A few years ago, Dr. James Li would never have dreamed of certifying his patients to use medical marijuana.

“I was a total skeptic,” says the emergency room doctor at LincolnHealth’s Miles Campus in Damariscotta. “I didn’t think there was any credibility. I thought it was a way for people to get a license to use illicit marijuana in a recreational fashion.”

But as Li saw firsthand the improvements some patients made as they traded hundreds of pills a month for medical cannabis, he started doing research. After reading all he could and talking to advocates, he decided he’d send patients he thought would benefit from marijuana to a doctor who could certify them to legally use the drug.

There were none to be found in the Damariscotta area.

So Li – still somewhat reluctant but willing to give it a try – opened a part-time private practice and joined the growing number of Maine doctors and nurse practitioners who are certifying patients to use medical marijuana.

There are now more than 300 medical providers in Maine certifying medical marijuana patients, according to data released by the Department of Health and Human Services. It’s difficult to say how that number has grown since the medical marijuana program was established in 1999 because the state did not track the number of certifying doctors until last year, but a state official, medical providers and advocates say anecdotally that there has been an increase.

The increase, according to doctors and medical marijuana advocates, is driven by patient demand, a change in state law that allows nurse practitioners to certify patients and a growing consensus among some doctors that cannabis can be used effectively to treat certain medical conditions.

In 2015, 302 doctors and nurse practitioners certified medical marijuana patients, according to data obtained by the Maine Sunday Telegram under the Freedom of Access Act. Last year was the first time state officials were able to record how many medical providers are certifying patients because of changes to the certification process. The data do not show how many patients each medical provider certified, but do indicate there are now doctors in all counties certifying patients.

DHHS, which oversees the medical marijuana program, in January 2015 started requiring medical providers to complete a certification process online and immediately provide an identification card to the patient. Medical providers have to register an account so they can log into that system.

Prior to the launch of the online portal, state officials knew only the number of doctors who certified patients voluntarily registered with the state. In 2013, 36 doctors certified patients who voluntarily registered and in 2014 that number increased slightly to 43.

Marietta D’Agostino, the DHHS program manager, said those numbers likely only captured some of the medical providers who were actively certifying patients. She said even the 2015 numbers captured from the online certification system may not show the exact number of medical providers because it’s possible someone could have been counted multiple times.

“What we do have is a much better picture of what’s going on statewide,” she said. “We probably do have more providers who are more accepting that marijuana can be used medicinally in the state of Maine. At first people may have been hesitant to get involved. I’m sure the number of providers has increased to meet the need and meet the demand.”

NO STATE REGISTRY OF MARIJUANA PATIENTS

Maine first legalized medical marijuana in 1999, then expanded the program in 2010 to include dispensaries. Since then, the number of patients and tax revenue have steadily increased.

The state cannot provide an exact number of patients because it does not keep a registry, but doctors have printed more than 35,000 certificates required under state regulations to certify patients. That number could include duplicates and replacement certificates and is likely higher than the actual number of patients, according to DHHS.

Last year, Mainers spent $23.6 million on medical marijuana from dispensaries, a 46 percent increase from 2014 driven by patients seeking alternatives to prescription painkillers and more doctors certifying people to use medical marijuana, according to dispensary operators. The dispensary sales generated $1.29 million in sales tax. The sales do not include numbers from the state’s 2,225 caregivers, who are authorized to sell marijuana to up to five patients at a time.

Despite the increase of doctors certifying in rural areas, advocates say patients in some parts of the state still have to travel long distances to see a doctor who will certify them as a medical marijuana patient, a practice that can be burdensome on patients who are already struggling with health problems and high medical costs. The average cost to see a doctor for certification is $200 a year and the visits are not covered by insurance. The cost to medicate with marijuana varies widely depending on the form taken, how often it is used and whether it is obtained from a dispensary or caregiver. A tincture could cost as little as $10 a bottle, while marijuana buds could top $300 an ounce. The medication is not covered by insurance.

“There were people driving from (Aroostook) County or Down East for three or four hours to get to a doctor’s appointment. Access was severely limited,” said Catherine Lewis of Medical Marijuana Caregivers of Maine. “I still hear from patients on a regular basis that they’re having a hard time finding a physician near them.”

RESPONDING TO ‘A LARGE AND UNMET NEED’

The 2015 data on medical providers writing certifications show they are located in all 16 counties, but with higher concentrations in more populous counties, including Cumberland, York and Penobscot. Of the 302 medical providers included in the state’s count, 174 are medical doctors, 60 are doctors of osteopathic medicine and 68 are nurse practitioners. Nurse practitioners were authorized to certify patients following a 2014 change in state law.

Nationwide, 76 percent of doctors support the use of marijuana for medicinal purposes, according to a 2013 survey published in the New England Journal of Medicine. A 2014 survey by WebMD/Medcape showed 56 percent of doctors support making marijuana legal nationwide.

Dr. Dustin Sulak, whose Falmouth-based practice Integr8 Health specializes in medical cannabis, says he was the second doctor in Maine to start certifying patients. When he opened a practice in Hallowell in 2009, he had so many requests for appointments that he was scheduling patients two months out.

“I quickly found there was a large and unmet need in the community,” he said. “We turned down hundreds of patients every month.”

Sulak now has two practices in Maine and one in Massachusetts that employ a total of 16 medical providers and treat between 18,000 and 20,000 patients.

Over the past few years, Sulak said he has noticed the stigma around recommending marijuana has lessened, but it’s still there. He said he talks to many doctors who are open to the idea of certifying patients, but cannot because they work for medical groups that prohibit the practice because of concerns about losing federal funding and licenses from the U.S. Drug Enforcement Administration to prescribe drugs.

Other doctors, including Li in Damariscotta, have started certifying patients because they saw firsthand the benefits of cannabis therapy or because they have long supported the use of plant-based medicine and a move away from pharmaceutical painkillers. Walk-in clinics like CannaCare Docs – with four locations and 12 practitioners in Maine – have also added to the pool of medical providers certifying patients.

Li opened his MMJ Physicians Services practice so he could certify medical marijuana patients, which he does not do in his role as an emergency room doctor for a subsidiary of MaineHealth. Most of his patients find him from referrals through their own doctors, who often can’t certify patients because of where they work.

When he first opened his part-time practice, Li thought he would try it for three months and see if his patients were actually benefiting from medicating with cannabis. That was nearly three years ago. While he has seen his patients make improvements, he still worries about being known as a “pot doctor” and about the potential of scrutiny from federal officials because marijuana is classified as a Schedule I drug.

“It’s not an overwhelming tension, but it sometimes gives me pause,” Li said. “Then I go and meet with patients. At this point, we have at least 50 patients who tell me, ‘This has changed my life for the better.’ ”

SOME PHYSICIANS HAVE WORKPLACE RESTRICTIONS

Dr. Stephen Blythe ran a medical practice in Down East Maine before relocating to Florida, but he maintains his Maine medical license and continues to certify medical marijuana patients through teleconference appointments. He said he decided to keep the Maine practice because so many of his patients couldn’t get certified by their primary care physicians.

“I have quite a few doctors who routinely refer patients to me,” he said. “They’re happy to see their patients certified because it helps them, but they can’t provide certifications because of where they work.”

Dr. Benjamin Newman, who retired after 46 years in the Navy and opened a private practice in Winter Harbor, started certifying medical marijuana patients three years ago, driven largely by his background in holistic medicine. Many of his patients find him through other patients or referrals from their own physicians, “who are unable or unwilling to certify patients.”

“They are afraid to prescribe marijuana even though many of them think it’s beneficial. Because of that, they refer patients to me or people like me,” he said. “They don’t want to take risks because of federal law.”

The Maine Medical Association maintains a section of its website devoted to medical marijuana to provide information both to doctors who certify and those who don’t, said Gordon Smith, the organization’s executive vice president. The resources include a guide to understanding the medical marijuana law and information about the process of certifying patients. It also includes a statement medical providers who don’t certify can give to patients explaining why they choose not to. That letter cites concerns about marijuana being a Schedule I drug, the lack of Food and Drug Administration approval, variability in dosage and potency, and the potential abuse of marijuana.

The American Medical Association’s policy on medical marijuana use calls for more studies of the efficacy of medical marijuana and its effect on patients and the reconsideration of marijuana as a Schedule I drug. The policy also states that the association “believes that effective patient care requires the free and unfettered exchange of information on treatment alternatives and that discussion of these alternatives between physicians and patients should not subject either party to criminal sanctions.”

OFFICIAL: POT’S ILLEGALITY HAS INHIBITED RESEARCH

In 2004, the U.S. Supreme Court upheld earlier federal court decisions that doctors have a constitutional right to recommend medical cannabis to their patients.

Jeff Austin, vice president of government affairs for the Maine Hospital Association, said he does hear from members who have concerns about DEA licenses and federal certifications, but that often is not the biggest reason medical practices and doctors refrain from certifying patients. He said the primary concern tends to be on the clinical side because cannabis products haven’t gone through the FDA approval process and there hasn’t been much research into its efficacy.

“Because of its illegality on the federal level, the research that could have been there for the past few decades hasn’t been there,” Austin said.

MaineHealth, a nonprofit health care system with roughly 35 locations and 1,500 physicians across the state, does not have a systemwide policy on certifying medical marijuana patients, according to spokesman John Porter. He said individual locations – such as hospitals and clinics – may make individual policies prohibiting medical providers from certifying patients.

Some of the concern about marijuana’s classification as a Schedule I drug – the same class as drugs such as heroin and ecstasy – may be alleviated if the DEA reconsiders classifying cannabis. Marijuana was first classified as Schedule I under the Controlled Substance Act in 1970 and the DEA has since rebuffed numerous attempts to reschedule it.

In a recent lengthy memo to lawmakers, the DEA said it hopes to decide whether to change the federal status of marijuana “in the first half of 2016.” The American Medical Association and the American Academy of Pediatrics have called on the DEA to consider the change, citing marijuana’s therapeutic potential for serious ailments such as chronic pain and epilepsy.