Pubdate: Sun, 21 Mar 2010
Source: Pueblo Chieftain (CO)
Copyright: 2010 The Pueblo Chieftain
Author: Loretta Sword


Two doctors who have certified hundreds of Coloradans as medical 
marijuana patients believe that a bill pending in the state 
Legislature to more strictly regulate that process will only hurt 
people who truly would benefit from the medicine.

The proposal, SB109, would effectively ban the current practice of 
doctors offering certification "clinics" at medical marijuana 
dispensaries by requiring that doctors have a "bona-fide 
relationship" with any patient they approve for the state's patient 
registry. The proposal says the doctors must have met with each 
applicant at least once before an evaluation exam to receive medical 
marijuana and be available for follow-up care.

Dr. Rita Starritt, a Denver-area internist, started working with 
dispensaries last year, after her triplets started school and she had 
extra time on her hands around her part-time practice.

Aside from the ability to choose her own hours and avoid dealing with 
insurance companies and paying office staff (and earning $100 per 
exam, doing 20 to 50 during an average dispensary clinic), Starritt 
said she believes in the medicinal value of marijuana for some people 
and suspected there were many patients who couldn't get certified for 
its use, either because their own doctors wouldn't sign the forms or 
because they don't have access to primary health care.

"Some people don't have a doctor, or they don't have insurance. 
They're already getting the medicine illegally. Many people have 
already tried this medicine before they get a license. I think it is 
a cruel and burdensome thing for patients who are in need of help to 
deny them access to pain relief because the last time they saw a 
doctor was five years ago in some ER," Starritt said.

The proposed law "will be more burdensome for the patients than for 
the doctors. They're trying to legislate something that's pretty 
difficult to legislate -- the relationship between doctors and 
patients. What about the ER doctors? You don't have to see one five 
times to get painkillers for a broken limb and get the limb set. They 
only see a patient once, usually, but they can prescribe painkillers. 
Specialists see people on referral, and usually only once or twice, 
but they can prescribe painkillers."

Starritt said many of the medical marijuana applicants she has 
evaluated are people for whom traditional painkillers aren't 
effective, or who find they can't function well when using them. Many 
also claim a history of addiction to opiates or other painkillers and 
are seeking pain relief without the risk of addiction.

She said she doesn't doubt that some marijuana registry applicants 
are recreational users who want to register as patients to eliminate 
the risk of being arrested for possession. But she's also seen plenty 
of patients in her private practice who fraudulently try to obtain narcotics.

"It's not my job to figure out who's lying to me. If I think people 
are lying to me, I'll deny them. But let's take migraines, for 
instance. If someone comes into my (private) office and says they 
have migraines, unless they're throwing up in front of me, I have no 
evidence. It doesn't show up on MRIs and there are no other 
definitive tests that show migraines. Same with fibromyalgia. We have 
to take the patient's word about a lot of things.

"I think it's cruel to tell someone who has migraines, 'Wait until 
you're having one and come into my office.' But if someone comes in 
and says, 'I need 500 Vicodin a month for my migraines,' that ain't 
gonna happen. I'm sure there are people who have pulled the wool over 
my eyes. It's gonna happen. But on some level, we have to believe 
what patients tell us because that's all we have to go on."

Starritt said she always requests medical records, but few applicants 
have them for a variety of reasons. Usually, it's because they have 
no insurance or regular doctor, she said, so their only care is 
delivered in emergency rooms and most patients don't know how to 
access those records, or can't afford them.

She agrees that some regulation of the evaluation process is logical 
because, "there are some doctors that are never seeing patients -- 
they're just signing the papers. And some are doing it with 
tele-medicine or over a computer. But there are hospice patients 
whose doctors won't sign for it," and many of those patients could 
enjoy a higher quality of life if their pain is controlled by 
marijuana instead of morphine, which often dulls the brain so much 
that they can't interact with others in a meaningful way during their 
last days.

"Even with newer pharmaceuticals, a lot of doctors get on board right 
away and others hang back until they see more evidence. We're seeing 
the same thing with medicinal marijuana," Starritt said. "A lot of 
doctors are just afraid, but I think the law as written offers plenty 
of protection."

Bottom line, Starritt said the government spends too much money 
trying to regulate a substance that's readily available on the street 
anyway, especially given that alcohol and nicotine are both more 
addictive and dangerous than marijuana is.

"It's safer than alcohol. You don't have people getting in bar fights 
and beatin' the crap out of each other," she said.

"As for the theory that it's a 'gateway' drug and all that, I'm not 
sure that it is. But putting all these people in jail for their 
second or third drug offense -- paying all this money to keep people 
in jail because of two joints -- it's a misappropriation of funds."

Dr. James Satt of Rocky Ford says he's no crusader for legalization, 
but he believes marijuana is a viable alternative to narcotics for 
many patients and has no qualms about signing evaluation forms at 
dispensary clinics in Pueblo West, Colorado Springs and Denver.

But Satt would be prohibited from providing that service at 
dispensaries, or in his private La Junta practice, if SB109 passes.

The bill would prohibit any doctor who has ever lost his or her 
federal Drug Enforcement Administration certification (needed to 
prescribe narcotics) from recommending medicinal marijuana to any 
patient under any circumstance.

Satt lost his DEA certification twice in the 1980s and was placed on 
probation by the state Department of Regulatory Agencies for 
over-prescribing narcotics.

He has since regained his prescribing privileges, but his current 
license status is valid "with conditions" because of a case in which 
the state Board of Medical Examiners found him guilty of malpractice 
for failing to diagnose and treat pneumonia in a La Junta patient.

Satt said he started recommending marijuana to some of his own 
patients in 2007 and began working with dispensaries last year.

"I was looking for an alternative for treating pain. What can a 
doctor do except give you pills or give you a prescription for 
physical therapy? I had read about it and thought it was a legitimate 
alternative to painkillers and arthritis medicine," Satt said, adding 
that he's never worried about facing legal trouble over his practice.

"To be honest, I worry more about license problems with prescriptions 
for narcotics. I'm not prescribing marijuana, I'm just validating 
that (patients) have a condition that would benefit from its use, so 
the threat to my license is less than the problems other people have 
with misusing narcotic prescriptions," he said.

Like Starritt, Satt said he asks marijuana applicants for medical 
records and documentation from primary care physicians, but doesn't 
always get them and doesn't deny patients if he believes their 
reasons for requesting inclusion on the patient registry.

"It's nice to validate that they do have a legitimate condition. I do 
like to have medical records, but there a lot of people who don't 
have a doctor. They may have a chiropractor as their only previous 
care provider, so sometimes I'll take records from a chiropractor. 
But I like to validate it with my own exam when I see the patient," he said.

"I want to make it clear that I don't have a marijuana business. I'm 
a medical doctor and I don't have a business relationship with any of 
the dispensaries I work for. I don't advertise the registry as part 
of my business. I'm a legitimate primary care doctor who just happens 
to have no objections to the medical use of marijuana and for some 
reason, I guess, that makes me different from many of my peers. I'm 
not a crusader. I don't even use it."

It's difficult to know how most doctors feel about medical marijuana 
or determine why so many are reluctant to recommend it to their patients.

Only three Pueblo doctors responded to a brief survey about the 
issue, sent via e-mail under the auspices of the Pueblo County Medical Society.

Dr. Robert McLean, president of the society, said he believes there 
are some limited legitimate uses for marijuana -- calming severe 
nausea in cancer patients, and stimulating appetite for AIDS patients 
among them -- but that doctors who sign off on registry applications 
for patients they've never met is engaging in a highly unethical 
practice, if not outright malpractice.

"The potential for abuse is extremely high, but people can abuse 
Oxycontin. What happens when a physician is basically dealing 
Oxycontin? We have checks and balances in place and those guys get 
their licenses yanked -- and rightfully so," McLean said.

"The abuse potential for the pill form of marijuana (Marinol) is much 
less. We don't have people setting up pill dispensaries. Patients get 
it from a pharmacy. The whole business where they're having marijuana 
in brownies and all that stuff -- it's insane. We've just opened the 
door to a huge mess. Medicine is supposed to be protecting the health 
of the citizenry, and this is just not doing that, and a two-minute 
exam is insufficient. It's medical malpractice. Those practitioners 
should get their licenses yanked.

"I think that we, as physicians, should have been on top of this and 
the American Medical Association and other organizations dropped the 
ball. We should have been controlling this much more tightly" since 
Colorado voters approved the medicinal use of marijuana in 2000.

Dr. Wes Boucher, a longtime Pueblo urologist, agreed.

He said in an e-mail that "As a physician in the Navy, over 10 years 
as a surgeon and as an ER doctor and a board-certified urologist for 
40 years, I can tell you that I never saw or heard of any patient 
needing marijuana. It is total baloney and there are no legitimate 
people prescribing it. Our Legislature worded the vote so people just 
accepted it and didn't think. Why would this drug do anything for 
pain that you couldn't do with an aspirin? There can be no license to 
rip off the public. Try and fight it. I wish I could."

Dr. Paul Rastrelli, a Pueblo eye specialist, said marijuana does 
temporarily ease eye pressure involved in glaucoma, but the effect 
only lasts for four to six hours "and therefore the patients need to 
take it almost 24 hours a day. There are much safer medications -- 
prescription eye drops -- that do a much better job."

Pharmaceutical companies "have tried to extract the active 
ingredients of marijuana -- THC and some other components -- and use 
that as an eye drop, and they don't work. The other reason why you 
don't want to prescribe marijuana is because of the other issues, 
mainly lung cancer, etcetera," Rastrelli said.

Starritt said some of her partners "aren't fans" of what she's doing 
outside her office hours, so she wouldn't consider seeing registry 
applicants in her private practice if a new law shuts her out of dispensaries.

"We don't do it out of our regular office, and couldn't. If we did, 
we'd never have time to see our private patients," she said.
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