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Legal but scarce: Medical marijuana proves difficult to get, particularly in rural areas

Medical marijuana is legal in Minnesota for 13 qualifying conditions, but patients are having trouble getting a prescription for it, particularly in rural areas where many doctors are not certified to prescribe it. Stock Art1 / 3
The majority of the medical cannabis products sold at dispensaries come in liquid form that patients vaporize and inhale. Submitted Photo2 / 3
The medical marijuana dispensary products are sold on a spectrum. Some have higher TCH content, others have higher CBD content. Indigo, one of the products, is CBD dominant. Submitted Photo3 / 3

Marijuana is slowly creeping onto the scene of Minnesota's medical industry. Whether people are for it or against it, cannabis has been approved to treat 13 qualifying conditions, from cancer to glaucoma to Alzheimer's, which was the latest to join the list.

While the substance is legal medically, it's still extremely difficult for people with qualifying conditions, particularly those in rural areas like Becker County, to get a prescription for medical cannabis. There are very few doctors in the area who are certified to write a prescription for it and, even if a patient is able to find one of the few, the nearest dispensary to get the product is 45 miles away, in Moorhead.

Joseph (Jay) Westwater, M.D., J.D. and CEO of Minnesota Medical Solutions, the medical marijuana dispensary in Moorhead, Minn., says he believes that many doctors are apprehensive about cannabis for a few reasons, whether it be a lack of understanding or the outright fear of it because it's classified as a schedule-one substance, which puts it in the same category as heroin and LSD.

"Most doctors don't get education in medical school about the benefits of medical cannabis," he said, adding that the lack of understanding leads to a harsh stigma that gets in the way of any health benefits medical cannabis may provide. "We had some patients who are also veterans, and they've talked about the significant stigma to try to find a provider who's willing (to prescribe medical marijuana) because the VA won't certify anybody."

But it's not just Department of Veterans Affairs doctors who aren't certified — it's most doctors.

Richard Vetter, the chief medical officer for Essentia Health's west market, says Minnesota's legalization of medical cannabis was a bit progressive, and they were indeed apprehensive about simply jumping on board with a new medication, when they already had treatment plans in place for people who have the illnesses on the list of conditions that qualify for treatment with medical cannabis.

"From an organization standpoint, there was a little bit of hesitancy to make sure we're not harming patients," he said. "We wanted to make sure that patients could have the best possible care that they could get and not just jump to something...when, really, I think the jury is still out on some of the benefits of medical marijuana."

Vetter says they do have a committee of doctors that patients who qualify for treatment with medical cannabis see. The patients, depending on their condition, see specialists and, if traditional medicine just isn't helping the patient, then medical marijuana becomes a possible treatment option. He says the question of whether they will prescribe it to the patient goes to their committee, but he says that process hasn't been very busy because they are able to effectively treat patients with traditional medicine.

Some other concerns Vetter expressed was the fact that medical marijuana still is not legal federally, which puts them and the patient in a pinch where insurance coverage is concerned. Though, he says, as medical cannabis is used and prescribed more and more, doctors are feeling more comfortable saying patients are benefiting from it more than expected, and he expects the prescription process to be reassessed at some point.

No miracle pill

Brandon, a Detroit Lakes resident who has been on Marinol, a prescription cannabinoid or synthetic version of cannabis, since 2014, says he knows of one doctor in the area who is certified to prescribe the substance.

Brandon opted to keep his last name private because of the stigma associated with cannabis. Two other people who were known to the reporter as current or former medical marijuana patients denied to comment because of the stigma.

Brandon says the prescription cannabinoid that he uses has actually been legal since the 80s. He, unlike other medical cannabis patients who have to travel to a dispensary, is able to get his prescription filled right in Detroit Lakes at the Essentia Health pharmacy.

Marinol is rarely prescribed, though. It's label use is for people with severe nausea and vomiting caused by chemotherapy. It's a last-resort drug for many. For Brandon, it's the only thing he could find to help treat his chronic nausea he says he experiences after developing calcium spots on his lungs and spleen when he contracted histoplasmosis as a kid.

"It's an off-label use. That's not what it's designated for," he said, explaining that because his nausea isn't caused by chemo, technically he shouldn't qualify for the drug. It was the only thing that eventually worked for him, though. "It works, but it's not, like, a miracle pill. It varies day to day."

Westwater also made comments about the fact that medical cannabis isn't a "miracle drug." Side effects include anxiety, heart palpitations, dry or red eyes, dry mouth, and affects to blood pressure that may cause fainting. Like any other drug, it can also react badly with other medications, which is why Westwater says patients are required to meet with a pharmacist before they are given any products.

Most of these negative effects are caused by one of the over 60 substances in the plant, Tetrahydrocannabinol (THC), which is the psychoactive component of the plant, the part that makes people high, said Westwater. Recreational marijuana is often grown with a higher THC content because that's the goal of users — to get high. But Westwater says THC also has some medical benefits.

"Some conditions, like intractable pain, a higher THC content...seems to be effective," he said.

Brandon says Marinol is mostly THC, and the warning label specifically says patients may experience a high.

"A lot of people can't take it. It makes them so high. It's a more potent version. Anything made in a lab is going to be more potent," he said.

The other component of cannabis that is isolated and used medically is Cannabidiol (CBD). CBD is not psychoactive, so the user does not get high. Westwater says CBD has proven to be effective in treating seizures. It has other health benefits as well.

"It can be helpful in terms of relaxation, a sleep-aid, and it has anti-inflammatory components," he said.

Highly regulated, highly spendy

CBD products are sold in lotion and other over-the-counter forms locally in places like the Tobacco Shop and Mellow Moods.

Certified Minnesota cannabis dispensaries sell products that have higher THC levels and products with higher CBD levels. Then there are products with both — it's sold on a spectrum. And Westwater says everything is highly regulated, so patients can be sure of the product they are getting every time.

"When we make a pill or we make a batch of vaporizing solution, it's the same quality...every time...That's also a product that has been tested. There are no pesticides, no heavy metals, or residuals of other substances that can be in street or illegal cannabis," he said. "The downside is that because of that, it's more expensive."

Brandon says if he didn't have health insurance, there's no way he could afford to be on Marinol. Each refill costs almost $800 before insurance, and he has to refill his bottle every month. Insurance doesn't cover the products sold at dispensaries, though, so patients have to pay hundreds of dollars out of pocket. Westwater says the high cost causes many people to quit treatment, and they are hoping to find ways to lower it.

"There are a few things that we're hoping for in terms of increasing access and helping reduce stigma," said Westwater, explaining that, currently, there is a legal limit of one dispensary per each congressional district in the state. "If you're in rural Minnesota, you have to travel and are only allowed to get a 30-day supply, which makes it difficult because a lot of these patients have mobility issues."

Westwater says they are anticipating tapping into teleservices, so patients can access a provider over telehealth and be certified that way. They are also looking to pass presumptive eligibility legislation, so patients who have a prescription for opioids can also automatically qualify as a medical cannabis patient. He says reducing opioid use is one of the biggest health benefits of medical marijuana.

"Intractable pain is the largest component of the (medical cannabis) program in Minnesota. I think there are about 1,600 active patients currently, and about 60 percent of those have intractable pain," said Westwater. "Over 60 percent of those patients had benefit, so they were getting some pain relief. But what they also noticed was people were sleeping better. They were less anxious. They were able to reduce sleep medicine and anxiety pills, and also eliminate other medications, like opioids."

Westwater estimates that 30 percent of patients who were taking opioids for intractable pain were able to stop using opioids completely when they switched to using medical cannabis, which he says greatly helps the opioid and overdose crisis.

"The thing about cannabis is that it's so safe. Sure, there are some side effects. It's not perfect...but no one has ever died from an overdose from cannabis," he said, adding that they are legally required to report adverse effects caused by their products (adverse effects are anything that cause a patient to feel so bad they end up in the hospital), and Westwater says they report about a handful every year.

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