Why Utah doctors are hesitant to recommend medical marijuana, even though it is now legal

(Jeff Chiu | The Associated Press) In this June 21, 2018, file photo, a laboratory manager holds a cannabis sample in Oakland, Calif. Oklahoma health officials on Friday, July 27, 2018, released new proposed medical marijuana rules that remove some of the most controversial provisions, including a ban on the sale of smokable pot and a requirement that female patients get a pregnancy test. The original rules approved by the board earlier this month prompted outrage from medical marijuana supporters who said they went too far.

David Parault visited his doctor earlier this month resolved to put it all on the table.

He explained how earlier in the year, he’d conducted a self-designed “case study” with THC-laced mints to soothe his chronic neck and back pain. The cannabis had not only blunted the ache but lifted him out of an extended depression. For the first time in years, he’d gone for a jog.

The interaction with the doctor seemed to be going well, he said. Then Parault reached the crux of the conversation — he asked for a medical cannabis recommendation.

“That’s when things went really south,” Parault, 36, of West Valley City, said.

The state’s medical marijuana law, passed by lawmakers earlier this month, empowers physicians to suggest cannabis treatments for a specific array of maladies, even now, well before medical marijuana is sold in the state. Utah patients can then use these physician recommendations to ward off criminal conviction, provided they carry a limited amount of cannabis in a medicinal form.

But Parault’s physician said he had no protocol to deal with his patient’s request. He left the room to consult with a colleague and returned even more resolute.

"He said he will not associate his name with anything medical marijuana," Parault said.

Crafters of Utah’s new cannabis measure have touted its immediate payoff. Even though it could be a couple years before the first medical cannabis pharmacy opens in Utah, the new law decriminalizes the use of medical marijuana in certain cases with the supervision of a doctor, the legislation’s writers have said.

But in the past few weeks, some patients have stepped forward to say their doctors are unwilling to venture into this new frontier.

Intermountain Healthcare, Utah’s largest provider, is working on medical cannabis guidelines for its roughly 1,500 physicians but for now is telling its physicians to not give patients letters of recommendation.

There are "too many unknown details at this point for these letters to be provided to patients, and the law does not go into effect until July 2019,” Mark Briesacher, Intermountain’s chief physician executive, wrote in the memo. (The law actually took effect earlier this month immediately after Gov. Gary Herbert signed it).

Briesacher advised providers to tell patients that “most prescribing practitioners are waiting for more information and guidance before providing certified written letters” and that Intermountain is looking to state agencies for more clarity and guidance about the letters and physician training on medical cannabis.

University of Utah Health is in a similar holding pattern. And a spokesman for the U.S. Department of Veterans Affairs said as long as marijuana is illegal under federal law, V.A. doctors are “not able to prescribe it.”

Connor Boyack, who was a central figure in designing Utah’s new cannabis law, said the newfound medical marijuana program would be stuck in neutral without buy-in from the state’s health-care professionals.

“I’ve been hearing doctors have been very much in the Wild West, just dealing with patients and being inundated with requests,” Boyack, founder of the Libertarian think tank Libertas Institute, said. “This program is vulnerable if physicians are uninformed or unwilling to participate, so our hope and expectation is everyone in a position of knowledge can be part of the education process.”

Andrew Talbott, a pain management specialist who has worked with medical cannabis advocates, estimated Friday that he’s issued recommendation letters for about 120 patients so far. There is no legal limit to the number of recommendation letters physicians can write at this point, as the state is pulling together its cannabis program. After the program is implemented, general practitioners will only be permitted to recommend cannabis to 175 patients at a time, while specialists will be capped at 300 cannabis patients.

For now, Talbott has designed a form letter stating that he believes the patient in question suffers from a qualifying condition listed in the state law and would benefit from use of medical cannabis.

While Talbott said he’s studied the substance, many other doctors are still “in the cannabis closet.”

“I think there’s still a lot of reservations at this point in time from physicians because we don’t know what the program is going to look like,” said Talbott, who serves on the board of Together for Responsible Use and Cannabis Education.

That reluctance puts Parault in a difficult position. Afraid of being arrested or losing his job, Parault stopped using medical cannabis months ago, and the intense pain he’s experienced for about 20 years — since a large piece of lumber slammed against the back of his head — has been creeping back into his life. Parault isn’t convinced getting a recommendation letter will make it completely safe to use cannabis in Utah, but it’s a step in the right direction, he said.

“At least with a physician, I could say, ‘Look, I’m not a junkie. I’m not a criminal. I just find relief through this medication,'" he said.

Medical marijuana advocates have warned that how law enforcement deals with the new law could vary from agency to agency and have advised patients to consult with their local departments. The Utah Highway Patrol has released a new training bulletin instructing troopers not to detain or cite people for carrying cannabis if they have a physician’s written recommendation and otherwise appear to be following the new medical marijuana law.

The legal protection afforded by the law only covers patients with specific qualifying conditions, including HIV, cancer, Alzheimer’s disease, epilepsy, multiple sclerosis, post-traumatic stress disorder, autism and pain that is unresponsive to other treatments.

A University of Utah Health spokeswoman said it will likely be a few months before its cannabis guidelines are released, and patient Chirine Touati says her U. clinic is not willing to suggest medical marijuana at this point. Touati, who suffers from multiple sclerosis and uses cannabis to manage the symptoms, emailed her neurologists earlier this month to ask them about writing her a letter of recommendation.

The clinic’s response: “At this time our providers are not prescribing nor recommending the use of medical marijuana for our patient population. There have been no clinical studies to document the safety or efficacy of this substance. For this reason, we would not be able to recommend a specific product or dose, or be able to advise on what to expect regarding effect or side effects,” a nurse wrote in the email, a copy of which Touati shared with The Salt Lake Tribune.

Touati, 40, of Orem, said she generally likes her health care providers at the U. and doesn’t intend to go “doctor shopping” to find a more cannabis-friendly physician. Her plan is to continue using medical marijuana without a recommendation letter.

Meanwhile, the U. is working "as quickly as we can” on developing an approach to cannabis, a spokeswoman said.

“Because of the complexity of this issue, we must consider many factors, including the health and well-being of our patients, the best approaches for our faculty and staff. Further, we must be sure that we’re compliant with state and federal laws,” Julie Kiefer, manager of science communications at University of Utah Health, wrote in an email.

John Macfarlane, a neurosurgeon affiliated with Intermountain, said he’s open to exploring cannabis treatments for his patients but was unaware that the new law allowed physicians to issue recommendations now.

Because of his speciality, Macfarlane doesn't expect he'll deal often in the world of medical cannabis, but he said he'd consider topical creams and oils for patients dealing with neck and back pain.

“I think that the alternatives to opioids need to be completely explored,” he said. “I don’t have experience with cannabis, but I’ve had patients coming to me from going to Colorado or somewhere else getting cannabis edibles or oils, and they say in some cases their opioid use has been diminished and their pain.”

Some doctors, such as Court Empey, are still trying to get their ducks in a row before pointing patients toward cannabis treatments.

Empey, a pain specialist based in St. George, said he’s already had patients ask for recommendations but he hasn’t yet written any. Since the law’s passage, he’s wanted to confirm that suggesting cannabis won’t run afoul of his medical malpractice insurance (it won’t, he learned). And now, he’s looking for some continuing education courses that will teach him and the other providers in his practice about medical cannabis.

Empey said he’s grateful that Utah health-care practitioners have another option at their disposal, but he wants to make sure they’re recommending it in the right cases.

Physicians “obviously carry a lot of the blame and responsibility for this opioid crisis, and we don’t want to start another problem with cannabis,” he said.

The state’s new cannabis law does require qualifying providers to complete four hours of education for starters, but Boyack said that mandate doesn’t kick in until later on, when the full program is up and running.

A spokesman for the Utah Medical Association said the organization will help connect health providers with training on medical cannabis.

But even for patients whose doctors are willing to recommend cannabis, the anxiety attached to carrying the substance doesn’t evaporate.

Carrie Nazzise of Draper said her physician has researched medicinal cannabis and feels comfortable recommending it for certain conditions.

Nazzise, 31, who has multiple sclerosis, said she first tried cannabis more than a year ago during a trip to Colorado with her husband and has since returned every few months for a treatment. For about a day at a time, she’s able to walk without a cane, and she can use her hands again to do the things she loves — sew, crochet, play the piano.

If cannabis were available to her in Utah, she believes she might be able to hold a job again.

She plans to ask her physician for a letter of recommendation over the next month or so, but she doesn’t view it as a bulletproof shield.

“I’m still a little shaky about how much protection it actually affords, just because [cannabis] is still federally illegal,” she said. “I feel like there’s a lot of gray area that I’m not 100 percent confident in, but at the same time, I don’t want to be in pain every day.”