Just 1 percent of the 16,000 doctors who treat patients in Maryland have signed up for the state's medical marijuana program, and two of the largest hospital systems in the state have banned their physicians from participating.
The lack of enthusiasm threatens to undermine the fledgling program by limiting access to the drug that has shown promise in easing pain and other severe conditions.
"Clearly there are not going to be enough physicians, given the level of demand anticipated," said Gene Ransom, CEO of MedChi, the state's professional association for physicians, which hasn't taken a position on medical marijuana.
"That's going to create a problem."
Only 172 doctors have registered to be able to recommend patients for medical marijuana, according to information obtained by The Baltimore Sun from the Maryland Medical Cannabis Commission through a public records request.
That means most patients wouldn't be able to see their own physicians, and patients in rural areas may have trouble gaining access to the drug. About 95 percent of the doctors who have signed up for the program say they plan to work in the Baltimore region or the Washington suburbs.
The doctors come from a wide range of specialties, from family care to reproductive medicine, weight loss, emergency medicine and tattoo removal. One is a psychiatrist and addiction specialist who is considering recommending marijuana for pain management to head off addiction to opioids.
Some said they would recommend medical marijuana as part of a separate practice, while others plan to work for consultancies that are being set up to see marijuana patients.
Some doctors and researchers are not only concerned about significant bottlenecks for patients but also about patients getting diagnosed by one doctor and then going to another to be certified to use medical marijuana. That gap in care coupled with a lack of understanding about when to recommend cannabis could invite abuses.
The program could become "a facade for recreational use," Ransom said.
Unlike other pharmaceuticals, which are approved by the FDA and come with prescribing guidelines, some doctors said not enough is known about medical marijuana to understand how and when to recommend it. It's also illegal under federal law, and doctors and hospitals are worried about liability.
Vanessa Lyon, a spokeswoman for the cannabis commission, said more physicians are expected to register for the program over time, especially as suffering patients with few options engender sympathy. Lyon also said the industry in Maryland is still evolving, and many doctors are likely waiting until the program is closer to launching next year.
"More doctors will sign on as patients start going to them and asking about the process," she said.
The medical marijuana program was authorized in 2014 by the state legislature but has been beset with delays, largely stemming from the licensing process for growers, processors and distributors.
The commission faces three lawsuits from companies that argue the process was unfair. One claims the commission illegally ignored racial diversity and two claim they were passed over to achieve better geographic diversity.
Doctor participation is voluntary, so there are no requirements for racial or geographic diversity, Lyon said.
Lyon emphasized that the commission's mission is "to create a process of providing safe and effective medical cannabis to patients." She noted that the state's Board of Physicians, which handles doctor licensing, will oversee doctors in the medical marijuana program.
To register with the cannabis commission, doctors must attest that their medical license is active and in good standing and that they are registered to prescribe controlled substances.
Physicians recommending marijuana must have a "bona fide" relationship with patients, which requires doctors to review medical histories, conduct evaluations, keep records and monitor patients as long as they are using marijuana.
The Maryland program is limited to patients with chronic diseases such as post traumatic stress disorder and glaucoma, debilitating medical conditions that require hospice or palliative care, and severe conditions that cause symptoms such as nausea, pain, seizures or wasting.
Shannon Moore, a Frederick mother of twins with a life-limiting form of epilepsy known as Miller-Dieker Syndrome, hopes more doctors consider participating, including her boys' physicians.
She already uses an extract of hemp, a weak form of cannabis bought legally online, with her sons' drug cocktail to control seizures. She hopes medical marijuana would allow her to reduce their reliance on pharmaceuticals that can have significant side effects.
Moore also sits on the state's cannabis commission. She said legal concerns about liability are overblown, pointing to a 2002 federal appeals court decision that affirms doctors' First Amendment right to discuss marijuana with patients and recommend its use.
Doctors cannot prescribe marijuana under a 2005 Supreme Court decision.
President Barack Obama's administration has declined to federally prosecute doctors who comply with state laws permitting medical marijuana. It's not clear what President-elect Donald J. Trump would do, but he has expressed support for states to be able to decide the issue.
"The takeaway message is, doctors have a protected right to protected speech with their patients," Moore said. "The Maryland law was set up to align with that right. .... I hope more doctors have an open mind about helping patients without a lot of other options."
Dr. Patricia Frye, owner of Takoma Park Alternative Care, came out of retirement as a pediatrician a few years ago to recommend medical marijuana via telemedicine to California patients. Now, she sees opportunity in Maryland.
She has studied how marijuana is used for various conditions and said she understands what doses and varieties to recommend that patients use. She would broadly recommend the drug to people who have been diagnosed by their doctors with disease.
"I am not a rubber stamp, but there are very few patients I probably wouldn't recommend it for," Frye said. "The reason is there are very few patients that wouldn't benefit from it."
Frye outlined exceptions: She wouldn't recommend it to pregnant women, to minors unless their parents approve, or to people with severe psychiatric conditions unless a mental health doctor is involved with treatment.
Dr. Karen Clarke-Bennett, a primary care and wellness doctor with the Odenton medical spa A Better You, said she hopes to attract new patients by offering medical marijuana. She anticipates treating clients with conditions such as seizures, anxiety, arthritis and PTSD. She doesn't plan to market the service until she can learn more about the drug.
"I certainly wouldn't want to offer a service I am not 100 percent ready to offer. ... I am going to take my time and do the appropriate training before I offer anything," Clarke-Bennett said, adding that she has had difficulty finding training opportunities.
Other states such as Pennsylvania are developing training programs; Maryland hasn't.
Some doctors say they may not ever recommend medical marijuana because they fear repercussions from federal authorities, but wanted to put themselves on the Maryland list in case they decide to do so.
One of them is Dr. Nicholas Scotto, a psychiatrist and addiction doctor. While medical marijuana is not approved in Maryland for addiction, he sees a narrow use: by patients who use opioids as directed for pain and have become dependent. Scotto said marijuana could replace or reduce the amount of prescription opioids those patients take and prevent some from going on to abuse drugs.
Scotto points to the ongoing opioid addiction epidemic in Maryland and nationwide that has lead to a record number of overdose deaths. Many abusers get their start with a prescription for opioids for pain.
"Opioids are much more dangerous than marijuana," he said. "Maybe we can get some people off them or at least decrease their dose. It's a good idea. Right now it's just an idea I was thinking about."
Scotto has grappled with addiction and says that's common for practitioners in his field — they become interested in treating addiction because of their own experiences.
The state Board of Physicians found Scotto guilty of "unprofessional conduct in the practice of medicine" in the late 1990s. He acknowledged at the time that he was addicted to prescription medications.
He complied with the terms of his probation that ended in 2003, according to the Board of Physicians.
Other doctors also said they didn't plan to make medical marijuana a big part of their practices.
Dr. Devinder Singh, chief and medical director of plastic surgery at Anne Arundel Medical Center, said he would only recommend marijuana for a small number of patients who suffer chronic pain from migraines. He sees such patients because some can be treated with botox injections or surgery to cut nerves around the scalp.
"It would be another tool for doctors in the business of migraine treatment," said Singh.
Some of the doctors who signed up don't specialize in areas of medicine for which medical marijuana has an approved use.
Several emergency room doctors from the Greater Baltimore Medical Center said they haven't made plans for where and how they would see patients because medical marijuana is for chronic conditions that aren't normally treated in the emergency room.
John Lazarou, a GBMC spokesman, said the hospital has no position on its doctors recommending medical marijuana but emphasized that no one would be recommending the drug in the emergency department. He said the participating emergency doctors would be acting "independent of, and unrelated to their GBMC ED practice."
Dr. Jeffrey Souryal, one of the GBMC doctors, said he became interested in the medical uses of marijuana after watching his dad die from pancreatic cancer seven years ago.
"The worst part was the pain and in the last year his loss of appetite," Souryal said of his father. "He just withered away before he passed way."
Several doctors who registered with the medical marijuana program listed the addresses of newly created consultancies. Greenway Consultants has advertised initial evaluations of patients wanting to be certified for medical marijuana for $200. The company has said it opened offices ahead of the program's launch so doctors could establish relationships with patients.
Some major health systems said they would not allow their doctors to recommend medical marijuana, including LifeBridge Health, which operates Sinai Hospital in Baltimore as well as other hospitals and medical facilities, and MedStar Health, which has seven hospitals in Maryland and several doctors' offices.
Both cited that marijuana is illegal under federal law as the reason.
Medical systems may not be able to prevent their doctors from getting into the medical marijuana business on the side, but Ransom said some doctors may not want to go against the wishes of their employers.
Other medical providers, including Johns Hopkins and Kaiser Permanente, are still devising policies on medical marijuana.
For now, Kaiser plans to allow doctors to discuss the potential benefits and risks of medical cannabis with patients who reside in Maryland, as long as they comply with both federal and state law.
Johns Hopkins officials said in a statement that a team of clinicians and administrators has been working for several months to establish a medical marijuana policyby considering potential scenarios, including how to deal with patients who have been certified to use medical marijuana by a physician outside of Hopkins' network.
"Legalized medical marijuana is new for Maryland and therefore new for Johns Hopkins," the hospital said in the statement. "We don't have all of the answers yet, but it is something we take very seriously and will continue to explore internally as well as with counterparts across the country."
About two dozen states have medical marijuana programs. In Washington, D.C., sales began in 2013 and the number of doctors participating has tripled to more than 360. Nearly 4,300 patients are in the program.
Other states have permitted or plan to allow recreational use of marijuana. Voters in several states including California voted in referendums this week to legalize recreational pot.
Some hesitation among doctors to sign up for Maryland's medical marijuana program stems from a lack of research. In a review of studies published in the Journal of the American Medical Association last year, researchers found mixed benefits, though trials are underway at institutions including the Johns Hopkins University.
Some doctors say research has been hampered by the U.S. Drug Enforcement Administration, which categorized marijuana along with heroin as ripe for abuse and having no accepted medical use. The American Medical Association has called on the DEA to reschedule marijuana to afford more study.
Dr. Deepak Cyril D'Souza, a professor of psychiatry at Yale University School of Medicine who studies cannabis, said there is moderate evidence of medical marijuana's effectiveness for four conditions: neuropathic pain, where nerves are damaged or dysfunctional; symptoms of the nervous system disease multiple sclerosis; wasting from AIDS; and chemotherapy-related nausea and vomiting. He said evidence of effectiveness for other conditions is largely anecdotal.
That makes recommending medical marijuana a "paradigm shift" for doctors, who normally rely on extensive study on dosing, interactions with other drugs and side effects, he said.
"We don't even have basic information on dosing like we do for all other medications generated from clinical trials," he said. 'What do we tell people? Take two hits and call me in the morning? I would argue that doctors do not yet have the necessary information to provide to patients."
Editor's note: This story has been updated from an original version that misspelled Vanessa Lyon's name. The Sun regrets the error.