After months of licensing, construction and cultivation, South Dakota’s young medical marijuana industry hopes to deliver a statewide supply of product to registered patients. But as product hits dispensary shelves, many physicians are hesitant to help patients obtain marijuana, and so are South Dakota health care systems.
Meeting with a licensed practitioner is the first step toward getting a medical cannabis card. But South Dakota’s three major health systems — Sanford, Avera and Monument — have all taken stances that leave the decision up to individual doctors.
Meanwhile, the state's young cannabis industry is starting to bring marijuana to registered patients. Despite statewide legalization in 2021, the only place where patients could buy product until recently was Native Nations Cannabis in Flandreau. Because the operation is located on tribal land, it was able to start growing cannabis before city governments implemented licensing regimes.
Companies hoping to grow, process and sell marijuana outside of tribal land had a slower start. They had to win a license in lotteries put on by local governments, then be certified by the state. And with cannabis plants taking about four months to reach maturity, dispensaries found themselves waiting for the product to become available.
Now, the industry is hoping to turn a corner. A Hartford dispensary called "Unity Rd." opened on July 20. The storefront sells product from Dakota Natural Solutions Grow, which cultivates marijuana near Wessington. Other dispensaries are expected to open this fall.
Card clinics driving certifications
As storefronts open, they'll be greeted by South Dakota's 1,732 registered cardholders. Many of those patients weren't certified by their primary care physicians. Like other states that have implemented medical cannabis programs, South Dakota has seen multiple “card clinics” run by groups like MyMarijuanaCards.com. The events feature doctors willing to endorse medical cannabis cards, and the process is advertised as “easy and convenient.” They charge around $275 for the service, but applicants are only billed if their application is approved. The price includes the state's $75 application fee.
The clinics drew the attention of state legislators on the Medical Marijuana Oversight Committee in July. When asked about the clinics, a state Department of Health official said the clinics are meeting the legal requirements for consultations. But Sen. Erin Tobin, a Republican from Tripp County, said she’s worried about the quality of the patient-practitioner relationship established at the clinics.
“I feel like the intent of the Legislature was that we have an actual relationship with a doc,” Tobin said. “When you have a medication that can cause side effects, we want a doc available or a provider/practitioner to be able to come in and follow up.”
Melissa Mentele sponsored the initiated measure that legalized medical cannabis in 2020. A patient herself, Mentele told the committee the clinics result from a lack of South Dakota doctors willing to endorse patients’ applications. She was warning about the potential for “doc-in-a-box” services as early as May 2021.
“A lot of us have primary care providers, but they're hesitant to be the one to put their name on it,” she said. “And so we'll hear from patients that have been told, ‘Well, I won't write the recommendation. Go see the card clinic and once you have obtained the card, please bring the record back.’”
Why have doctors been hesitant?
This spring, lawmakers made two changes intended to increase the number of practitioners participating in the program. Prior to this July, doctors had to certify that cannabis would provide a “therapeutic or palliative benefit.” Now, they are simply required to certify that a patient suffers from a "debilitating medical condition" that is causing cachexia, severe pain, nausea, seizures or muscle spasms in the patient.
Registered lobbyists for Sanford and Avera gave committee testimony in support of the change.
Advanced practice nurses and physician’s assistants who already prescribe medication were also granted the ability to endorse cards. The Department of Health said a handful have already signed up since the law took effect in early July.
It’s unclear how hospitals and health systems will approach other legal questions surrounding medical cannabis. Sarah Aker formerly served as fiscal director for the South Dakota Association of Healthcare Organizations. She told lawmakers last year that the association's membership, which includes the biggest three health systems in the state, have concerns about the legal ramifications of certifying cannabis patients.
As a Schedule I drug, the federal Drug Enforcement Administration (DEA) maintains that cannabis has “no currently accepted medical use in treatment in the United States, and a lack of accepted safety for use under medical supervision.”
Technically, South Dakota physicians don’t prescribe cannabis — they merely certify that a patient has a condition, and the patients obtain marijuana themselves.
““This is ultimately where some providers may not ever feel comfortable providing certification for marijuana,” said Aker. “Prescribing, administering or dispensing a Schedule I drug could be cause for revoking your DEA registration, which would then threaten your ability to really practice because you wouldn't be able to prescribe other medications. You also wouldn't be able to participate in programs like Medicare or Medicaid.”
Aker said other states haven't had problems with doctors losing their DEA registrations for prescribing medical cannabis, but practitioners should be aware of the risk.
Advocates envision a robust referral system that’s integrated into the major health care networks. Mick Niess is a retired firefighter who uses cannabis to treat arthritis. He moved to South Dakota last year from Washington, where medical marijuana was legalized in 1998. Niess said he got his Washington card after his cardiologist referred him to a practitioner with medical cannabis expertise.
“They have professional doctors there that talk to you about dosage, that talk to you about safety, that talk to you about terpenes,” Niess said, referring to aromatic compounds that can influence the effect of cannabis. “There is absolutely no structure for that right now in South Dakota. A lot of the doctors that are doing it are self-taught. They’re not working together.”
Medical cannabis advocate Liz Tiger said a stigma is keeping practitioners from certifying medical cannabis patients.
“Understanding why a patient might want this or might feel like it's their best choice, or even to have an open and unbiased conversation with our physicians right now is very difficult,” she said.
A representative for Sanford confirmed that the system has not formally changed its policies beyond deferring to individual practitioners. Avera and Monument Health did not immediately respond to a request for comment.
