Pennsylvania physicians are taking a cautious approach when it comes to medical marijuana.
Statewide, a scant 1,201 doctors have completed requirements for certifying patients to receive medical cannabis, the Health Department reports.
That's barely 2 percent of the state's 51,089 physicians with active licenses.
Even those who have joined the program admit there are many unanswered questions.
“Data in medical textbooks on how much to use and how to use it, doesn't exist,” Dr. Molly Trostle said at her family practice office near Ebensburg, in Cambria County. “We are just starting.”
Participating physicians have completed a four-hour course to work with patients who are diagnosed with any of 23 conditions approved for medical marijuana.
But those doctors do not prescribe marijuana in the traditional sense, Health Department Spokesman Nate Wardle said. Instead, they certify patients to receive marijuana from a licensed dispensary.
At the dispensaries, patients work with pharmacists to identify the form and strength of cannabis for their health issues.
The process frequently involves several visits and the trying of different products before one has some effect, Trostle said.
“I follow up with my patients on a regular basis to see how it's working,” Trostle said. “But the pharmacist at the dispensary is much more experienced with it. They guide the patients.”
'We have no science'
Dr. Antoine Douaihy is professor of psychiatry and medicine and senior academic director of addiction medical services at the University of Pittsburgh and UPMC Western Psychiatric Hospital. He helped develop some of the state's cannabis guidelines as a member of Pennsylvania's medical marijuana advisory board.
Douaihy warns that there are few clinical studies to support the use of marijuana, even for the approved conditions.
“The recommendation of medical marijuana has to be the last, kind of, resort, decided through a conversation between the physician and the patient, if medical marijuana is indicated for that type of condition,” Douaihy said.
“Unfortunately, for a majority of these conditions, we have no science that supports the benefits of medical marijuana.”
Trostle would also like to see more research, but points out that science is hampered by the federal government's classification of marijuana as a Schedule 1 controlled substance – along with LSD, heroin and ecstasy. The FDA defines these as having no accepted medical use, but high potential for abuse.
Federal funds are not available for research on Schedule 1 drugs.
"I'd like the government make it so that research can be done by the (National Institutes of Health) or privately," Trostle said. "They should allow researchers to actually work with it and study it."
Give patients 'the option'
In practice, doctors are seeing mixed results in patients using medical marijuana.
Dr. Kevin Sugalski, a family physician with Richard M. Kastelic & Associates in suburban Johnstown, said he has seen many patients get relief from chronic pain.
“With medical marijuana, a lot of patients on opioids are able to cut down and even stop the pills,” Sugalski said. “They tell me, 'I get better relief with medical marijuana.' It improves their overall quality of life. It's been a life-changer for them, for the better.”
Trostle has seen less dramatic results in chronic pain treatment, but says her epilepsy, Parkinson's disease and post-traumatic stress disorder patients have been helped.
“It will stop seizures cold, and it will stop tremors,” she said. “It's amazing.”
Trostle became interested in the medical marijuana option when a close relative started having seizures following treatments for brain cancer.
“Medications for epilepsy were giving such a poor quality of life that we need another option,” Trostle said, adding that the law prohibits doctors from certifying family members for medical marijuana.
“My goal is to give my patients the option,” she said.
Dr. James Chlebowski, a family medicine physician in Selinsgrove, Snyder County, has seen positive results in his patients.
“I’ve been pleasantly surprised,” Chlebowski said. "It works for young people with autism, older people with chronic pain. I've had a number of people who were able to completely come off all of their narcotics."
'Needs closely monitored'
Although Trostle warns, "It is not the magic bullet we hoped it would be," the co-founder of a Pittsburgh-based physicians group certifying patients throughout Western Pennsylvania says medical marijuana has been a game-changer.
Dr. Bryan Doner is chief medical officer for Compassionate Certification Centers, with 20 doctors and nine locations.
"Other than antibiotics, this is the best medication I've seen as a medical physician," Doner said. "Medical marijuana helps people where modern medicine has been unable to help.''
Dr. Yi Yan Hong, a pain management specialist in Johnstown, is not signing up to certify patients. He has has encouraged some of his patients to be certified by other physicians.
Although they have reported less trouble sleeping and improved mood, the pain-relief results have been disappointing, Hong said.
“I see no significant pain-relief effect in my patient population,” he said.
Like Douaihy and Trostle, Hong voiced concerns about the lack of research backing up the medical marijuana industry's claims. Putting control over dosage, strength and product type in the hands of pharmacists who work for the dispensaries is problematic for Hong, who considers himself a scientist and researcher.
“It is not a precise science,” he said. “It needs closely monitored. I think we should provide better followup and better monitoring. I won't be surprised you'll see more about the side effects from emergency room physicians.”
Hong laments the cost of medical marijuana treatment, which is not covered by Medicare, Medicaid or even most private insurance companies. His patients pay from $60 to $200 a month for legal cannabis, and it has cost up to $200 for the first visit with a certifying physician to qualify for the medical marijuana card.
“My patients are very desperate,” he said, explaining that those who suffer chronic pain have usually completed physical therapy, occupational therapy and tried a long list of pain medications – including opiates – along with homeopathic pain treatment.
“I am open to new ideas for treatment of pain,” Hong said. “We have to look at the risk-benefit ratio when we are heading in a new direction for this type of desperate patient.
“I don't want this to be the next Oxycontin.”
Displaying medical marijuana product packaging his patients gave him, Hong points out there are no instructions for taking the medication.
“You can use it 10 times a day or one time a day,” he said. “There is no end point.”
Even for the approved conditions, he points out, there are few clearly defined benefits. "Terminal illness,” for example, is one of the 23 conditions.
“Are we looking at pain? Are we looking at stress? Sleep? Appetite? There are no clear treatment end points and no guidelines.”