In February 2012, a man showed up at the Doctor Green Blossom clinic in Loveland saying he wanted to smoke marijuana legitimately.

Dr. Joseph Montante first considered a decade-old ankle sprain as a potential source of pain that would qualify the patient for a medical marijuana card. “I guess I better look at your ankle, right?” he said. “Otherwise, it’s not a legitimate exam, is it?”

Montante eventually signed a recommendation citing back pain the man said did not exist. “Somebody’s got to do it; it might as well be me,” he said. “You know what I’m saying? Why not, right?”

The patient was an undercover detective acting on an informant’s tip. The exchange — detailed in court documents — led to what is thought to be the first and only conviction of a Colorado doctor for a questionable medical marijuana recommendation.

Thirteen years after Colorado voters approved a constitutional amendment legalizing medical marijuana — and four years since the patient registry grew from 6,000 people to more than 100,000 with the explosion of dispensaries — oversight of doctors who write pot recommendations is lax and inconsistent.

The Denver Post reviewed the state’s monitoring of the doctors and found:

• The Department of Public Health and Environment has not referred any medical marijuana physicians to the Colorado Medical Board for investigation since 2011.

• The state Department of Regulatory Agencies, which oversees the medical board, could not provide a full accounting of how many doctors the board has acted against related to their medical marijuana recommendations. The agency was able to identify six cases since 2009.

• In the cases of two doctors who were among the most active in writing recommendations for patients, the board put restrictions on their licenses but allowed them to continue to practice.

State auditors last month faulted the health department for insufficient oversight of pot doctors. The audit questioned physicians taking on huge numbers of patients — one had more than 8,400 — and approving plant counts that far exceed reasonable numbers.

The health department referred five prolific doctors to the medical board for further investigation in 2011 — but none since. The medical board this spring admonished two of those physicians and put restrictions on their licenses.

Separately, the board last month suspended the license of Montante, 65, after a jury found him guilty of attempting to influence a public servant. He was sentenced Aug. 20 in Larimer County District Court to three years of probation.

Montante said he would not comment until his case is appealed.

The legalization of recreational pot in Colorado calls into question the future of medical marijuana in the state. But doctors still are expected to play a role in treating patients between 18 and 21, those whose conditions might call for higher plant counts and anyone seeking to avoid paying high taxes on recreational pot.

Sgt. Jim Gerhardt of the North Metro Task Force said going after problem physicians is complicated by a lack of case law, no criminal sanctions in a 2010 law designed to hold doctors more accountable and a little-known process for filing complaints.

“You’ve got doctors with carte blanche to bring people in, sign them up and take their money, with virtually no oversight,” he said. “Very little has occurred to any of these physicians until now.”

Some prefer a lower profile

Dr. Alan Shackelford’s medical office is next to a used-car lot on South Broadway in Denver. A Patients Choice dispensary is two doors down. Across the street is another dispensary, Sticky Buds.

Some doctors specializing in medical marijuana prefer a low profile. Not Shackelford, who trained at Harvard-affiliated hospitals and is a founding member of the local Cannabis Business Alliance.

“I don’t think I have anything to hide,” Shackelford said. “There are absolutely clear benefits for a great many people using cannabis. Sometimes it’s most effective and sometimes it shouldn’t be used at all. And that’s up to us as physicians to determine.”

Shackelford, a sub-specialist in nutritional medicine and behavioral medicine, said he began recommending marijuana after he found it to be safer for treating everything from seizures to severe pain.

That 94 percent of the roughly 107,000 people on the registry cite pain as their qualifying condition does not surprise him. These are desperate people, he said, at their last resort.

The 2010 law required doctors writing recommendations to have “bona fide” relationships with patients, including fully assessing their medical histories and conducting physical exams.

“I can tell,” Shackelford said, “when someone is reciting the Wikipedia entry they read.”

The certification forms Shackelford and other doctors complete go to the state health department, which administers the patient registry. In 2010, the state legislature signaled it wanted the department to take a more active role, authorizing it to reimburse the medical board for up to five investigations of doctors per year in fiscal years 2011 and 2012, the state audit noted.

In January 2011, the health department referred to the board the most prolific doctors — five who accounted for nearly 35,000 recommendations, or 28.5 percent of those written over about a year, said Ron Hyman, who oversees the registry for the department.

“When we are making a referral to the board of medicine, we are not saying, ‘We think these guys are bad,’ ” he said. “What we are saying is, ‘We’ve got some outliers that we think you ought to take a look at.’ “

Medical marijuana advocates say high patient volumes are expected because specialists see more patients, and recommendations are taboo for many doctors and health plans.

“Doctors I typically refer people to have always done things properly,” said Jill Lamoureux, a patient advocate and former dispensary owner. “Most doctors are not comfortable doing them. Therefore, the few that specialize get the majority of the recommendations.”

The medical board — made up of health professionals and members of the public — has issued final agency actions in two of the five cases so far.

A board order signed in April stated Dr. Jon Shick did not properly evaluate or document medical histories, or perform or document sufficient exams. Shick admitted to unprofessional conduct and received a letter of admonition. His license was put on probation for five years, which is to include ethics training.

Shick did not return calls seeking comment, and a woman who answered the phone at his office at Medical Marijuana Doctors in Denver said Shick is not making recommendations.

In a May order, the board said Dr. Michael Camarata of Columbine Family Care in Nederland violated generally accepted medical standards by failing to properly evaluate patients.

He also prescribed “narcotics/opioids and benzodiazepines” — pain medication and a class of drugs used to treat conditions such as anxiety and insomnia — to patients in large amounts, it said.

Camarata had run afoul of the medical board before. In 2004, he was diagnosed with a substance abuse disorder after testing positive for cocaine, records show. His employer notified the board, which resulted in Camarata’s license being placed on probation for five years.

Yet Camarata — who did not respond to interview requests — continues to be licensed to practice medicine in Colorado.

He received a letter of admonition and another five-year probation as a result of the medical marijuana investigation. He agreed to follow restrictions — including limits on prescribing drugs and agreeing not to issue any recommendations while on probation.

Ronne Hines, interim program director with the Department of Regulatory Agencies, which includes the medical board, said the board “takes the entire picture into consideration. They do look at the individual case on its face and they do look at past discipline. I think they are careful to ensure consumers are protected, and they put a number of limitations in the stipulations to make sure that occurs.”

Colorado is a “rehabilitation state,” meaning it tries to control substandard care without taking away licenses, said DORA spokeswoman Cory Everett-Lozano. She said state statute calls for regulation up to the minimum standard of care, “not the gold standard.”

The board by statute investigates complaints brought to it by others, including doctors, law enforcement, consumers and other agencies.

Former State Sen. Chris Romer, a Democrat who co-authored the 2010 legislation that defined the relationship between doctors and medical marijuana patients, questioned why the health department has not referred doctors for investigation since 2011.

“Are you are telling me it was a problem in 2011 and then it miraculously went away in 2012 and 2013?” Romer said. “Sounds like Public Health needs to refocus on this issue.”

He said oversight of doctors will become more important in protecting young adults when recreational pot shops open next year, a consequence of Amendment 64’s passage in November. Recreational stores will be open to those 21 and over, leaving dispensaries to serve patients between 18 and 21.

Hyman, of the health department, noted the medical board process takes time. He said it is his understanding some investigations begun in 2011 are ongoing.

“We didn’t want to overload the medical board with too many investigations at one time,” he said.

Since the growth of dispensaries in 2009, the medical board has taken final agency action against at least six physicians related to medical marijuana recommendations, DORA said. Among those that pre-date the cases from this year, according to records:

• Dr. Manuel Aquino-Villaman surrendered his licence after the board voted to suspend it in November 2010. Aquino-Villaman wrote a recommendation for a 20-year-old woman he never physically examined. The woman was 28 weeks pregnant.

• Dr. Toribio Robert Mestas surrendered his license in October after the board had suspended it. The board noted his meeting patients in hotels and tattoo parlors made follow-up care difficult.

Both Aquino-Villaman and Mestas were targets of undercover police stings; criminal cases against them were dismissed.

Another doctor arrested in the same operation as Montante — Dr. Dallas Williams, 75, of Milliken — is scheduled to go to trial in December in Larimer County. The medical board has not disclosed any actions taken against him related to medical pot.

The fate of the medical marijuana speciality is uncertain. No one knows how much demand for doctors will drop with the arrival of recreational pot.

Dr. James Boland, former medical director at two large medical marijuana clinics in metro Denver, one of which has closed, said most doctors are either moving to other states or other areas of practice.

Boland said he was one of the high-volume doctors that health department officials referred to the medical board, and he believes his case remains open.

“I guess the jury is still out on that,” he said. “I just try to do the best I possibly can and treat each patient with the same thoroughness and concern.”

Boland said he is moving on to another specialty — surgical hair restoration.

Eric Gorski: 303-954-1971, egorski@denverpost.com or twitter.com/egorski