A Journal investigation: Specialists in marijuana recommendations draw scrutiny

Oct. 25--To use medical marijuana, first you need a doctor's permission. And these days, doctors aren't hard to find.

"Medical marijuana card consultations and renewals: Now only $149," advertises one doctor's office operating in Fall River.

"No appointments necessary. Walk ins always welcome," proclaims the website of another Massachusetts practice.

These medical practices exist solely to provide the state-required written recommendations for patients. Rhode Island has at least three such practices. Massachusetts has even more.

The medical marijuana doctors say they fill a void other doctors shy away from. But some out-of-state practices have drawn controversy.

This summer in Massachusetts -- where 38 percent of all Rhode Island patients get their recommendations -- regulators suspended the license of the medical director for one practice, Canna Care Docs. The state alleged he improperly allowed nurse practitioners instead of doctors to evaluate patients and issue medical marijuana recommendations.

Rhode Island only allows a doctor to make such a recommendation. One challenge for state regulators is that 85 percent of the recommendations are written for severe and debilitating pain. And pain is subjective and hard to validate.

But, in a decision that seemed to highlight the ambiguity in Massachusetts' four-year-old medical marijuana program, a state administrative law judge recommended last month that the license for the Canna Care Docs director be reinstated.

He argued that nurse practitioners had independent authority under the law to issue recommendations. The case is pending. In the meantime, Canna Care Docs said through a spokesman last week that the company, "does not presently use nurse practitioners to conduct its evaluations."

Canna Care Docs has offices in Fall River and Seekonk that attract many Rhode Island patients. Early this year the Raimondo administration proposed banning out-of-state practices from making recommendations for Rhode Island patients, concerned with the volume of recommendations they were writing for Ocean State residents.

"We want to minimize and eliminate abuse of the system," says Nicole Alexander-Scott, director of the Department of Health.

The measure, opposed by lobbyists for Canna Care Docs, failed last session in the General Assembly.

What about the patients?

The hesitancy of mainstream doctors in Rhode Island to consider writing medical marijuana recommendations forces patients such as Shaun McDonald, of Coventry, to look elsewhere.

On a recent day, McDonald, a 31-year-old suffering from severe back pain from an auto accident, showed up flustered at the door of North Kingstown's Medical Cannabis Consultants, also known as "The Green Script."

McDonald's orthopedic doctor initially cleared him for the program two years ago, but when McDonald asked for a renewal, he was told the office no longer made medical marijuana recommendations.

"I'm kind of scared thinking I'm going to lose my medicine that's changed my life, got me back to work," McDonald said. "I was thinking, oh man, I'm not going to get the medicine. I'm going to have to quit my job. And then Green Script got everything right."

Rhode Island's two other main practices are: 11th State Consultations, on Reservoir Avenue, in Providence, and B&B Medical Marijuana Evaluation Center, in Warwick.

Inside B&B

Bill and Jessica Cotton, who run B&B, acknowledge problems with some medical marijuana physician practices, particularly those operating in Massachusetts. They call them "doc shops."

But B&B isn't a doc shop, they say. The Cottons opened the practice in a Toll Gate Road office building four years ago. Neither are doctors themselves, but the practice employs three doctors. They don't treat or diagnose, but they review patients' existing medical records and fill out recommendation forms.

Bill Cotton, a patient who uses medical marijuana to treat his multiple sclerosis, said he saw a need to have a nonjudgmental place where potential patients could consult a doctor. It's no different than going to a pain clinic, he said.

"A lot of doctors were federally funded and were scared," they might lose funding by associating with what the Feds consider an illegal drug, Bill Cotton said.

Today, their practice has some 3,500 patients. Jessica works the front office. Bill educates patients about the various strains of marijuana and how they work.

The Cottons require patients to submit medical records substantiating they have a qualifying condition. B&B also requires patients to come back for a follow-up visit with one of its doctors to demonstrate the bona fide doctor-patient relationship required under law.

No health insurance provider covers a medical marijuana patient's bills, which can be as high as $250 for an initial consultation and $75 for follow-ups.

As a result, some patients, Bill Cotton says, opt to visit practices that are more lenient and don't require followups. Those practices are attracting illegitimate patients who might be producing marijuana for the black market.

"If you have a place that's not doing their due diligence, that's where the 18-to-27-year-olds are getting the OK," Bill Cotton said. "They're coming back over the border ... and have huge grows. It's literally feeding the black market."

Canna Care's lobbyists

The Raimondo administration was particularly concerned about patients getting proper evaluations over the border in Massachusetts.

A month after her budget proposal threatened to cut into their business, Canna Care Docs hired the well-known lobbying team of Wallace Gernt and Christopher Reilly and became one of their highest paying clients.

Gernt and Reilly are also the lobbyists for the Marijuana Policy Project, which pushes for recreational legalization. And Reilly helped develop the Thomas C. Slater Compassion Center dispensary and serves as its spokesman.

The provision was stripped from the budget when the House reworked the plan.

House Speaker Nicholas Mattiello, who declined to be interviewed for this series, offered this explanation the night the House's budget was unveiled.

"It's a prescription," he said. "I looked at it from the point of view of if you get a prescription for some other medication, an out-of-state prescription is good in Rhode Island, so why would you treat that differently?"

Other steps

While the Raimondo administration failed to eliminate out-of-state doctors, the health department now requires patients to submit medical records documenting their condition.

Joseph Wendelken, a spokesman for the health department, said the law has always allowed this. And is doing so now because there are "so many out-of-state doctors involved in the program."

Still the regulation is drawing concern over medical privacy.

"It is a recipe for confusion and arbitrary decisions and may greatly slow the already slow application process to a crawl," said JoAnne Leppanen, the director of the Rhode Island Patient Advocacy Coalition.

"Imagine if your doctor wrote a prescription that you needed today but you had to wait weeks or months for the permission of the health department. What happens to a patient in the meanwhile?"

More from this series:

Part 1 The Transformation

Part 2 The Dispensaries

Part 3 Pot Entrepreneurs

Part 4 Pot Doctors

Part 5 Gray Areas (coming Thursday)

Part 6 The Debate (coming Friday)

Part 7 The Man Behind the Curtain (coming Saturday)

Part 8 The Future (coming Sunday)

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