New Hampshire's Medical Marijuana Law Shuts Out People With Chronic Pain
New Hampshire’s medical marijuana program finally got off the ground in April, with the opening of the state’s first cannabis treatment center. Three of the four state-licensed dispensaries are now operating, and more than 1,100 people with serious illnesses are approved to use the drug.
But many, if not most, of the New Hampshire residents who could potentially benefit from medical marijuana won’t be able to legally obtain it.
Tens of thousands of residents who suffer from chronic pain, a common medical condition that research shows is often relieved with marijuana, are ineligible for the program.
As New Hampshire continues to battle an opioid epidemic brought on by prescription painkiller abuse, the question is: Why?
The state's “therapeutic cannabis” registry is restricted to people with qualifying medical conditions, such as cancer, AIDS and HIV, multiple sclerosis, epilepsy and Parkinson’s disease. Patients with “severe pain” are eligible - but only if their pain is associated with a qualifying condition.
That’s different than most states with medical marijuana laws, including every other state in New England. In Vermont, three of every four patients on the state’s registry use the drug for intractable pain, no matter the cause.
New Hampshire’s policy, on the other hand, leaves people suffering from arthritis, fibromyalgia, diabetic nerve damage, degenerative disk disease and other common conditions, shut out of the state’s dispensaries.
Many of these patients already take opioids, a root cause of the drug crisis that’s killed nearly 1,400 state residents since 2011. New Hampshire consumed more prescription painkillers per resident than every state but Maine and Delaware in 2012, and only two states had higher rates of fatal overdose in 2014.
The restrictions in the law mean many people who use cannabis for chronic-pain relief will remain at risk of arrest and prosecution, said Matt Simon of the Marijuana Policy Project.
“The story from patients all along has been, 'Look, I have Oxycontin and all this other crap in my medicine cabinet, and I’m sick of being a zombie,’” he said. “Whether the pain is from cancer or just pain they’ve been prescribed opioids for, having access to cannabis allows them to reduce and in some cases eliminate their need for drugs that are obviously much more dangerous and addictive.”
Indeed, some of the latest research on medical marijuana suggests it can reduce patients' reliance on prescription painkillers, leading to fewer deaths from overdose.
A word apart
What sets New Hampshire apart is language -- a single word, actually -- that makes the state’s law one of the most restrictive in the country.
For years, seriously ill patients and their caregivers begged lawmakers to legalize cannabis for medical use. On two occasions, in 2009 and 2012, then-Gov. John Lynch vetoed bills approved with large legislative majorities. The 2013 bill, HB 573, was headed for the same fate until lawmakers removed a home-cultivation provision to appease new Gov. Maggie Hassan, who also threatened a veto if the list of qualifying conditions wasn’t narrowed.
“Those of us trying to get the bill passed had to agree to a very limited list of conditions to get the governor’s signature,” recalled Kirk McNeil, executive director of New Hampshire Coalition for Common Sense Marijuana Policy. “The placating words at the time were, 'This is what it will take and other conditions could be added later on once the program was underway.' ”
Most states give physicians leeway to certify patients with a qualifying condition or symptom. Vermont’s law covers a handful of “debilitating medical conditions,” such as cancer and multiple sclerosis; or one or more “intractable symptoms,” including chronic pain, nausea or seizures.
New Hampshire requires a condition and a symptom. It’s just one word, chosen for political expediency. But it makes a big difference in who can walk into a dispensary and buy cannabis, and who can’t.
Earlier this year, Nicole Orzechowski, a rheumatologist at Dartmouth-Hitchcock Medical Center in Lebanon, tried to certify a patient with osteoarthritis that caused debilitating pain in her back, neck, shoulders, hip and hands.
“To be clear, therapeutic cannabis is not the standard of care for patients with osteoarthritis,” Orzechowski said in an interview. “But in this extreme case, when everything else had been tried, it seemed reasonable.”
Osteoarthritis is not a qualifying condition in New Hampshire. So, on the state’s four-page application, Orzechowski described the woman’s condition and checked a box certifying she had “one or more injuries that significantly interferes with daily activities.”
The Department of Health and Human Services rejected the application. Orzechowski responded with more detail on the patient’s symptoms and suggested arthritis be added as a qualifying condition. She has yet to receive a response.
After repeated phone calls to her state representative, the woman was eventually approved, more than three months after her initial application. Orzechowski said cannabis has improved the woman’s quality of life dramatically.
“Vermont gives providers more latitude,” she said. “She would qualify based on symptoms alone, not her specific diagnosis.”
Simon, of the Marijuana Policy Project, said advocates warned lawmakers that relying on a list of diseases to determine eligibility would exclude people with scores of painful conditions. But, he said, that was the goal of law enforcement groups and the New Hampshire Medical Society, both of which vigorously opposed HB 573.
“I think there was a lot of will in the legislature to let doctors make these choices for themselves,” Simon said. “And when the opponents realized they couldn’t stop the law from passing, they focused on trying to make it as tough as possible and as restrictive as possible so that as few patients as possible would be able to qualify. And they got their way on most of it.”
The restrictions reflect not just the compromise necessary to legalize medical marijuana in New Hampshire. They also underscore the lack of consensus on the drug among physicians.
Many are passionate supporters who argue its therapeutic qualities were undisputed by mainstream medicine until the 1930s. Others say too little is known about an illegal substance that is the most popular recreational drug in the world.
In New Hampshire, the divide is personified by two well-respected practitioners who, all things considered, share a lot in common.
Dr. Gil Fanciullo assured his patients for years that he’d someday be able to treat their pain with something besides opioids. As it turns out, the only truly novel drug he’s been able to recommend is marijuana.
“When I saw patients with pain 20 years ago and I couldn’t help them, I’d say, ‘Don’t worry - all these big pharmaceutical companies are working on drugs and five years from now, I’ll be able to treat your pain,’” said Fanciullo, who’s director of pain management at Dartmouth-Hitchcock.
“Nothing happened. There’s been another opioid, another anticonvulsant, another antidepressant. There’s never been a new drug.”
Fanciullo has authorized marijuana for at least two dozen of his patients in Vermont, where it’s been legal for medical use since 2004. Back then, Fanciullo -- who helped shape Vermont’s law as a legislative advisor -- didn’t know much about the drug’s effects on chronic pain, which was based largely on anecdotal reports.
But that’s changed. In a recent interview in his office, Fanciullo motioned toward a bookshelf stacked with some 15 years of research on cannabinoids - marijuana’s active ingredients - and pain.
“I know all of the literature, but I know the pain literature the best,” he said. “Neuropathic pain -- pain caused by an injury to a nerve -- is probably the most common kind of chronic pain. There is now overwhelming evidence that cannabis is useful to treat that kind of pain.”
In fact, there is very little scientific evidence that cannabinoids work as well for most of the 16 qualifying conditions in New Hampshire’s law. The drug’s effect on Crohn’s disease is supported by a single clinical trial, for example, and while people with Lou Gehrig’s disease often use marijuana to ease their symptoms, it hasn’t been studied in humans yet. Cannabis has been shown to relieve spasticity caused by multiple sclerosis, but there is almost nothing to prove it works on muscular dystrophy and epilepsy.
The best that can be said for most of the conditions is that cannabis can make symptoms more tolerable, without serious adverse effects. Fanciullo said that’s true for an untold number of painful diagnoses.
“If you’re going to list diseases,” he said, “I think it’s impossible to list all of the diseases that can be potentially helped by medical marijuana.”
A decade ago, Fanciullo helped write the clinical guidelines for the use of opioids for non-cancer pain. Since then, he and other specialists have watched as opioid addiction and overdoses increased, while the evidence supporting long-term use of the drugs grew thinner.
Meanwhile, several recent studies have examined the association between medical marijuana and painkiller use and abuse. One study found that states with cannabis dispensaries have lower rates of admission for addiction treatment and fewer overdose deaths. Another surveyed a few hundred chronic-pain patients at a Michigan dispensary and found they had reduced their opioid use by an average of 64 percent.
Convinced marijuana is a much safer alternative than opioids, Fanciullo has put his name and prestige behind therapeutic cannabis. He’s now the chief medical officer for dispensaries in two states, including one in Merrimack, Prime Alternative Treatment Center of New Hampshire.
Fanciullo had little involvement in New Hampshire’s legislation, and he’s reluctant to criticize the law. Policymakers he spoke with were understandably wary of the situation in California and Colorado, where almost 2 percent of all residents are registered medical marijuana users.
But adding chronic pain as a qualifying condition “would be a reasonable thing to do,” he said.
“I think a cautious beginning is prudent, and I’m not criticizing that. However, it makes it very difficult for us to treat patients who would really benefit from cannabis.”
Like Fanciullo, Dr. Seddon Savage is a board-certified pain specialist who teaches anesthesiology at Dartmouth’s Geisel School of Medicine. A former president of the American Pain Society, she’s also a well-regarded expert on addiction, a perspective that’s made her much more skeptical of marijuana as medicine.
“I think making the assumption that cannabis is going to cure everyone and have no harmful effects for some people is naive,” she said. “It’s really a grand experiment.”
Savage led opposition to the state’s medical marijuana law on behalf of the New Hampshire Medical Society. She told a House committee there was “no question” cannabinoids relieve pain, reduce nausea and improve appetite in some patients. But establishing a network of dispensaries could, as she put it, “create an infrastructure for widespread distribution of marijuana.”
Savage proposed scrapping the dispensaries and launching what amounts to a clinical trial. The cannabis would come from the National Institute on Drug Abuse, the only legal source of the plant in the United States. A team of researchers would screen potential subjects to make sure they had tried every alternative first. Approved patients would submit detailed health information every three months in order to continue receiving marijuana.
Lawmakers rejected the idea, missing what Savage now says was an opportunity to find out how safe and effective marijuana really is.
“We don’t know the impact of introducing clinical cannabis on the public health or on the individual,” she said. “In terms of our scientific understanding, we don’t know what the ideal combination of cannabinoids or dosing of cannabinoids are for different symptom management. It’s not contemporary medicine.”
Savage nonetheless believes cannabis holds “great promise” as a treatment for a few conditions, including pain. The only thing standing in the way is federal drug policy.
Marijuana is still classified as a Schedule I narcotic, on a par with heroin and LSD, “with no currently accepted medical use.” Researchers need approval from three federal agencies, including the Drug Enforcement Administration, before launching a clinical trial, and the process can take years.
As a result, researchers studying cannabis as medicine have had to rely almost exclusively on synthetic cannabinoids. Of 150 controlled studies of cannabinoids between 1975 and 2015, less than 20 involved smoked or vaporized marijuana.
Most trials used dronabinol or nabilone, THC extracts available in the United States for chemotherapy-induced nausea and as an appetite stimulator; or Nabiximols, a mouth spray that’s not yet been approved by the Food and Drug Administration. Available in two dozen countries as Sativex, nabiximols is one part THC and one part cannabidiol, or CBD, a cannabinoid that preclinical research indicates might be useful for pain and epileptic seizures.
Savage says these medications have little in common with herbal cannabis sold in dispensaries. Whole-plant marijuana contains more than 500 chemical compounds, including dozens of cannabinoids that are a mystery to researchers. Potency can vary depending on the source. Research-grade cannabis from the NIDA has levels of THC - the intoxicating compound - of below 10 percent. Dispensary cannabis can have THC levels as high as 30 percent.
Savage acknowledged that it’s “reasonable” to make cannabis available to patients whose symptoms don’t respond to more conventional treatments. But, as a pain specialist, she’s confident most patients can find relief from FDA-approved medications, including opioids.
“I have seen few patients I have been unable to help who might have benefited from cannabis when other things didn’t work,” she said. “I think we have pharmaceuticals that meet most patients’ needs, and it’s surprising to me that we need four dispensaries treating hundreds of patients each.”
In May, a group of Canadian pain specialists published a review of 26 clinical trials on cannabis and pain conducted since 2003 - including a half dozen completed since debate on New Hampshire's medical marijuana law began in early 2013.
The analysis concluded that, based on the research, cannabinoids were effective in the treatment of numerous chronic pain conditions, including musculoskeletal disorders and fibromyalgia. They categorized the side effects - mostly dizziness, fatigue and dry mouth - as mild to moderate and “generally well-tolerated.”
That’s good news for the 11 percent of American adults - more than 25 million men and women - who suffer from chronic pain, according to the National Institutes of Health.
Whether it’s enough to convince critics of medical marijuana remains to be seen.
Kate Frey is deputy director of New Futures, a nonprofit that works with lawmakers on policies to reduce drug and alcohol abuse. She said the organization opposed New Hampshire’s law because of concerns about public health, especially the potential to increase recreational use of cannabis.
“We have to remember that it is still an addictive substance,” she said. “And with marijuana there is always the concern that if you see it as less harmful or less of a risk, the use goes up. That’s something that always happens.”
But does it?
In a 2012 study, researchers from McGill University found “limited evidence” that therapeutic cannabis laws led to increased use by adolescents. A study funded by the NIDA reported last year that adolescent use in states that passed medical marijuana laws “did not differ significantly” from before the laws were passed.
Frey said New Futures wants to make sure the program operates within “the letter of the law.” Any move to add dispensaries or expand the qualifying conditions should be based on New Hampshire’s experience, she said, not clinical trials that aren’t necessarily conclusive.
“It doesn’t make sense to change the qualifying conditions until we have some outcomes based on how the program stands now,” she said.
Some lawmakers agree. Last year, a House committee killed a bill that would have allowed patients to be certified with a qualifying condition or a symptom.
The bill was sponsored by Rep. Joe Lachance, a Republican from Manchester. An Army veteran with service-related back and spinal injuries, Lachance figures no lawmaker in New Hampshire keeps closer tabs on marijuana research than he does.
“I was addicted to opioid painkillers for almost five years, and I almost killed myself,” he said. “Cannabis saved my life. That’s why I’m so passionate about this.”
Lachance said, if re-elected, he'll introduce the bill again, along with others to expand access for people in pain. Citing new research that found states with medical marijuana see fewer Medicare prescriptions for narcotic painkillers, he's also preparing legislation to add opioid addiction as a qualifying condition.
Lachance is optimistic he’ll receive a fair hearing.
“I believe now that there is more research coming in and more conversation about the benefits, we can bring forward a more sensible list of conditions,” he said.
Seddon Savage and Gil Fanciullo don’t share the same enthusiasm for medical marijuana. But the Dartmouth colleagues have collaborated on what might be the only clinical guidelines in the country for physicians whose patients use cannabis to treat their symptoms.
The paper, published this spring in the Journal of Pain, begins with the assumption that doctors know very little about the herb. Savage, who opposes legal medical marijuana, said even physicians who don’t intend to certify patients are ethically obliged to learn.
“They’re dealing with a substance that may not have the overdose risk of opioids, but it does have some risks of misuse and associated harm,” Savage said. “So the recommendations are essentially to be prudent and monitor patients as you would for any other controlled substance.”
Physicians have had little incentive to learn about the clinical uses of marijuana. It’s been illegal to prescribe since 1970, and the discovery of how it works is a fairly recent breakthrough. Moreover, the therapeutic benefits of certain varieties of cannabis, how much should be consumed and whether it should be smoked, eaten, swallowed or absorbed are still in the experimental stages.
Indeed, a first trip to the dispensary might be overwhelming for most patients. Even seasoned users have never encountered the combination of strains, concentrates, tinctures, capsules, oils and edibles available. Adding to the challenge is that, while dispensary personnel may understand cannabinoids - marijuana’s active ingredients - they have no medical training.
“It’s a little backwards that way,” admitted Shayne Lynn, who was a professional photographer when he decided to open Vermont’s first medical marijuana dispensary in 2013. He now runs two in the state, as well as a 28,000-square foot cultivation and research facility.
“Part of it’s really cool, but it’s also a challenge,” he said. “You have to a do a little experimenting with cannabis, because we don’t have enough information to tell you exactly which strain you should use and how much you should use of it.”
That knowledge is coming along, though, said Brett Sicklick, chief operating officer of Prime Alternative Treatment Center of New Hampshire. The Merrimack dispensary hasn’t opened yet, but its Connecticut affiliate features 27 strains of herbal cannabis, more than 30 edibles and dozens of concentrates.
Sicklick said the science of marijuana’s therapeutic effects has exploded as researchers honed in on an active ingredient called cannabidiol, or CBD. Unlike THC, CBD won’t get you high. The cannabinoid has even intrigued the National Institute on Drug Abuse, which is involved in preclinical trials on CBD’s potential to reduce seizures in people with epilepsy.
In response to demands from patients and dispensaries, growers are manipulating cannabis strains or creating hybrids with higher ratios of CBD to THC to reduce the substance's psychoactive effects. Sicklick said it has the potential to quiet critics and change the debate over medical marijuana.
“This is all very, very new, but extremely exciting because a lot of patients aren’t looking for those effects,” Sicklick said. “They just want the relief and these ratios provide that.”
It’s been working for Sherrie Maurer, who switched from methadone to medical cannabis about a year ago for relief from arthritis and fibromyalgia.
Maurer, who is 76, uses a cannabis tincture in the morning if she’s working in the kitchen and she smokes herbal cannabis in a vaporizer to help her sleep. She also has a supply of lozenges for when she travels.
Her pain isn’t totally gone, but it’s manageable. And she doesn’t get high. She just feels better.
“I know it’s hard for a lot of older people to drop the label and try it,” she said. “But it does make a difference.”
As medical marijuana use grows in New Hampshire, physicians will have to reconsider their prejudices against the drug, too, said Fanciullo, a pain specialist who is chief medical officer for Prime Alternative Treatment Center.
He said the clinical guidelines drafted with Savage and a handful of other researchers are aimed at filling the knowledge gap that currently exists between the dispensary and the clinic. They cover everything from the latest research on the health effects of cannabis to how to counsel patients on strains and THC content.
The guidelines have been adapted and submitted to state health officials, who say they are under review.
Fanciullo said the sooner New Hampshire physicians have the information, the better care their patients who use the drug will receive.