Growing Pains at N.J. Marijuana Dispensary
May 23, 2013
Jennifer Hanawald, Pharmacy Practice NewsWhen New Jersey’s first alternative treatment center opened for business in December 2012 in Montclair, patients from all corners of the state began trickling into the urban-suburban town 12 miles west of Manhattan. Residents with chronic pain and 13 other diagnoses joined a growing number of people across the country now able to fill legal prescriptions for marijuana. But then, overwhelmed by servicing the entire state, the dispensary (Greenleaf Compassion Center) said in late March it would only take new customers residing in seven northern counties.
It took almost three years for the Garden State to move from legalizing its medical marijuana program (MMP) to implementing it. Some involved in that process express strong satisfaction with its outcome. Others say a combination of overly zealous regulations—only one of six slated dispensaries is operational—and reticence on the part of physicians to prescribe a drug that still has stigma attached to it have hampered real progress.
Not De Facto Legislation
According to Joseph Stevens, the co-founder of the Greenleaf Compassion Center, new patients receive about half an hour of education that includes advice on risks and benefits of medical cannabis and methods of ingestion, which include smoking, vaporizing and potentially, cooking products in their homes. “We tell patients to start slowly. If they have been using it illegally, we explain that ours is a little different, it’s truly medical grade. Patient feedback is ‘Wow, I’m using a quarter of what I used in the past.’”
Patients fill prescriptions for up to two ounces of the dry flower (three strains are available)—the state-mandated maximum allowed for a 30-day period. Doctors set the time period for which patients can obtain the medicine (30, 60 or 90 days), after which they must reassess the patient’s status before renewing.
Health care providers and scientists at a February conference sponsored by Americans for Safe Access (ASA), an organization that works to advance legal medical marijuana therapeutics and research, presented extensively on the developing area of science of cannabinoids. Attendees from other areas of the country who have been prescribing the medicine for patients dealing with pain emphasized the drug’s usefulness, in addition to, and sometimes instead of, standard opioid treatment.
Deborah Malka, MD, who is board certified in integrative and holistic medicine, holds a PhD in molecular genetics, and is the former director of health services with MediCann, a California-based network of medical cannabis doctors, noted that she has seen many older patients who were looking for another option, encouraged to do so by their children. “The side effects are the main thing. People get so hooked on opioids. There are better ways with less toxic side effects.”
But getting in the door in New Jersey isn’t easy. Wait times for new patients were about two months as of early March, and no one is allowed in the building who hasn’t already been diagnosed with one of 14 qualifying conditions. That diagnosis must be made by a physician registered to participate in the MMP and with whom the patient has a “bona fide” relationship. The doctor in turn certifies the patient online, a step that allows the patient to then register, which itself costs $200 ($20 for those on state or federal assistance programs).
As of March 1, 206 New Jersey physicians in more than 20 specialties were registered in the MMP, in areas ranging from internal medicine and oncology to anesthesia and ophthalmology. (All are searchable on the state’s website by specialty and geographic location.)
One busy family doctor practicing within a couple of miles of the Montclair center said she saw the program as something for specialists, such as oncologists and neurologists, and doubted there would be widespread physician involvement, adding, “I wouldn’t use it in my practice. That doesn’t mean I wouldn’t refer someone to another doctor. These days, it’s easier, especially when the government is involved, to not do it. There’s too much paperwork involved for my office.”
Mr. Stevens acknowledged that there is a degree of bureaucracy for doctors and patients to work through but insisted that it was manageable and noted that most of the physicians calling him have educated themselves on medical marijuana and the program, which is spelled out with step-by-step instructions on the state’s Department of Health website.
“It’s been a long process to navigate rules and regulations and a little difficult, but the state has done a great job in creating the program and setting a standard in the United States. The security that they put in place, the oversight on the centers—it’s a great program. It’s limited to patients. Only they can get it. As Gov. [Chris] Christie [R] said, it’s not de facto legalization.”
Learning From Others
Legal experts say the system will give access to those with legitimate conditions but prevent abuse of the Schedule I controlled substance. They suggest that New Jersey was able to learn from the mistakes of other states.
“California was the first state to decriminalize medical marijuana. Initially, it was very loose in terms of regulations, and didn’t have a statute with restrictions or ounces allowed or anything about dispensaries,” said Diane Hoffmann, JD, the director of the Law and Health Care Program and a professor of law at University of Maryland Francis King Carey School of Law, in Baltimore, who has written on the issue of decriminalization.
“[Los Angeles] had hundreds of dispensaries. They’ve subsequently attempted to scale back, but this has been challenged at every turn. It’s hard once you have an unregulated situation to pull it back in.”
Ms. Hoffmann believes that states forming MMPs now are watching what has happened in California and other states that passed laws early on, and are taking measures to avoid what they see as abuse of the system. New Jersey, she noted, “doesn’t allow cultivation. They are saying you can only get it [through the alternative treatment centers]. They are tightening up but are trying to balance access for medical purposes with concerns about diversion to those who are not lawfully approved to possess marijuana, especially minors.”
Mr. Stevens said he has already witnessed a number of what he describes as success stories. “On the first day [Greenleaf was in operation] a guy came in. He was on 300 mg of morphine a day. He was like a zombie. He would take his dose of morphine and he would lie on the couch and his wife would go to work. She would come back and he was still in the same position. One and a half months later, he’s vibrant and full of life. His life is back.”
But some say the restrictions mean few will see any benefit. Ken Wolski, RN, MPA, the executive director of the Coalition for Medical Marijuana in New Jersey, said, “We consider the program pretty dysfunctional at this point. Less than 200 patients have gotten access to medical marijuana, despite the bill passing into law more than three years ago.”
Mr. Wolski, who estimates that potential beneficiaries of medical marijuana in the state could number in the hundreds of thousands, asserted, “Regulations were designed to make this program fail.” He noted that home cultivation was taken out of the bill during the legislative process, the drug is only available at alternative treatment centers—which are more heavily regulated than pharmacies—and that the Christie administration added restrictions that were not in the bill, including the requirement that physicians be registered. Physician registration is not a requirement in most other states, and 15 of the 18 states that have decriminalized medical marijuana allow for some or all of the patients and caregivers to cultivate their own plants.
Another obstacle, according to Mr. Wolski, is mindset. “Doctors have to recognize there’s a whole new field of emerging science on the endocannabinoid system. There is so much misinformation about it. That has to be overcome and the only way to do that is by physician education. This science about cannabinoids and how they work in the human body was discovered in the 1980s and 1990s. Doctors didn’t learn about this in med school. It’s incumbent on them to figure this out. They should be taking continuing medical education credits devoted to this.
“Marijuana works synergistically with opioids—it’s not one plus one equals two, it equals three or four. With marijuana, the body needs less opioid. Analgesic properties are enhanced, and some patients say they manage to go off these dangerous, potentially lethal drugs entirely when they use marijuana.”
Whether New Jersey’s system will achieve the delicate balance between truly meeting public health needs and addressing concerns about misuse remains to be seen. One thing is clear, however: The state brings yet another model to the patchwork of solutions popping up across the country, and it’s attracting interest. Mr. Stevens has been busy fielding calls, not just from physicians and patients, but also representatives from other states. “I’ve spoken to states looking to create their program—
New York, Connecticut, Delaware—they are looking at New Jersey as a guide.”