Weeding Out The Pain

Medicinal marijuana is now legal in New Jersey, but many of the state’s doctors remain perplexed about how to prescribe the drug. Will Jersey’s strict regulations limit the impact of pot for those patients who need it most?

Photo by James Worrell.

Dr. Mark Angelo has noticed a curious pattern in the lectures he gives to fellow physicians about medicinal marijuana. “The lecture hall is always overflowing,” says Angelo, who is head of palliative care at Cooper University Hospital’s Cancer Institute in Camden. “But when I ask who plans on recommending it to their patients, only a few hands go up. It seems most doctors are still somewhat skeptical about the program.”

The waffling on medicinal marijuana is not for lack of prep time. First introduced in the legislature in 2008, the Compassionate Use Medical Marijuana Act was signed into law by then governor Jon Corzine on January 18, 2010. Now, qualified New Jersey patients will finally have access to ameliorative cannabis when six stand-alone Alternative Treatment Center (ATC) dispensaries open across the state in the coming months.

Since few physicians have any formal training in the arena of medicinal marijuana, there is widespread uncertainty about how to prescribe, administer and monitor the drug. Moreover, some Garden State docs feel professionally conflicted about recommending marijuana—which remains a federally classified Schedule I controlled substance—to their patients. Just how prominent a role cannabis will play in New Jersey medicine remains to be seen.

“Since the bill was passed, I get requests about [medicinal marijuana] from patients every day,” says Angelo, who plans on integrating cannabis into a small segment of his practice. “But a lot of doctors still don’t know how they plan on incorporating this new product into their lineup of treatment in ways that can make patients feel better.”

By most accounts, New Jersey’s plan is the strictest of the 16 states that allow patients to access medicinal marijuana. For example, New Jersey’s list of medical conditions that qualify patients for the drug is narrower than any other. According to the state’s Department of Health and Senior Services (DHSS)—the entity responsible for managing and regulating the program—these debilitating conditions include amyotrophic lateral sclerosis (Lou Gehrig’s disease), multiple sclerosis, muscular dystrophy, inflammatory bowel disease and terminal cancer. Other terminal illnesses also qualify if a physician determines the patient has less than 12 months to live. And if conventional medical therapies prove ineffective, a few other conditions may qualify, including epilepsy and glaucoma.

New Jersey is also the first medicinal- marijuana state to prohibit patients from growing their own crops at home and to cap the level of THC concentration (the main psychoactive substance found in cannabis) at 10 percent.

“The 110 pages of regulations promulgated by Health and Senior Services is a monument to overly cautious bureaucratic detail,” says Ken Wolski, a registered nurse and executive director of the Coalition for Medical Marijuana New Jersey.

One of the regulatory details Wolski finds most troubling is the state’s physician registry. Since the fall of 2010, New Jersey physicians interested in recommending medicinal marijuana to their patients have been required to electronically register with the DHSS. In addition to making sure the registering physician is certified to practice medicine in the state, the online form requires that physicians have completed medical education in addiction medicine and pain management within the past two years.

“The physician registry is a major stumbling block,” Wolski says, adding that such narrow qualifiers will prevent many of the state’s top physicians from providing cannabis to patients who need it. “If the state wanted to make sure physicians have some type of training to provide medical marijuana—that would be reasonable. The only problem is that the training they require has nothing to do with the therapeutic uses of marijuana and why it’s effective in treating so many different diseases and conditions.”

In fact, some of the physicians interviewed by New Jersey Monthly expressed concern about their lack of information on dosage and potential side effects. But such marijuana-specific education is not part of the required training.

At deadline, 103 Garden State physicians had registered with DHSS. Even though he isn’t yet one of them, Dr. Jeffrey Miskoff says he plans to sign up despite his criticisms of the registry.

“The registration application is a joke,” says Miskoff, a pulmonary-disease and critical-care specialist in Manasquan. “I deal with severe illness and dying every day. I have four board certifications. And you want me to take a course on addiction? When I deal with things like morphine drips on a regular basis? It’s just so stupid.”

Dr. Jeffrey Pollack, who specializes in internal medicine in Mays Landing, was one of the first doctors to register with the state. He has written extensively—in letters to the DHSS as well as local newspaper editorials—about his objections to the registration process. “It’s another hassle for a very busy physician, and doctors are tired of hassles,” says Pollack.

Pollack says the application qualifiers—particularly the requirement for training in pain management and addiction medicine—are superfluous at best and potentially harmful to patients at worst: “If someone has terminal cancer, cannabis could be an indicated treatment. But are oncologists really getting pain-management training? That’s not their specialty. And how much is addiction really a concern in a terminally ill patient?”

Angelo does not share those concerns. He says the registration process—along with its qualifiers—is a good way to ensure tight control over the program.

“I love it,” he says. “I think it’s excellent to say we require physicians to have this kind of training. I think we should do that for all narcotics and [controlled] substances.”

Some physicians have expressed concern that the registration process may create the impression among peers and patients that they are “pot docs,” a caution that Miskoff dismisses.

“I think it’s bunk,” Miskoff. says “If you’re scared that just because you registered you will be labeled a pot doc, then in my opinion you’re an idiot. But if you don’t take loving care of your patients, or if you make your practice out of prescribing medicinal marijuana, then yes, you’ll be the pot doctor.”

Just as doctors must register to prescribe marijuana, so too patients will have to go through specific steps to get the drug. A patient whose name has been submitted by a qualified physician will have to pay a fee of $200 to the state before being issued a photo identification card, which can be used at one of the state’s six alternative-treatment centers to obtain no more than 2 ounces of marijuana every month.

The going rate for medical marijuana in New Jersey is unclear. “The ATC,” explains DHSS director of communications Donna Leusner, “may charge the patient for the reasonable costs associated with the production and distribution of medicinal marijuana.” According to a recent USA Today report, an ounce of medicinal marijuana sells for about $350 in Colorado and is considered sufficient for about six weeks of use by the average patient. Whatever the cost, it is unlikely that patients will be reimbursed for their prescribed pot. “Medical marijuana is not expected to be covered by insurance companies, neither the product nor the ID-card fee,” says the Medical Marijuana Coalition’s Wolski.

Still, the program gets high marks from those poised to produce and distribute the medicinal-quality herb. “We applaud the governor and health commissioner for taking a cautious approach to this,” says Raj Mukherji, a lobbyist representing Compassionate Care Centers of America Foundation Inc., which will operate an ATC in Central New Jersey. “We don’t want Jersey’s program to get out of control. And it’s not going to, because this is a contained medical model.”

As division chief of neurology at Mountainside Hospital in Montclair, Dr. John Vaccaro embraces medicinal marijuana’s potential benefit to his patients, some of whom suffer from qualifying conditions like MS. But despite the state’s cautious approach to doctor and patient registration, Vaccaro (a 2011 Top Doctor) is still concerned about the day-to-day monitoring of his patients’ progress with the drug and its efficacy in treating various conditions.

“I’m for it,” says Vaccaro, adding that he plans to register with the state. “But I don’t know the doses. I don’t know how to prescribe it.”

Dr. Jack Goldberg has similar concerns. The Cherry Hill-based oncologist (and 2011 Top Doctor) says he’s been following the growing popularity of medicinal marijuana since its folkloric origins in the early 1970s. Even though he sees the value it has in the area of supportive care management, Goldberg has not decided if he’s going to use cannabis in his practice.

“How do I administer it? How do I assess it? How do I know it’s benefiting? How do I know if I’m underdosing or overdosing?” says Goldberg, who views medicinal marijuana more like a supplemental treatment (such as massage or art therapy) and less like a traditional pharmaceutical that promises specific, quantifiable results such as weight gain or pain reduction. “Would I be the first in line to sign up to have privileges to prescribe this? No. Will I get it for my patients if they ask for it? Yes I will.”

Since neither the state nor the six ATCs plan to provide the training that might help physicians answer the types of questions posed by Goldberg and Vaccaro, New Jersey doctors will largely be left to their own due diligence. To that end, Dr. Steven Fenichel, an outspoken supporter of medicinal marijuana who practices at the Community Health Care clinic in Cape May Court House, hopes the state’s doctors will seek out the multitude of educational materials available across the country, including a large store of literature written by Dr. Lester Grinspoon, associate professor emeritus of psychiatry at Harvard Medical School and former senior psychiatrist at the Massachusetts Mental Health Center in Boston. As a physician and prominent marijuana activist, Grinspoon has written extensively on the topic of medicinal cannabis, and many of his volumes, such as Marihuana: The Forbidden Medicine, provide detailed medical uses for the plant while outlining the best ways doctors can monitor the drug’s benefits and side effects.

“A lot of docs still buy into the great mythologies of marijuana and the madness of propaganda,” says Fenichel. “I would love for them to understand that if they have a patient who is truly suffering and unable to get relief from other medications, they can cause no harm by recommending a trial of cannabis sativa. There’s nothing to be afraid of.”

Despite such claims, some doctors don’t see any need for medicinal marijuana. Dr. Kathleen Toomey is one of them. A hematologist and oncologist at Somerset Hematology-Oncology Associates (and a 2011 Top Doctor), Toomey opposes New Jersey’s medicinal marijuana initiative and has no intention of making it part of her patients’ treatment regimens.

The growing trend toward legalization across the country, Toomey says, is being driven by those dedicated to the larger goal of legalizing marijuana entirely—for recreational as well as medicinal use. While she does not necessarily oppose full legalization, Toomey rejects the notion that marijuana needs to be added to a physician’s arsenal of treatment options.

“It’s superfluous, and the big lie is that this is for the patient’s benefit,” says Toomey, who is satisfied to prescribe Marinol, a synthetic THC pharmaceutical used to relieve the nausea and vomiting associated with chemotherapy for cancer patients and to assist with loss of appetite in AIDS patients.

“They are trying to legalize marijuana through the back door using patients as an excuse, and as a medical professional I do not need it and won’t use it,” Toomey says. “I deal with evidence-based medicine. I believe in research, science. We’re putting a drug on the market for political reasons.”

Some physicians not opposed to recommending marijuana nonetheless have concerns about its long-term effectiveness and consequences. Dr. Michael Nissenblatt of the Central Jersey Oncology Center in New Brunswick (and a 2011 Top Doctor) says he is apprehensive that marijuana smoke may irritate the bronchial surfaces causing respiratory symptoms, allergic asthma, bronchitis, and diminished ciliary function.

“I’m not going to avoid it, but physicians have many reasons to be cautious about the drug. It’s not a panacea that will routinely correct every problem without consequence,” says Nissenblatt, who sees nearly 500 patients a month and estimates that he will recommend cannabis to about two patients a month. “But if we use it in the proper circumstances and know that it can cause other injuries to the lung, then I think it has application.”

As a lung specialist, Miskoff has similar concerns. He believes smoking marijuana may harm his patients, which is why he is particularly disappointed that DHSS regulations bar ATCs from selling marijuana in edible forms such as brownies.

“Let’s say my patient wants a brownie like you can buy in other states. That patient will have to cook it at home,” says Miskoff. “They aren’t looking to be Betty Crocker right now. They want easy care and to not have to work to be comfortable.”

Miskoff also questions the state’s 10 percent cap on THC concentration, saying such a relatively low dosage renders the drug far less effective than its potential.

“I [prescribe] high-powered narcotics all the time,” says Miskoff. “This THC limit is going to be like pissing in the wind.”

Wolski understands these concerns, but hopes New Jersey’s docs will continue to educate themselves, “for the sake of the patient.”

“I get calls all the time from patients who say, ‘My doctor doesn’t want anything to do with this.’ Or, ‘My doctor just laughs at me when I talk about using medical marijuana for my conditions,’” says Wolski. “These are patients with very serious medical problems, and right now it seems as though they are caught between a rock and a hard place. Only the physicians can help them out of it.”

Nick DiUlio is South Jersey bureau chief for New Jersey Monthly.

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SIDEBAR: NJ’s Legal Pot Purveyors

None of New Jersey’s six Alternative Treatment Center marijuana dispensaries would confirm their precise locations at deadline. Here are the names of the six ATCs, the regions they expect to serve and their contact information:

Northern Region (Bergen, Essex, Hudson, Morris, Passaic, Sussex and Warren counties):
• Foundation Harmony
Marina Karavas, 201-840-5800

• Greenleaf Compassion Center
Joe Stevens, 973-248-7927

Central Region (Hunterdon, Middlesex, Mercer, Monmouth, Ocean, Somerset and Union counties):
• Breakwater Alternative Treatment Center Andrew Zaleski, 732-703-7300

• Compassionate Care Centers of America Foundation, Inc. Raj Mukherji, 201-222-3300

Southern Region (Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester and Salem counties):
• Compassionate Care Foundation, Inc.
Bill Thomas, 267-614-3341

• Compassionate Sciences, Inc.
Andrei Bogoloubov, 917-849-9300


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