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For thousands of Oregonians, the path to a medical marijuana card starts at a clinic in Southeast Portland staffed by Dr. Thomas Orvald, an 80-year-old retired heart surgeon from Yakima.
The Oregon Health Authority says a typical doctor is unlikely to see more than 450 medical marijuana patients at a time.
In the past year, Orvald has signed off on 4,180.
And he is not alone. The health authority says 37 doctors have exceeded the 450-patient threshold since 2005. These doctors signed statements asserting "primary responsibility for the care and treatment" of as many as 5,400 medical marijuana patients each.
The Oregonian's examination of high-volume marijuana doctors -- including interviews with physicians and clinic operators as well as a review of state documents, medical licensing reports, court records and caseload data -- paints a picture of a highly specialized industry. Among the newspaper's findings:
In a year when Washington and Colorado voted to legalize marijuana outright, it seems strange to imagine doctors carefully deliberating over who gets to use the drug. But that is how Oregon voters, who approved medical marijuana in 1998 and rejected subsequent efforts to broaden access, were told the law would work.
The law was pitched as a way to permit marijuana use as palliative medicine for critically ill and dying Oregonians. The drug's potential risks and benefits would be discussed with each patient by a doctor with "primary responsibility for the care and treatment of a person diagnosed with a debilitating medical condition."
Who gains access to the medical marijuana program matters. An investigation by The Oregonian in September found that a surplus of cannabis, grown in the name of Oregon medical marijuana patients, feeds the lucrative nationwide black market.
Dr. Richard Bayer, a chief petitioner for the 1998 initiative, said he intended to allow primary care doctors, oncologists, neurologists and other specialists to feel comfortable offering professional advice about marijuana to their patients. Although he didn't envision an industry of clinics specializing in medical marijuana, Bayer said they fill a void left by mainstream medicine.
"The patients' regular doctors should be doing it," said Bayer, who practiced internal medicine in Lake Oswego until 1996. "But the patients' regular doctors don't have enough guts, because the patients' regular doctors are afraid of losing their licenses."
Some legislative allies of the program take a different view.
Sen. Alan Bates, D-Medford, was stunned to hear that nine physicians are responsible for more than half the medical marijuana patients in the state. Bates, a key leader on health policy, said the program was intended to allow sick people access to marijuana. He said the numbers suggest recreational users are seeking out doctors strictly to obtain the drug.
"That doesn't seem like that is what the program was set up to be or what the public expected from it," said Bates, a physician who's authorized the drug for some of his patients. "I think we've got a problem."
An unlikely advocate
On a recent morning, the brightly lit lobby of the clinic where Orvald works bustled with patients. Signs featuring close-up images of marijuana plants and the message "legalize, regulate, educate" hung from the ceiling.
Orvald, a tall, white-haired man in a white coat, pressed blue-and-white checked shirt and khakis emerged from a butter-yellow office and ushered in a patient. In a 20-minute period, he saw four people.
Next came Tonja Swift, a 43-year-old Portland woman who uses medical marijuana to treat pain from irritable bowel syndrome, carpal tunnel and herniated discs.
"In this situation, you are coming back to renew your card, and that will make you legal once again for another year," Orvald said to Swift. "Legal in what respect?"
"Legal where I can use my medicine inside my home or in facilities where you are allowed to use medicine," Swift said. "But not in public and, of course, not where the federal government can see it."
"You bet," said Orvald. "You bet."
Swift told Orvald she's been a medical marijuana user for four years. She consumes it daily and uses a vaporizer, which she carries in her purse.
"Tell me, quickly, off the top of your head, what does cannabis do for you?" he asked.
"It alleviates the pain," she said. "It doesn't get rid of it. It makes it easier to get through the day."
Orvald practices at the Southeast 18th Avenue clinic of The Hemp and Cannabis Foundation, whose clinics see 25,000 patients in Oregon each year, owner Paul Stanford said. Orvald ranks No. 4 among doctors signing medical marijuana applications statewide; two other foundation doctors rank No. 2 and No. 3.
Orvald said he relies on patients' past medical records to determine whether they qualify for medical marijuana. "I am not the primary physician in this," he said. "I am the physician of final judgment."
Flipping through a pocket-size calendar, Orvald landed on a week in late summer.
"I have so many enormous clinic days," he said. "My book here is filled with people: 41, 41, 48, 47. ... These are all patients I have seen on those days."
He readily acknowledges he sees a lot of patients.
"I am the busiest in the state, let's face it," he said. "But I am proud of what we do, and I am proud of what we accomplish."
Orvald seems an unlikely marijuana advocate.
Until his retirement eight years ago, Orvald was a cardiac surgeon who figures he performed 3,000 open-heart surgeries and 25 transplants.
These days, he regularly flies to Portland from his hometown of Yakima to see patients, staying in a hotel and working out of The Hemp and Cannabis Foundation clinic. Orvald's name is printed on a paper sign taped beside his office door.
He declines to see medical marijuana patients in Washington. He said he's discreet about his work out of respect for his wife, who disapproves. He added he "wouldn't go within 10 miles" of marijuana out of concern for his family.
"I won't do it in Yakima because I don't want to have any of that stuff get to my daughter," Orvald said.
He refers patients with questions about marijuana to another member of the foundation's staff.
"There are doctors who know one hell of a lot more about cannabis than I do," Orvald said. " I know the essence of what cannabis is and what its chemical composites are. I know there are strains that are very, very strong and there are strains that are not very strong."
Orvald, who has glaucoma, qualifies for medical marijuana. Though he said marijuana tincture quickly relieves eye pressure in glaucoma sufferers, he prefers to use prescription drops.
"I try to stay away from it just for moral and ethical purposes," he said. "That doesn't mean I don't think it's effective. I know it's effective, but I have chosen not to."
High-volume business
Orvald and other physicians on the list described fast-paced, volume-driven workdays with little time for follow-up or patient relationships.
Dr. Sandra Camacho-Otero, who worked for The Hemp and Cannabis Foundation until 2011, recalled signing more than 8,000 patient applications in 2009. If patients asked a question that required a detailed response, Camacho-Otero referred them to another clinic staff member so she could stay on schedule.
"I would not say it was good medicine," said Camacho-Otero, who left the foundation in 2011. "I had just 10 minutes to talk to the person."
Camacho-Otero now runs her own medical marijuana clinic and limits her day to 25 patient visits. She remains No. 9 on the list of doctors approving medical marijuana cards.
Owner Stanford defended the foundation, saying his clinics set the "gold standard" in marijuana medicine.
Stanford, who pleaded guilty to a federal marijuana possession charge in 1994 and was sentenced to 30 days in prison, started his medical marijuana clinic business in Oregon in 2001. He operates clinics in eight other states.
Stanford said his office staff thoroughly reviews up to three years' worth of patients' medical records. Visits at the foundation typically last 10 to 15 minutes and can cover any health concern the patient has.
"Most people tell us they have never had the period of time to sit down and talk with a doctor before," said Stanford, author and chief petitioner of this year's unsuccessful ballot campaign to legalize marijuana.
Caughron, the doctor who left for Texas this year, saw enough Oregon patients that he still ranks No. 5 in the state. He worked starting in 2011 at Medical Marijuana Card Services, a Portland clinic with the phone number 503-384-WEED.
Caughron said he felt pressure to see as many patients as possible and had little time to address anything more than cannabis, when diet and lifestyle changes "were critical in most of these people's healing."
Officials at the clinic declined to comment.
Dr. Andrew Dorfman, who is No. 8 on the list of doctors authorizing medical marijuana cards, acknowledged that some patients at his clinic in Ashland may game the system just as patients seek Vicodin to sell on the street.
"If you trust your patients, you are going to make the mistake of giving dishonest patients medicine," said Dorfman, a Harvard-trained family medicine specialist. "If you don't trust your patients, you will make the mistake of withholding medicine from people who have real pain."
The No. 1 physician in the program, Sanjeev K. Sharma, is a full-time marijuana doctor who sees four patients an hour at Medford-based Southern Oregon Alternative Medicine, according to clinic owner Brent Kenyon.
Sharma, a former cardiothoracic surgeon for Providence Medford Medical Center, approved 5,476 patients in the past year.
Kenyon, who operates medical marijuana practices in Eugene and 11 other locations, said he pays his doctors based on the number of patients they see.
He has felony drug convictions in 2008 for selling marijuana and in 2001 for manufacturing hashish. Kenyon said the 2008 conviction came after he sold marijuana to a critically ill friend whose medical marijuana card had expired.
Kenyon said the criminal cases are in the past and that his goal has always been to help sick and dying patients, who deserve an alternative to attending traveling clinics.
"I started my own clinic to get it out of motel rooms and into doctors' offices, where medicine belongs," said Kenyon, who also owns a Medford restaurant.
His clinical group, tweeted under the handle SOAM420 in January: "Come on down & get your medical marijuana card. ... We have offices everywhere ..."
The state's role
Public health officials first noticed that a handful doctors were signing off on thousands of patients a few years after Oregon's medical marijuana program was created. In response, the state wrote rules in 2005 to ensure "a legitimate attending physician/patient relationship exists."
Officials determined a typical primary care doctor's caseload is 2,200 patients and that it was "unlikely" more than 20 percent would both qualify for and want to use medical marijuana. So the state decided to require additional documentation from doctors with 450 or more medical marijuana patients. High-volume doctors must note that they've done a physical exam and reviewed a patient's medical record.
"It's really a matter of due diligence," said Jonathan Modie, a spokesman for the Oregon Health Authority. "We do what we can to ensure that physicians are providing the appropriate level of patient care."
Thirty-seven doctors have submitted paperwork since the policy was put into place.
Rep. Andy Olson, who supports medical marijuana, said the state should do more. Olson has pushed for legislation requiring physicians to document how the drug addresses each patient's condition.
"Medical marijuana has its place for helping people out," said Olson, R-Albany. "But there really is, as far as I am concerned, no accountability from the physician's perspective."
The Oregonian found that four of the 37 doctors flagged as high-volume since 2005 have been reprimanded, had a license revoked or surrendered a license for a range of problems during their careers. A fifth physician on the list voluntarily withdrew from practice this year pending a board investigation.
For comparison: The Oregon Medical Board, which licenses doctors, typically disciplines about four physicians for every 1,000 licensed statewide each year.
The board has also investigated at least nine doctors not on the list of high-volume doctors based partly on their authorization of medical marijuana patients. The board disciplined four, citing problems that ranged from signing medical marijuana forms without seeing patients to recommending marijuana to a pregnant woman without warning her of the risks.
Filling need
Bayer, an author of the medical marijuana initiative, said the law has not evolved as he had anticipated.
In 1998, Bayer expected that a nationwide medical marijuana movement would lead Congress to make it a legal prescription drug.
It didn't turn out that way. Oregon physicians remain resistant to marijuana for fear of running afoul of federal authorities, Bayer said, and Oregon patients won't discuss marijuana with their doctors for fear the information will be noted in medical records where employers can see it.
Clinics specializing in medical marijuana solve both problems.
"I do not have any guilt whatsoever about how we have made this law work for patients over the last 14 years," said Bayer, who became a medical marijuana patient in 2000 to treat severe nerve pain from an injury.
Bates, the Medford lawmaker, said the role high-volume doctors play in the medical marijuana program wouldn't be a concern if Oregonians had voted to legalize the drug in November.
"But right now, the law is in place," Bates said, "and we have to go with the law that we have in place."
Betsy Hammond of The Oregonian staff and news researcher Lynne Palombo contributed to this report.
News Hawk- TruthSeekr420 420 MAGAZINE
Source: oregonlive.com
Author: Noelle Crombie
Contact: Contact OregonLive.com or The Oregonian
Website: Medical marijuana: A few high-volume doctors approve most patients | OregonLive.com
The Oregon Health Authority says a typical doctor is unlikely to see more than 450 medical marijuana patients at a time.
In the past year, Orvald has signed off on 4,180.
And he is not alone. The health authority says 37 doctors have exceeded the 450-patient threshold since 2005. These doctors signed statements asserting "primary responsibility for the care and treatment" of as many as 5,400 medical marijuana patients each.
The Oregonian's examination of high-volume marijuana doctors -- including interviews with physicians and clinic operators as well as a review of state documents, medical licensing reports, court records and caseload data -- paints a picture of a highly specialized industry. Among the newspaper's findings:
- Nine doctors approved half the 56,531 medical marijuana patients and pending applicants in Oregon.
- About 75 percent of Oregon medical marijuana patients are seen by doctors with large caseloads.
- Physicians cite "severe pain" as the patient's sole qualifying condition in 57 percent of their cases, list cancer as a condition for 4 percent of patients and HIV/AIDS for 1 percent.
- None of the nine doctors topping the state list specializes in addiction treatment or pain management, even though several said that patients use marijuana as an "exit drug" to wean themselves from addiction to narcotic painkillers.
- One of the top doctors on the list, Dr. Stephen Caughron, said he saw 40 to 80 patients a day -- a schedule he described as "absolutely asinine" -- and left the practice this year.
In a year when Washington and Colorado voted to legalize marijuana outright, it seems strange to imagine doctors carefully deliberating over who gets to use the drug. But that is how Oregon voters, who approved medical marijuana in 1998 and rejected subsequent efforts to broaden access, were told the law would work.
The law was pitched as a way to permit marijuana use as palliative medicine for critically ill and dying Oregonians. The drug's potential risks and benefits would be discussed with each patient by a doctor with "primary responsibility for the care and treatment of a person diagnosed with a debilitating medical condition."
Who gains access to the medical marijuana program matters. An investigation by The Oregonian in September found that a surplus of cannabis, grown in the name of Oregon medical marijuana patients, feeds the lucrative nationwide black market.
Dr. Richard Bayer, a chief petitioner for the 1998 initiative, said he intended to allow primary care doctors, oncologists, neurologists and other specialists to feel comfortable offering professional advice about marijuana to their patients. Although he didn't envision an industry of clinics specializing in medical marijuana, Bayer said they fill a void left by mainstream medicine.
"The patients' regular doctors should be doing it," said Bayer, who practiced internal medicine in Lake Oswego until 1996. "But the patients' regular doctors don't have enough guts, because the patients' regular doctors are afraid of losing their licenses."
Some legislative allies of the program take a different view.
Sen. Alan Bates, D-Medford, was stunned to hear that nine physicians are responsible for more than half the medical marijuana patients in the state. Bates, a key leader on health policy, said the program was intended to allow sick people access to marijuana. He said the numbers suggest recreational users are seeking out doctors strictly to obtain the drug.
"That doesn't seem like that is what the program was set up to be or what the public expected from it," said Bates, a physician who's authorized the drug for some of his patients. "I think we've got a problem."
An unlikely advocate
On a recent morning, the brightly lit lobby of the clinic where Orvald works bustled with patients. Signs featuring close-up images of marijuana plants and the message "legalize, regulate, educate" hung from the ceiling.
Orvald, a tall, white-haired man in a white coat, pressed blue-and-white checked shirt and khakis emerged from a butter-yellow office and ushered in a patient. In a 20-minute period, he saw four people.
Next came Tonja Swift, a 43-year-old Portland woman who uses medical marijuana to treat pain from irritable bowel syndrome, carpal tunnel and herniated discs.
"In this situation, you are coming back to renew your card, and that will make you legal once again for another year," Orvald said to Swift. "Legal in what respect?"
"Legal where I can use my medicine inside my home or in facilities where you are allowed to use medicine," Swift said. "But not in public and, of course, not where the federal government can see it."
"You bet," said Orvald. "You bet."
Swift told Orvald she's been a medical marijuana user for four years. She consumes it daily and uses a vaporizer, which she carries in her purse.
"Tell me, quickly, off the top of your head, what does cannabis do for you?" he asked.
"It alleviates the pain," she said. "It doesn't get rid of it. It makes it easier to get through the day."
Orvald practices at the Southeast 18th Avenue clinic of The Hemp and Cannabis Foundation, whose clinics see 25,000 patients in Oregon each year, owner Paul Stanford said. Orvald ranks No. 4 among doctors signing medical marijuana applications statewide; two other foundation doctors rank No. 2 and No. 3.
Orvald said he relies on patients' past medical records to determine whether they qualify for medical marijuana. "I am not the primary physician in this," he said. "I am the physician of final judgment."
Flipping through a pocket-size calendar, Orvald landed on a week in late summer.
"I have so many enormous clinic days," he said. "My book here is filled with people: 41, 41, 48, 47. ... These are all patients I have seen on those days."
He readily acknowledges he sees a lot of patients.
"I am the busiest in the state, let's face it," he said. "But I am proud of what we do, and I am proud of what we accomplish."
Orvald seems an unlikely marijuana advocate.
Until his retirement eight years ago, Orvald was a cardiac surgeon who figures he performed 3,000 open-heart surgeries and 25 transplants.
These days, he regularly flies to Portland from his hometown of Yakima to see patients, staying in a hotel and working out of The Hemp and Cannabis Foundation clinic. Orvald's name is printed on a paper sign taped beside his office door.
He declines to see medical marijuana patients in Washington. He said he's discreet about his work out of respect for his wife, who disapproves. He added he "wouldn't go within 10 miles" of marijuana out of concern for his family.
"I won't do it in Yakima because I don't want to have any of that stuff get to my daughter," Orvald said.
He refers patients with questions about marijuana to another member of the foundation's staff.
"There are doctors who know one hell of a lot more about cannabis than I do," Orvald said. " I know the essence of what cannabis is and what its chemical composites are. I know there are strains that are very, very strong and there are strains that are not very strong."
Orvald, who has glaucoma, qualifies for medical marijuana. Though he said marijuana tincture quickly relieves eye pressure in glaucoma sufferers, he prefers to use prescription drops.
"I try to stay away from it just for moral and ethical purposes," he said. "That doesn't mean I don't think it's effective. I know it's effective, but I have chosen not to."
High-volume business
Orvald and other physicians on the list described fast-paced, volume-driven workdays with little time for follow-up or patient relationships.
Dr. Sandra Camacho-Otero, who worked for The Hemp and Cannabis Foundation until 2011, recalled signing more than 8,000 patient applications in 2009. If patients asked a question that required a detailed response, Camacho-Otero referred them to another clinic staff member so she could stay on schedule.
"I would not say it was good medicine," said Camacho-Otero, who left the foundation in 2011. "I had just 10 minutes to talk to the person."
Camacho-Otero now runs her own medical marijuana clinic and limits her day to 25 patient visits. She remains No. 9 on the list of doctors approving medical marijuana cards.
Owner Stanford defended the foundation, saying his clinics set the "gold standard" in marijuana medicine.
Stanford, who pleaded guilty to a federal marijuana possession charge in 1994 and was sentenced to 30 days in prison, started his medical marijuana clinic business in Oregon in 2001. He operates clinics in eight other states.
Stanford said his office staff thoroughly reviews up to three years' worth of patients' medical records. Visits at the foundation typically last 10 to 15 minutes and can cover any health concern the patient has.
"Most people tell us they have never had the period of time to sit down and talk with a doctor before," said Stanford, author and chief petitioner of this year's unsuccessful ballot campaign to legalize marijuana.
Caughron, the doctor who left for Texas this year, saw enough Oregon patients that he still ranks No. 5 in the state. He worked starting in 2011 at Medical Marijuana Card Services, a Portland clinic with the phone number 503-384-WEED.
Caughron said he felt pressure to see as many patients as possible and had little time to address anything more than cannabis, when diet and lifestyle changes "were critical in most of these people's healing."
Officials at the clinic declined to comment.
Dr. Andrew Dorfman, who is No. 8 on the list of doctors authorizing medical marijuana cards, acknowledged that some patients at his clinic in Ashland may game the system just as patients seek Vicodin to sell on the street.
"If you trust your patients, you are going to make the mistake of giving dishonest patients medicine," said Dorfman, a Harvard-trained family medicine specialist. "If you don't trust your patients, you will make the mistake of withholding medicine from people who have real pain."
The No. 1 physician in the program, Sanjeev K. Sharma, is a full-time marijuana doctor who sees four patients an hour at Medford-based Southern Oregon Alternative Medicine, according to clinic owner Brent Kenyon.
Sharma, a former cardiothoracic surgeon for Providence Medford Medical Center, approved 5,476 patients in the past year.
Kenyon, who operates medical marijuana practices in Eugene and 11 other locations, said he pays his doctors based on the number of patients they see.
He has felony drug convictions in 2008 for selling marijuana and in 2001 for manufacturing hashish. Kenyon said the 2008 conviction came after he sold marijuana to a critically ill friend whose medical marijuana card had expired.
Kenyon said the criminal cases are in the past and that his goal has always been to help sick and dying patients, who deserve an alternative to attending traveling clinics.
"I started my own clinic to get it out of motel rooms and into doctors' offices, where medicine belongs," said Kenyon, who also owns a Medford restaurant.
His clinical group, tweeted under the handle SOAM420 in January: "Come on down & get your medical marijuana card. ... We have offices everywhere ..."
The state's role
Public health officials first noticed that a handful doctors were signing off on thousands of patients a few years after Oregon's medical marijuana program was created. In response, the state wrote rules in 2005 to ensure "a legitimate attending physician/patient relationship exists."
Officials determined a typical primary care doctor's caseload is 2,200 patients and that it was "unlikely" more than 20 percent would both qualify for and want to use medical marijuana. So the state decided to require additional documentation from doctors with 450 or more medical marijuana patients. High-volume doctors must note that they've done a physical exam and reviewed a patient's medical record.
"It's really a matter of due diligence," said Jonathan Modie, a spokesman for the Oregon Health Authority. "We do what we can to ensure that physicians are providing the appropriate level of patient care."
Thirty-seven doctors have submitted paperwork since the policy was put into place.
Rep. Andy Olson, who supports medical marijuana, said the state should do more. Olson has pushed for legislation requiring physicians to document how the drug addresses each patient's condition.
"Medical marijuana has its place for helping people out," said Olson, R-Albany. "But there really is, as far as I am concerned, no accountability from the physician's perspective."
The Oregonian found that four of the 37 doctors flagged as high-volume since 2005 have been reprimanded, had a license revoked or surrendered a license for a range of problems during their careers. A fifth physician on the list voluntarily withdrew from practice this year pending a board investigation.
For comparison: The Oregon Medical Board, which licenses doctors, typically disciplines about four physicians for every 1,000 licensed statewide each year.
The board has also investigated at least nine doctors not on the list of high-volume doctors based partly on their authorization of medical marijuana patients. The board disciplined four, citing problems that ranged from signing medical marijuana forms without seeing patients to recommending marijuana to a pregnant woman without warning her of the risks.
Filling need
Bayer, an author of the medical marijuana initiative, said the law has not evolved as he had anticipated.
In 1998, Bayer expected that a nationwide medical marijuana movement would lead Congress to make it a legal prescription drug.
It didn't turn out that way. Oregon physicians remain resistant to marijuana for fear of running afoul of federal authorities, Bayer said, and Oregon patients won't discuss marijuana with their doctors for fear the information will be noted in medical records where employers can see it.
Clinics specializing in medical marijuana solve both problems.
"I do not have any guilt whatsoever about how we have made this law work for patients over the last 14 years," said Bayer, who became a medical marijuana patient in 2000 to treat severe nerve pain from an injury.
Bates, the Medford lawmaker, said the role high-volume doctors play in the medical marijuana program wouldn't be a concern if Oregonians had voted to legalize the drug in November.
"But right now, the law is in place," Bates said, "and we have to go with the law that we have in place."
Betsy Hammond of The Oregonian staff and news researcher Lynne Palombo contributed to this report.
News Hawk- TruthSeekr420 420 MAGAZINE
Source: oregonlive.com
Author: Noelle Crombie
Contact: Contact OregonLive.com or The Oregonian
Website: Medical marijuana: A few high-volume doctors approve most patients | OregonLive.com
