How I became a marijuana doc

Photo Cred: Freepik/jcomp

By Ken Sharlin

I am a neurologist who has practiced medicine in the State of Missouri since 2000 when I moved to Springfield from Nashville, Tennessee. I have an integrative hybrid-model practice in which I accept third-party payment for traditional neurology services and have a cash-pay practice for functional medicine. I do clinical trial research, too.

My patients run the gamut of general neurology from migraines to multiple sclerosis, epilepsy, Alzheimer’s disease, Parkinson’s disease, Amyotrophic Lateral Sclerosis, spine-related problems, peripheral neuropathy, and so on.

For many years, neurologists were known as great medical detectives, best at sleuthing out the elusive diagnosis, with few tools to treat their patients once the disease was given a name. This “diagnose and adios” reputation has improved in more recent years with the discovery of treatments for a variety of conditions, particularly epilepsy, migraine, and multiple sclerosis. But we have a long way to go in traditional allopathic medicine, and I am grateful to functional medicine for helping me to reframe my thinking about the root causes of disease.

Neither approach, of course, is perfect, and we are still in the business of disease management, supporting and nurturing our patients through their illness journey. Some we are able to guide back to resilient health, and for others we are able to change the trajectory of their illness so that they can live better quality lives despite their condition with fewer medications, improved function, and less daily suffering. I am always looking for new tools to add to my therapeutic toolbox.

In November 2018, Missouri residents approved a ballot measure to legalize the medical use of marijuana. The measure allows qualified patients to grow up to six cannabis plants or purchase up to four ounces of marijuana per month from authorized dispensaries. Since the approval of the ballot measure legislators have been created the bureaucratic infrastructure so that state legalized use of marijuana for medical purposes can become a reality.  

As of May 2019, Missouri was one of 33 states, in addition to the District of Columbia, to allow the use of marijuana for medical purposes. Importantly, the recreational use of marijuana remains illegal at both the Missouri State and federal level. Furthermore, the United States government has not legalized the use of medical marijuana. This means that users of medical marijuana, dispensaries, and providers who authorize the use of medical marijuana for their patients are in violation of federal law.

While this is unlikely to cause problems for Missouri residents, it should be a consideration when evaluating the benefit of medical marijuana for personal use. This could apply, for example, to eligibility for federal loans for education, housing, or disaster relief. In addition, the U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms, and Explosives has explicitly stated that any person who uses marijuana regardless of whether his or her state has passed legislation authorizing marijuana for medicinal purposes, is an unlawful user, and is prohibited by federal law from possessing or purchasing firearms or ammunition.

Since I am a neurologist, the legalization of medical marijuana in Missouri is especially important to me. According to the State of Missouri, most of the qualifying medical conditions for marijuana under the law are neurological conditions. These include:

• Epilepsy
• Intractable migraines unresponsive to other treatment
• A chronic neurological condition that causes severe, persistent pain or persistent muscle spasms, including but not limited to those associated with multiple sclerosis, seizures, Parkinson’s disease, and Tourette’s syndrome
• Amyotrophic lateral sclerosis
• Huntington’s disease
• Neuropathies
• Alzheimer’s disease with agitation
• Autism

Knowing that my patients would ask me to provide physician certification for medical marijuana, I decided to educate myself on the process and develop a framework in my office that would serve my patients while following state law and allow for fair profit from a business perspective. In the process, I did consult an attorney. I will share with you my process but urge you to review the laws of your own state and consult with your attorney before implementing this framework into your own practice.

I made the decision to provide medical marijuana physician certification to patients who fit the scope of my practice only. Therefore, patients who do not have a neurological condition will not qualify. Also, I view my role as a physician who treats patients holistically, not a doctor with a license to dispense a specific drug, including marijuana. Anyone who receives medical marijuana physician certification in my practice must be my patient and must see me on a regular basis in order to maintain their physician certification.

Because I accept insurance, and insurance reimbursement is based on billing for a condition whether that be diagnosis or symptoms-based, the patient’s first visit is a comprehensive history and physical with review of the pertinent records, including test results, all documented in my medical record. If the patient’s diagnostic evaluation is incomplete, they will be referred for testing or additional tests will be performed in my office.

No one under the age of 18 years of age is eligible. Those without insurance are offered the standard self-pay rate in my office. Patients unable to sign their own consent due to cognitive impairment may receive physician certification for medical marijuana on a case-by-case basis and must have a legal guardian or custodial parent. Medical marijuana physician certification will not be offered to pregnant or breast-feeding women.  

My policy applies to new patients in my practice and to established patients. Those patients who have been established longer than one year are scheduled for an extended, updated review of their condition whereas those who have been established less than one year will not require re-documentation as long as their initial evaluation is complete. They will still require a brief follow up visit to discuss our policy and make sure they understand the steps to receive and maintain medical marijuana physician certification.

Upon completion of this initial evaluation or extended follow up visit, a urine sample is collected for a urine drug screen. I will only provide medical marijuana physician certification to patients who have a clean urine drug screen. Individuals who test positive for illegal drugs or drugs that they are not prescribed will not receive certification through my office.

Once the results of the urine drug screen are reviewed, patients will be informed whether they are eligible for medical marijuana physician certification and an appointment will be offered to them for that purpose. As a courtesy, those who are not eligible will be informed as well. All eligible for medical marijuana physician certification will be asked to pay a fee to my office. In my state, physician certification fees range from $185 to $300. The fee must be paid in advance of the visit and is non-refundable for “no shows.” 

The medical marijuana physician certification visit consists of a brief review of the data collected, including any tests that have been performed. The next step is to go through the Medical Marijuana Consent Form. The version I use in my office is from the State of Florida and is the April 2019 revised form. Missouri has not published a state-specific consent form. I reviewed it with my attorney, and I have added the following language as an addendum:

“The U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms and Explosives follows federal law which prohibits any person who is an unlawful user of or addicted to any controlled substance from shipping, transporting, receiving or possessing firearms or ammunition. Marijuana is listed in the Controlled Substances Act as a Schedule I controlled substance and there are no exceptions in Federal law for marijuana purportedly used for medical purposes, even if such us is sanctioned by State law. By signing below, I am indicating that I have read and understand the above statement.”

As of June 28, 2019, Missouri began accepting applications for a medical marijuana card. The state requires that patients submit their physician certification form more than 30 days after the date of their application. Therefore, I strongly suggest they do not submit their application with the state until they receive their completed physician certification form.

In Missouri, the application must be submitted online, and this is the responsibility of the patient, not my office, although I am prepared to provide an electronic version of their physician certification form for their convenience. To maintain medical marijuana physician certification, I require that my patients are seen in my office by me on a quarterly basis. While these visits can be billed to insurance, this is the same policy established for anyone receiving a controlled substance from me.

Those who follow these guidelines will be provided their annual physician recertification at no charge provided there are no other changes in their condition and they continue to produce a urine drug screen that is consistent with the medications prescribed, including marijuana. Those who are lost to follow up and present later will be required to complete the process again and pay their physician recertification fee to my office.

I hope you have found this information helpful for your practice. Medical marijuana is unlikely to go away, and I suspect (my personal opinion) that in the next few years it will be accepted in all 50 states, and eventually be adopted into federal law.

The information has been presented without judgement, and this is not intended as a comprehensive evidence-based review of the pharmacological properties, therapeutic benefits, safety or side effects of marijuana. I am offering this information from the perspective of an experienced physician new to medical marijuana and the steps I went through to put protocols into my office. I invite comments from those who are also new to medical marijuana physician certification, and from those with more experience who live and practice in states where medical marijuana has been legal for much longer than Missouri.

Editor’s note: The opinions in this article are that of the author and do not reflect any opinions or official positions of Integrative Practitioner. Any information is not intended to be a substitute for professional legal advice. Always seek the advice of a licensed attorney. Photo credit Freepik/jcomp.