July Is Pivot Point For Scope Of AMMA Impact

The Arizona Medical Marijuana Act (AMMA) as adopted by the voters contained a limited universe of debilitating medical conditions that patients had to have to become Qualified Patients (QP)  legally authorized to possess and use cannabis. That universe included eight specific diseases and five symptoms that could be caused by any chronic disease or condition or the treatment of any of them.  Arizoneout detailed the specifics in a June 6, 2011 post.

But that universe was not static, as the AMMA itself requires a process where the citizens can petition the Arizona Department of Health Services (ADHS) to add new debilitating medical conditions for which medical pot use could be authorized.  ARS § 36-2801.01  The law requires ADHS to set rules for the consideration of such requests, and to act on them within 180 days.

The rules ADHS created allow it to designate a very short window in which ADHS will accept petitions in January and July of each year.  The first such window was open for five days at the end of January 2012, and ADHS received a number of petitions during that window. 

Per ADHS rule, the petition had to include: 

1. evidence that the medical condition impairs the ability of the individual to accomplish activities of daily living;
2. evidence that marijuana provides a therapeutic or palliative benefit for the condition; and
3. whether conventional medical treatments provide a benefit for the medical condition.

Petitioners also had to submit supporting data from peer-reviewed scientific journals.

ADHS' medical review team made a preliminary decision that four of the petitions had enough evidentiary support to warrant a full hearing.  ADHS accepted on-line public comments, and conducted a public hearing on those four petitions on May 25, 2012.  The decision is due by the end of July.

Of the original debilitating conditions in the AMMA − the ones we have been operating with for more than a year − the one the overwhelming majority of QPs cite in their applications is chronic pain.  That condition, which is extremely subjective and, some would say, easily faked, has been cited by nearly 89% of the nearly 31,000 applications ADHS has received so far.  The next most prevalent condition is muscle spasms, at nearly 14%, and nausea, at just over 10% of applicants.  Like chronic pain, muscle spasms and nausea are largely self-reported and subjective.  In other words, a recreational user could fake it easily enough, especially with the help of a cooperative physician.

The four conditions currently under consideration arguably fall in the same category as chronic pain, muscle spasms, and nausea.  The pending petitions seek to add post-traumatic stress disorder, depression, migraines, and generalized anxiety disorder to the list of eligible debilitating medical conditions.

ADHS has assembled a lot of information and public comments on these four conditions, including research ADHS commissioned from the University of Arizona College of Public Health,  all of which is available on its website.  Between now and the announcement of the decision on the four petitions, Arizoneout will be reviewing the collected materials and offering tidbits of particular interest to employers.

ADHS Director Will Humble is quite firm that the decision will be based on the medical evidence.  "I want to make sure I'm basing my decision on good science, and Iʼm really looking at the full weight of the evidence," he told the Arizona Republic.

Humble has no illusions, however, that the ADHS decision on the petitions will go down without challenge.  No, being the litigation veteran he has become since passage of the AMMA in November 2010, he probably expects to be sued no matter what ADHS decides.  The AMMA itself authorizes judicial review of decisions on petitions to add debilitating medical conditions.
 
July also likely will bring another round of petitions, and some probably will propose the same four conditions now under ADHS review, if more scientific evidence has become available in the last six months.  ADHS will accept such petitions for five days from July 23 to 27.  Just part of the AMMA's never-ending, ever-expanding mechanism for making marijuana available for medical use.

 

Humble Follows Through On Reporting Suspect Physicians

In a June 7 post, Arizoneout reported on Arizona Department of Health Services (ADHS) Director Will Humble’s outreach to physicians on the requirements for certifying Qualified Patients (QPs) eligible to use marijuana under the Arizona Medical Marijuana Act (AMMA).  While seeking to educate physicians, ADHS also warned then that it would monitor demographics and report physicians suspected of unprofessional conduct to their licensing boards.

Director Humble has followed through on his threat.  On August 19, 2011, Humble announced that he and his Chief Medical Officer, Laura Nelson, M.D., had written letters to the licensing boards of 8 physicians, 3 of them M.D.s and 5 of them naturopaths.  Humble did not identify the physicians in a post to his blog, but he did say that among them, the eight physicians accounted for nearly half of the 10,000 medical marijuana certifications ADHS has received since the program started taking applications in April 2011.

The certification form requires a physician to affirm that he has checked the QP’s profile on the Arizona Board of Pharmacy’s Controlled Substances Prescription Monitoring Program database.  Director Humble had identified 10 physicians who had issued more than 200 certifications each, and then checked with the Board of Pharmacy to see if the 10 physicians have been logging in and checking the database as they have attested.  The reports he got back from the Board of Pharmacy caused him to report that it appears that 8 of the 10 physicians were making false statements in their certifications.

According to a story in the August 20, 2011 Arizona Republic, one physician issued more than 1,000 recommendations, yet checked the database only 56 times.  Three physicians had never even accessed the database.  Humble said it was obvious the physicians were not acting “on the up and up.”

Ads for Pot Docs Proliferate

I am a fan of Phoenix New Times.  The alternative weekly has some hard-hitting reporting and covers stories that the mainstream local media sometimes ignores or gives superficial coverage.  So it is no criticism of the editorial content of that publication when I say I turned to its ad pages to see how Arizona physicians were handling their responsibilities under the Arizona Medical Marijuana Act (AMMA).

A couple of recent issues had two full pages of ads for medical marijuana related products and services.  Most of those ads promoted medical marijuana evaluations.   The going rate seems to be about $100 for certifications.

The ads feature clever phrases such as "Get Legal Now," and "Chronic pain qualifies you!"
Other ads feature smiling, attractive and predominantly female health care providers in white lab coats with stethoscopes draped around their necks.  The ads assure that services are "100% Privacy Guaranteed!!!"   There's even one ad offering a "compassionate special" -- refer five people and the renewal is 50% off.

Arizona employers need to know that it does not appear difficult for workers who want a medical marijuana ID card to find a doctor who will certify their need for one.

Many Physicians Eligible to Prescribe Medical Marijuana in Arizona

The Arizona Medical Marijuana Act (AMMA) authorizes medical doctors, osteopaths, naturopaths, and homeopaths who are licensed in the state to provide the medical certification to the Arizona Department of Health Services (ADHS) that equates to a valid medical marijuana prescription.

During the ramp-up to the AMMA’s implementation, one of the most closely watched issues was whether the ADHS regulations would require a long-standing physician-patient relationship before the physician could provide a medical certification as part of the Qualified Patient (QP) application process.  The proposed regulations issued originally by ADHS contained a requirement that the physician-patient relationship either:

(1) had been in existence for at least a year and had included at least four in-person visits during the course of the relationship in which the physician had assessed the debilitating medical condition for which the medical marijuana was being prescribed; or

(2) be one in which the certifying physician has assumed primary responsibility for the management and routine care of the patient’s debililtating medical condition at the time of certification

In essence, the original proposed regulations would not allow a physician to provide a medical certification solely for the purpose of prescribing medical marijuana. 

When the final regulations came out, the requirement that the physician have a yearlong preexisting relationship with the patient or assume primary responsibility for the ongoing treatment of the condition had been eliminated. 

Instead, as the ADHS FAQ on QPs states,

The written certification given to a qualifying patient does not have to come from the physician diagnosing the qualifying patient’s debilitating condition or from the qualifying patient primary care provider.  The written certification can be obtained from a different physician whom the qualifying patient has consulted about the qualifying patient’s medical use of marijuana.”

In other words, a QP can see a physician solely for the purpose of obtaining a prescription for marijuana.  All that is required of the certifying physician is that he or she

• Make a confirmed diagnosis of a debilitating medical condition.
• Establish and maintain a medical record for the QP as required by state law.
• Conduct an in-person medical exam “appropriate” to the debililtating medical condition.
• Review other medical records from physicians who have treated the QP within the past 12 months, the QP’s responses to conventional medications and medical therapies, and the QP’s profile on the Arizona Board of Pharmacy Controlled Substances Prescription Monitoring Program.
• Explain the potential risks and benefits of medical marijuana to the QP.
• Disclose the physician’s relationship with any dispensary to which he refers the QP.
• Attest that in his or her professional opinion, the QP is likely to receive therapeutic or palliative benefit from medical marijuana to treat or alleviate the QP’s debilitating medical condition.

ADHS Director Will Humble and Chief Medical Officer Laura Nelson, M.D. sent a joint open letter to physicians just after the final regulations were released.  The letter characterizes the Arizona regulatory program as one crafted to “be the first true medical marijuana program in the country” because of the expectations it sets for the clinical assessment required to issue a medical marijuana certification.”  Director Humble and Dr. Nelson say this is their way to try to avoid a program that over time becomes “largely recreational.”

ADHS has warned physicians that it will review the demographics of the QPs.  If ADHS determines that a physician is engaging in unprofessional conduct, it has promised to provide information to the physician’s licensing board.

The warning is not stopping the “pot docs” from advertising their services.  A couple of days ago, my craigslist search for “medical marijuana certification” located 17 offers in the Phoenix area alone.  The weGrow outlet whose grand opening I reported on last week offers medical certification assistance.  Several medical providers have set up dedicated websites.

Thus, despite the sincere efforts of the ADHS regulators, it appears that some Arizona physicians are making a thriving practice out of medical marijuana certifications.  Your employees should not have a difficult time getting a QP ID card if they need one, and maybe if they just want one.  Only time will tell.