FARGO — Dr. Rich Vetter, chief medical officer for Essentia Health of Fargo, said the health organization is taking a cautious approach in working with patients who would like to try medical marijuana for their conditions.

And to his knowledge, none of the doctors at Essentia so far have certified any patients.

That's perhaps one of the reasons why patients have been expressing concerns about being unable to gain approval from their doctors as the program finally began operating in the state with the opening of the first dispensary on March 1 in Fargo. Seven other dispensaries across the state are expected to open yet this year.

However, Vetter was emphatic in his defense of the slow and wary approach, although the multi-state health care organization has been working with a similar program in Minnesota since 2015.

Vetter and Sanford Health representatives, however, said there is no "blanket ban" on their doctors certifying patients in North Dakota.

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Vetter said they are working on a North Dakota policy that will go through a clinical practice committee of doctors, administrators and nurse practitioners to help guide Essentia doctors.

What the policy is likely to say, Vetter said, is similar to one in Minnesota that states "medical marijuana isn't the first treatment but the last treatment when traditional, proven treatments have been exhausted."

He said, for example, if a patient has neurological problems that they should see a neurologist and then make sure other treatment options have been exhausted and that the specialist has "nothing else to offer."

Vetter didn't know the numbers of medical marijuana patients in Minnesota, but he said it is "limited." Minnesota Department of Health statistics show that the number of patients and visits is climbing, however. As of Dec. 31, the department said there were 14,481 patients certified, an increase of 6,352 patients from the year before with 1,415 health care practitioners in the state registered with the program.

Vetter said, the feedback he has heard from Minnesota doctors about the program is that cost is a factor at $300 to $1,000 a month and health insurers don't help cover the prescriptions.

The doctor said other feedback he has received is that some patients discontinue use over a period of time because "they don't find it of value."

Vetter knows medical evidence is "scarce" on the benefits of medical marijuana, with the major reason being researchers are leery because it's still an illegal drug on the federal level.

"That does scare people away from research that probably should be done," he said.

Once Essentia starts working with medical marijuana as an option, he said he would want the organization to gather its internal evidence to "add to the body of knowledge."

That would include evidence about whether it's helping, possible side effects and drug-to-drug interactions.

Medical marijuana has been approved for use in 33 states and was approved by 63 percent of North Dakota voters in 2016.

Since 2016, state officials have been working on getting the program off the ground. But Vetter said there are some difficulties with some of the processes in place for receiving certification.

Although the North Dakota Legislature is working on changes dealing with physicians, Vetter said one of the other concerns and a barrier is that state rules require a "bona fide relationship" between a patient and the doctor to gain a certification.

He said some patients are requesting certification but don't have that relationship of seeing a primary care or specialized care doctor on a regular basis.

"Some physicians were wondering if once they start certifying if they would get a wave of people" seeking to get certified so they can get a medical marijuana card, Vetter said.

That opens up the possible misuse of medical marijuana in the certifying process, he said.

Jason Wahl, who heads up the marijuana medical division of the North Dakota Department of Health, said legislation has sailed through the House and is before a Senate committee that might alleviate some of the concerns of physicians.

An amendment being proposed, Wahl said, would modify the requirements of a "bona fide" relationship. However, he said what would also help with physicians is a change that doctors would no longer have to state when certifying that "in their professional opinion the patient is likely to receive a medical benefit" from using marijuana.

In addition, a bill that allows physician assistants to certify patients also passed the House by a wide margin and could help in more rural communities where there aren't as many doctors.

The Minnesota year-end report said that intractable pain was the No 1 reason patients were applying, followed by post-traumatic stress disorder and severe muscle spasms.

When asked if marijuana probably was a better solution than opioids for pain because there haven't been any marijuana overdose deaths, Vetter said Minnesota doctors have told him that people don't get off the opioids all together as marijuana only helped to limit the dosage.

Vetter said he believes medical marijuana should be the last treatment option because "our first rule is to do no harm to patients and we want to adhere to that."

As for other health care organizations in the state, including Sanford Health, Trinity Health in Minot and Altru Health System in Grand Forks, they have all left decisions up to physicians without taking a stand on usage, according to statements. The only exception among the major health care players is CHI Alexius in the central and western part of the state. They have stated they don't support the use of the product because of its illegality on the federal level.

When asked for an update, Sanford didn't offer an interview with a physician but did release a statement that said "Sanford does not endorse or oppose the use of medical marijuana. The decision to certify a patient is up to each Sanford doctor and what they feel is medically best for their patients.

"We base our discussions with patients on medical research to ensure the best treatment for our patients. It’s also important to remember, the North Dakota Department of Health said there has to be a bona fide patient-provider relationship when medical professionals are asked to certify a patient," the statement said.

Meanwhile, Acreage Holdings with The Botanist dispensary in Fargo said the organization was planning to send members of their medical advisory team to the state to meet with health organizations about the "amazing benefits" of medical marijuana to patients.

Wahl said the opening of The Botanist on March has gone "very well." A call to the company to find out the number of customers in the first week wasn't returned.

However, Wahl said the number of certified patients in the state has grown to 160, with about 140 applications pending.