Editor's note: Today, the Missoulian concludes a three-day special report on issues surrounding the state's rapidly expanding medical marijuana industry.
Plenty of Montana doctors supported the voter initiative that made medical marijuana legal. Good luck finding one who supports what is happening now.
Medical providers across the state are mystified and angered by the way hundreds of Montanans have secured "green cards," or medical marijuana cards, at mass clinics staffed by out-of-state doctors.
"I think it's being corrupted," said Dr. Jim Guyer, director of the medical clinic at RiverStone Health in Billings. "What I see is there's been a wedge developed and the door's open. The people coming through the door are exploiting it. The people who are going to get hurt are the people the law was intended for."
Guyer and others who voted for the 2004 Medical Marijuana Act believed it would allow people suffering from terminal illnesses or a handful of other debilitating diseases to ease their pain with marijuana.
"I didn't envision there would be marijuana stores on every corner of Grand Avenue and these fairs at the Holiday Inn," said Dr. Deric Weiss, an internist at Billings Clinic who chairs the hospital's ethics committee. "Most of us envisioned it would be through your personal physician and part of a comprehensive plan of care."
Some patients have asked their regular doctors for help in accessing medical marijuana.
Under the Medical Marijuana Act, providers do not prescribe marijuana but certify that a person has a medical condition that qualifies for treatment with the drug. The state Department of Public Health and Human Services issues licenses based on provider authorizations.
But many, if not the majority, of medical marijuana patients in Montana have been authorized by physicians at traveling clinics set up inside convention centers or hotel ballrooms.
The doctors' identities are often kept secret; many - but not all - are from out of state. In a day, they see more than 100 patients who have paid to be evaluated.
"We have reached the point in Montana where medical marijuana certification is for sale with a physician's signature," Dr. Chris Christensen said during a recent meeting of the Montana Board of Medical Examiners in Bozeman.
Christensen, who runs a primary care clinic in Victor, said he has certified at least 3,000 patients for medical marijuana. But all of them received thorough assessments, and not everyone who asks for Christensen's signature gets it.
"I don't want to be painted with the same brush as physicians who sell their signatures," he said.
The medical board responded to concerns about mass clinics by issuing a position paper on medical marijuana. The paper will allow the board to discipline doctors whose care does not meet generally accepted standards.
It was clear that physicians who certify patients for medical marijuana after brief consultations at mass clinics are practicing below expected standards.
At most medical offices, providers spend 15 to 20 minutes with new patients, require multiple visits before prescribing powerful painkillers and follow up with patients after ordering any course of treatment.
"If you're treating diabetes, which is a chronic condition, you don't see a patient once and say, ‘Here's a medicine. Good luck with that,' " said Dr. John Petrisko, an occupational health specialist at Billings Clinic.
Doctors who authorize medical marijuana for chronic pain after a quick visit and without seeing the patient again are not doing their jobs, Petrisko and others said.
"What if there's another underlying cause that's not treated?" he asked. "Do you have back pain because you strained your back at work or do you have cancer?"
Members of the Board of Medical Examiners seemed to share the skepticism expressed by many Montanans over the mushrooming number of people with medical marijuana cards, but they were careful not to take a position on the legitimacy of marijuana as medicine.
Doctors interviewed for this story said they would authorize a patient for marijuana in the right circumstances, but that those circumstances are rare.
"I just can't see all these stores serving people with real medical symptoms," Weiss said. "It's being abused."
Dr. Camden Kneeland, a pain specialist at the Montana Center for Wellness and Pain Management in Kalispell, speculated that 3 percent of current cardholders have valid medical problems that can be treated with marijuana.
Kneeland and his colleagues authorize patients to use marijuana in three specific situations - when a dying patient is in pain, when other medications do not help patients with chronic nausea and vomiting, and when a patient has cachexia, a wasting disease that causes life-threatening weight loss.
"I have not seen a single patient using medical marijuana for pain who because of their use of medical marijuana has returned to work or reduced their opioid need," Kneeland said. "Basically, reading between the lines, they're smoking marijuana for all the same reason's everybody else does - to get high. When you're high, you don't care about pain."
Kneeland said marijuana can be psychologically addictive, which is not the same as chemical dependency. A marijuana user who stops using the drug will not experience physical withdrawals, Kneeland said, but might struggle to stop because of a psychological addiction.
"People can be addicted to shopping even though there's no chemical dependency there," he said.
Meanwhile, people who use marijuana for purely analgesic reasons might have trouble controlling their pain because marijuana is not regulated for quality or potency.
"I think there are valid uses for it," said Lee Ann Bradley, a pharmacist in a Missoula pain clinic and president of the Montana Board of Pharmacy. "I don't think you can control the potency. There's no quality control. I don't think you can treat it the same way as prescription drugs until it's regulated."
Few clinical studies examining the efficacy of marijuana as a painkiller have been conducted in the United States, and doctors like to have evidence that a therapy works - and works better than existing medicine - before they recommend it.
A handful of studies conducted at the University of California's Center for Medicinal Cannabis Research found some analgesic properties to marijuana, but the results should not be taken as proof that marijuana is an effective painkiller, said Dr. J. Hampton Atkinson, a co-director of the center.
In one of the studies, HIV patients with nerve pain who smoked marijuana cigarettes reported a significant reduction in pain, Atkinson said.
About half of the patients said their pain was reduced, compared with 15 percent of patients in a control group who smoked marijuana cigarettes with the active ingredient removed.
The most pain relief occurred when moderate amounts of THC were in the patients' systems.
"You don't need to be stoned and be out of it to experience analgesia," Atkinson said.
But many of the study participants were on other painkillers, so it is difficult to know whether the marijuana alone eased their pain.
"We've done the science. There seems to be something there," Atkinson said. "It's up to policymakers to decide what to do with this data."
Billings Gazette reporter Diane Cochran can be reached at (406) 657-1287 or email@example.com.