PROVIDENCE – They are on the front lines of the marijuana debate, the ones who decide who should be allowed to smoke, ingest or inhale what is still an illegal drug in Rhode Island without fear of arrest.

They include neurologists, oncologists, infectious disease specialists, family clinic doctors, the medical director of a drug-abuse addiction center and a psychiatrist running for mayor of Providence who is a conservative on most other issues, but not the politics of marijuana for a patient prone to nausea, anxiety and panic attacks.

Altogether, 355 Rhode Island doctors have signed state forms asking the Department of Health to issue marijuana-use cards to at least one of their patients.

But twenty-one of those doctors account for more than a third of the 1,347 medical marijuana cards issued so far, according to the Department of Health.

Dr. Vladislav Zayas, an East Providence neurologist, tops the list, having signed off on the legal use of marijuana by 100 of his patients. The next closest doctor signed 54; the third signed 36.

Dr. Zayas has declined comment. But nine doctors talked openly in recent interviews about why they opened the door to legal marijuana use by their patients.

Some are more convinced than others of the medicinal value of the drug.

Providence mayoral candidate Daniel S. Harrop III acknowledges some discomfort in knowing that the one AIDs patient for whom he has approved marijuana use has to “sneak around the garage he goes to on the west side of Providence to buy this stuff…but I don’t ask about that.”

Dr. Debra Roberts, a family doctor in a community health center in Warwick, says she has become increasingly uncomfortable at being the final arbiter in what she views as a legal, political and ethical debate. “I feel like it’s a political issue that I don’t love being in the middle of,” says Roberts, who has signed 18 applications.

“I think people use it. I think it does help their pain,” she said. “I don’t like to be the one to allow people who may have other addictions the right to not get arrested for having this marijuana…I feel like they should just legalize marijuana then. Instead they have to come to me, and I legalize it for them.”  

But several doctors said they signed the medical marijuana applications because their patients told them they were already using the drug and did not want to get arrested for doing something that eased their pain, and improved their “quality of life.”

Dr. Josiah Rich, a Brown University professor and infectious-disease doctor, who is an outspoken advocate for decriminalizing marijuana, says: “It’s absolutely crazy to incarcerate somebody for doing something they believe is good for their health.”

In a candid moment, however, another doctor acknowledged signing the paperwork for an inveterate drug-user because “his fiancé wants him not to break the law.”

In retrospect he rationalized his decision this way: “He has a construction job. He goes to work. He does his part. His life is a lot better when he is not chasing Vicodin, 20 to 30 pills a day.”

Technically, all a doctor need do is check off one of the boxes on a patient’s application for a medical marijuana card that broadly describes the patient’s qualifying condition, such as cancer, glaucoma or AIDS. The patient then takes the paperwork to the Department of Health which has taken the position it cannot second-guess or even question a doctor-signed application. More than two-thirds of the cards the Department of Health has issued so far went to people whose doctors checked off: “chronic or debilitating disease or condition.”

Here is what some of the doctors with the highest number of patients using marijuana legally had to say

Dr. Syed A. Rizvi is near the top of the list with 36 patients approved for marijuana use. He is a neurologist, specializing in the treatment of patients with multiple sclerosis.

Rizvi says he does not recommend marijuana to his patients. “They would ask me if they could use it.” Even then, he said, he would only sign the application if he had been seeing the patient for years, and the patient had “fairly advanced disease.”

Dr. Rizvi said he tells his patients “there is no good study supporting the use” of marijuana by people with multiple sclerosis, except perhaps to help alleviate leg spasms, while “there may be studies suggesting that it can worsen your cognitive function.

But “these patients, like I said, are doing it anyway,” he said. “They want more security by having a form signed. That’s all they want.”

Asked whether he believed the drug had medicinal value, he said: “It’s a strange answer.”

“All the patients that take it like it,” he said. But, “if you are [taking] a drug which has certain effects which are euphoric…and people who don’t have MS taking it [also] say — ‘Oh, I feel good’ — I don’t know what that means. Does it help MS patients? Well, individually, these patients feel better…They’ll say all kinds of symptoms are better….[But] you really can’t make any judgment unless you have a controlled trial.”

Rizvi, 43, said he has nonetheless signed applications for patients “who are extremely disabled. At that point, their quality of life is probably the biggest thing.”

As an internist and medical director for a methadone clinic known as the Discovery House, Dr. John S. Straus says: “We are in the harm reduction business.”

“When someone isn’t using IV drugs and committing crimes and ending up in emergency rooms overdosing and ending up with HIV and Hepatitis C, they are successful…,” he said. “And so while marijuana philosophically is a drug and it has potential to do harm, relatively speaking, it’s in the minor leagues.

“I mean people don’t get HIV from marijuana.”

Dr. Straus said the 12 patients he helped get medical marijuana cards have a variety of “pain syndromes” resulting from osteoarthritis, for example, or fibromyalgia. But he said: “Some people find it highly effective for anxiety as well.”

He said it is a juggling act, knowing which drugs to prescribe to reduce a patient’s dependence on or craving for more potent drugs, including methadone. “In my private practice, I am into doing what is effective…If there is no other effective treatment and there is no harm with the marijuana in terms of the person’s functional status, then I see nothing wrong with it.”

On the other hand, he said he doesn’t always say yes and has “doubts about decriminalizing it…because you can let the genie too much out of the bottle. There has to be some constraint on drug use.”

He told about a patient he saw just the other day who has been taking a prescribed alternative to methadone, called Suboxone, who “wanted marijuana for his anxiety. But I feel like he is not doing his part to help his anxiety. Like he is doing nothing and I said I can’t write it for you. You have to exercise. You have to see a counselor. You have to do your part.”

Dr. Dennis Mikolich is an infectious disease doctor who has helped 54 patients get medical marijuana cards.

With the second-highest caseload of legal marijuana users, Mikolich did not shy away from talking about the decisions that he said he made on behalf of patients with chronic and debilitating conditions, such as HIV and Hepatitis C.

But he acknowledged a concern about having his name in the newspaper and half-jokingly asked if “instead of using my name, you could refer to me as an ID ( infectious disease) physician with an office in Cranston with a Slavic sounding … name?”

He is also uncomfortable because he believes “the public still isn’t entirely convinced it is a good thing…I think there are some negative connotations associated with it.”

“It is not a good position to be in, but it is one I put myself in because the patients I treat …seem to respond to the medical marijuana,” he said. He also stressed that he only approved applications from patients with whom he had an established relationship.

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He said “most of my patients who opt to use [medical marijuana] are either severely debilitated from chronic infections… associated cancers… [or] treatments using anti-viral medications or chemotherapy , and this is an act of compassion.”

“Many cannot drive, and if I suspect potential for abuse or danger then one is not given access by myself for a license.”

Asked how he would describe the benefits, he said: “Many patients I treat feel the immediate benefit of having this license psychologically, as they are already using [marijuana] and are afraid of legal consequences if found to be in possession of it, and not licensed.”

In fact, he said the majority told him they were already using it and are getting positive results: weight gain, a “better quality of life during the day,” and relief from side effects of their medical conditions, “including nausea, vomiting, different pains, depression, mood irritability.”

“My life is dedicated to helping patients, and improving quality of life,” he wrote in a follow up e-mail. “If it is legal and helps relieve whatever malady, then if I think it is safe and doesn’t jeopardize one’s well being, a form is signed.”

Like most of the doctors interviewed for this story, he said, he doesn’t know where his patients get the drug, but his staff provides his patients with the phone number of someone he knows only as “Reefer Jane” who “directs people to people who can grow it for them.”

A familiar face at the State House, Dr. Josiah D. Rich is a physician at Miriam Hospital and Brown Medical School who visits the Adult Correctional Institutions each week to give medical care to inmates. He is also an activist in drug abuse treatment.

He does not recommend legalizing the use of marijuana, because he doesn’t want to “encourage people to do harmful things.” But, he “doesn’t think anybody should go to jail for smoking marijuana.”

Over the last four years, he has helped 11 patients get medical marijuana cards.

He said he told each he “would not strongly recommend marijuana because of the potential damage to [their] lungs,” but recognizes that if “somebody is taking a life-saving medication [which they] can only tolerate by taking a small toke of a joint,” the marijuana may indirectly be saving their life.

One of the handful of doctors who acknowledged trying marijuana during his younger years, Rich said he “didn’t like what it was doing to my thought processes. It seemed to be clouding my memory.”

But he said the same “could be true for any mind-altering substance…even though they are of pharmacy grade.”

A family physician in West Warwick, Dr. Frank W. Lafazia has signed marijuana card applications for 31 patients over the last four years.

He seemed surprised by the number, but said the patients in this group have multiple sclerosis, Crohn’s disease, or are dependent on drugs such as Vicodin or Oxycontin for pain control.

“I treat a lot of low income people,” he said, and “there seems to be some correlation between socioeconomics and people getting addicted to narcotics.”

“What I try to do is wean them off the narcotics,” he said. “People will steal to get narcotics…If they get addicted, they will do terrible things in their families. Marijauna doesn’t seem to cause that. Nobody is going to go out and rob your house…(or) rob a store because they need money to buy marijuana.”

“This isn’t the majority of my practice. I am not a pot doctor. I practice real medicine,” said Dr. Todd E. Handel, 37, who has signed 31 applications.

As a physiatrist with a sub-specialty in interventional pain medicine, he oversees the diagnosis, treatment and rehabilitation of people with sports injuries, and other causes of back and neck pain including spinal cord injuries and herniated discs.

Once the law allowed the medical use of marijuana, Handel said signing marijuana-card applications was not hard. “If my state legislature has said to me patients with these types of conditions should be allowed to have access to this medicine…my view is, I have been asked by the state legislature to provide this.”

Conversely, “am I violating the law by not signing it?” he asks.

He said he counsels his patients that marijuana might help their pain, but is also a psychotropic that could “affect their executive levels of function,” such as their decision-making and ability to drive.

From his own anecdotal observations, he said, the drug helps control his patients’ pain and muscle spasms, and in at least one case, “decreased the amount of opiates he is needing.” He said the majority of those for whom he has approved marijuana use “are able to decrease the amount of pain medication they are taking with medicinal cannabis.”

“Is it safer for a 21-year-old to be drinking alcohol and intoxicated versus [smoking] marijuana?

“I am not qualified to address that,” Dr. Handel said, but “an obvious opinion would be that the consumption of alcohol in this country is a much bigger problem, and the illicit use of narcotics…Vicodin… Percocet…Oxycontin …in this country is a much bigger problem.”

December 19, 2009 – Ned Calonge is appalled by the level of care provided by some dispensaries. ​The Colorado Department of Public Health and Environment’s Board of Health has had a rough few months navigating the issue of medical marijuana.

In July, the board determined that a caregiver only had to provide a patient with marijuana to earn that label. Then, in November, the board voted to strike language to this effect in an emergency action, only to have Denver District Court Judge Larry Naves nix the switch. Afterward, the board postponed a meeting at which members were scheduled to try and figure out what to do next.

Now, however, the department is taking the initiative regarding the handful of physicians who’ve authorized the vast majority of the state’s medical marijuana patients — fifteen who’ve accounted for 73 percent of the state’s nearly 16,000 total, with a third of them okaying nearly half that amount.

Ned Calonge, the state’s chief medical officer, speaks plainly about such docs. “I don’t believe these physicians are practicing within the community standard of medical care,” he says.

Calonge offers an example from numerous anecdotes he’s heard.

“You might walk in to a dispensary, and they give you a pre-completed form. You check off chronic pain. They might do a blood-pressure check, and then a physician looks at you, asks you a couple of questions, signs your form and your application is complete. And that’s not appropriate medical care. That’s substandard.

“Let’s just lay it out. There’s no other setting in medicine where this can occur — where you can walk in off the street, see a physician who’s never seen you before, have him or her diagnose you with a chronic condition without ever examining you, document this chronic debilitating condition, refer you to a pharmacy that he or she may have an interest in or gets a kickback from, give you a psychoactive substance, and when you walk out the door, you’ll never see that doctor again.

“If it was any other substance — if it was dilaudid, say — that doctor would be arrested and his or her license would be taken away. That’s substandard care. But we have report after report that this is exactly what’s happening, and the public-health department can’t sanction substandard care. One of my obligations as a licensed doctor in the state of Colorado is that if I have concerns about substandard care being delivered by another physician, I have a duty under my license to report it — and not reporting it is grounds for disciplinary action.”

A strong argument. But many patients believe that they must work with dispensaries and physicians like these because more mainstream doctors are not open to the possibility that medical marijuana may help them and therefore refuse to prescribe it. Calonge acknowledges that this is a legitimate issue.

“Medical care is delivered within kind of a set model — what we call the medical standard of care,” he says. “And I think most physicians, most mainstream physicians, tend to use the traditional medical model as their first line of approach. We usually prescribe medications that are very carefully regulated by the FDA in their manufacture, purity, the amount of medication, the dose, the potency, the activity. All of that is carefully regulated, so we know what blood levels we do, how it’s going to interact with other medication. And, of course, other medicines don’t come with their own carbon monoxide poisoning. So we’re likely to try those therapies first and consider medical marijuana for a chronic, debilitating condition for those for whom we’re not making an impact.”

According to Calonge, he’s actively encouraged physicians to take this latter course.

“I’ve had several doctors call me as this [medical marijuana issue] has gotten more interesting and say, ‘I have patients, one or two, three or four, who I think might benefit from this’ — maybe a chronic pain patient or a cancer patient or a patient with another condition for which the physician has tried the traditional methods and they’re not working. Or the medications have so many side effects that the quality of life for the patients isn’t very good. And they’ll say, ‘I’d like to try this. Do you think this is a bad thing?’”

His response? “I’ll tell them that I think this is what the constitutional amendment was written to provide. And when patients get medical marijuana in this kind of setting, doctors are able to bring them back and say, ‘Did it work?’ So I’d like to use this opportunity to raise awareness among physicians and let them know it’s okay — that no one will ever come after them and no one will ever know they prescribed it, at least from us. That way, we can make sure patients who really need this therapeutic approach have access to it.”

Another option for getting around what Calonge describes as “the issue about, what if my doctor is old and crotchety and isn’t going to do it”? Integrated care clinics.

“Let’s say I’m a chronic pain patient, or I have one of the other conditions on the list,” Calonge begins. “I can go to a clinic where I’m brought in as a legitimate patient, and I have this full assessment, and they say, ‘Medical marijuana might be useful to you, but we want to figure that out through an exam and reviewing your past records. We want to come up with a pain treatment that’s tailored specifically for you — and that might include medical marijuana.’

In Calonge’s view, such an approach “would establish a legitimate doctor-patient relationship that would meet the standard of care. The doctor could prescribe a treatment, then bring a patient back to see if he needs to add something to it. To me, that’s the answer to the question, ‘What if my doctor just won’t do it?’ I’ve heard from doctors who are interested in setting up that kind of clinic model, and I believe in working with the governor’s office, we’ve suggested legislative wording that would allow that model to work and meet the standard of care to which all physicians should aspire. And a doctor in that situation might have 200 patients, or 1,000 patients, on the registry, because that’s all he or she does. But they’re not sitting in a dispensary. They’re in a real, bona fide medical clinic setting.”

By legitimizing the medical marijuana system, Calonge is hopeful that “more doctors will think about where medical marijuana fits in their overall armamentarium, and we’ll see appropriate use rise as we hopefully reduce fraud and abuse.”

And he believes there’s plenty of both.

“We have to deal with this issue of economic ties to dispensaries,” he stresses. “That’s actually a question of federal law. As a doctor, I can’t own a pharmacy, I can’t sell drugs that I make, I can’t get a kickback. That’s all illegal. So you have to sever the economic ties between the documentation of the recommendation to get medical marijuana and the economics associated with selling it to patients. Those have to be separated, because that’s just unethical. You can’t do that for any other pharmaceutical.”

As for criticism of the Board of Health within the medical marijuana community, Calonge thinks the perception is “we don’t like this program and we want to get rid of it. But it would be nice to have people hear that we understand there are people for whom medical marijuana might be helpful. The people voted for that and put it in the constitution, so what we at the health department want to do is make sure we administer the program and make sure the people who are going to benefit from it from a health standpoint will do just that.

“That’s a true medical marijuana program and not a backdoor entry to fraud and abuse and potential legalization of marijuana,” he goes on. “Now, I’m not giving you an opinion about whether that should or shouldn’t happen. But I am telling you that shouldn’t be done through the public health system.”

Look below to read the health department’s news release about prolific prescribers.

Medical Marijuana Registry Data Shows Cause for Concern

DENVER — The latest data from the Medical Marijuana Registry maintained by the Colorado Department of Public Health and Environment shows that as of Dec. 15 a total of 820 licensed physicians had authorized medical marijuana for 15,800 patients. Of those 820 physicians, just 15 accounted for 73 percent of total patients, and just five have authorized 49 percent of all recommendations.

“These figures are representative of the concerns we have about whether some physicians really have a bona fide physician-patient relationship, as required in the Constitution, with those for whom they are authorizing the use of marijuana,” said Chief Medical Officer Ned Calonge. “Working with the Governor’s office, we have crafted statutory language changes that would, among other things, clarify what constitutes a bona fide physician-patient relationship.”

The department is asking legislators crafting medical marijuana related bills to include the following subjects to help address issues of fraud and abuse:

• define a bona fide physician-patient relationship that includes an on-going relationship, a complete assessment of a patient’s medical history and follow up care

• ensure a physician recommending medical marijuana is in good standing and has not had his/her federal drug enforcement administration registration revoked or suspended

• prohibit physicians from receiving remuneration from a primary care giver or dispensary

On average, the 805 physicians with the lowest number of medical marijuana authorizations have approved just over five patients per doctor, while the 15 physicians with the most authorizations for medical marijuana have approved an average of 760 patients per doctor. These dramatic differences raise concerns about the medical care being provided to these patients.

According to Calonge, these data are all the more reason to make statutory language changes that will better assure that the appropriate patients are participating in the medical marijuana program, with assessment and treatment that meets the medical standard of care in the community and assures the health outcomes intended by those voting in favor of the original constitutional amendment.

“Many of these requirements parallel federal laws designed to provide protection from economic conflicts of interest that may arise when a physician stands to benefit directly from the sale of a medication or service that he or she prescribes,” said Calonge.

The latest estimate from the Colorado Department of Public Health and Environment is that approximately 29,000 to 30,000 individuals now have submitted the necessary applications/authorization to be included on the state’s medical marijuana registry. An exact count is not available at this time due to the high volume of mailed applications being received by the registry each day.