By BLAKE NICHOLSON, Associated Press

BISMARCK, N.D. (AP) — As North Dakota's Health Department enters the final stages of implementing a statewide distribution system for medical marijuana, state lawmakers are considering proposals that would make it easier for patients to get doctor approval for the drug.

Medical marijuana advocates are applauding, especially after more than two years of waiting for the drug approved by voters in November 2016.

"At this point, we'll take anything that makes it easier for providers to certify any patient that they feel would benefit," said Anita Morgan, spokeswoman for North Dakota Compassionate Care, which pushed for legalization of medical marijuana.

A proposal that appears headed for a floor vote in the House would add physician assistants to the list of medical professionals who can certify patients. The list currently includes physicians and advanced practice registered nurses.

Another important proposed change would help ease the concerns of doctors who must give their approval before patients can get state-approved medical marijuana cards.

The Health Department hopes to have medical marijuana dispensaries operating in the state's eight major cities by fall. Medical marijuana grown at a state-approved Bismarck manufacturing facility could be available at either the Grand Forks or Fargo dispensary within weeks, according to Jason Wahl, director of the department's Medical Marijuana Division.

The state estimates that as many as 4,000 residents will legally be using the drug by summer 2021. But so far, it has issued fewer than 100 medical marijuana cards to patients and caregivers. Applications have been accepted since late October.

Medical marijuana advocates say finding doctors willing to certify patients has been a struggle.

"As somebody who worked really hard to get this approved, this is not what we wanted," said Sheri Paulson, who has multiple sclerosis. "We were looking for something to help patients, and we still feel that was not obtained, and that breaks my heart. It shouldn't be such an uphill climb."

The concerns of the medical community are many, including that marijuana can be addictive and can have adverse side effects, according to the American Medical Association. Medical marijuana also is still illegal under federal law. Doctors are largely protected from losing their Drug Enforcement Administration licenses to prescribe controlled drugs if they recommend marijuana to patients in good faith, but some doctors still "don't want to deal with even the remotest risk of certifying a Schedule 1 drug," said Chris Meeker, chief medical officer in Bismarck for Sanford Health.

The drug's status also has made it difficult to conduct medical research, he said, and "a lot of the evidence is lacking in some of these areas for the efficacy of marijuana."

Current state law requires doctors who certify a patient to assert that medical marijuana will help that person. Meeker and North Dakota Medical Association Executive Director Courtney Koebele say that puts many doctors in an uncomfortable ethical position.

"There's not enough studies to ensure that it will be beneficial for a lot of people," Koebele said.

The Legislature is considering removing that requirement, and allowing doctors to simply state that a patient has a medical condition that qualifies under the law.

"The less you require physicians to say about marijuana, the more likely they will be" to certify patients, Meeker said.

Wahl said the state Health Department supports removing the requirement, which Morgan called "a poison pill."

Democratic Senate Minority Leader Joan Heckaman, one of the sponsors of the legislation two years ago, said there was nothing nefarious about it. That provision and one requiring a continuing-care relationship between the certifying doctor and patient were added to protect patients, and were similar to what other states were doing, she said.

Most medical marijuana states require certifying doctors to make some sort of statement about patient benefit, according to Marijuana Policy Project State Policies Director Karen O'Keefe and National Conference of State Legislatures Behavioral Health Director Karmen Hanson.

"The whole point of getting the certification is that the doctor believes, yes, this may help," Hanson said.

Other proposals in the North Dakota House would add edible products to the list of approved medical marijuana forms and would add to the list of approved medical conditions.

Meeker said he would rather see the state list treatable symptoms rather than conditions, "because this list will do nothing but continue to grow. Every two years, there's going to be an advocacy group at the Legislature saying, 'this should be added.'"

Advocates would prefer that the Health Department be given some sort of authority to add qualifying illnesses as research advances, according to Morgan.

"You can't wait every other year for things to be added," she said.

Lawmakers have killed a proposal to allow patients to grow their own marijuana, and they're backing off on a proposal that would have removed the state requirement that a doctor who certifies a patient also be responsible for the patient's continued treatment. Meeker said such a change could lead to "marijuana mills," with transient doctors setting up temporary shops for the sole purpose of doling out patient approvals.

"It would be one step short of recreational marijuana," he said.

O'Keefe and Hanson said most medical marijuana states require some type of doctor-patient relationship, though Hanson said the level of North Dakota's requirement is "on the high end."

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