Medical cannabis has been available to thousands of Iowa patients for a little more than a year. Before someone can use it, a doctor has to certify they have a medical condition that qualifies them for the program. But in some parts of the state, there aren’t a lot of doctors doing that.
Lucas Nelson, MedPharm Iowa's general manager, peered into a room filled with developing cannabis plants at the company's manufacturing facility in Des Moines. Some of the plants were just peeking out from their pots. The company is one of two that produce medical cannabis products in Iowa.
“As you can see here, we’ll start these out in trays,” Nelson said. “A number of them will die. We know that happens. We are always prepped for that.”
Nelson has given doctors a handful of tours of the facility and a dispensary in nearby Windsor Heights. He answers their questions about medical cannabis. But he said in western Iowa, near MedPharm’s Sioux City dispensary, it’s a lot tougher to start conversations with doctors.
“Just haven’t had as many doctors willing to certify, as many people willing to give it a shot,” Nelson said. “But we’ll continue to work on that because we know there’s a lot of people in Sioux City that could benefit, just like other folks have up there and just like we have here in Windsor Heights, too.”
"The process is a little unusual"
For a patient to get to MedPharm’s dispensaries or the other three in the state to buy medical cannabis products, they have to go through a doctor first. A doctor fills out a form verifying that a patient has one of the debilitating medical conditions that allow them to use medical cannabis. With that approval, a patient can apply for a registration card that gives them access to the five dispensaries in the state.
“Well, the process is a little unusual,” said Ronald Kloc, an interventional pain specialist in Mason City.
Kloc is one of 911 doctors who have certified that a patient has a debilitating condition they can use medical cannabis for. He said he’s still a little cautious about it.
“All the other drugs that we’ve prescribed as physicians, they all go through this rigorous process of being approved by the [U.S. Food and Drug Administration],” Kloc said.
But not medical cannabis, which is state-approved but still federally illegal. Kloc said he heard national experts discuss it at pain management symposiums and that helped him gain confidence. He’s signed off on six to eight patients.
“Pain is my career and pain is my practice and I’m going to do what I can to try to help patients,” Kloc said.
More than 215 miles southwest of Mason City and just over the Iowa-South Dakota border, Jeremy Poulsen, an anesthesiologist and interventional pain specialist who is a partner with Siouxland Pain Clinic, has signed off on 70 Iowa patients for untreatable pain.
“I think what I was the most hesitant about was the perception that a lot of the patients had that this was going to be the Holy Grail for their pain management, that this was going to take care of everything,” Poulsen said.
Poulsen, who is licensed to practice in Iowa, is the only doctor at the Dakota Dunes, South Dakota-headquartered clinic participating in the program. Before he began certifying patients’ conditions, he sat down with staff at the clinic and they put together a list of criteria that patients had to meet to get his approval. The gist of it is that patients who have incurable, excruciating pain have tried and failed other medications first, and physical therapy has not given them sufficient relief. Patients also have to go through a mental health evaluation.
“I see this as another option, another spoke, if you will, in an attempt to attack the pain from all angles,” said Poulsen, about medical cannabis.
Studying physician attitudes
A University of Iowa College of Public Health study from April to May examining physician attitudes about medical cannabis in Iowa received responses from close to 750 physicians. More than 40 percent said they were not knowledgeable about the safety, side effects and precautions of using medical cannabis. More than half of the physicians who responded said they were not knowledgeable about the rules surrounding Iowa’s medical cannabis program. Kanika Arora, an assistant professor with UI’s College of Public Health, co-authored the study.
“Essentially what we're finding is physician certifying behavior is very closely related to their knowledge and availability on take-up of training on cannabis related pharmacology, as well as other aspects of medical cannabis,” Arora said.
Most of the physicians surveyed said they saw medical cannabis as an acceptable medical therapy for end-of-life and palliative care.
Richard Deming, the medical director of MercyOne Cancer Center in Des Moines, said he sees medical cannabis as something for cancer that could help manage patients’ symptoms and improve their quality of life.
“All of the patients that that I've been involved with think that it's something they want to try in order to help manage the symptoms of the cancer or the side effects of the cancer treatment,” Deming said.
Deming, who has toured MedPharm’s manufacturing facility in Des Moines, said he has also fielded questions from other doctors who are considering certifying patients.
"And I tell them my perspective that I think there's very little risk from a legal perspective of verifying to the state of Iowa that your patient has a condition for which you have knowledge of that condition," Deming said.
Caution persists one year later
More than a year into medical cannabis sales, which launched in Iowa on Dec. 1, 2018, there are more than 4,000 patients who have been approved to use medical cannabis. Iowa’s Office of Medical Cannabidiol has been working to educate doctors about the program and Iowa’s law.
But some doctors are still uncomfortable with the program, like Rachel Venteicher, a family medicine physician in the northern Iowa town of Algona. She said she would not be comfortable with signing off on a patient’s condition.
“I don’t think that we have good evidence for it to be working or being safe in the long term,” Venteicher said.
Venteicher said she has never been directly asked to sign a patient's form, but patients have asked her if medical cannabis could help them, mostly for untreatable pain.
“Typically what I tell them is that there are multiple other methods that are proven to be beneficial, that we have better data on their short-term and long-term safety,” Venteicher said.
Venteicher is not completely ruling it out as a treatment. She said she wants to see more research and evidence, and she’ll continue to think about it for her patients. In Algona’s Kossuth County, there are nine patients who have registration cards to get medical cannabis. No doctors in this county are participating, according to data from Iowa's Department of Public Health (though patients may see a doctor from outside of the county or their doctor could have an out-of-state address with their medical license). The closest dispensaries to Kossuth County are in Waterloo and Windsor Heights, each more than 120 miles away.
Ongoing efforts to educate doctors
Officials with Iowa’s medical cannabis program point to the number of participating physicians and the patients who have been approved to use medical cannabis as big increases from last year when sales started. The state’s Office of Medical Cannabidiol touts the more-than 900 physicians participating as a greater-than 160 percent increase since sales started last year.
Owen Parker, the program manager with Iowa’s Office of Medical Cannabdiol, said there’s still work to do, especially in rural areas where both patient and doctor numbers thin. He travels the state to educate providers and their health care networks about the program. He’s given presentations in larger, more urban areas, including a recent one in Council Bluffs, and more rural areas including Creston, Cherokee and Manchester.
“That’s a lot of what I’ve been doing, is providing high level education to the networks,” Parker said, “Because generally speaking, practitioners will prescribe, or they will use the treatments that they know best, and this is something that’s new.”
One thing that keeps the number of certifications down is only physicians can participate in Iowa's program. Parker said some patients in rural areas tend to go to advanced registered nurse practitioners and physician assistants as their primary care providers.
“I would certainly say that having physicians only with a state that’s largely rural certainly restricts some access,” Parker said.
There’s a sign that could change. The state’s board that advises the medical cannabis program recommends the Iowa Legislature allow mid-level providers like advanced registered nurse practitioners and physician assistants to be a part of the program. This could make things easier for rural patients.
But last year, a similar change was proposed as part of a larger effort to expand medical cannabis. Iowa Gov. Kim Reynolds vetoed that, saying a proposed new limit on the chemical in marijuana that makes users high, could be dangerous to health.