“The future of MMJ treatment is dependent on several issues: physicians must establish legitimate, bona fide, physician/patient relationships, patients must have a method of determining the best medication for their unique symptoms, and clinical outcomes for ongoing treatment must be obtained to validate the field of medical marijuana. These are the three areas our company focuses on.” (C. Croan)

The anti-medical marijuana lobby is effective so let’s recognize how they are effectively undermining the medical marijuana industry:

 They have raised the issue of whether MMJ dr/pt relationships are valid, legitimate or even professional.
 The MMJ “evaluation” does not employ “MMJ care” it only uses “MMJ evaluation” in other words “care” or “treatment” is missing in the MMJ treatment model.
 Anti-mmj legislators have adroitly maneuvered MMJ physicians into performing evaluations only – with no follow up care. The MMJ docs thought they were winning a major point and they would cash in on evaluations. This robs the MMJ industry from obtaining positive clinical outcomes.
 Currently there is no vehicle to use aggregate data to indicate whether MMJ actually works as a treatment. “Pharma” trials do that but MMJ has entered the market essentially untested.

The current MMJ care model dooms the field.

In regard to physician/patient relationships the state legislators the author is familiar with intended only for a physician to perform the MMJ evaluation. It is clearly specified that a physician’s assistant or other professional may not perform the evaluation and have the doctor sign off – it’s flirting with disaster to operate against the legislative intent and administrative policy. We don’t need people in the field who cut corners. But they won’t be around long without licenses or clinics as we are seeing.

If a clinic takes your money for an evaluation…shouldn’t they reimburse your money if they dropped the ball about an aspect of their compliance and you were NOT provided a legitimate evaluation? Should you have received a refund from the clinic? This makes some clinics, or organizations look, pretty…mercenary.

Oh, and to the physician who related to the author, “Since PTSD is psychic pain I’m going to recommend that condition for MMJ because technically it’s chronic pain and PTSD isn’t authorized”. Bullshit, that’s dishonest.

Anyone cutting legal corners in the MMJ field is doing EVERYONE a disservice.

Failure to follow up in medicine is contradictory to the mainstream medical care model which is called “evidence based medicine”. After all – who would recommend a Schedule I substance and not follow up on the effect for treatment?

In every Medical Practice Act, in every state where MMJ is authorized, there lies the seed of one of the next regulations. Ever physician is actually required, now, to follow up with the patient about the medical intervention (the MMJ recommendation). Our prediction at Enigami is that legitimate follow up will be increasingly enforced by the regulatory agencies. At the time of this writing four states mandate follow up.

But what is it the regulatory agencies are going to require? Evidence based medicine. Wikipedia defines it like this: “Evidence based medicine aims to apply the best available evidence gained from the scientific method to clinical decision making.” In other words there needs to be some type of legitimate method to “follow up” or to monitor whether the medical intervention actually works. Okay, that’s just good medicine and good for the consumer.

Currently, in those states where there is no follow up care – we obtain no clinical evidence of whether MMJ actually is effective. Grrrrr.

The Colorado Medical Practice Act is pretty typical of the different States and partially relies on case law. Colorado’s Act quotes case law defining medical practice as not being a discrete single event. Yet in the MMJ care model it stops at a single event – evaluation. It’s true that in many areas of medicine consumers may go to a specialist who evaluates us and refers us on for ongoing needs – and therein is the key – MMJ evaluators have no viable follow up referrals because they don’t exist. How many primary care doctors will perform the follow up? There are a few MMJ doctors who perform minimal follow up and still more physicians who are concerned about the question of having a legitimate physician/patient relationship. Follow up care would go a long way to enhancing the MMJ care model. In fact performing follow up care, “evidence based medicine”, will help patients determine the best medication.

But there’s another great benefit to follow up care besides just practicing legitimate medicine. It can provide clinical outcomes which legitimize the entire field of medical marijuana. The “evaluation only model” was considered a win by physicians in legislation. So I say, “Congratulations, you’ve robbed the field of MMJ from establishing itself as legitimate by not being able to show hard research outcomes!”

Help is on the way though. Pioneering MMJ legislators are making legitimate follow up mandatory. It’ll be a short step to collecting those outcomes and being able to quote hard data instead of relying on anecdotal success stories. Instead of saying, “it MIGHT shrink tumors” we’ll get to say, “in an multi-year study involving 350,000 MMJ patients – those with such and such tumors showed reduction in size (etc.)”

The lack of a legitimate medical marijuana care model concerns us so here is what we did.

We created Enigami Systems, Inc., to uses outbound email inquiries (or other methods of media communication) to follow up and inquire about a client’s unique symptoms and how they are responding to a specific MMJ medication which we also track. The information, helps determine which medication is the best used to diminish, or contain, distressing symptoms. The outbound inquiries come from our online portal where the individual’s personal health record exists. We can monitor with whatever frequency is desired which makes a heckuva medical record but after all is said and done it beats the pants off of ANY mainstream medicine follow up.

Oh, our aggregate “outcomes” legitimize the MMJ field’s effectiveness

Medical Marijuana Is Becoming All About the Money …Less About the Care.

Let me share how I came to see the present medical marijuana business as “…all about the money”.

I’m a clinician and very interested in health information technology and how it may assist patients to improve care so I began to look at medical marijuana (MMJ) care with an eye to contributing to that care method. I also have to say I’m a sixties child and still full of that Love, Peace, and “people are basically good” approach to the world (thus my career as a caregiver).  I’m with a little IT company that helps patients track symptoms and the medical marijuana field seems to be an ideal place to help people in this regard. My company and I are unimportant to this article but where the field is going in respect to patients managing their treatment is important. My personal interests and background have helped me to frame an understanding of the cannabis care model. Here’s what we see…

In the medical marijuana field a patient has an evaluation (and if recommended) then purchases medication. In order to keep getting medication a person has to have an annual certification renewal. The docs get a buck, the dispensaries get a buck, and even the state gets a buck on the certification. So you got a condition and a medication – how is a patient supposed to manage treatment? Where’s that part of the care model fit in? Wasn’t someone supposed to have said something about that along the way?

In “mainstream medicine” an individual gets an evaluation (and if recommended) may get a medical intervention (like medication) but the patient will undergo some type of assessment of the interventions success later. If you’re in the medical field you would say, “that’s practicing real medicine”. That leaves it to reason that the cannabis care model is not considered legitimate medical practice by many. If you’ve been around medicine the last few decades you know that “evidence based medicine” (looking at the interventions results) is the norm and ethical practitioners ALWAYS assess their interventions. This makes MMJ look kind of, well funny.

In the medical marijuana care model there are three distinct, mutually exclusive, areas of involvement:

  • physicians manage evaluations
  • patients manage ongoing treatment or “follow up care”
  • dispensaries manage selling medication 

Why should patients needing help with multiple sclerosis, cancer, glaucoma,  pain management, or other illnesses be told, “we got ours…you’re on your own !”. Don’t the physicians and dispensaries feel any sense of partnership in the care model? Don’t the professionals owe it to the patient to get involved in the overall care model instead of concentrating solely on the profit side?

Should cannabis care be defined as more than the product, the physician, or the dispensary and more about the actual process of care? What sector is going to step up and help the sufferer find a way to manage treatment (right medication, right dose, right method of administration, strain, THC/CBD/CBN count, etc.). When you’re flopping around on a floor having a seizure or throwing your guts up these are a bit more important than just a recreational feature. You’re care is not a cookie cutter deal and you’re an individual with unique needs.

Why are these “mutually distinct groups” the care model for cannabis? Maybe it’s simply because the patients need for managing their care simply isn’t an area of interest to the other parties. Maybe it really is about the Almighty Dollar but maybe there’s more to it than that.


Docs like to specialize – when they do they make more money. In MMJ this is very true. Is there anything wrong with wanting to operate in a specialty area of medicine? No. Is it a bad thing to be a diagnostician and not involved in subsequent care? No, again.  Do most cannabis physicians operate only in the MMJ field? Yes.

Regulatory authorities are struggling with the idea of treatment management and questioning whether it should be tied to the evaluating physician. This obligation hasn’t panned out because physicians in other areas of medicine are allowed to specialize in the same manner that cannabis physicians do. If physicians don’t help manage care are patients qualified to manage their own treatment? On a limited basis patients can manage their care but that’s not to say they don’t need meaningful consults from professionals like the cannabis physicians and “professionals” like the dispensary staffs are trying to be. Certainly no one expects a patient to travel too far into the “practicing medicine” area but to a limited degree patients can manage their well being reasonably well.

Is there a bit of trickery going on in the various state regulations when it comes to indicating the cannabis physicians should operate in a manner consistent with other areas of medicine and provide ongoing care? In my opinion I believe this may be the case because it takes us back to the “normal” way of practicing medicine “evidence based medical care” and I believe we’ll see a number of test cases where evaluating physicians are being prompted to provide ongoing care. (In some states follow up care is now mandated.) But this just takes us back to the “specializing in areas of medicine” paradigm and it’s really just an attempt to tie care to the evaluating physician. If a physician doesn’t really want to provide ongoing care he won’t.

If you want to know the answer to the question, “Does the doc really care about my well being?”…ask yourself this…did he REALLY steer you in the direction of specific, meaningful, and ongoing, care…or was it “try some acupuncture or yoga – and see you next year for the re-cert !”

But the docs aren’t the bad guys here. They’re just doing a job.


Does your dispensary truly offer an array of ancillary services focused on your well being? Or, does the dispensary really just offer that one high dollar product? Check out Harborside Health Center in Oakland and see their commitment to their patients well being. They offer all kinds of ancillary services focused on patient’s well being. That’s a good model but it can be improved.

Dispensaries remind me of the plethora (yes, I actually used that word) of clothing boutiques which sprung up in the 1960’s (okay, I’m an old guy). Everyone just had to have a boutique, they were so cool, and so very hip. But most owners lost their businesses because they weren’t good business people – so perhaps we can forgive the dispensaries a bit because like the clothing boutiques they have a business to run and for many it’s new territory. For them the business is truly a bread and butter proposition and it’s not as if they took some kind of pledge to heal people or reduce people’s suffering.

A few months ago there were about 1285 dispensaries in Colorado now there are approximately 950. Do you think a few big money interests are getting together and forming chain dispensaries like in California? It’s just business folks.

And just trying to make a decent living doesn’t make you a bad guy either so the dispensaries are off the hook too.


Can consumers manage their care? Hasn’t that always been the bottom line reality anyway? Aren’t we forced to become our own advocates when we face our doctors in those 10-15 minute sessions? If you don’t speak up, you’re screwed. But where is the line for our competency as consumers?

Final rag, options for patients to manage their care will not appeal to businesses that are predominately concerned with helping people “score” legally. People who want to “get high” are NOT concerned about their well being or ongoing treatment. Businesses that wish to serve this type of customer will have no interest in legitimate treatment management options.  We all know the score on this issue.

So how do we create a workable cannabis care model?

Medical marijuana is a new, promising, and legitimate area of medicine. As a clinician I heartily believe it. As a human being I’m sold. It scared the pants off me to take a pipe and pot to my father in Texas when he was dying. Nauseated, and vomiting, the great man could have had some relief if only he could have gotten past the stigma and lit up. I was married to a wonderful woman who died of disabling asthma. I wish we’d known before the last year of her life that cannabis helped her breathe. She died when she was 44. They both deserved better medical options.

We need cannabis in the medical market and we need a decent model of care. We need the players to step up to the plate and do the right thing – get involved. Not because they have to, they don’t, but because it’s the right thing to do.

Ultimately it comes back to us, it’s our responsibility to look after ourselves. I hate to get all existential but you’re the one in charge – not just of your life but of your well being.

Now, go find the tools to take care of yourself. Look for good people to guide you. And along the way nag your doc and dispensary about helping you to manage your care. Try the guilt trip but remember to take your cash when you visit them.

Maybe Gordon Gecko was right, “It’s all about the money and the rest is conversation.”  

I hope not.

Enigami Blog 8-2-2012Copyright 2011 by Clifton D. Croan