card, therefore, becomes more like a permission slip than a prescription.

Mammen said he prescribes medications derived from plants all the time, including some derived from parts of the cannabis plant. But those are regulated, standardized products vetted by the Food and Drug Administration, not a raw plant of unknown composition.

Still, he said he expects doctors will soon have patients asking them to sign off on their applications for marijuana cards from the Missouri Department of Health and Senior Services.

"If you follow what's happened in other states, that's very typical," Mammen said. "Based upon the publicity, individuals will go to their physicians and ask for marijuana, which actually puts physicians in a little bit of a difficult spot because there's a lack of data to indicate when is a potentially good time, if there is one, to be able to suggest the use of marijuana."

Marijuana research has been hampered because the federal government deems it a Schedule I controlled substance. But it has shown promise in treating pain and psychiatric or neurological disorders like Parkinson's disease, and some parts of the plant have already been incorporated into FDA-approved products for treating epilepsy and for nausea caused by chemotherapy.

But Mammen said marijuana, like other drugs or even herbal supplements, can interact dangerously with other medications patients might be taking, and doctors also need to be concerned about side effects like vomiting or, for people with mental illness, psychotic episodes.

He said he hopes that when the state develops a medical marijuana application form, it doesn't ask doctors to explicitly recommend marijuana, but rather just asks them to confirm that patients have conditions that qualify them for the card.

Some doctors in the state are more receptive.

In a 2016 survey conducted by the Kansas City Medical Society, 50 of 109 respondents said they would recommend it marijuana it were legal. But the survey was unscientific because it was voluntary—not a random sample—and less than 5 percent of the organization's about 2,500 members responded.

Missouri Rep. Jim Neely, a family physician from Cameron, north of Kansas City, has been one of the leading proponents in the state legislature. He sponsored a bill this year to legalize smokeless marijuana for patients with terminal illnesses. "Marijuana's everywhere anyway," he said. "We've got to find a better way of dealing with it." The bill didn't pass.

Neely didn't respond to a request for comment for this story.

If patients have trouble finding doctors to recommend marijuana, at least one Missouri business is stepping in to help.

Missouri Medical Marijuana, headquartered in Columbia, was founded the day after the election, with the goal of creating an online directory of doctors and dispensaries—or "a Yelp! for the legal medical marijuana industry in Missouri."

"We're super excited about the election results and can't wait to get the ball rolling," said founder Brian Klug.

Doctors who are willing to write marijuana recommendations have found a lot of business in other states. A Michigan doctor estimated last month that his clinic had performed 70,000 to 80,000 exams for medical marijuana cards after he moved there when the law passed in 2008.

It will be probably a year before the Missouri health department has finished writing rules and Missourians can walk into dispensaries in the state and buy medical marijuana.

The Missouri State Medical Association, which represents the state's doctors, had opposed the marijuana ballot measures. Now Jeff Howell, the group's head of government relations in Jefferson City, said he's already hearing from concerned doctors, and the association will provide input on the rule-making process.

Howell doesn't want the process to be like Oklahoma, where the state medical association demanded strict restrictions—including a ban on smokeable products—which spurred lawsuits and the intervention of the state attorney general to make sure the public's vote was respected.

But he said his organization wants to make sure the commercial aspects of medical marijuana don't reflect poorly on the medical profession, with a few "fly-by-night" doctors making it their main source of income.

"The important thing for me is that it doesn't turn into Venice Beach (California), where you have storefronts that say 'Come in and get your marijuana card,'" Howell said.

https://medicalxpress.com/news/2018-11-missouri-medical-marijuana-legal-doctors.html