How much education do doctors need before recommending medical marijuana to patients?

After Massachusetts voters passed a ballot initiative on Tuesday legalizing the use of marijuana for medical purposes, I’m wondering how the law will be implemented, as my colleague Chelsea Conaboy details the challenges in today’s Globe.

The state’s Department of Public Health will follow the lead of other states and require patients to get a physician’s approval to apply for a medical marijuana identification card. This card will enable them to obtain and possess a certain amount of the drug from a state dispensary if they have a debilitating condition.

How easy it will be to obtain such a card and how many dispensaries the state will allow to open, however, remain unknown. And whether the state will ensure quality control and standardization of products sold in these dispensaries also is uncertain. State health officials also need to define which conditions are debilitating enough to constitute pot use.


In Colorado, college students have no trouble getting a card and getting as much pot as they need at one of the more than 1,000 dispensaries scattered throughout the state. (They’ll probably have an even easier time now that Colorado along with Washington passed a ballot measure on election day to legalize the drug for all adults over age 21.)

Dr. Lauren Smith, interim commissioner for the Department of Public Health, said in a statement on Wednesday that “the Department will work closely with health care and public safety officials to develop smart and balanced policies and procedures over the coming months. We will work carefully, learn from other states’ experiences and put a system in place that is right for Massachusetts.’’

In other words, they haven’t figured out exactly how the system is going to work.

Part of the dilemma centers around determining whether marijuana, or cannabis, is a legitimate medicine or whether it’s just a mind-altering substance that — like alcohol, caffeine, or herbal remedies such as St. John’s Wort — is safe enough for consumers to figure out on their own how much of a dose they can tolerate.

Dr. David Bearman, a pain management physician from Santa Barbara, Calif., who treats patients with marijuana, told me he’d like Massachusetts to take the former approach, treating pot as a pharmaceutical that’s dispensed in places that have some form of quality control to ensure standardized doses. Some states require physicians to be in charge of these dispensaries, but Bearman said most don’t require any medical practitioner to be on hand to discuss doses and side effects with patients.


“I’m not sure if a doctor needs to be in charge but a nurse practitioner or pharmacist would help ensure higher quality,’’ he said.

For more than a decade since California first legalized medical marijuana, Bearman has been advising patients on how to use various cannabis products — that are swallowed, smoked, vaporized, or rubbed on the skin. Most are seeking pain relief, but others have glaucoma, nausea, muscle spasms or a host of other conditions. He gets frequent referrals from primary care physicians who are nervous about signing off on the medical cards.

As president of the American Academy of Cannabinoid Medicine, Bearman advocates for physicians who sign approvals for their patients to use marijuana to receive several hours of continuing medical education training and accreditation before they start treating patients with what he considers to be a very effective drug for pain relief.

For example, Bearman has found in his experience that patients may need a higher dose to relieve pain than to relieve nausea from cancer treatments. And certain preparations have different levels of active ingredients such as CBD and THC. Some patients experience no high from the drug, while others have some euphoria, and still others may have too much euphoria or negative experiences such as paranoid feelings that would require them to use a different preparation.


“As a pain doctor I may tell a patient to take 1 or 2 tablets of hydrocodone three or four times a day, depending on their level of pain’’ and whether the pills make them feel queasy or drowsy, explained Bearman. “Whether they take 30 milligrams a day or 80 mg. depends on them.’’ That same concept also applies to making recommendations on using medical marijuana, which he believes is less habit-forming and presents fewer health risks than opiate painkillers.

But first doctors have to make sure patients are appropriate candidates. “We encourage physicians to spend at least 40 minutes with a first-time patient to evaluate their condition and symptoms,’’ Bearman said. “I spend at least an hour with mine.’’

He also turns away many college students — the University of California, Santa Barbara is three miles from his office — who call his office describing vague symptoms such as loss of appetite or insomnia in an effort to obtain a marijuana card.

No doubt, some doctors in the state will refuse to issue approvals for marijuana card. The Massachusetts Medical Society staunchly opposed the ballot question, and medical research showing the safety and effectiveness of marijuana used for medicinal purposes is lacking. Just to illustrate one example: Medical marijuana has been purported to be an effective treatment against post traumatic stress disorder by Bearman and others. But a quick literature search revealed a paucity of evidence on whether it really works.

Animal studies like this one and a few anecdotal case reports like this one suggest that cannabis reduces anxiety associated with PTSD, but researchers have delved more into the increased likelihood to abuse marijuana that occurs in those who have been diagnosed with the condition.



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