They are on the front lines of the marijuana debate, the ones who decide who should be allowed to smoke, ingest or inhale what is still an illegal drug in Rhode Island without fear of arrest.
They include neurologists, oncologists, infectious disease specialists, more than one family clinic doctor, the medical director of a drug-abuse addiction center and a psychiatrist running for mayor of Providence who is a conservative on most other issues, but not the politics of marijuana for a patient prone to nausea, anxiety and panic attacks.
Altogether, 355 Rhode Island doctors have signed state forms asking the Department of Health to issue marijuana-use cards to at least one of their patients.
But 21 of those doctors account for more than a third of the 1,347 medical marijuana cards issued so far, according to the Department of Health.
Dr. Vladislav Zayas, an East Providence neurologist, tops the list, having signed off on the legal use of marijuana by 100 of his patients. The next closest doctor signed 54; the third signed 36.
Zayas has declined comment. But nine doctors talked openly in recent interviews about why they opened the door to legal marijuana use by their patients.
Some are more convinced than others of the medicinal value of the drug.
Providence mayoral candidate Daniel S. Harrop III acknowledges some discomfort in knowing that the one AIDS patient for whom he has approved marijuana use has to “sneak around the garage he goes to on the west side of Providence to buy this stuff…but I don’t ask about that.”
Dr. Debra Roberts, a family doctor in a community health center in Warwick, says she has become increasingly uncomfortable at being the final arbiter in what she views as a legal, political and ethical debate. “I feel like it’s a political issue that I don’t love being in the middle of,” says Roberts, who has signed 18 applications.
“I think people use it. I think it does help their pain,” she said. “I don’t like to be the one to allow people who may have other addictions the right to not get arrested for having this marijuana…I feel like they should just legalize marijuana then. Instead they have to come to me, and I legalize it for them.”
But several doctors said they signed the medical marijuana applications because their patients told them they were already using the drug and did not want to get arrested for doing something that eased their pain, and improved their “quality of life.”
Dr. Josiah Rich, a Brown University professor and infectious-disease doctor, who is an outspoken advocate for decriminalizing marijuana, says: “It’s absolutely crazy to incarcerate somebody for doing something they believe is good for their health.”
In a candid moment, however, another doctor acknowledged signing the paperwork for an inveterate drug-user because “his fiancé wants him not to break the law.”
In retrospect he rationalized his decision this way: “He has a construction job. He goes to work. He does his part. His life is a lot better when he is not chasing Vicodin, 20 to 30 pills a day.”
Technically, all a doctor need do is check off one of the boxes on a patient’s application for a medical marijuana card that broadly describes the patient’s qualifying condition, such as cancer, glaucoma or AIDS. The patient then takes the paperwork to the Department of Health, which has taken the position it cannot second-guess or even question a doctor-signed application. More than two-thirds of the cards the Department of Health has issued so far went to people whose doctors checked off: “chronic or debilitating disease or condition.”
Here is what some of the doctors with the highest number of patients using marijuana legally had to say.
Dr. Syed A. Rizvi is near the top of the list with 36 patients approved for marijuana use. He is a neurologist, specializing in the treatment of patients with multiple sclerosis.
Rizvi says he does not recommend marijuana to his patients. “They would ask me if they could use it.” Even then, he said, he would only sign the application if he had been seeing the patient for years, and the patient had “fairly advanced disease.”
Rizvi said he tells his patients “there is no good study supporting the use” of marijuana by people with multiple sclerosis, except perhaps to help alleviate leg spasms, while “there may be studies suggesting that it can worsen your cognitive function.”
But “these patients, like I said, are doing it anyway,” he said. “They want more security by having a form signed. That’s all they want.”
Asked whether he believed the drug had medicinal value, he said: “It’s a strange answer.”
“All the patients that take it like it,” he said. But, “if you are [taking] a drug which has certain effects which are euphoric…and people who don’t have MS taking it [also] say — ‘Oh, I feel good’ — I don’t know what that means. Does it help MS patients? Well, individually, these patients feel better…They’ll say all kinds of symptoms are better….[But] you really can’t make any judgment unless you have a controlled trial.”
Rizvi, 43, said he has nonetheless signed applications for patients “who are extremely disabled. At that point, their quality of life is probably the biggest thing.”
As an internist and medical director for a methadone clinic known as the Discovery House, Dr. John S. Straus says: “We are in the harm reduction business.”
“When someone isn’t using IV drugs and committing crimes and ending up in emergency rooms overdosing and ending up with HIV and Hepatitis C, they are successful…,” he said. “And so while marijuana philosophically is a drug and it has potential to do harm, relatively speaking, it’s in the minor leagues.
“I mean people don’t get HIV from marijuana.”
Straus said the 12 patients he helped get medical marijuana cards have a variety of “pain syndromes” resulting from osteoarthritis, for example, or fibromyalgia. But he said: “Some people find it highly effective for anxiety as well.”
He said it is a juggling act, knowing which drugs to prescribe to reduce a patient’s dependence on or craving for more potent drugs, including methadone. “In my private practice, I am into doing what is effective…If there is no other effective treatment and there is no harm with the marijuana in terms of the person’s functional status, then I see nothing wrong with it.”
On the other hand, he said he doesn’t always say yes and has “doubts about decriminalizing it…because you can let the genie too much out of the bottle. There has to be some constraint on drug use.”
He told about a patient he saw just the other day who has been taking a prescribed alternative to methadone, called Suboxone, who “wanted marijuana for his anxiety. But I feel like he is not doing his part to help his anxiety. Like he is doing nothing and I said I can’t write it for you. You have to exercise. You have to see a counselor. You have to do your part.”
Dr. Dennis Mikolich is an infectious disease doctor who has helped 54 patients get medical marijuana cards.
With the second-highest caseload of legal marijuana users, Mikolich did not shy away from talking about the decisions that he said he made on behalf of patients with chronic and debilitating conditions, such as HIV and Hepatitis C.
But he acknowledged a concern about having his name in the newspaper and half-jokingly asked if “instead of using my name, you could refer to me as an ID (infectious disease) physician with an office in Cranston with a Slavic sounding … name?”
He is also uncomfortable because he believes “the public still isn’t entirely convinced it is a good thing…I think there are some negative connotations associated with it.”
“It is not a good position to be in, but it is one I put myself in because the patients I treat …seem to respond to the medical marijuana,” he said. He also stressed that he only approved applications from patients with whom he had an established relationship.
He said “most of my patients who opt to use [medical marijuana] are either severely debilitated from chronic infections… associated cancers… [or] treatments using anti-viral medications or chemotherapy, and this is an act of compassion.”
“Many cannot drive, and if I suspect potential for abuse or danger then one is not given access by myself for a license.”
Asked how he would describe the benefits, he said: “Many patients I treat feel the immediate benefit of having this license psychologically, as they are already using [marijuana] and are afraid of legal consequences if found to be in possession of it, and not licensed.”
In fact, he said the majority told him they were already using it and are getting positive results: weight gain, a “better quality of life during the day,” and relief from side effects of their medical conditions, “including nausea, vomiting, different pains, depression, mood irritability.”
“My life is dedicated to helping patients, and improving quality of life,” he wrote in a follow up e-mail. “If it is legal and helps relieve whatever malady, then if I think it is safe and doesn’t jeopardize one’s well being, a form is signed.”
Like most of the doctors interviewed for this article, he said, he doesn’t know where his patients get the drug, but his staff provides his patients with the phone number of someone he knows only as “Reefer Jane” who “directs people to people who can grow it for them.”
A familiar face at the State House, Dr. Josiah D. Rich is a physician at Miriam Hospital and Brown Medical School who visits the Adult Correctional Institutions each week to give medical care to inmates. He is also an activist in drug abuse treatment.
He does not recommend legalizing the use of marijuana, because he doesn’t want to “encourage people to do harmful things.” But, he “doesn’t think anybody should go to jail for smoking marijuana.”
Over the last four years, he has helped 11 patients get medical marijuana cards.
He said he told each he “would not strongly recommend marijuana because of the potential damage to [their] lungs,” but recognizes that if “somebody is taking a life-saving medication [which they] can only tolerate by taking a small toke of a joint,” the marijuana may indirectly be saving their life.
One of the handful of doctors who acknowledged trying marijuana during his younger years, Rich said he “didn’t like what it was doing to my thought processes. It seemed to be clouding my memory.”
But he said the same “could be true for any mind-altering substance…even though they are of pharmacy grade.”
A family physician in West Warwick, Dr. Frank W. LaFazia has signed marijuana card applications for 31 patients over the last four years.
He seemed surprised by the number, but said the patients in this group have multiple sclerosis, Crohn’s disease, or are dependent on drugs such as Vicodin or Oxycontin for pain control.
“I treat a lot of low-income people,” he said, and “there seems to be some correlation between socioeconomics and people getting addicted to narcotics.”
“What I try to do is wean them off the narcotics,” he said. “People will steal to get narcotics…If they get addicted, they will do terrible things in their families. Marijuana doesn’t seem to cause that. Nobody is going to go out and rob your house… (or) rob a store because they need money to buy marijuana.”
“This isn’t the majority of my practice. I am not a pot doctor. I practice real medicine,” said Dr. Todd E. Handel, 37, who has signed 31 applications.
As a physiatrist with a sub-specialty in interventional pain medicine, he oversees the diagnosis, treatment and rehabilitation of people with sports injuries, and other causes of back and neck pain including spinal cord injuries and herniated discs.
Once the law allowed the medical use of marijuana, Handel said signing marijuana-card applications was not hard. “If my state legislature has said to me patients with these types of conditions should be allowed to have access to this medicine…my view is, I have been asked by the state legislature to provide this.”
Conversely, “am I violating the law by not signing it?” he asks.
He said he counsels his patients that marijuana might help their pain, but is also a psychotropic that could “affect their executive levels of function,” such as their decision-making and ability to drive.
From his own anecdotal observations, he said, the drug helps control his patients’ pain and muscle spasms, and in at least one case, “decreased the amount of opiates he is needing.” He said the majority of those for whom he has approved marijuana use “are able to decrease the amount of pain medication they are taking with medicinal cannabis.”
“Is it safer for a 21-year-old to be drinking alcohol and intoxicated versus [smoking] marijuana?
“I am not qualified to address that,” Handel said, but “an obvious opinion would be that the consumption of alcohol in this country is a much bigger problem, and the illicit use of narcotics…Vicodin… Percocet…Oxycontin …in this country is a much bigger problem.”
By Katherine Gregg
March 14, 2010
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Doctors tell why they OK medical marijuana requests