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Western New York physicians cautious about rollout of medical marijuana treatment

The Dent Neurologic Institute in Amherst receives as many as 100 calls a day about medical marijuana, and for good reason.

Of the 226 doctors certified to recommend marijuana in New York State as of last week, 12 of them work at Dent.

Dent wants to be on the leading edge of using and researching marijuana for treatment in Western New York. But don’t expect a flood of recommendations for their patients to use the drug, said Dr. Laszlo Mechtler, Dent’s medical director.

While a strong advocate for marijuana’s use where the scientific evidence shows it can help, Mechtler – like many other physicians – remains wary about the drug.

“We need to step up and respond to the needs of our patients,” Mechtler said. “But we’re going to be very conservative. We want to go by the book. The thing is, with medical marijuana, there is no book.”

Mechtler said the small but growing body of research around marijuana’s benefits in neurology and cancer led Dent to move toward building a robust program.

“We have a responsibility to see these patients and provide compassionate care,” said Mechtler, who also sees cancer patients as chief of neuro-oncology at Roswell Park Cancer Institute. “They deserve it even if the science is not there yet.

Without good science – and with conflicting state and federal laws – doctors are uncertain about recommending medical marijuana.

Mechtler said he and his colleagues have devised protocols based on what’s currently known, including a review by the American Academy of Neurology.

The plan is to be cautious.

“We’re going to start slow and start low,” he said, referring to dosage. “There is going to be a period of trial and error.”

Strict guidelines

New York earlier this month became the 23rd state to allow the use of marijuana as a medicine. The guidelines for patients and doctors stand out as among the most strict, as are the limits on the number of dispensing facilities where the drug can be sold. There are 20 statewide, including two in Erie County, both in Amherst.

Who will recommend marijuana?

There’s no simple way to know.

It’s not clear how many or which physicians in the region have registered to make medical marijuana a part of their practice.

The state intends to keep track through a database of the doctors and their specialties. But access to the database will be limited to physicians and other health care professionals who have patients appropriate for a referral. What’s more, doctors who issue certifications to buy marijuana can choose not to be identified in the database, allowing them to treat only their established patients.

Mechtler estimates that as many as 150,000 patients in New York State could qualify for medical marijuana. He dismissed as unrealistic a widely reported number from an advocate that as many as 400,000 could qualify. So far, only about 170 patients have obtained approval from a physician to buy the drug, according to the state Health Department.

The federal government banned marijuana in 1937. The government in 1970 categorized it as a dangerous drug – joining the ranks of heroin and LSD – with no accepted medical use.

Like others, Mechtler’s perspective on marijuana has evolved.

“There was always this stigma about it,” he said. “But once you read the history and the scientific literature, you realize it has some benefit, and it is not a gateway drug. Marijuana does not kill like alcohol, tobacco and prescription drugs.”

Call for more study

Still, doctors face a big challenge. Its listing as a dangerous drug made it difficult to research marijuana’s potential benefits.

“That is the fault of the government for discouraging research,” Mechtler said.

There is little good evidence yet to support the use of medical marijuana and, even where there is decent evidence, little information about dosage or using the various formulations of the drug when supplied as a plant, pill, spray or oral extract.

Each state has its own list of approved illnesses for medical marijuana, some allowing marijuana for conditions with little evidence that it has value.

In New York, you must be diagnosed with certain debilitating or life-threatening conditions that are accompanied by an associated or complicating condition. These conditions include cancer, HIV infection or AIDS, amyotrophic lateral sclerosis, Parkinson’s disease, multiple sclerosis and epilepsy. The complicating issues include cachexia or wasting syndrome, severe or chronic pain, severe nausea and seizures.

Advocates call for relaxing federal laws to encourage more research.

Last year, the Journal of the American Medical Association published two reviews of the scientific literature with mixed and limited results.

One analysis of 79 studies involving nearly 6,500 people found moderate support for using marijuana to treat muscle spasms related to multiple sclerosis and chronic pain. There was low-quality evidence for nausea and vomiting due to chemotherapy, sleep disorders, HIV-related weight loss and Tourette syndrome.

Another analysis found high-quality evidence to use marijuana for chronic or nerve pain, and muscle problems due to multiple sclerosis.

But researchers stress the need for more well-designed studies.

“Marijuana is not a panacea, and testimonials about its benefits don’t equate with science. Let’s do the proper research,” Mechtler said.

Not like Colorado

Mechtler contrasted New York’s program with that in Colorado, which decriminalized medical use of marijuana in 2000 and legalized possession for recreational use in 2012.

In New York, patients can consume the drug only through an oil, pill or vapor, but not smoke it, and the law limits the number of marijuana strains that can be offered. In Colorado, where regulations are less stringent, more than 315,000 people have registered to buy medical marijuana. There are about 110,000 current active users. And 93 percent of the patients use the drug for severe pain. Colorado patients with a qualifying condition can buy up to 2 ounces of all forms of cannabis products after obtaining a recommendation from a physician.

Medical marijuana remains popular in Colorado because it is taxed at a lower rate than recreational marijuana, so it’s less expensive. Patients also can possess 2 ounces instead of the 1 ounce for adult recreational users.

Westword, Denver’s weekly alternative newspaper, carries page after page of display ads for marijuana-related businesses, including for physicians that promise quick and cheap office visits to receive the required recommendation for a medical marijuana card.

Only a small number of physicians generate the vast majority of the medical marijuana cards in Colorado, said Edward Bednarczyk, pharmacy practice chair in the University at Buffalo’s School of Pharmacy and Pharmaceutical Sciences, who lectures on medical marijuana.

For example, a single physician issued 10 percent of the medical marijuana cards in Colorado. Fifteen physicians issued 50 percent of the cards and 50 physicians issued 85 percent of the cards, said Bednarczyk, citing data from a 2011 article in the Journal of General Internal Medicine.

“To a certain extent, there is a Wild West atmosphere,” said Dr. Steven Wright, a family physician in Littleton, Colo., who specializes in pain management and addiction medicine.

“Doctors should not be recommending it to the snowboarder with a sore shoulder,” he said.

Wright said that greater marijuana use has led to increases in poison center calls and self-referrals to treatment centers. But it also generated $63 million in tax revenue and an additional $13 million in licenses and fees in 2014, and it is helping many patients when used appropriately, he said.

He and others criticize what they see as lax medical practices, including the failure of some Colorado doctors to properly assess medical marijuana patients and to consider medical factors that may serve as a reason to deny a recommendation.

This month Colorado put in to place new guidelines that call for physicians to more closely examine patients seeking marijuana, such as asking about past substance abuse or mental health problems. But Wright said he’s unsure they go far enough.

“People are coming into some doctors’ offices, asking for marijuana and walking out with a recommendation, and the doctors didn’t do standard things like a risk assessment,” he said. “We don’t do that with insulin or other drugs. We shouldn’t do it for marijuana.”

News Business Reporter Stephen T. Watson contributed to this report. email: hdavis@buffnews.com