From time to time I will post article of general interest the the medical marijuana community. Some are related to Michigan, others simply things that might be of interest to patients. Many can be found at:
This is the 4th annual Dr. Bob’s Call to Action- A summary of my thoughts on goals we should, as a community, try to accomplish in 2014. Previous years focused on talking to your doctor, expanding the program by encouraging a friend ‘on the fence’ about registering, etc. This year I want to focus on the forgotten medical marijuana patient.
Since the start of the program, the detractors of the MMMA have constantly harped about how those that voted for medical were ‘duped’ into thinking that medical marijuana was to be used for ‘seriously ill if not terminal patients’ only, and that the backers of the Act were using it to effectively legalize drug use. The report of the program seems to bear that out at first glance, but on deeper reflection they give us a clear direction for the coming year.
Let’s look at some numbers…. According to the ‘Michigan Medical Marihuana Act Statistical Report for Fiscal Year 2013′ published Dec 4th, 2013 there are approximately 118,000 active patients in the state. There are problems with this report. First, HIV and AIDS are listed as two categories, yet they are the same. So are Cachexia and Wasting Syndrome, and the totals of all the conditions come to 103%. My own experience shows that most patients have several qualifying conditions, yet the report seems to say otherwise as the total of all is close to 100% rather than 120 or 130% as one would expect if many had pain and spasm, or cancer and nausea, as one would expect. But let’s assume the numbers are correct. What do they tell us?
Let’s do some simple math with the percentages listed. First let’s divide the conditions into three categories:
Those conditions the voters clearly ‘had in mind’ when they voted for the Act- Seizures, Cancer, Glaucoma, HIV, Crohn’s, Wasting Syndrome, and Hep C. No one would disagree these are SERIOUS and potentially TERMINAL conditions and those that suffer from them are clearly ill and deserve our vote for compassionate use of medical marijuana. They account for approximately 9,504 patients or about 7.9% of all medical marijuana patients in the state.
The ‘orphan conditions’ with very low incidence. ALS and Nail Patella account for a total of 36 and 24 patients in the ENTIRE program. Add to that Alzheimer’s and you have another 36 patients for a total of 96 patients in the entire state.
Pain, Spasm and Nausea account for 113,796 patients or just shy of 95% of the program.If we are to believe the numbers, then it would seem the ‘backaches’ outnumber the ‘real patients’ by more than 12 to 1, and confirm the detractors’ assertion that the ‘compassion of the voters’ for very sick or terminal patients is being turned into an excuse for getting high by folks with minor problems. IF the numbers are to be believed, I see some trends here. Medical marijuana is becoming a ‘one trick pony’ for chronic pain. Much as AIDS was initially viewed as only being a problem of gay men. The importance of medical marijuana is being diminished by further characterizing this ‘chronic pain’ as being ‘minor’ and not ‘worthy’ of special permission to use a schedule 1 controlled substance.
This needs to be countered by the fact that chronic pain is life limiting, that 1 in 5 visits to primary care doctors are for complaints of chronic pain, and chronic pain, treated with 4 time a day narcotic such as Vicodin, accounts for over 13,000 doses of narcotic per month per physician in primary care (120 doses per monthly prescription x 5 patients per day x 22 working days per month). If the use of marijuana can reduce that by 1/2, that will reduce the total number of doses per year by nearly 80,000 doses of narcotic per physician. So chronic pain is a good use for medical marijuana and exactly what the voters envisioned.
There are only 3156 certified for cancer, 312 AIDS patients, and 1236 with Glaucoma in the ENTIRE PROGRAM. How many cancer patients are there in Michigan? According to this report issued by the State of Michigan there were about 19,000 active cases of AIDS in Michigan in 2012, yet we have 312 AIDS patients in the medical marijuana program? Why is this? What are we going to do about it? Why do I call these patients the ‘forgotten medical marijuana patients’?
In order to gain acceptance by the medical community, medical marijuana cannot just be a ‘one trick pony’. It is approved for many conditions. It is effective for many conditions. WE MUST USE IT FOR MANY CONDITIONS! We must make sure that those conditions the ‘average man’ on the street thinks should be treated with medical marijuana are in fact treated with medical marijuana. It is far to easy to minimize chronic pain as justification for special permission to use a schedule 1 controlled substance, yet a ‘real’ condition like cancer only accounts for a tiny percentage of the total. We need to increase that percentage, we need to remember the forgotten patients. Cancer and HIV both have very active community support groups. Can we get the discussion of Medical Marijuana started in these groups?
I am going to make it a point to reach out to these groups in 2014, to explain how and why marijuana can help their conditions and improve the quality of their lives, and to encourage participation in the program. I ask that every Michigan medical marijuana patient look for these groups, find a glaucoma patient to encourage, or support a relative with cancer and GET THEM INVOLVED with the program. The pain patients come on their own, if for no other reason that chronic narcotics are not helping them and Bill Schuette is constantly on the news talking about medical marijuana patients and their ‘backaches and sore shoulders’.
Cancer patients are under the care of oncologists in hospital cancer centers. They are not, in many cases, allowed to offer medical marijuana as a matter of hospital policy. HIV patients are in federally funded programs as well. They are not being educated about medical marijuana. Similar situations apply to Crohn’s, Glaucoma, and Seizure patients. They are NOT getting the information from their clinics. We need to step up and help them learn about cannabis.
You could say it is up to us- the medical professionals in cannabis medicine. to educate them. But only 1500 doctors out of more than 30,000 primary care doctors wrote even ONE certification in 2013. There are simply not enough of us, and we are too busy trying to meet the need to educate the sheer numbers of groups and individuals that need to get the message.
So my call to action is to you, the 118,000 patients in Michigan. Find a glaucoma or cancer patient. Educate them. Encourage them to research on their own and ask questions. There are many hospice patients in Michigan, if you know one, educate them on the quality of life issues with medical marijuana. Educate their hospice nurse. Get these people involved in the program. Medical Marijuana is not just for pain. Let’s prove that in 2014.
Due to a sea change in attitude in Lansing, we may have legislation that makes dispensaries legal soon. Many seriously ill patients are physically not capable of growing their own medication, and don’t have the first clue as to how to find a caregiver. With dispensaries, their barrier to access may be lifted, it is time for them to use that access and participate in the program to make their lives better. Let’s get the focus on the forgotten medical marijuana patients and bring them in.
The Bonafide Dr/Pt Relationship- What you don’t know CAN hurt you!
The voters of Michigan approved medical marijuana in 2008. The concept of the law was simple: Sick people could use marijuana to relieve their suffering. Many thought it would be as simple as going to their primary care doctors with a qualifying condition. Unfortunately, due to the politics of cannabis, many primary care physicians refused to take part in the program, even if their patients were clearly qualified. Because many primaries would not write certifications, Michigan saw the rise of ‘Certification Clinics’ where physicians would meet with patients and sign the applications for a medical marijuana card. While many physicians were ethical, required records, kept charts, etc, others were not. These ‘clinics’ went from hotel to hotel signing as many as certifications as they could, in many cases without requiring records or any documentation from the patients to support their conditions. The first rumblings of problems came in Sept 2010 with he Redden Decision. The court made it clear that there had to be some sort of standards to include a bonafide relationship with the doctor to the certification process similar to the standards of traditional medicine- records, face to face visits, and follow up. But it was without teeth, without the force of law. Then the medical board stepped in and put out some guidance on medical marijuana certification, but again, without the force of law, just the threat of doctors being held somewhat accountable by the licensure boards if they strayed too far. This situation pointed out some weaknesses of Michigan’s MMJ program. First, every case that went before the court trying to claim a section 8 defense not only had to prove the three prongs of section 8, they had to prove what a ‘Bonafide Dr/Pt Relationship’ even was- then they had to prove they had one. Every case let a prosecutor attempt to define a ‘Bonafide Dr/Pt Relationship’ to THEIR advantage. Even the Court of Appeals in the Tuttle case pointed out this flaw, and used it to come up with their own definition to the detriment of Mr. Tuttle. This problem was clearly solved by PA 512 of 2012- The Bonafide Dr/Pt Relationship Act. Now we had a very simple and clear definition of EXACTLY what a bonafide relationship was. Without it we are in a situation when a police office can decide you are speeding based on whatever HE thinks the speed limit should be, because there are not speed limit signs on the road. Follow the law, you have a bonafide relationship. Don’t follow it, and you can kiss your Section 8 Defense goodbye.
The Bonafide Dr/Pt Relationship Law Why do we even need one? Here are five reasons:
1/ It is a professional evaluation based on standard medical practice, and it requires the same data that any doctor would need to make a considered medical judgement- records, visit with the patient, a chart is made, follow up is offered- just like any other medical visit. 2/ It defines the standard, follow the standard and the court cannot claim the relationship wasn’t there. This specifically prevents prosecutors from trying to wing it every case, and gives the court a specific ‘check list’ to say yes or no. 3/ It protects the physician from the board. To say someone violated the standard of care, we must know what the standard of care is. To claim you followed the standard of care, again, you have to define it. 4/ It gives the regulatory authorities (like the medical board) the ability to specifically stop physicians that violate the standards, this in the end protects patients. Just as malpractice laws protect patients, just like the food and drug administration keeps bad drugs off the market to protect patients. 5/ It implies that physicians offering certifications meet a certain standard, thus letting patients going to these physicians take comfort in that they are getting good care from a qualified doctor.
People v Goodwin- The Failure of the Bonafide Dr/Pt Relationship
The Michigan Court of Appeals recently ruled on the case of People v Goodwin. The particulars of the case are not important, the appeal centered on the bonafide dr/pt relationship between Mr. Goodwin and his certification physician. While Mr. Goodwin clearly had a qualifying medical condition which was supported by his medical records, they proceeded to deliver a blistering condemnation of the bonafide relationship offered by his physician. While the patient had medical records and clearly qualified for a card, his doctor could not produce them, claiming that he had a release to get them if he needed them. Certifications require review of records, and merely having a release does not constitute actually reviewing records. As a court certified expert witness I am absolutely mystified as to a time I could need the actual records more than when I was called into court to defend my certification, but his doctor apparently didn’t feel he needed them even as he was on the witness stand. That alone crippled his patient’s defense. In addition to this shocking lack of preparation for trial (much less certification) the court found that his doctor clearly had no intention of following up on his patient to monitor care or check the efficacy of his treatment. There was no discussion at the visit or at any time afterwards on amounts of cannabis that may help, again required by law and absolutely KEY to establishing what is a reasonable amount for the patient to possess, which would have clearly caused a failure of the second and third prongs of the section 8 defense. The result was that this by all appearances otherwise medically qualified patient lost his section 8 because he chose to go to a hotel signature clinic to simply obtain a signature on his application.
What Can Patients Do?
Patients have the ultimate responsibility for their own bonafide dr/pt relationship. By knowing the law, patients can recognize and avoid a substandard certification that could lead them to lose their Section 8 defense under the MMMA. There are several elements to the bonafide dr/pt relationship: 1/ Patients must provide records to their certification clinic to confirm their qualifying condition. These records must be retained by the certification physician and should be available for review AT THE TIME OF THE OFFICE VISIT. The office visit should be in a medical setting- a fixed based office. If a certification is performed outside of a medical office, there should be a good reason for doing so. 2/ A face to face, in person visit with the physician is required for all new and renewal certifications. Under no circumstances are through the mail acceptable, and Skype visits were specifically not allowed. Dr. Townsend was involved in the development of the standards of care for certifications, and argued for telemedicine, but the law was written specifically to exclude Skype Certifications. 3/ An expectation of follow up must exist to monitor the efficacy of your treatment with cannabis. Goodwin lost his section 8 defense in large part because his doctor only planned on seeing the patient for a renewal when the license expired. There was not effort or intention of doing any follow up (nor was there a discussion of reasonable amounts of cannabis to treat the condition). At Denali we offer free on line follow up for our patients. 4/ An offer must be made to the patient to notify their primary care physician of the certification visit. The patient may elect to have the records sent to their primary, or not, but the subject must be addressed.
Through the Mail Certification may not protect your section 8 defense
Sending in records and $150 does not qualify for a face to face meeting with the physician. In the event a patient does not meet the requirements of a bonafide dr/pt relationship the Goodwin decision shows that despite a qualifying condition, the patient does not meet the burden of the first prong of the section 8 defense. Several low standard clinics are attempting to encourage their patients to renew by mail, but have specific waivers patients must sign to relieve the clinic of liability for court and attorney costs, property forfeiture, and incarceration.
The State has an Obligation to Enforce the Standards to Protect Patients
The state has passed laws setting standards for certification. Patients have a reasonable right to expect that their physicians are meeting those standards, because if they didn’t, the state would act and bring their physician into compliance. Unfortunately, there have been very few actions against substandard certification physicians, and some have repeatedly had their certifications called into question in court, yet continue to do them based on questionable practices. Why hasn’t the state acted?
Denali Healthcare has been working with the people that brought you the caregiver/patient matching service GrassMatch.com to beta test a new web based clinic software program called MichiganMarijuanaForms.com.
What Michigan Marijuana Forms Does
After working with certification for over 5 years, we have helped michiganmarijuanaforms.com identify common problems with the application process and develop solutions to correct them.
The state is very particular about the names and addresses on the forms.
They are also very hard on mistakes- cross outs, poor penmanship, and other simple errors
Boxes that need to be check can be small and overlooked, resulting in denials.
MichiganMarijuanaForms.com helps patients with this process. Simply go to the site and complete the simple, well explained on line form, and all the work is done for you. Once finished, you can simply print your portion of the application and take it to the certification doctor of your choice. This is a free service presented as a courtesy to the medical marijuana community.
The True Power of the Program
While the ability to quickly and simply fill out your application is very helpful to patients, the true power of MichiganMarijuanaForms.com comes from the clinic aspect. Not only can patients pre-fill out their application and send it to a participating clinic via a secured electronic connection, patients that just come in to the clinic with their records can have their form filled out simply by scanning their drivers license and answering a couple of questions (is this your mailing address, will you possess your plants, what is your phone number and what is your email address). The physician then gets your application, and by selecting your name from their list of patients ready to be seen and checking your conditions, not only is your application completed and ready to print, but a medical chart note is automatically generated. This chart note clearly documents all aspects of your visit to confirm the bonafide dr/pt relationship and your section 8 defense to include:
A face to face meeting with the doctor and review of records
Documented offer to notify your primary physician and whether you approved or not
Quantities and Methods of use
Recommendation for follow up at a certain interval
Your documentation (drivers license, intake, medical records, etc) are able to be uploaded directly to your record. All is organized, meets all statutory requirements and is available for your attorney should you need them. Even a 'Convention Style' mass certification clinic can properly document your chart so it stands up in court. In this era of prosecutions of medical marijuana patients, everything you can do to protect yourself should be done. With Denali and any other clinic participating in the Michigan Marijuana Forms system, you can be assured all the i's are dotted and all the t's are crossed, there are no weak spots in the record for a prosecutor to exploit.
Denali Healthcare uses Michigan Marijuana Forms
Denali Healthcare will use the MichiganMarijuanaForms.com system to properly document our certifications, any other clinic in the state can also use the system by contacting the company directly. Dr. Townsend and others will make themselves available to help with implementation if requested. The hand held scanner will be included in the service for the clinics, the web based program is encrypted, all clinic data is private to the clinic (other clinics cannot access the data), and it works with all browsers, macs and pc's, and all scanners that can produce a pdf or jpg scan so no new equipment is required.
Cannabis and the Endocannabinoid System by Dr. Sunil Kumar Aggarwal, (M.D, 2010, Ph.D., Medical Geography, 2008.) This presentation is scientific and is directed towards Physicians and Healthcare professionals. Dr. Aggarwal is a graduate of University of Washington's NIH-supported Medical Scientist Training Program and an Associate Member of the New York Academy of Medicine. As a NSF Graduate Research Fellow, Dr. Aggarwal conducted and published studies of medical cannabis use under the first-ever granted federal Certificates of Confidentiality which protected 176 study subjects recruited from sites of cannabis delivery and medical consultation. He has authored or co-authored papers on cannabinoid medical science, dosing, and human rights in journals of Pain medicine, Hospice and Palliative Medicine, General Medicine, and Law, in addition to book chapters. He has presented at the national meetings of the National Association of Boards of Pharmacy, the American Psychiatric Association, the American Academy of Neuromuscular and Electrodiagnostic Medicine, the American Academy of Hospice and Palliative Medicine, the American Academy of Physical Medicine & Rehabilitation and the University of Denver School of Law, with his writing and testimony being used by several state health agencies such as the Iowa and Oregon Boards of Pharmacy as expert evidence. He was a delegate to the AMA Medical Student Section and successfully lobbied the Washington State Medical Association and AMA, through education and internal coalition-building, to change their position on the scheduling status of cannabis in the federal schedules and served as an expert reviewer their report on medical cannabis science. The AMA now urges the government to reconsider the schedule I status of cannabis and have struck down their prior policy advocating its retention in schedule I. This was broadcast on numerous news outlets, including CNN and LA Times. His work has been cited in The Medical Letter, Discovering Psychology-a widely used college-level introductory textbook, Mayo Clinic Proceedings, and MayoClinic.com. 1. Cannabinoid Medical Research: overview of current research. 2. Cannabis Pharmacokinetics: types of administration and metabolism. 3. Cannabis Pharmacodynamics: effects of cannabinoids on the endocannabinoid system. 4. Misconceptions: evidence based research on misconceptions and contraindications.
New Forum for Michigan Medical Marijuana Patients!
The Michigan Cannabis Patient Forum was started back in 2010 by a group of activists in the UP for the purpose of providing solid information for Michigan Medical Marijuana Patients without the drama and bickering so common with other forums. It ran for several years and saw many postings by leaders of the Michigan Cannabis Community- but it went away last year. The forum has been restarted in a slightly different format, but they are hoping to attract the quality of posting that it once was know for, to incorporate members of other closed forums such as 3MG and to attract those that are tired of the behavior common to other sites. Folks do not want to go to a forum to learn about dirt growing, only to see a couple of strong opinionated individuals bicker back and forth and call each other names because one likes one type of dirt and the other has a different favorite brand.
Quick Guide to the Site. Unlike other forums that take you directly to the phpBB site, the Michigan Cannabis Patients Forum has an entry page. Although you can obviously link directly to the index, it is recommended you go to the page. On the webpage, you will find articles, posts and updates, along with RSS feeds for news. The menu has a link to a page of 'Helpful Links' which is constantly updated and serves as a collection of useful information concerning Michigan Medical Marijuana. These are news services, activist groups, several caregiver/patient matching services, regional organizations like compassion clubs, and strain guides. Denali Healthcare maintains this list, but is not associated with the site other than as a contributor (and we supported the launch by notifying our mailing list). There is also a menu item linking to Michigan Compassion Clubs- a new website devoted to providing web support and resources to all original model compassion clubs. Clubs needing websites can have them build and web mastered by Michigan Compassion Clubs free of charge. This site is not quite ready but should be very useful within a month. But the big link is to the Michigan Cannabis Patients Forum itself.
It Consists of a comprehensive forum with 8 Sections- General Rules, Patients Helping Patients, Caregivers and Growers, Compassion Clubs, State Laws and Court Cases, Medical Forum, Legal Forum and General Discussion. These individual sections can be accessed on the sliding photos at the top of the page (the forum is named vertically on the left of the photo) as well as on the forum list on the left side bar. The main forum index is on the menu bar in the middle.. Note, in the Compassion Club Forum, individual compassion clubs will have a sub forum run by one of their own members for their club. There is also a 'Guard Channel' monitored by all clubs for statewide coordination for rallies, court support, and statewide communication. Finally, there is a policy of One Topic/One Subject. If the Topic is dirt growing, that is NOT the place to post about hydro- put that in a hydro topic (make one if you wish). They want focused, on topic discussions useful to new patients looking for an intelligent discussion of a subject of interest to them, not a rambling conversation that degenerates to an on-line flaming session between strong willed individuals. Those that start a topic should monitor that topic for a month or so to make sure the conversation stays focused.